Trusted Contacts Training Modules

Hello! Welcome to the disruptions in access to opioid prescriptions trusted contacts training module 1. This is the first of three modules developed by the Association of State and Territorial Health Officials in partnership with the Centers for Disease Control and Prevention’s Opioid Rapid Response Program. This training will include background on disruptions in access to opioid prescriptions and the responsibilities of a state trusted contacts when planning for and responding to these emergencies.

Before we begin, I want to provide some background on who we are and what we do at the Association of State and Territorial Health Officials. ASTHO is a national nonprofit that represents the health officials from all 59 US states, territories, and freely associated states. Our mission is to support, equip, and advocate for state and territorial health officials in their work of advancing the public’s health and well-being. We are funded through a combination of membership dues, grants, contracts, and cooperative agreements. This particular project was made possible through a cooperative agreement with CDC’s Center for Injury Prevention and Control.

Before jumping into what a trusted contact is and their role, we’ll provide some background as to what disruptions in access to opioid prescriptions are and the role of CDC’s Opioid Rapid Response Program or ORRP.

An opioid prescription disruption is any event that halts the ability of a patient to access opioid prescriptions or medications for opioid use disorder also known as MOUD. A disruption may occur for several reasons, including the death of a prescriber, retirement, resignation of a provider, medical license suspensions, or a federal or state law-enforcement action against a prescriber often resulting in a partial or full closure of the practice. These temporary or permanent disruption events can be dangerous for displaced patients, who face an increased risk for negative physical and mental health effects, including feelings of abandonment, depression, and symptoms of withdrawal. This can be especially dangerous for patients with a physical dependency on opioids or opioid use disorder. In the absence of continued care, disruptions could lead to increases in drug seeking, drug diversion, illicit drug use, overdose or death among displaced patients. With the changing landscape in the illicit market, disruptions have become a more urgent and pressing issue as fentanyl and counterfeit prescription pills have created a more deadly supply. 

In collaboration with CDC’s Opioid Rapid Response Program or ORRP, ASTHO’s Opioid Preparedness project supports state capacity for responding to disruptions via preparedness exercises and other technical assistance needs.

ORRP, is a coordinated interagency federal effort designed to mitigate drug overdose risks among patients impacted by law enforcement actions that disrupt access to opioid prescriptions. ORRP leverages relationships across federal and state agencies to increase capacity to prepare for and respond to these events. Working as an intermediary between public health and public safety, ORRP facilitates timely communication about disruptions to states through state trusted contracts. ORRP also provides technical assistance support to state health agencies throughout a response, as needed.

While disruptions may occur for several reasons, ORRP may notify state trusted contacts when there is a disruption due to a federal law enforcement action taken against a prescriber which could result in a DEA registration immediate suspension order, or a voluntary DEA surrender, for cause.

A DEA registration immediate suspension order (ISO) occurs when the DEA determines a healthcare provider’s prescribing or dispensing is found to cause “imminent danger to the public’s health or safety.” Following an ISO, healthcare providers are unable to dispense controlled substances while the case is ongoing.

In other cases, providers who are subject to DEA investigations related to prescribing of controlled substances may choose to voluntarily surrender their DEA registration. In this case, the provider will immediately lose the ability to possess, prescribe, or dispense any controlled substances.

So why are opioid prescription disruptions important, and why are patients at increased risk of overdose when these actions occur?

First, patients may be receiving high doses of opioids or co-prescribing with other medications such as Benzodiazepines.  Abrupt discontinuation and/or forced tapering of controlled substances increases the risk for withdrawal which can be very uncomfortable for patients and in some cases dangerous as there is a risk of seizures and death. The CDC’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain recommends that patients do not abruptly stop taking their previously prescribed opioids or taper too rapidly. It’s essential that displaced patients receive individualized, patient-centered care.

Secondly, many displaced patients may encounter difficulty in identifying new healthcare providers who have the capacity and are willing to continue the patients’ treatment protocol. This barrier may be the result of scheduling challenges, workforce capacity, and/or fear from healthcare providers of being investigated themselves.

