key: cord-291753-9p5ppawn
authors: Winhusen, Theresa; Walley, Alexander; Fanucchi, Laura C.; Hunt, Tim; Lyons, Mike; Lofwall, Michelle; Brown, Jennifer L.; Freeman, Patricia R.; Nunes, Edward; Beers, Donna; Saitz, Richard; Stambaugh, Leyla; Oga, Emmanuel; Herron, Nicole; Baker, Trevor; Cook, Christopher D.; Roberts, Monica F.; Alford, Daniel P.; Starrels, Joanna L.; Chandler, Redonna
title: The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based Practices in the HEALing Communities Study
date: 2020-10-04
journal: Drug Alcohol Depend
DOI: 10.1016/j.drugalcdep.2020.108325
sha: 
doc_id: 291753
cord_uid: 9p5ppawn

BACKGROUND: The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four states. The CTH intervention seeks to facilitate widespread implementation of three evidence-based practices (EBPs) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (OEND), effective delivery of medication for opioid use disorder (MOUD), and safer opioid analgesic prescribing. A key challenge was delineating an EBP implementation approach useful for all HCS communities. METHODS: A workgroup composed of EBP experts from HCS research sites used literature reviews and expert consensus to: 1) compile strategies and associated resources for implementing EBPs primarily targeting individuals 18 and older; and 2) determine allowable community flexibility in EBP implementation. The workgroup developed the Opioid-overdose Reduction Continuum of Care Approach (ORCCA) to organize EBP strategies and resources to facilitate EBP implementation. CONCLUSIONS: The ORCCA includes required and recommended EBP strategies, priority populations, and community settings. Each EBP has a “menu” of strategies from which communities can select and implement with a minimum of five strategies required: one for OEND, three for MOUD, and one for prescription opioid safety. Identification and engagement of high-risk populations in OEND and MOUD is an ORCCArequirement. To ensure CTH has community-wide impact, implementation of at least one EBP strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in HCS-facilitated EBP implementation.

In order to promote OEND, effective delivery of MOUD, and safer opioid prescribing the study team developed an approach to EBP implementation with utility for all participating communities, which vary widely in their current EBP implementation, access to resources including needed workforce, and perceived acceptability of various EBPs. This paper describes the framework developed to guide EBP selection and implementation strategies contained in the Opioid-overdose Reduction Continuum of Care Approach.

For each EBP component of the CTH intervention, a workgroup consisting of EBP experts from each research site was established to develop an approach that would include standardization requirements across communities, while also providing enough flexibility to meet the varying needs of the 67 HCS communities. A significant reduction in opioid-involved overdose deaths will require widespread implementation of OEND, effective delivery of MOUD, and prescription opioid safety efforts. Therefore, effective implementation of strategies for each of these three EBPs is an HCS goal. The first task undertaken by this workgroup was developing a framework for organizing the targeted EBPs and potential strategies for their implementation. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA), shown in Figure 1 , was adapted from the Cascades of Care for OUD developed by Williams and colleagues . Cascades of Care emphasizes four domains: Prevention, Identification, Treatment, and Remission. The ORCCA places greater emphasis on the HCS-goal of implementing EBP strategies that will reduce opioid-involved overdose fatalities and demonstrates how overdose reduction strategies overlap across a continuum of care rather than being discrete steps. The workgroup then developed the ORCCA's required elements and a companion Technical Assistance Guide referencing existing resources to assist communities with implementation. Based on research literature and expert consensus, the ORCCA includes required and recommended community settings, priority populations, EBPs, and implementation strategies.

In order to ensure the CTH intervention has impact across multiple sectors interacting with individuals at high risk for an opioid-involved overdose and across the care continuum, each community is required to implement at least one of the EBPs within each of three community settings:

J o u r n a l P r e -p r o o f 1) healthcare; 2) behavioral health; and 3) criminal justice. Healthcare settings include outpatient healthcare centers, pre-hospital providers, emergency departments and urgent care, hospitals, primary care settings, and pharmacies. Behavioral health includes substance use disorder and mental health treatment centers and social service agencies. Criminal justice includes pre-trial, jails, probation, parole, drug and problem-solving courts, police and "narcotics" task forces, halfway houses, community-based correctional facilities, and department of youth services. Communities provide a rationale for not engaging all three community settings.

Most people with OUD in the U.S. are not enrolled in effective treatment . Any individual misusing opioids or with OUD is at risk for opioid-involved overdose death, particularly if not engaged in MOUD. A substantial proportion of people who die from opioid-involved overdose have had no interaction with the healthcare system in the previous year (Larochelle et al., 2019) . Thus, reducing overdose deaths will require engaging people who currently are not accessing overdose prevention or OUD treatment services. This reality is the justification for an ORCCA requirement to identify and intervene with high-risk populations. Individuals who are at highest risk for overdose, such as those who have overdosed or those who recently were treated in a withdrawal management program (colloquially referred to as "detox"), do not typically access MOUD (Larochelle et al., 2018; Walley et al., 2020) . Specific factors that further elevate the risk of overdose among those using opioids include: 1) having had a prior opioid overdose (Caudarella et al., 2016; Darke et al., 2011; Larochelle et al., 2018; Larochelle et al., 2019; Winhusen et al., 2016) ; 2) having reduced opioid tolerance (e.g., completing medically supervised or "socially" managed withdrawal, or release from an institutional setting such as jail, residential treatment, hospital) (Binswanger, Ingrid A. et al., 2007; Larochelle et al., 2019; Merrall, E. L. C. et al., 2010; Strang et al., 2003; Walley et al., 2020) ; 3) using other substances (e.g., alcohol, benzodiazepines, stimulants) (Brugal et al., 2002; Cho et al., 2020; Gladden et al., 2019; Larochelle et al., 2019; Park et al., 2015; Sun et al., 2017) ; 4) having a concomitant major mental illness (e.g., major depression, bipolar disorder, schizophrenia, anxiety disorders) (O'Driscoll et al., 2001; Pabayo et al., 2013; Tobin and Latkin, 2003; Wines et al., 2007) ; 5) having a concomitant major medical illness (e.g., cirrhosis, chronic kidney disease, COPD, asthma, sleep apnea, congestive heart failure; infections related to J o u r n a l P r e -p r o o f drug use) (Bosilkovska et al., 2012; Green et al., 2012; Jolley et al., 2015; Larochelle et al., 2019; Vu et al., 2018) ; and/or 6) injecting drugs (Bazazi et al., 2015; Brugal et al., 2002) .

