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Project Orange

State: NY Type: Model Practice Year: 2018

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Albany County Department of Health
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Project Orange
Albany County is located in eastern New York State and home to the state capital of Albany. The total County population is estimated at 308,846 and predominantly white (76.5%), followed by Black/African American (13.9%), Asian (6.5%), and Hispanic/Latino (5.8%). While the percentage of minorities in Albany County is lower than New York State; however, minorities are primarily in urban areas. The City of Albany is home to 32% of the County population, but over 77% of African Americans and 53% of Hispanics live in the city (Census.gov QuickFacts 2017). According to CDC, over 90 Americans die every day from opioid-related overdoses. In Albany County, the crude death rate due to opioids in 2015 was 104% higher than five years prior. From 2003-2015, opioid-related deaths in Albany County grew 28% per year on average to 31 deaths in 2015; more than three times higher than a decade ago (NYSDOH Vital Statistics 2003-2015). Albany is in the bottom quartile of New York State counties with 237 emergency department admissions due to opioids per capita (Healthy Capital District Initiative, 2017). Project Orange is a new, innovative public health practice for rapidly educating the public and reducing community supply of unused opioids. Public health detailing and public-private partnerships are used to establish patient education and a prescription take back method at independent pharmacies. The practice has two goals: 1. Reduce opioid deaths reduce the opioid-related emergency department admission rate (37.2* per capita) and opioid death rate (8.4* per capita) in Albany County by 10% by December 31, 2018. 2. Increase public awareness about the dangers of unused, unlocked, and undisposed opioids. Practice objectives include coalition building between local government, academia, and independent pharmacies; providing education and a perpetual take back method at prescription pick-up; and expanding practice reach to additional pharmacies. Project Orange is a collaborative effort between Albany College of Pharmacy and Health Sciences, Crestwood Pharmacy, Four Corners Pharmacy, Lincoln Pharmacy, Marra's Health Mart, and Albany County Department of Health. The practice targets priorities established by Albany County's Opioid Task Force, especially education, prevention and public outreach.” The practice was implemented using public health detailing skills, including provider identification, presentations on topic, leave-behinds, staff training, and follow-up visits (NACCHO Hepatitis C Public Health Detailing Kit 2017). Pharmacists were trained to deliver key education messages to consumers picking up an opioid prescription. Drug disposal envelopes at pharmacies are available at no cost to consumers with unused opioids. Follow-up visits track envelopes distributed, consumers educated, and sustain the practice. Project Orange launched with a press event covered by radio, TV, and print media to build immediate public awareness. Six months after launch, Project Orange has realized three quantifiable milestones regarding consumer education, adoption of mail back envelopes, and greater practice reach. As of November, 2017, 1,750 consumers have been educated; 127 consumers have taken mail back envelopes; and Lincoln Pharmacy became the fourth independent pharmacy participating in Project Orange. Project Orange is on track to meet all goals and objectives by December 31, 2018. Public-private partnerships that were instrumental in launching Project Orange continue to sustain the practice. Participating pharmacies are educating approximately 58 consumers per week, which will result in several thousands residents with greater knowledge about opioids. The adoption rate of mail back envelopes is expected to improve through upcoming New York State legislation that will require pharmacies to offer either a prescription drop-off box or mail back envelopes to consumers. The practice reach will also grow as other pharmacies join the practice. Project Orange is successful because it leverages independent pharmacists, using effective education at prescription pick-up, and offers mail-back envelopes for free to consumers. Pharmacists are underutilized leaders on the healthcare team who have an opportunity to educate at every prescription pick-up. Project Orange's education is straight-forward and simple: 1) take your opioid medications as directed and do not share it with others; 2) store your opioid medications securely; and 3) safely dispose of unused or expired opioids. Mail back envelopes are offered at no cost to consumers, encouraging safe disposal. Project Orange impacts public health behaviors and indicators through greater public awareness and knowledge, encouraging safe opioid storage and breaking down barriers to safe disposal. Final quantitative data on opioid-related overdoses and ED visits for 2017 will not be available until 2018 in New York State's Quarterly Opioid Report. However, preliminary surveys and anecdotal evidence indicate that pharmacy consumers are more knowledgeable about safe opioid storage and disposal after receiving education from pharmacists at prescription pick-up. http://www.albanycounty.com/Government/Departments/DepartmentofHealth/ProjectOrange.aspx