Also, addressing risk mitigation and providing care continuity during a disruption in access to opioid prescriptions has become even more pressing as the illicit market has become more potent. If patients no longer have access to their prescribed medications, they may turn to an alternate source through the illicit market and are at risk of encountering drugs that are more potent and lethal than their prescriptions. Pills that are illicitly purchased may look the same as prescribed medications but may be counterfeit and contain dangerous substances such as fentanyl and/or xylazine, increasing the risk of overdose and death.

Now, moving on, what is a trusted contact and what is their role in responding to disruptions in access to opioid prescriptions?

State trusted contacts, or trusted contacts, typically include one individual from the state health department and another from the state behavioral health or substance use services agency, for example, the state opioid treatment authority (SOTA), opioid program managers, health department directors, or division chiefs.

Trusted contacts serve as the point of contact for ORRP and are entrusted with confidential law enforcement information prior to an action being taken against a prescriber. ORRP works with the state health department and behavioral agency to determine who should be designated trusted contacts.

ORRP provides trusted contacts with information that can help them assess patient risk and direct resources to mitigate the risk of overdose among patients and others in the community - in cases of diversion. Sensitive information related to the action is shared with trusted contacts only at the request of law enforcement agents. Once the state trusted contacts are notified of a disruption and based on the anticipated patient risks, needs, and location, they may determine which partners will be included as key response coordinators for this event. This response team is then in charge of effectively and efficiently mobilizing information and resources to ensure care continuity and access to services for displaced patients.

During a disruption, the state trusted contacts are tasked with coordinating the response team to provide support during the day of and following the action to ensure care continuity and mitigation of risk. This includes notifying emergency departments and health systems to be aware of the potential increase in patients seeking prescriptions for opioids or withdrawing from their medications, ensuring ample amounts of naloxone are available to patients and within the community, supporting displaced patients in transitioning their care over to new healthcare providers, offering bridge care, and/or transportation to services.

State trusted contacts also often play a role in developing and/or refining the state’s response protocol to prepare for when these disruptions occur.

During the various stages of the response, the state trusted contacts and their team may reach out to ORRP for assistance, as needed.

As mentioned earlier, there are typically two trusted contacts per state, one from the behavioral health agency and another from the public health agency. When responding to a disruption in opioid prescriptions, behavioral health and public health must work together to ensure all available state resources are leveraged and communities are supported in a holistic manner.

When planning for a disruption, the trusted contact focused on behavioral health may be more equipped to connect and coordinate with state or local hotlines like 988 or 211, and substance use disorder treatment locators. They may also be able to develop a list of behavioral health resources, connect displaced patients with mental health providers and provide on-site peer support.

The trusted contact on the public health side may coordinate with local and community emergency rooms, pharmacies, and community-based organizations to ensure the community has the capacity to support displaced patients when the disruption occurs. The public health side would also coordinate the availability of harm reduction services, deploy onsite mobile integrated health units, and develop any communication resources to alert patients, providers, and community members of the event.;

The trusted contacts would coordinate and work together to develop a response plan and leverage their networks to deploy resources, as necessary. 

Trusted contacts are intended to work together to leverage various resources throughout the state. Resources include state and local resources devoted to crisis response, overdose prevention and treatment, behavioral health care, harm reduction services, and other resources funded by SAMHSA and injury/overdose prevention resources funded by the CDC.

If a trusted contact has access to the state’s prescription drug monitoring program (PDMP), at the point at which the provider's name and National Provider Identifier (NPI) is given, the trusted contacts can leverage the PDMP data to conduct additional risk assessments and identify the best ways to focus resources, depending on the counties in which affected patients reside.

The notification process includes a series of steps and involves a handful of law enforcement and federal ORRP coordinators before reaching the state’s trusted contacts.

To begin, the DEA or the Office of Inspector General within the US Department of Health and Human Services (HHS-OIG) will alert ORRP of an action that could potentially disrupt patient access to care. ORRP then has a call with the investigators to discuss possible risks to patients. ORRP coordinators are prohibited from sharing any law enforcement sensitive information to state trusted contacts without the express permission of law enforcement. It is important to note that CDC does not participate in any law enforcement activities. Their role is to anticipate the possible risks to patients and convey those risks to their law enforcement partners as law enforcement considers whether any advanced notification can be shared so that risk mitigation can be arranged. Information related to active investigations is sensitive and confidential and may only be shared with established trusted contacts to protect the investigative process and the safety of law enforcement agents. Adherence to confidentiality is vital to ORRP's partnership with law enforcement, without which the program could not be sustained.