In developing the ORCCA, the workgroup delineated three approaches to identifying high risk populations (See Table 1 ). These approaches include: 1) identification within criminal justice settings and venues where high-risk populations seek services Malta et al., 2019; Park-Lee et al., 2016; Suffoletto and Zeigler, 2020; Weiner et al., 2020) , 2) field-based outreach including point-of-contact for emergency response (Bagley, S. M. et al., 2019; Waye et al., 2019) , and 3) the use of surveillance or other existing data sources to locate individuals likely needing intervention (Formica et al., 2018; Merrick et al., 2016) . In the first approach, EBPs are incorporated into services at venues where people at high-risk may be present. The second approach includes real-time community outreach to high-risk venues and individuals. The third approach includes identifying newly emerging risk groups utilizing overdose surveillance data. In addition to defining populations at high risk for overdose, the ORCCA also identifies populations that would likely warrant tailoring EBP strategy implementation. These groups include adolescents (Bagley et al., 2020; Chatterjee et al., 2019; Lyons et al., 2019) , pregnant and post-partum women (Goldman-Mellor and Margerison, 2019; Nielsen et al., 2020) , homeless populations (Bartholomew et al., 2020; Doran et al., 2018; Magwood et al., 2020) , rural populations without transportation (Arcury et al., 2005; Bunting et al., 2018) and other factors related to poverty (Snider et al., 2019; Song, 2017 ), veterans (Lin et al., 2019 Mudumbai et al., 2019) , non-English speaking and immigrant populations (Salas-Wright et al., 2014; Singhal et al., 2016) , racial and ethnic minorities (Barocas et al., 2019; Lippold et al., 2019) , people with mental health disorders (Turner and Liang, 2015) and mental/physical disabilities (Burch et al., 2015; West et al., 2009) , people involved in transactional sex (Goldenberg et al., 2020; Marchand et al., 2012) , and people who have chronic pain (Bohnert et al., 2011; Dunn et al., 2010; James et al., 2019) . As one of the HCS requirements, communities will record the high-risk populations and community venues included in the selected EBP strategies.

J o u r n a l P r e -p r o o f Subgroups were established for each of the three EBPs to assemble strategies and resources contained in the ORCCA. These subgroups created a forum for networking and collaboration among investigators with specific content expertise. Subgroups drafted each respective menu (OEND, MOUD, and safer opioid prescribing) and their Technical Assistance Guide subsections. Based on the likelihood of overdose reduction, the subgroups made recommendations on which strategies should be required and which should be optional. For example, the OEND subgroup recommended that "active" distribution of OEND be required, because it was concluded that reducing overdose on a community level required OEND being pro-actively provided to high-risk populations. It would not be enough to "passively" make it available regardless of overdose risk. Each subgroup reviewed the literature and completed online searches (e.g., SAMHSA website) for resources and toolkits. Upon completion of each subgroup's section, the full workgroup convened to vote and approve the ORCCA.

Naloxone reverses an opioid overdose if administered quickly. Overdose prevention education and broad community access to naloxone is associated with reduced opioid-involved overdose death (Bird et al., 2016; Clark et al., 2014; Giglio et al., 2015; McDonald and Strang, 2016; Walley et al., 2013b) . OEND includes clear, direct messages about how to prevent opioid overdose and rescue a person who is overdosing to empower trainees to respond to overdoses. OEND can be successfully implemented at multiple venues among diverse populations. The OEND menu (see Table 2) includes three sub-menus: a) active OEND, which is required; b) passive OEND, which is optional; and c) naloxone administration, which is optional.

The following sections describe the rationale and evidence for the OEND submenus. a) Active OEND Active OEND is proactive and targeted towards high-risk populations and their social networks or venues where high risk populations are likely to be found. Active OEND is a required ORCCA menu element because the best evidence for reducing overdose via OEND has been shown among communities that pro-actively make OEND accessible to those at high risk for overdose (Walley et al., 2013b) including people released from J o u r n a l P r e -p r o o f incarceration (Bird et al., 2016) , and people with chronic pain treated with chronic opioid therapy through community health centers (Coffin et al., 2016) . Opioid overdose education typically includes education about overdose risk factors and how to recognize and respond to an overdose, including naloxone administration; training can be provided in a variety of formats including in-person or on-line. Active OEND examples include: syringe service program workers providing OEND to people who inject opioids (Doe-Simkins et al., 2014; Walley et al., 2013b; Wheeler et al., 2015) ; emergency department staff providing OEND to patients seen for opioid-use complications (Dwyer et al., 2015; Gunn et al., 2018) ; and equipping people released from incarceration with naloxone (Bird et al., 2016; Wenger et al., 2019) .

Passive OEND increases OEND access to individuals referred by other providers and those seeking OEND on their own and makes naloxone available for immediate use in overdose hotspots. As an optional ORCCA submenu, passive OEND strategies are encouraged but not required because their impact is unlikely to be adequate to reduce overdose deaths compared to active OEND strategies. Examples of passive OEND include distributing naloxone at a community meeting or making naloxone available at a pharmacy without a prescription Pollini et al., 2020; Sohn et al., 2019) , for example through pharmacy standing orders (Abouk et al., 2019; Davis and Carr, 2017; Evoy et al., 2018; Xu et al., 2018) . This submenu also includes publicly available naloxone for emergency use where overdoses commonly occur, such as public restrooms (Capraro and Rebola, 2018) .

The naloxone administration submenu focuses on increasing capacity for opioid overdose response and rescue by first responders such as police (Wagner et al., 2016) and fire and emergency medical technicians (Davis et al., 2015; Davis et al., 2014a; Davis et al., 2014b; Rando et al., 2015) . In these programs, first responders are trained in overdose response and equipped with naloxone, so they have the capacity to administer naloxone when called. They do not distribute naloxone to others in the community. This is also an optional menu item because the impact is unlikely to be adequate to reduce overdose deaths compared to active OEND.

2.4.2 Effective delivery of MOUD, including agonist / partial agonist medication J o u r n a l P r e -p r o o f MOUD decreases the risk of opioid-involved death (Larochelle et al., 2018; Pearce et al., 2020; Sordo et al., 2017) but is widely underutilized (Volkow and Wargo, 2018; Williams et al., 2018) . Barriers to improved MOUD utilization include inadequate treatment availability, failure to identify and engage high-risk populations in MOUD, and poor treatment retention (Morgan et al., 2018; Samples et al., 2018) . Accordingly, the MOUD menu (Table 3) is composed of three sub-menus: a) expand MOUD treatment availability; b) interventions to link people in need to MOUD; and c) MOUD engagement and retention. It is required that communities choose at least one strategy from each of the three MOUD submenus. Evidence for decreasing mortality is strongest for methadone and buprenorphine. Therefore, communities are required to choose strategies that expand access to, and improve retention in, treatment with these medications. Strategies that focus on naltrexone are optional since this medication has less evidence for reducing opioid-involved overdose (Larochelle et al., 2018) , although clinical trials suggest extended-release injection naltrexone can be effective for relapse prevention if adherence is secured (Lee et al., 2016; Lee et al., 2018; Tanum et al., 2017) . The following sections describe the rationale and evidence for the three required submenus within the MOUD menu.