The Surgeon General's Report on Alcohol, Drugs, and Health in 2016 revealed that over 78 people died every day from an opioid overdose, almost quadruple the rate in 1999. The CDC now estimates that number to be over 90 Americans every day in 2017. Over 75.7% of state, local, and tribal law enforcement in New York and New Jersey reported heroin as the highest drug threat in 2016 (DEA NDTS 2016). New York State law enforcement also reported a sharp rise in encounters with synthetic opioids like fentanyl from an estimated 100 encounters in 2014 to over 500 encounters in 2015 (CDC Fentanyl Encounters 2014-2015). The opioid crisis has advanced to a serious public health issue in Albany County. The crude death rate due to opioids per capita in Albany County was 104% higher in 2015 than it was five years prior. From 2003-2015, prescription or illicit opioid-related deaths in Albany County grew an average of 28% annually to 31 deaths in 2015; more than three times higher than a decade ago (NYSDOH Vital Statistics Opioid-Related Deaths 2003-2015). Compared to New York State's 55 counties, Albany is in the bottom quartile with 237 emergency department admissions due to opioids per capita; this metric is also trending upward (Healthy Capital District Initiative 2017). As a result, substance abuse (specifically opioids) became a priority area in the Albany County Community Health Improvement Plan for 2016-2018. Project Orange directly implements the strategy of promoting safe storage and proper disposal of unused prescription medications. Opioid use has not been shown to disparately impact a particular race or ethnicity, but it does disproportionately impact adults 25-54 years of age (CDC Vital Statistics 2017). The population of adults in Albany County is approximately 251,092 (Census.gov QuickFacts 2017). Using the estimated 1,750 educated patients as of November 29, 2017, the practice has reached up to 1% of the target population in six months. Other organizations in Albany County have opioid-related interventions that precede Project Orange but are not explicitly public health focused nor aimed solely at opioids. Catholic Charities of the Diocese of Albany operates Project SafePoint, a program focused on syringe disposal, access/exchange services, risk reduction and recovery readiness counseling, treatment access, HIV/Hepatitis testing and Opioid overdose prevention.” City of Albany Police Department's Law Enforcement Assisted Diversion (LEAD) program is a community-based police diversion approach…” to divert individuals to a community-based, harm reduction intervention for law violations driven by unmet behavioral health needs.” This diversion is for any non-violent offender they offer deems could benefit from case management and/or treatment through LEAD; this includes those with a substance use disorder. Project Orange is a primary prevention strategy against opioid misuse, overdose, and opioid-related deaths. The practice's education messages are designed to fit within a typical prescription pick-up and written for a 9th grade reading level: 1. Take your opioid medications as directed and do not share them with others. 2. Store your opioid medications securely. 3. Safely dispose of unused or expired opioids. Consumers who hear this education learn safe use, to store opioids at home using lock boxes or out of reach places for children and visitors; and to dispose of unused opioids using safe methods. Project Orange leverages a largely untapped and trusted leader of healthcare teams and in the community: pharmacists. Pharmacists are uniquely positioned to regularly interact with both the target population as well as community influencers e.g. seniors, parents, and grandparents. Pharmacies are typically targeted for public health detailing, but pharmacy consumers reportedly shop at food/drug retailers an average of 1.9 times per week;” thus offering more opportunities for patient education and fulfilling practice objectives (NACCHO Public Health Preparedness Report March 2013). The practice uses public health detailing components when working with new and existing pharmacy partners, including provider identification, presentations on topic, leave-behinds, training of pharmacy staff, and follow-up provider visits (NACCHO Hepatitis C Public Health Detailing Kit 2017 User Guide). And although public-private partnerships are recommended in public health preparedness for emergencies, Project Orange is unique in its leveraging of pharmacists to rapidly increase public awareness, influence public health behaviors through education, reduce opioid overdoses and/or morbidity. Project Orange is new to the field of public health and while it is not evidence-based, it does use proven public health intervention tools. Public health detailing skills including provider identification, presentations on topic (opioid crisis), leave-behinds, training of pharmacy staff, and follow-up provider visits (NACCHO Hepatitis C Public Health Detailing Kit 2017 User Guide) help train pharmacists as effective patient educators. Public-private partnerships were also critical; private business (independent pharmacies), local academia (ACPHS), and our health department resulted in pharmacists' buy-in and commitment to be health educators, leading to education that is simple and effective in the short time frame of prescription pick-up.