Once given permission by law enforcement, ORRP will notify and meet with the state’s trusted contacts to discuss potential patient risks and anticipated needs, as well as a timeline of when the law enforcement action is expected to occur, which is typically within 2 weeks of the notification. Once notified of an impending disruption, the state will need to move quickly to mobilize information and resources to ensure continuity of care and access to needed services for displaced patients. Throughout the process, ORRP continues to serve as a supporting resource and mediates communication between law enforcement and trusted contacts as well as key response partners in the state, as needed.

It is essential that communication travels through ORRP as ORRP acts as a “middleman,” coordinating between law enforcement and the public health agencies to ensure the right people are alerted and the correct resources and plan can be put in place to best support patients and communities. If needed, ORRP coordinators will also engage federal agencies, such as SAMHSA or HRSA.

After notification, however, there are a series of steps and processes that trusted contacts and their key response partners often go through to address disruptions in access to opioid prescriptions. While the 5 phases of response to an opioid prescription disruption are depicted here as flowing one into the next, as with most emergency responses, it’s not in practice quite that simple, but it does provide a framework for thinking through those priorities that states and ORRP have seen are most critical during a response. Additionally, it’s important to note that every state and every response are a little different.

• As discussed in the previous slide, the first phase is notification... during which the state’s trusted contacts receive notification of an event and document the key characteristics of the notification. This information includes, date of the action, type of action, healthcare provider type, estimated number of patients, jurisdiction(s) impacted, co-prescribing, diversion, commonly prescribed medicines, and more that will allow them to begin assessing risks to patients. Again, during this stage, the trusted contacts also need to be mindful of how and what information can be shared at this stage without compromising the integrity of the investigation.
• The next phase is response preparation...during which trusted contacts identify which response partners will need to be engaged, and depending on their ability to disclose information, they may be permitted to notify or assemble response partners. The state trusted contacts from the behavioral health side may leverage their network and contact partners like peer recovery staff and mental health providers. Where the trusted contact from the public health side may plan to reach out to the PDMP administrator, local health departments, Medicaid, and emergency medical services. The group continues to assess and communicate risks by reviewing available data and information. This includes identifying a plan to triage patients, notify local health departments, and assessing healthcare, harm reduction, and treatment resource availability in the community. Often, trusted contacts are the ones to develop and update resource flyers for patients. During this stage, the state trusted contacts, along with the additional response partners also identify and coordinate resources that can support the response effort.
• The next phase, and possibly the most important, is risk mitigation. As coordinators, at this stage, trusted contacts oversee the communication of risks to patients, providers, and others in the community and coordinate resources amongst partners to assist patients, address their needs, and try to facilitate care continuity. Trusted contacts often lead in notifying local pharmacies, crisis hotlines, local healthcare providers, and harm reduction/community-based organizations to ensure resource availability, amongst other partners. Trusted contacts, along with the response team, coordinate the deployment of local triage teams and provide support for healthcare providers who have absorbed impacted patients.
• The next phase is monitoring and evaluation...during which the response team should monitor the threat, including clinic operational status, and response efforts. This includes checking in regularly with response partners to assess how many patients have been contacted or have called help lines, how many have been successfully referred to new healthcare service providers, and other outcomes captured through outreach efforts. Here also, trusted contacts are tasked with following up with the state licensing authority to determine licensing status/long-term status of the disruption, notifying partners, as appropriate. Trusted contacts may also initiate and facilitate after-action debrief with partners to identify what worked well and what modifications may need to be incorporated into future response plans.
• Communication and coordination are cross-cutting because some form of communication and coordination will be happening at every stage. As a trusted contact, who you are communicating/coordinating with may change depending on what stage you’re in, but it is critical at every step.