Communities must select at least one strategy that expands MOUD treatment availability with buprenorphine or methadone from this submenu.

Though each potential strategy includes multiple venues, the ORCCA does not prescribe which venues must be included outside of the overall requirement that communities choose at least one strategy that addresses healthcare, behavioral health, and criminal justice settings across all three main menus. The first submenu strategy is adding and/or expanding MOUD treatment in primary care, other general medical and mental health settings and substance use disorder treatment and recovery programs. Historically in the US, addiction treatment has been isolated from general medical and mental health care settings, and MOUD treatment has been omitted from the care provided in primary care, hospitals (Fanucchi and Lofwall, 2016; Jicha et al., 2019) , emergency departments (Hawk et al., 2020) , and general mental health (Novak et al., 2019) . Furthermore, according to data from the National Survey of Substance Abuse Treatment Facilities, many substance use disorder treatment programs do not provide MOUD (Substance Abuse and Mental Health Services Administration, 2019c). Specifically, in 2018, the proportion of facilities offering buprenorphine, methadone, and J o u r n a l P r e -p r o o f long-acting naltrexone treatment was 33%, 10%, and 28% respectively (Substance Abuse and Mental Health Services Administration, 2019c). MOUD treatment can be successfully integrated in these settings, increasing capacity and reducing treatment barriers (Blanco and Volkow, 2019; Chou, R et al., 2016; Korthuis et al., 2017) .

The second submenu strategy is adding and/or expanding MOUD treatment in criminal justice settings. Despite the strong evidence base, MOUD is not commonly provided in criminal justice settings, with only 30 out of 5,100 US prisons and jails offering methadone or buprenorphine in 2017 (Substance Abuse and Mental Health Services Administration, 2019e). Incarceration is associated with increased risk of overdose death postrelease largely due to loss of tolerance after forced withdrawal during incarceration (Binswanger et al., 2013; Merrall, E. L. C. et al., 2010) . Improving availability of MOUD in criminal justice settings, including pre-trial, jail, prison, probation, and parole, is a critical opportunity to reduce opioidinvolved overdose deaths (Moore et al., 2019).

The third submenu strategy is expanding access to MOUD treatment through telemedicine, interim buprenorphine (Sigmon et al., 2016) , interim methadone (Newman, 2014; Schwartz et al., 2006) , or medication units (Office of the Federal Register and Government Publishing Office, 2019b).

Expanding access to MOUD through telemedicine is especially salient as communities consider ORCCA strategies during the COVID-19 pandemic.

Telemedicine models for buprenorphine treatment already existed (U.S. Department of Health and Human Services, 2018), but guidance from the US Drug Enforcement Agency, SAMHSA, the Centers for Medicare & Medicaid Services, and state regulatory agencies changed rapidly ; Opioid Response Network, 2020; Providers Clinical Support System, 2020a; Substance Abuse and Mental Health Services Administration, 2020c) to allow greater flexibility of MOUD treatment via telemedicine during the pandemic. For example, the requirement for an in-person visit to begin MOUD was waived and dispensing of medications was allowed for longer periods of time. It is unclear how effective these changes will be or whether they will remain, but telemedicine is part of the OUD treatment landscape and an important tool to support treatment access. "Interim" treatment with methadone or buprenorphine refers to treatment with medication dispensed directly to patients (no prescription given) at licensed opioid treatment programs, which are heavily regulated at a federal and state level and require comprehensive ancillary services (e.g., on-site counseling). When there J o u r n a l P r e -p r o o f are waiting lists, these programs may receive regulatory approval to provide medication for up to 180 days while patients await the full array of nonmedication services. This is called "interim" treatment and is superior to waiting lists on multiple outcomes including illicit opioid use and treatment retention (Sigmon, 2015) . A medication unit is a satellite to a licensed opioid treatment program providing primarily medication dispensing in order to make treatment more accessible to patients (Office of the Federal Register and Government Publishing Office, 2019b). New patients are required to have direct supervision of their daily dispensed medication for the first 90 days of treatment, making travel a barrier to treatment if the program is located far away from the patient. Therefore, medication units are a way to extend the availability of methadone treatment over a wider geographic region.

The second submenu focuses on strategies that link people with OUD to MOUD. There are two strategies to choose from: improving linkage to MOUD from venues where persons with OUD may be encountered (e.g., general medical and mental health treatment programs, syringe service programs, and criminal justice settings); and using MOUD initiation as a bridge to longer-term care (starting MOUD at the venue where the patient is encountered in addition to linkage to ongoing MOUD treatment). On-site MOUD initiation strategies are preferred and can occur across multiple community-based settings such as in emergency departments and hospitals where patients may present with complications of untreated OUD such as an opioid overdose or a deep-seated infection related to intravenous injection of opioids. Starting MOUD in these venues is safe, feasible, and can significantly increase likelihood of continuing MOUD treatment (D'Onofrio et al., 2015; Weinstein et al., 2018) . c) MOUD treatment engagement and retention MOUD treatment retention beyond 6 months is challenging (Samples et al., 2018) , but critical to saving lives. Research is clear that MOUD treatment retention is strongly associated with decreased mortalityboth from overdose and all-cause mortality, with risk of overdose increasing dramatically after discontinuation of MOUD (Pearce et al., 2020; Wakeman et al., 2020; Walley et al., 2020; Williams et al., 2020) . Communities must choose at least one of the following five strategies: a) enhancement of clinical delivery approaches to support engagement and retention; b) use of J o u r n a l P r e -p r o o f virtual retention approaches; c) retention care coordinators; d) mental health and polysubstance use treatment integrated into MOUD care; and e) reducing barriers to housing, transportation, childcare, and accessing other community benefits for people with OUD. Comprehensive strategies to improve MOUD treatment retention include addressing each individual's treatment needs, which commonly include treatment for comorbid mental health and non-opioid substance use disorders as well as reducing barriers to resources such as housing, transportation, insurance coverage, food security, childcare, employment and other psychosocial and community services (Substance Abuse and Mental Health Services Administration, 2020d).

Shared decision making, case management, legal assistance and advocacy, on-site psychiatric services and psychosocial recovery support, insurance navigation, behavioral interventions such as contingency management for comorbid non-opioid substance use disorders (De Crescenzo et al., 2018) , and technology-delivered therapies (Christensen et al., 2014) are some example strategies aimed at improving engagement and retention.