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Project Orange, named for the orange controlled substance label on prescription bottles, is a primary prevention strategy focused on patient education about opioids and prescription take back to achieve two goals: 1. Reduce opioid deaths – reduce the opioid-related emergency department (ED) admission rate (37.2* per capita) and opioid death rate (8.4* per capita) in Albany County by 10% by December 31, 2018. 2. Increase public awareness about the dangers of unused, unlocked, and undisposed opioids. *The 2016 outpatient emergency department admission rate and opioid death rate are based on preliminary data made available through the New York State Department of Health's Quarterly Opioid Report. According to NYSDOH, there is significant lag time in confirming and reporting the causes of death and patient information. Albany County Department of Health implemented Project Orange on May 3, 2017 with three (3) pharmacies with the following objectives: Reduce the community supply of unused opioids by offering DEA certified mail back envelopes at participating Project Orange pharmacies at no cost to consumers to incentivize use. Promote community pharmacists to educate consumers, who fill opioid prescriptions, about safe opioid use, storage, and disposal of medication. Albany County Executive Daniel P. McCoy established the Albany County Opioid Task Force (Task Force”) in 2016 to combat the opioid epidemic. He called for collaboration between local leaders in public health, behavioral health, public safety, and the community to build an effective local response. The Task Force priorities include, but are not limited to: 1) education, prevention, and public outreach; 2) streamlining access to care; and 3) improving data coordination The Albany County Department of Health's (ACDOH”) Commissioner of Health, Elizabeth F. Whalen, MD, MPH, organized local independent pharmacies to help achieve the Opioid Task Force priorities, through public education and outreach. The Albany College of Pharmacy and Health Sciences (ACPHS”), Crestwood Pharmacy, Four Corners Pharmacy, and Marra's Health Mart met with Dr. Whalen to form a specific public-private partnership to educate the public and reduce the number of unused opioids in the community. This public-private partnership between local government, academia, and private business developed Project Orange's three key education messages and take back strategy. Project Orange leverages the critical role of independent pharmacies and pharmacists' community relationships to conduct public education and establish a novel opioid take back strategy. An Albany County Public Health Educator completed public health detailing training to develop skills for enlisting new pharmacy partners and ensure practice sustainability. No grant funding is used to pilot the mail back envelope take back strategy. The Project Orange initiative is presently financed by the Albany County Executive's Office which purchased 750 mail back envelopes for partner pharmacies to offer to their consumers at no cost, specifically those who wish to return unused opioids. Consumers can place other unused medications in the envelope if there is room. Project Orange start-up and ongoing costs are straightforward: each mail-back envelope purchased was $4.00 for a $3,000 up-front investment to eliminate envelope cost as a barrier to consumer adoption. Other related costs include staff time, mileage, and printing costs for education materials. Education tools, including a flyer and envelope voucher, are designed in-house at Albany County Department of Health as leave-behinds to display at each pharmacy's consultation and/or pick-up counters. The Public Health Educator provides a supply of special vouchers to each pharmacy and a PDF for printing additional vouchers as needed. Pharmacists hand the voucher to every person filling an opioid prescription. While the voucher is designed as an incentive for a free mail-back envelope, the ultimate purpose is for vouchers to serve as take-home reminders for consumers to dispose of unused opioids. Consumers do not need a voucher to receive a free mail-back envelope. The Public Health Educator conducts follow-up visits and/or phone calls to Project Orange pharmacies on a monthly basis to gather feedback from pharmacists and ensure practice objectives are on track. An additional independent pharmacy (Lincoln Pharmacy) is now participating in Project Orange and offering education and envelopes to their consumers. This expands Project Orange's reach to address minority and low income populations. The Albany County Opioid Task Force conducted a press conference on May 3, 2017 to publicize Project Orange and build public awareness about the opioid crisis. The practice is ongoing and sustainable with a current time frame of May 3, 2017 – December 31, 2018, at which point practice efficacy and sustainability will be further evaluated. The success of Project Orange, to date, is attributed to the public-private partnership of local public health, academia, and private independent pharmacies.