Often, when ORRP notifies trusted contacts of a disruption, the action is still an ongoing investigation. Law enforcement shares sensitive information with ORRP, and it is critical that the investigations and law enforcements’ safety not be compromised. Therefore, it may be helpful to think about the different levels of confidentiality. First, CDC shares confidential information with only the established state trusted contacts. Second, to help with response planning, the trusted contacts will inform response coordinators of important details when it is safe to share information with them. Next, the core planning team made up of trusted contacts and response coordinators may share specified information with the response partners, but only when permission to do so has been granted and it’s safe. Finally, once the information about the disruption is made public, then everyone can access general information about the disruption. 

In summary, a disruption is any event that halts the ability of a patient to access opioid prescriptions or MOUD. These events are especially dangerous as displaced patients face an increased risk for negative physical and mental health effects, including feelings of abandonment, depression, and symptoms of withdrawal.;

Disruptions can occur for a number of reasons, ORRP supports states in responding to disruptions that occur when a law enforcement action is taken against a prescriber.

State trusted contacts are individuals, usually from the state public health agency and state behavioral health agency, to serve as initial points of contact for ORRP and are entrusted with confidential information when a law enforcement action is taken against a prescriber. The state trusted contacts are responsible for organizing, planning, and coordinating response efforts among state and local response partners to ensure care continuity and risk mitigation for the affected patients and communities.

For more information about the Opioid Preparedness work from ASTHO and ORRP, please visit our websites which are listed here. For more specific information about state trusted contacts and their role, please visit this FAQ page developed by ORRP. Finally, if you are interested in learning more about how state trusted contacts plan for disruptions in opioid prescriptions and the other partners that are involved in response efforts, please check out our third trusted contacts training module. Thank you!

Hello! Welcome to the Disruptions in Access to Opioid Prescriptions Trusted Contacts Training. This is Module 2: Preparing for a Response. This is the second of three modules developed by the Association of State and Territorial Health Officials in partnership with the Centers for Disease Control and Prevention’s Opioid Rapid Response Program.

By the end of this module, participants will walk away with an enhanced understanding of the role of trusted contacts in developing and refining a response protocol, considerations for identifying and engaging partners during a response, and knowledge of where to access additional helpful resources when planning to respond to disruptions in access to opioid prescriptions.

Developing a Response Protocol

States can benefit from having a written protocol in place for planning and responding to disruptions in access to opioid prescriptions or other controlled substances. In this section, the key components of a response protocol and the role of trusted contacts in developing this essential preparedness document will be defined.

What is a response protocol? A response protocol can be defined as a written document that helps states plan and prepare to respond to disruptions in access to opioid prescriptions and other controlled substances by outlining key steps and strategies for communication and coordination with partners throughout the duration of the response. Additionally, a well-written response protocol will outline strategies for patient risk assessment, patient risk mitigation, and monitoring and evaluation.

Let's take a closer look at the key elements of a written response protocol:

A well written protocol will include a plan for communication and coordination across key response partners. For example, the response protocol should spell out contact information, roles, and responsibilities for trusted contacts, response team members, and partner agencies at each phase of the response. In addition to internal communications across response partners, protocols should include a plan for outgoing communications to impacted patients and the public during each phase. In the context of disruptions due to a law enforcement action against a provider, confidentiality designations should be noted and implemented where necessary.

A response protocol should also incorporate patient risk and needs assessment. States should leverage what information they have available to fill in key response details and obtain a better understanding of the challenges and unique needs of patients. This will help to assess what risks they may face, as well as what services and supports they need. For example, descriptive details such as patient demographics, commonly prescribed medications, behavioral health needs, and other details should be identified within the protocol and aligned with response implementation activities to mitigate risk.

In addition to assessing the risks and needs of patients, it's important to assess the state's capacity and ability to respond. Once again, leveraging available data and information, states should assess community resource availability and designate response activities and roles accordingly. For example, community health mobile units may be deployed on site the day of the disruption.

Finally, a response event checklist is useful in ensuring that each essential strategy or step has been carried out to completion and in determining when to initiate a closeout of a response. Once all response activities have been implemented, states should monitor the ongoing threat, follow-up with partners, and evaluate the response protocol before closing out a response.