Opioid analgesic prescribing practices can increase the risk of long-term opioid use, the development of OUD and opioid-involved overdose deaths. For example, an opioid analgesic prescription is associated with increased risk for OUD in persons with chronic non-cancer pain (Edlund et al., 2014) and the length of an initial opioid prescription for acute pain is a significant predictor of long-term use (Shah et al., 2017) . Similarly, high doses of opioids (e.g., >90 morphine milligram equivalents) (Bohnert et al., 2016; Dasgupta et al., 2016) , use of extended-release/long-acting opioids (Zedler et al., 2014) and concurrent prescribing of benzodiazepines increase the risk of overdose (Hernandez et al., 2018; Sun et al., 2017) . Those with cooccurring mood disorders, other non-opioid substance use disorders, chronic medical conditions, and chronic pain are at heightened risk (Campbell et al., 2018) . When prescribed opioids are not properly stored or go unused, the excess supply is a potential source for non-medical use and/or diversion; the majority of persons reporting non-medical use of prescription opioids obtain them from a friend or family member (Substance Abuse and Mental Health Services Administration, 2019a). Numerous safer opioid prescribing guidelines have been published (Chou et al., 2009; Franklin and American Academy of, 2014; Manchikanti et al., 2012; Nuckols et al., 2014) , however, adherence to these guidelines is low (Hildebran et al., 2014; Sekhon et al., 2013; Starrels et al., 2011) . Pain management education remains inadequate (Mezei et al., 2011) , but is a key strategy to address poor adherence to J o u r n a l P r e -p r o o f guideline-based safer opioid prescribing practices. Accordingly, the prescription opioid safety menu (Table 4) includes two submenus: a) safer opioid prescribing/ dispensing practices, which is required, and b) safer opioid disposal practices, which is optional. a) Safer opioid prescribing/dispensing practices Communities must select at least one of the following three strategies: 1) safer opioid prescribing for acute pain across healthcare settings, such as inpatient services, emergency departments, outpatient clinics, ambulatory surgery and dental clinics; 2) safer opioid prescribing for chronic pain, including adherence to the CDC guideline recommendations and patient-centered opioid tapering; or 3) safer opioid dispensing. A variety of approaches have been effective in promoting safer opioid prescribing. For example, opioid prescribing changes were observed following implementation of the CDC 2016 chronic pain guidelines (Bohnert et al., 2018) . Online and in-person continuing education has been shown to improve knowledge, attitudes, confidence and self-reported clinical practice in safer opioid prescribing (Alford et al., 2016) . Academic detailing, an interactive one-on-one educational outreach by a healthcare provider to a prescriber to provide unbiased, evidence-based information to improve patient care, has been applied successfully to improve opioid prescribing behavior (Larson et al., 2018; Voelker and Schauberger, 2018) . The utilization of state Prescription Drug Monitoring Programs to assess patients' controlled substance prescription histories and identify potential risky patterns of opioid use or drug combinations has resulted in reduced multiple-provider episodes (i.e., "doctor shopping") (Strickler et al., 2020) , reduced high-risk opioid prescribing (Strickler et al., 2019) , and reduced prescription opioid poisonings (Pauly et al., 2018) . Prescriber feedback regarding a patient's fatal overdose can also change prescriber behavior (Doctor et al., 2018; Volkow and Baler, 2018) . Most efforts to promote safer opioid analgesic use have focused on prescriber behavior change. However, pharmacists are the last line of defense against unsafe opioid prescriptions and have a corresponding responsibility to ensure legitimate prescriptions (Office of the Federal Register and Government Publishing Office, 2011).

Providing safe, convenient, and environmentally appropriate ways to dispose of unused prescription opioids can help reduce the excess opioid supply within communities and prevent access by children, adolescents, and other vulnerable individuals. Communities have the option of selecting a J o u r n a l P r e -p r o o f strategy to promote safe disposal practices such as the installation of permanent disposal kiosks or the implementation of other disposal programs such as distribution of drug mail-back envelopes. Studies have shown that leftover medication from an opioid prescription is common (Bicket et al., 2017; Kennedy-Hendricks et al., 2016) and that patient education regarding disposal practices can increase opioid disposal rates (Hasak et al., 2018) , although education about disposal is suboptimal (Gregorian et al., 2020) . According to a recent study, only 30% of persons who had received an opioid prescription in the previous two years disposed of their unused opioid medication; however, over 80% indicated they would be more likely to dispose of opioid medications in the future if disposal kiosks were in a location they visited frequently (Buffington et al., 2019).

Because the evidence base will evolve during the course of this study, additional strategies can be added to the menus if any of the following inclusion criteria are met: 1) listed in a registry of EBPs (federal, state, or community) that documents it has been replicated multiple times with positive effects; 2) evidence of its efficacy through, at a minimum, a quasi-experimental design; 3) evidence of its efficacy in reducing opioid-involved overdose death that has been published in a scientific journal; or 4) it has been reviewed and approved by the ORCCA Steering Committee.

Upon completion of the ORCCA menus, the subgroups developed a companion Technical Assistance Guide which provides greater detail about the resources included in the ORCCA menus (i.e., the resources listed in the "Sample Resources" column of Tables 1-4). The resources compiled in the Guide (e.g., toolkits, publications, websites) are designed to help implement and sustain each EBP and strategy included on an ORCCA menu and provides examples of successful national, state, and local programs. The Guide is considered a "living document" and is updated every six months by a dedicated subgroup spanning the research sites.

The HCS seeks to facilitate widespread uptake and expansion of three EBPs with the potential to reduce opioid-involved overdose fatalities: 1) OEND; 2) effective delivery of MOUD, including agonist / partial agonist medication; and 3) prescription opioid safety. This paper described the J o u r n a l P r e -p r o o f development of the ORCCA, which includes a menu-based approach to organizing strategies and resources for facilitating implementation of these EBPs. The ORCCA includes requirements and recommendations for EBP implementation to help ensure standardization across the research sites. At minimum, five strategies need to be selected to implement the three EBPs: one for OEND, three for MOUD, and one for prescription opioid safety.

Based on a literature review and expert consensus, the ORCCA requires identification, and engagement of, high-risk populations in healthcare, behavioral health, and criminal justice settings, which will help ensure both that individuals most in need of services receive them and that implementation of EBPs will be more widespread in communities than could be achieved by allowing implementation within a narrower range of settings.