Albany County Department of Health implemented Project Orange on May 3, 2017 with three (3) pharmacies with the following objectives: Reduce the community supply of unused opioids by offering DEA certified mail back envelopes at participating Project Orange pharmacies at no cost to consumers to incentivize use. Utilize community pharmacists to educate consumers, who fill opioid prescriptions, about safe opioid use, storage, and disposal of medication. As of November 30, 2017 1,750 consumers have been educated through Project Orange and 127 consumers have taken mail back envelopes. Further, a fourth independent pharmacy (Lincoln Pharmacy) subsequently is now participating in Project Orange and offering education and envelopes to their consumers. These process measures are obtained via primary data sources including: Pharmacy owner interviews/self-reported surveys on the number of patients receiving education to Albany County Department of Health Public Health Educator; Envelope inventory maintained by the Albany County Department of Health Public Health Educator tracking the number of envelopes assigned to each pharmacy and subsequently distributed to consumers; and Exploratory surveys conducted with pharmacy consumers at prescription pick-up by pharmacists. The Public Health Educator collected completed surveys to identify preliminary insights about changes in consumer knowledge and to inform ongoing research design. Consumers who completed the survey report increased knowledge about safe opioid storage and disposal after receiving education from their pharmacist at prescription pick-up. The adoption rate of mail back envelopes is expected to improve due to pending New York State legislation that will mandate pharmacies to offer either a DEA-authorized prescription collection box or mail back envelopes (NY Senate Bill S6750). Data on mail back envelope use will be limited until a means is established for tracking the randomized numbers on the mail back envelopes. Project Orange evaluation data gathered to date provides evidence for expanding the practice beyond independent pharmacies, to include locally owned chain pharmacies. In order to scale the practice for the larger consumer bases of chain pharmacies, these future local chain pharmacy partners will be asked to cover the cost of mail-back envelopes to ensure sustainability in the absence of any grant funding. Mail back envelopes will be paid by Albany County for any additional independent pharmacies that are recruited.
Sustainability of the Project Orange program depends on covering the costs of takeback envelopes and dedicating staff time to conduct public health detailing of participating pharmacies. There is sufficient stakeholder commitment to continue the Project Orange initiative. Participating pharmacies welcome the opportunity to provide health education, contribute to addressing the misuse of prescription medication, and reinforce their role as community leaders. Albany County Department of Health intends to expand the Project Orange practice to additional independent pharmacies and explore interest by chain pharmacies to pilot the take back program locally. To date, Project Orange has demonstrated positive results and has been recognized by Dr. Howard A. Zucker (Commissioner of Health for New York State) for the innovative contribution to addressing opioid misuse / prevention. Albany County Department of Health will employ quantitative and qualitative evaluations data to document success and leverage additional financial resources to offset the costs of takeback envelopes (e.g. opioid prevention funds, pharmacies). Albany County Commissioner of Health is actively advocating for sustained funding for Project Orange envelopes and commits time and skills of Public Health Educators to public health detailing of pharmacies.
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