You may recognize this slide from module 1 outlining the four phases of a response: Notification, Response Preparation, Risk Mitigation, and Monitoring and Evaluation. Please feel free to pause the video here and take a few minutes to review the information on the slide to refamiliarize yourself with the steps designated for each phase.

Now, consider how the different elements of a written response protocol fit into this framework. Remember, communication and coordination are a cross cutting effort that happens at every stage of the response. Event checklist activities for each phase of a response signify progress and direction as it relates to carrying out response efforts. Assessing patient risks and needs allows for a targeted, more robust response, and state capacity assessments can help inform preparation for the dissemination of resources and implementation of response activities. Finally, monitoring and evaluation signify the closeout of a response and can be helpful in identifying strengths and gaps within the protocol, thus improving future efforts.

When developing and evaluating a response protocol, it's important to understand that circumstances surrounding disruptions in access to opioid prescriptions and other controlled substances can differ by state and locality. Additionally, state and local structure, landscape, and capacity will vary by jurisdiction. Not all steps outlined in one protocol will be taken for every action by every state, and some states may have additional steps to consider. One size does not fit all! Because of this, response protocols should be regarded as unique, living documents and modified over time to fit the nature of the individual response scenario and response needs.

What is the role of trusted contacts in developing a response protocol? Trusted contacts oversee the planning, development, evaluation, and refinement of the response protocol. Essentially, they are the "owners" of the written document. Their unique position allows them to be privy to information that can be leveraged to plan and prepare for a response. Specifically, trusted contacts lean on their own subject matter expertise to draft and refine the response protocol, convene response partners to exercise and implement protocol activities, and finally, monitor response outcomes and leverage that data to evaluate the strengths and gaps of the existing protocol, then refining, as necessary.

Throughout the protocol development process, trusted contacts may consider looping in key partners at both the state and local level to ensure strong, robust preparation for these events, requesting collaboration from ORRP and ASTHO, as needed.

Trusted contacts serve as the primary conveners between the state's behavioral health and public health agencies. Behavioral health oversees substance use and mental health treatment, recovery, and harm reduction services. Public health oversees overdose prevention, epidemiology, and surveillance. Response activities cannot be achieved in a vacuum, thus emphasizing the importance of coordinating resources and efforts across both areas is crucial.

Identifying and Engaging Partners

Preparedness activities are most successful when communication and coordination are streamlined among key response partners. In this next section, we will focus on strategies to identify and engage partners when structuring response roles and activities.

In the early stages of planning, it's important to consider and identify who, in addition to the state's trusted contacts, should be a part of a broader response coordination team. Trusted contacts will work with many state and local partners to form a response team. These individuals should also be looped into planning and exercises to ensure an understanding of roles, capabilities, and responsibilities. Response partners may vary depending on the nature of the disruption, the location of the patients, and the unique needs of patients.

Preparedness activities should include as many potential partners as possible to help ensure rapid response capability if and when they are called upon to assist with a response. When thinking about potential response partners, it helps to consider who can assist with the following response activities:

• Who can help assess healthcare resource and bridge care availability?
• Who should directly communicate with affected patients?
• Who can help ensure increased access to and distribution of naloxone?
• Who will alert harm reduction organizations?
• And who might be able to assess substance use disorder treatment capacity?

States might also consider:

• Which healthcare providers and health systems can absorb displaced patients?
• Who can provide clinical support, including training and education, to healthcare providers who take on displaced patients?
• Who will provide direct patient triage and care coordination?
• Who can assist with effective messaging to different groups at the time of the disruption?
• Finally, who will monitor for overdoses and other long-term adverse health effects among patients and the community?