Importantly, the ORCCA does not prescribe the implementation of any single strategy; rather, it provides flexibility with multiple strategy options for implementing the required EBPs, all of which were chosen based on the scientific evidence. Because each community will vary in the need, feasibility, readiness, desirability, stage of current implementation, and expected impact for specific practices, they will likely differ in their strategies and venues for implementing the three required EBPs. Many of the resources included in the ORCCA menus and Technical Assistance Guide have been developed to directly assist community coalitions, implementation teams, administrators, and practitioners who seek to implement or expand EBPs. In the HCS, the implementation of selected strategies will be a partnership between the community coalitions and the research site team, with the research site providing technical support. A limitation of the approach taken to ORCCA development is that a formal systematic review of the literature, such as that outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher et al., 2009), was not completed and, thus, potential strategies that could effectively support EBP implementation may have been missed. A strength of the approach is that, in addition to meeting the needs of the HCS communities, the ORCCA was designed for dissemination to other communities struggling with the opioid crisis should the HCS model prove effective. The flexibility included in the ORCCA, along with the resources included in the ORCCA menus and the Technical Assistance Guide, will increase the ease of implementation, with knowledgeable clinical experts in place of a research team, who partner with coalitions and organizations to select and implement practices that will achieve desired outcomes and foster sustainability. o Single-item Drug Screening Question (Smith et al., 2010) o TAPS Tool (Tobacco, Alcohol, Prescription Medication and Other Substance Use) (McNeely et al., 2016b; Schwartz et al., 2017) o Rapid Opioid dependence screen (RODS) (Wickersham et al., 2015) o Prescription Drug Monitoring Program systems (Huizenga et al., 2016) o o Police Assisted Addiction Recovery Initiative o Relay, a peer-delivered response to nonfatal opioid overdoses (Welch et al., 2019) o Recovery Initiation and Management after Overdose (Scott et al., 2020; Scott et al., 2018) o J o u r n a l P r e -p r o o f OEND by referral (e.g. prescription to fill at pharmacy Guy et al., 2019; Mueller et al., 2015) , referral to OEND dispensing program (Coffin et al., 2016; Sohn et al., 2019) General Resources/Toolkits for OEND by referral and OEND by self-request o Prescribe to Prevent (Lim, J. K. et al., 2016; Prescribe to Prevent, 2020) o GetNaloxoneNow.org training (Simmons et al., 2018) o Prevent & Protect: Pharmacy Outreach to improve community naloxone access (Prevent and Protect, 2020) o OEND self-request (e.g. at pharmacy, community meeting or public health department) (Jones et al., 2016) Naloxone availability for immediate use in overdose hotspots (NaloxBox, 2020; Salerno et al., 2018) NaloxBox (mounted supply of naloxone) (NaloxBox, 2020) (Clark, L et al., 2010;  SAMHSA-HRSA Center for Integrated Health Solutions, 2014) Safer opioid prescribing for chronic pain (Barth et al., 2017; Bohnert et al., 2018; Bohnert et al., 2011; Dunn et al., 2010; Edlund et al., 2014; Gaiennie and Dols, 2018; Gomes et al., 2011; Guy et al., 2017; Jeffery et al., 2019; Liebschutz et al., 2017) Pain management guidelines and toolkits 

Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose

Cost-Effectiveness of Intranasal Naloxone Distribution to High-Risk Prescription Opioid Users

SCOPE of Pain: An Evaluation of an Opioid Risk Evaluation and Mitigation Strategy Continuing Education Program

Hour and 24 Hour MAT Waiver Training

American Academy of Addiction Psychiatry, State Targeted Response Technical Assistance Consortium

ACEP-ONDCP webinar on naloxone

American College of Emergency Physicians, 2020a. E-QUAL Opioids Toolkits: Pain Management and Safe Opioid Use

Ending the Stigma of Opioid Use Disorder (video)

Waiver Qualifying Training

Buprenorphine Home Induction App

Access to Transportation and Health Care Utilization in a Rural Region

Interactive Versus Video-Based Training of Police to Communicate Syringe Legality to People Who Inject Drugs: The SHIELD Study

AIDS Volunteers of Kentucky

Expanding access to naloxone for family members: The Massachusetts experience

Characteristics and Receipt of Medication Treatment Among Young Adults Who Experience a Nonfatal Opioid-Related Overdose

Overdose Education and Naloxone Rescue Kits for Family Members of Individuals Who Use Opioids: Characteristics, Motivations, and Naloxone Use

A scoping review of post opioid-overdose interventions

A scoping review of post opioid-overdose interventions

Opioid Prescribing After Surgical Extraction of Teeth in Medicaid Patients

Unified protocol for the transdiagnostic treatment of emotional disorders

Sociodemographic factors and social determinants associated with toxicology confirmed polysubstance opioid-related deaths

Targeting practitioners: A review of guidelines, training, and policy in pain management

Examining risk behavior and syringe coverage among people who inject drugs accessing a syringe services program: A latent class analysis

High prevalence of non-fatal overdose among people who inject drugs in Malaysia: Correlates of overdose and implications for overdose prevention from a cross-sectional study

Brief overdose education is sufficient for naloxone distribution to opioid users

From Peers to Lay Bystanders: Findings from a Decade of Naloxone Distribution in Pittsburgh

Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review

Opioid use disorder and incarceration -hope for ensuring the continuity of treatment

Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from

Release from Prison -A High Risk of Death for Former Inmates

Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison

Management of opioid use disorder in the USA: present status and future directions

Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention's 2016 Opioid Guideline

A Detailed Exploration Into the Association of Prescribed Opioid Dosage and Overdose Deaths Among Patients With Chronic Pain

Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths

Analgesics in patients with hepatic impairment: pharmacology and clinical implications

BMC TTA Addiction Chat Live

BMC Office Based Addition Treatment Training and Technical Assistance (OBAT TTA)

Police-related barriers to harm reduction linked to non-fatal overdose amongst sex workers who use drugs: Results of a community-based cohort in Metro Vancouver

Maternal drug-related death and suicide are leading causes of post-partum death in California

Opioid dose and drug-related mortality in patients with nonmalignant pain

Extended-release naltrexone for pre-release prisoners: A randomized trial of medical mobile treatment

Reframing the Opioid Epidemic as a National Emergency

Prescription disposal practices: A 2-year ecological study of drug drop box donations in Appalachia

Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System

Orienting patients to greater opioid safety: models of community pharmacybased naloxone

HIV infection and risk of overdose: a systematic review and meta-analysis

Safe Opioid Storage and Disposal: A Survey of Patient Beliefs and Practices

The Emergency Department as an Opportunity for Naloxone Distribution

Vital Signs: Pharmacy-Based Naloxone Dispensing -United States

Vital Signs: Changes in Opioid Prescribing in the United States

Drug Addiction and Recovery Team (DART)

Harm Reduction Coalition

Harm Reduction Coalition

A primer for impementation of OEND programs in jails and prisons

Low Barrier Tele-Buprenorphine in the Time of COVID-19: A Case Report

Pharmacists' role in opioid safety: a focus group investigation

Collaborative care approaches for management of OUD

Identification, counseling, and treatment of OUD

Understanding addiction

Empowering Post-Surgical Patients to Improve Opioid Disposal: A Before and After Quality Improvement Study

Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine

Results of a type 2 translational research trial to prevent adolescent drug use and delinquency: a test of Communities That Care

Opioid overdose prevention training

Summit: Procedures for Medication-Assisted Treatment of Alcohol or Opioid Dependence in Primary Care

Exposure-Response Association Between Concurrent Opioid and Benzodiazepine Use and Risk of Opioid-Related Overdose in Medicare Part D Beneficiaries

How clinicians use prescription drug monitoring programs: a qualitative inquiry

Guideline for discharge opioid prescriptions after inpatient general surgical procedures

NARxCHECK® Score as a Predictor of Unintentional Overdose Death

Maternal opioid use during pregnancy

Mortality After Discontinuation of Primary Care-Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study

Extended-release injectable naltrexone for opioid use disorder: a systematic review

Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016

Substance Use Disorder Assessment, Diagnosis, and Management for Patients Hospitalized With Severe Infections Due to Injection Drug Use

Understanding Heroin Overdose: A Study of the Acute Respiratory Depressant Effects of Injected Pharmaceutical Heroin

Naloxone Co-prescribing to Patients Receiving Prescription Opioids in the Medicare Part D Program

Increase in naloxone prescriptions dispensed in US retail pharmacies since 2013

Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users

The Journey Recovery Project

Behavioral health treatment utilization among individuals with co-occurring opioid use disorder and mental illness: Evidence from a national survey

Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain

Predictors of accidental fatal drug overdose among a cohort of injection drug users

Code of federal regulations: 21 CFR 1306.04 -Purpose of issue of prescription

Code of federal regulations: Opioid treatment program certification: (g) Interim methadone

Code of federal regulations: Opioid treatment program certification: (i) Medication units

Project DAWN (Deaths Avoided With Naloxone

Connecting with a Peer Recovery Supporter

Ohio Recovery Housing

COVID-19 public health update

Tapering -Guidance & Tools (BRAVO protocol

The role of depression and social support in non-fatal drug overdose among a cohort of injection drug users in a Canadian setting

Receipt of services for substance use and mental health issues among adults: Results from the 2015 National Survey on Drug Use and Health

Associations between prescribed benzodiazepines, overdose death and buprenorphine discontinuation among people receiving buprenorphine

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study

Safeguard Against Medicine Abuse: Securing and Disposing Medications

Patient-Centered Primary Care Institute

Vital signs: overdoses of prescription opioid pain relievers---United States

Features of prescription drug monitoring programs associated with reduced rates of prescription opioid-related poisonings

Pear Therapeutics, 2020. reSET Prescription Digital Therapeutic Software

Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study

JCAHO pain management standards are unveiled

The value of clinical case management in a methadone maintenance treatment program

Assessing pharmacy-based naloxone access using an innovative purchase trial methodology

Promoting opioid overdose prevention and recovery: An exploratory study of an innovative intervention model to address opioid abuse

Prescribe to Prevent

Prescription Drug Abuse Policy System

Agency outreach

How-to guide for drug take-back: Managing a pharmacy-based collection program for leftover household pharmaceuticals

Project ECHO Chronic Pain

Project SHOUT, California Health Care Foundation

Integrating Motivational Interviewing Techniques for Brief Intervention into the Curriculum

A Systematic Review on the Use of Psychosocial Interventions in Conjunction with Medications for the Treatment of Opioid Addiction

Providers Clinical Support System

A primer on antagonist-based treatment of opioid use disorder in the office setting

Developing a Behavioral Treatment Protocol in Conjunction with MAT (Revised)

Improving Opioid Prescribing: The CDC Guideline for Prescribing Opioids for Chronic Pain, and Considerations for Dentistry

Providers Clinical Support System Webinars

Providers Clinical Support System

Providers Clinical Support System, 2020a. COVID-19 resources (national and state

Providers Clinical Support System, 2020b. Overview of Medications for Addiction Treatment (MAT Waiver Trainings

Providers Clinical Support System, 2020c. PCSS Mentoring Program

Intranasal naloxone administration by police first responders is associated with decreased opioid overdose deaths

Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: A randomised, open-label trial

Opioid tapering template

Substance use disorders among first-and second-generation immigrant adults in the United States: evidence of an immigrant paradox?

Simulation of the effects of co-locating naloxone with automated external defibrillators

Center for Integrated Health Solutions, Medication assisted treatment implementation checklist

Expanding the use of medications to treat individuals with substance use disorders in safety-net settings

Three Strategies for Effective Referrals to Specialty Mental Health and Addiction Services

Health-and-Addiction-Services-8.19.15.pdf

Now What? The Role of Prevention Following a Nonfatal Opioid Overdose

Risk factors for discontinuation of buprenorphine treatment for opioid use disorders in a multi-state sample of Medicaid enrollees

Implementation and Preliminary Results of an Emergency Department Nontargeted, Opt-out Hepatitis C Virus Screening Program

A police-led addiction treatment referral program in Gloucester, MA: Implementation and participants' experiences

A randomized controlled trial of interim methadone maintenance

Findings from the recovery initiation and management after overdose (RIMO) pilot study experiment

Opioid recovery initiation: Pilot test of a peer outreach and modified Recovery Management Checkup intervention for out-of-treatment opioid users

Compliance with opioid treatment guidelines for chronic noncancer pain (CNCP) in primary care at a Veterans Affairs Medical Center (VAMC)

A nationwide pharmacy chain responds to the opioid epidemic

Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use -United States

Limiting Opioid Overprescription after Prostatectomy: How Payer-Provider Collaboration Can Lead to Improved Patient Safety and Reimbursement

A Transitional Opioid Program to Engage Hospitalized Drug Users

Randomized pilot trial of Web-based cognitive-behavioral therapy adapted for use in office-based buprenorphine maintenance

Interim treatment: Bridging delays to opioid treatment access

Interim Buprenorphine vs. Waiting List for Opioid Dependence

Harmonizing disease prevention and police practice in the implementation of HIV prevention programs: Up-stream strategies from

Implementation of online opioid prevention, recognition and response trainings for laypeople: Year 1 survey results

Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse

A Single-Question Screening Test for Drug Use in Primary Care

Association Between State Medicaid Eligibility Thresholds and Deaths Due to Substance Use Disorders

Patient experiences with a transitional, low-threshold clinic for the treatment of substance use disorder: A qualitative study of a bridge clinic

Association of naloxone coprescription laws with naloxone prescription dispensing in the United States

Mortality Quadrupled Among Opioid-Driven Hospitalizations, Notably Within Lower-Income And Disabled White Populations

Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies

Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain

Naloxone resources

Ohio Automated Rx Reporting System (OARRS)