It's important to remember that a response first occurs at the local level, with direction and support from the state. Partners should be engaged across both state and local jurisdictions. For example:

• State emergency preparedness and response staff have expertise in emergency preparedness and response principles and procedures and can help inform response planning and implementation.
• State Prescription Drug Monitoring Program (or PDMP) administrators can provide data that supports public health interventions, analysis of prescribing and dispensing trends, notification to partners through state-wide health alerts, and evaluation and monitoring of linkage to care for patients and communities.
• State hospital associations represent and serve healthcare networks throughout the state and can play a key role in identifying providers and health systems willing to absorb displaced patients.
• State medical licensing boards serve as regulatory partners and may work closely with state trusted contacts when a licensing action is set to take place, or has taken place, against a provider.
• The State Medicaid office may serve as a connector between patients and bridge care services, ensuring care continuity, and can also be a useful data source.
• Community health centers have knowledge of local level community resources and can provide direct, wraparound services to displaced patients.
• Harm reduction service organizations can provide specialized services for patients with substance use disorder or opioid use disorder and can be vehicles for distributing lifesaving resources, such as naloxone
• Similarly, peer recovery services can offer specialized support for those with a SUD or mental health disorder and help patients navigate certain systems.
• Finally emergency medical services and emergency departments should be alerted and prepared to respond to a surge in patients seeking treatment and, at worst, a potential spike in overdose.

*Note, once again, that response partners will vary depending on the scope of the disruption. This list is not exhaustive, but merely a starting place for states to begin to identify partners and their roles.

Preparedness Resources

Congratulations! You have made it to the end of Module 2. Before moving on to Module 3, please take a moment to visit the links to the resources listed on the next slide.

For more information about the Opioid Preparedness work from ASTHO and ORRP, please visit our websites which are listed here. For more specific information about state trusted contacts and their role, please visit this FAQ page developed by ORRP. Finally, if you are interested in learning more about how state trusted contacts plan for disruptions in opioid prescriptions and the other partners that are involved in response efforts, please check out our third trusted contacts training module. Thank you!

Hello! Welcome to the Disruptions in Access to Opioid Prescriptions Trusted Contacts Training. This is Module 3: Response Implementation. This is the third and final module developed by the Association of State and Territorial Health Officials in partnership with the Centers for Disease Control and Prevention’s Opioid Rapid Response Program (ORRP).

During this module, participants will learn more about the suggested response activities and risk mitigation strategies that state trusted contacts, and their teams may take when responding to a disruption in access to prescription opioids.

You will also hear about strategies to monitor and evaluate your state’s response implementation.

To recap, trusted contacts are specific individuals selected by ORRP who serve as points of contact with ORRP coordinators and state response partners when preparing for and responding to a disruption in access to opioid prescriptions. State trusted contacts play a central role in coordinating and communicating with key partners throughout the lifespan of a response.

Confidentiality was covered in Module 1. The appropriate level of confidentiality should be maintained at each phase of the response. It is important to emphasize that, often, when ORRP notifies trusted contacts of a disruption, the action is still an ongoing investigation. Due to the confidential nature of an ongoing law enforcement investigation and as the primary organizers and communicators in a response, the state trusted contacts may only share specified information with the response partners only when permission has been granted by the ORRP coordinator to do so.

Now, what do some of these risk mitigation and response activities look like?

During Phase II, Response Preparation, which was covered in the previous module, ORRP and ASTHO suggest that a state conduct patient risk assessments. To best support displaced patients, response team members must assess patient risk and take inventory of the state’s capacity to respond. The quality and amount of information that the state has about the prescriber and patient population can help determine how accurately the state can assess potential patient risk and determine what supports and services may be needed.

When collecting this information, it is important to document the type of healthcare provider, clinic, or office involved, then using the data that the state has available, assess the number of patients receiving opioids or other controlled substances from the healthcare provider to evaluate potential risks as well as healthcare needs.

In terms of data access, if the state has access to the Prescription Drug Monitoring Program (PDMP) during this phase, the PDMP can provide valuable insights about affected patients, including location, prescription composition, age range, and insurance coverage. PDMP data also allows healthcare providers who inherit displaced patients to see prescription histories, which can help inform care continuity. However, the laws and regulations that govern how each state’s PDMP operates vary by state, impacting a response team’s access and usage of PDMP data. Other helpful data sources include medical claims data and the information that is obtained by law enforcement investigators.

A wide range of patient needs should be considered and accounted for, including pain management, general healthcare, mental and behavioral health, harm reduction, treatment for substance use disorder, and more, all based on healthcare risk and needs assessments, given the data available.