Initiating buprenorphine treatment for opioid use disorder during short-term inpatient 'detoxification': a randomized clinical trial

Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study

Opioid Prescribing Behaviors -Prescription Behavior Surveillance System, 11 States

Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use and on risky prescribing

General principles for the use of pharmacological agents to treat individuals with co-occurring mental and substance use disorders. HHS Publication No. SMA12-4689

Pharmacologic Guidelines for Treating Individuals with Post-Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders. HHS Publication No. SMA12-4688

Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide. SMA14-4892. Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Substance Use and Suicide: A Nexus Requiring a Public Health Approach

Substance Abuse and Mental Health Services Administration

Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants

Substance Abuse and Mental Health Services Administration

Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality

Medication-assisted treatment (MAT) in the criminal justice system: Brief guidance to the states. National Mental Health and Substance Use Policy Laboratory

Substance Abuse and Mental Health Services Administration

Substance Abuse and Mental Health Services Administration

Use of medication-assisted treatment for opioid use disorder in criminal justice settings. National Mental Health and Substance Use Policy Laboratory

Substance Abuse and Mental Health Services Administration

Substance Abuse and Mental Health Services Administration

Substance Abuse and Mental Health Services Administration, 2020c. Coronavirus (COVID-19

Substance Abuse and Mental Health Services Administration, 2020d. Medications for opioid use disorder: Treatment Improvement Protocol (TIP) Series 63. Publication No. PEP20-02-01-006

Substance Abuse and Mental Health Services Administration, 2020e. SAMHSA National Helpline

Substance Abuse and Mental Health Services Administration, 2020f. Substance Use Treatment for Persons With Co-Occurring Disorders

Technical Assistance Package: Contemplating Client Engagement and Retention in Recovery Services

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 50. Publication No. SMA-154381

Substance Abuse and Mental Health Services Administration, Wraparound Evaluation and Research Team

Risk and protective factors for repeated overdose after opioid overdose survival. Drug Alcohol Depend. 209, 107890. Suicide Prevention Resource Center

The association between cocaine use and treatment outcomes in patients receiving office-based buprenorphine/naloxone for the treatment of opioid dependence

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis

Effectiveness of Injectable Extended-Release Naltrexone vs Daily Buprenorphine-Naloxone for Opioid Dependence: A Randomized Clinical Noninferiority Trial

Dissemination of Evidence-Informed Interventions: Integrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care

The Massachusetts Substance Use Helpline

AnchorED: Recovery Supports for Overdose Survivors

Overdose prevention through medical treatment of opioid use disordersoverdose prevention through medical treatment of opioid use disorders

Preventing addiction related suicide: a pilot study

Risk factors for opioid overdose among hospitalized patients

Training law enforcement to respond to opioid overdose with naloxone: Impact on knowledge, attitudes, and interactions with community members

Another tool for the tool box? I'll take it!": Feasibility and acceptability of mobile recovery outreach teams (MROT) for opioid overdose patients in the emergency room

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

Opioid overdose prevention with intranasal naloxone among people who take methadone

Association between mortality rates and medication and residential treatment after in-patient medically managed opioid withdrawal: a cohort analysis

Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis

Under Review. The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a Cluster Randomized Trial at the Community Level to Reduce opioid Overdose Deaths through Implementation of an

Implementing peer recovery services for overdose prevention in Rhode Island: An examination of two outreach-based approaches

Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool

One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose

Inpatient Addiction Consult Service: Expertise for Hospitalized Patients with Complex Addiction Problems

Integrated group therapy for bipolar disorder and substance abuse

Relay: A Peer-Delivered Emergency Department-Based Response to Nonfatal Opioid Overdose

Overdose Education and Naloxone Distribution in the San Francisco County Jail

Rates of alcohol/other drug treatment denials to persons with physical disabilities: Accessibility concerns

Opioid Overdose Prevention Programs Providing Naloxone to Laypersons -United States

Validation of a brief measure of opioid dependence: The Rapid Opioid Dependence Screen (RODS)

Developing an opioid use disorder treatment cascade: A review of quality measures

Acute Care, Prescription Opioid Use, and Overdose Following Discontinuation of Long-Term Buprenorphine Treatment for Opioid Use Disorder

Drug and opioid-involved overdose deaths-United States

Overdose after detoxification: a prospective study

Development and initial testing of a tailored telephone intervention delivered by peers to prevent recurring opioid-overdoses (TTIP-PRO)

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics

Community management of opioid overdose

The opioid overdose epidemic: opportunities for pharmacists

Treatment utilization among persons with opioid use disorder in the United States

Opioids Prescribed After Low-Risk Surgical Procedures in the United States

State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies

Utilizing risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) scores to prioritize offer of rescue naloxone in an outpatient veteran population: A telephone-based project

Initiation of buprenorphine during incarceration and retention in treatment upon release

Risk factors for serious prescription opioidrelated toxicity or overdose among Veterans Health Administration patients

• Providers Clinical Support System SUD 101 Curriculum (Providers Clinical Support System

• Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder (Wakem • Clinical Guidelines for Use of Depot Buprenorphine in the Treatment of Opioid Dependence (N • Providers Clinical Support System Primer on Antagonist-Based Treatment of Opioid Use Diso Support System

Clinical use of extended-release injectable naltrexone in the treatment of Opioid Us and Mental Health Services Administration

State Targeted Response Technical Assistance C (American Academy of Addiction Psychiatry and State Targeted Response Technical Assistanc • Project ECHO

Practitioner Locator (Substance Abuse and Mental Health Services A

American Society o • Harvard Medical School free, accredited online courses in Opioid Use Disorder Education ○ Understanding Addiction

○ Identification, Counseling, and Treatment of OUD

○ Collaborative Care Approaches for the Management of OUD

Expanding the Use of Medications to Treat Individuals with Substance Use Disorders

• Procedures for Medication-Assisted Treatment of Alcohol or Opioid Dependence in Primary C • Getting Started with MOUD with Lessons from Advancing Recovery

Medications for OUD (Substance Abuse and Mental Health Services Admin • SAMHSA MAT Guide for Pregnant Women with OUD (Substance Abuse and Mental Health • SAMHSA TIP 42: Substance Abuse Treatment for Persons with Co-Occurring Disorders

Association: The Opioid Guide

Integrating Buprenorphine Treatment for OUD in Primary Care

• Providers Clinical Support System Overview of Medication Assisted Treatment (Providers Cli • Provider Clinical Support System Mentoring Program (Providers Clinical Support System

California Department of Health Care Services, 2018) and Project "Support SHOUT and California Health Care Foundation

Buprenorphine Home Induction smart phone application

• National Institute on Drug Abuse Home Induction guide

• Continuum of Care ECHO: Inpatient treatment programs and Methadone providers

Office Based Addiction Treatment Clinical Guidelines (Boston Medica • American College of Emergency Physicians Addressing the Opioid Stigma in the

Initiating Buprenorphine treatment in detoxification settings

• Association between mortality rates and medication and residential treatment

• Institute for Health and Recovery Maternal Opioid Use During Pregnancy Toolkit (Institute for Quality Collaborative

• Adolescent Substance Use and Addiction Program -Primary Care

• Integrating BUP treatment in HIV primary care settings (Target HIV

Intensive Course Series continuing medical education on controlled substance pr

State-Specific Resources o Kentucky • Find Help Now Kentucky (Locate Addiction Specialty Clinics) (Find Help Now KY

The Massachusetts Substance Use Helplin • Journey Recovery Project Pregnancy and Parenting (Journey Recovery Project

• Massachusetts Health Hospitals Association Guideline Treating Opioid Use Disorder in the E Hospital Association

• Protecting others and protecting treatment

 National Commission on Correctional Healthcare Jail-Based Medication-Assisted Treatment: P Resources for The Field (National Commission on Correctional Healthcare

Use of Medication Assisted Treatment for Opioid Use Disorder in Criminal Justice Services Administration

Medication Assisted Treatment in the Criminal Justice System: Brief Guidance to t Health Services Administration

 California Health Care Foundation Medication-Assisted Treatment in County Criminal Justice Foundation

Principles of Drug Abuse Treatment for Criminal Justice Populations-A Research-Based Guide  Protocol for Consent to Treatment with Medications for Opioid Use Disorder in Correctional F Addiction Services, 2019) Expanding access to MOUD treatment through telemedicine, interim buprenorphine or methadone, or medication units  Medication units: electronic-Code of Federal Regulations -8.11 (Office of the

 Interim methadone: electronic-Code of Federal Regulations -8

Support for Hospital Opioid Use Treatment" Webinar on Telemedicine and MOUD T Health Care Foundation

Linkage Programs (all relevant settings)

Within (or initiated within) Service Settings • Massachusetts Post-Overdose Public Health -Public Safety Partnerships

Now What? The Role of Prevention Following a Nonfatal Opioid Overdose

• Police Assisted and Addiction Recovery Initiative

• Community Reinforcement and Family Training (Center for Motivation and Change

• The 20 Minute Guide

• The Foundation for Opioid Response Efforts (Foundation for Opioid Response Efforts

Within Outreach/Field Settings • Colerain (Cincinnati) Quick Response Teams

• Safety and Health Integration in the Enforcement of Laws on Drugs

• Harmonizing Disease Prevention and Police Practice model

Access to Recovery (Massachusetts Access to Recovery, 2020) Peer Navigation • Ohio Mental Health & Addiction Services: Peer Recovery Support

• Recovery Coach Academy (Friends of Recovery

• Providers Clinical Support System (Providers Clinical Support System, 2016a) and Addicti Interviewing Training

Referral Only • SAMHSA/HRSA Three Strategies for Effective Referrals to Specialty Mental Health and for Integrated Health Solutions

Review of Post Opioid Overdose Interventions in Preventative Medicine (Bagl Starting individuals on MOUD as an adjunct to linkage programs (all relevant settings

Within (or initiated within) Service Settings • SAMHSA TIP 63: Medications for OUD (Substance Abuse and Mental Health Services Admin • California Bridge (California Department of

Use of Medication Assisted Treatment for Opioid Use Disorder in Criminal Justice Services Administration

Principles of Drug Abuse Treatment of Criminal Justice Populations: A Research-Based Guid

Clinical use of extended-release injectable naltrexone in the treatment of Opioid Us and Mental Health Services Administration

Opioid Response Network (American Academy of Addiction Psychiatry and State Targeted Re

• Harm Reduction agencies as potential site for buprenorphine treatment

Addiction consultation services -Linking Hospitalized patients to outpatient addiction treatme • A Transitional Opioid program to Engage Hospitalized Drug Users

2019) c) MOUD Treatment Engagement and Retention (required) retention

Use of Psychosocial Interventions in Conjunction With Medications for Clinical Support System

with Community Reinforcement Approac Incentives (Center for the Application of Substance Abuse Technologies

Use of virtual retention approaches (e.g., mobile, web, digital therapeutics) (Pear Therapeutics, 2020; Substance Abuse and Mental Health Services Administration

• reSET® Prescription Digital Therapeutic Software (Pear Therapeutics

Computer-Based Training for Cognitive Behavioral Therapy (Carroll

• Connections smartphone app

Program Reviews (Center for Technology and B Utilize retention care coordinators • SAMHSA: Wraparound Implementation and Practice Quality Standards

HIV Care Coordination Program (Centers for Disease Control and • Patient-centered Primary Institute Care Coordination Tip Sheet (Patient-Centered Primary Care • Patient-centered Primary Institute Referral and Care Coordination (Patient-Centered Primary C • Boston Medical Center Office Based Addiction Treatment Continuum of Care ECHO (Boston • Boston Medical Center Nurse Care Manager Office Based Addiction Treatment (Boston Medic Mental health and polysubstance use treatment integrated into MOUD care

Preventing Addiction Related Suicide

General Principles for the Use of Pharmacological Agents To Treat Individuals Wi Disorders

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders

Pharmacologic Guidelines for Treating Individuals with Post-Traumatic Stress Dis (Substance Abuse and Mental Health Services Administration

Association Learning Center: Treating Co-Occurring Depression and Op

• Integrated Group Therapy bipolar and substance use disorders

Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders

with Community Reinforceme Motivational Incentives (Center for the Application of Substance Abuse Technologies

• Addiction Technology Transfer Center Network Motivational Interviewing Training (Addictio • Providers Clinical Support System Webinars (Providers Clinical Support System

Brief: Substance Use and Suicide: A Nexus Requiring A Public Health Approach Services Administration

TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatmen Services Administration and Center for Substance Abuse Treatment

• National Institute of Mental Health Suicide Prevention Website (National Institute of Mental H • Suicide Prevention Resource Center

Programs and Resources (Substance Abuse and Mental Health Servic • Ryan White HIV/AIDS Medical Case Management

The Massachuse • Ohio recovery housing (Ohio Recovery Housing, 2019) • Kentucky: Voices of Hope

Chrysalis House (residential SUD treatment and supportive housing) (Chrysalis Hou • Kentucky: Acquired Immunodeficiency Syndrome Volunteers KY (supportive housing, recove

MOUD =Medication for opioid use disorder

SAMHSA=Substance Abuse and Mental Health Services Administration; ECHO =Extension for community healthcare outcomes; HRSA= The Health Resources and Services Administration