As discussed in prior modules, disruptions can be an emotionally distressing, traumatic experience for displaced patients. Inheriting displaced patients could also be stressful for providers who take on these patients. In order to communicate the most up-to-date information with both patients and providers, here are some suggested activities that a state can do:

• Design or update a resource flyer for patients to be posted outside of the closed clinic and online. The flyer may include signs of withdrawal, where to get naloxone, an SUD treatment locator/hotline, HRSA healthcare facility locator, other peer support networks, and/or instructions to contact their health insurance provider.
• Generate and publish a general media statement, like a press-release and letters of support from the health department, or medical licensing board including more specified information once known and as appropriate.
• A state can also create and provide language or talking points for hotlines to use when responding to calls from displaced patients
• Designate and deploy local triage teams for peer support to be “on standby” the day of the disruption to offer patients a warm connection to resources and other services
• Develop other resources for insurance providers, partner organizations, community clinics, etc. to help communicate the changes in care for the patient
• And if the state is available, the trusted contacts may organize other channels for connecting with patients. For example, multi-media modalities like Facebook, Twitter, Instagram, or radio to launch short 30 second advertisements that highlight where to find services and support resources. The online media postings can be tracked by number of clicks, etc. Trusted contacts and partners may also decide to develop resources that can be posted on bus benches, gas station doors and pumps, billboards, etc.

When developing a plan to respond to these events, as mentioned in Module 2, it is important that the state trusted contacts identify specific partners who will develop and share these communications deliverables with the appropriate partners.

In general, public health agencies are not direct service providers and do not typically have providers on staff waiting to deploy when disruptions occur. Instead, public health agencies rely on partnerships with the local healthcare workforce to assess and support displaced patients. Due to the complexities and fragmentation of the healthcare system, responding to a disruption in access to opioid prescriptions requires very coordinated and layered strategies which include various key response partners. Additionally, with the wide variety of healthcare needs among patients paired with workforce shortages among healthcare staff, finding providers who are able and willing to take on these patients can be a huge challenge for state trusted contacts.

When responding to a disruption, states have found it helpful to locate healthcare providers, emergency departments, and pharmacies that are close to the impacted services and nearby impacted communities and alert them of the potential increase in patients who are seeking support once they are no longer able to meet with their previous healthcare provider. States may decide to develop a contact list of primary care providers, pain management specialists, addiction medicine specialists, and behavioral health providers, among others, who are able to take on new patients. Trusted contacts may also consider connecting with partners in emergency departments and providing guidance and training on intake, triage, and prescribing take-home medications. This guidance should be tailored and provided to all healthcare providers within the emergency department. It is also helpful to alert pharmacies to ensure that they are aware of the potential increase in patients seeking to fill bridge scripts or obtain naloxone.

For those providers who have absorbed displaced patients, it is important that state trusted contacts be prepared to collaborate with the healthcare systems to offer or connect them to education, training, and mentoring services to ensure provider confidence, comfort, and skill in caring for patients who are prescribed controlled substances. This may include hosting a Project ECHO or launching academic detailing services for providers.

In addition to coordinating patient/provider communications and workforce support, trusted contacts are also tasked with assembling and ensuring proper resource provision to support the impacted community. This means that during the planning phase, trusted contacts must assess the infrastructure of the area. For example, transportation to new care facilities or access to telehealth due to limited bandwidth may pose a barrier to displaced patients, especially those located in rural areas.

As mentioned earlier, when responding to a disruption, states may also consider identifying and deploying available mobile units, peer recovery specialists, and healthcare providers to serve as bridge care staff. Given the workforce shortage and lack of capacity among healthcare workers, it is imperative that the state build relationships and trust with these response partners to streamline and ensure that staff will be available to support response efforts.

Finally, to ensure care continuity both in the immediate and interim while patients transition to new providers, it is important that states ensure proper availability and distribution of harm reduction resources like naloxone and fentanyl test strips to impacted communities.

Monitoring and evaluation

When closing out a response, state trusted contacts role consists of following up with various players and tracking information to ensure that all patients have received appropriate care and response activities have gradually closed out. This includes:

• Monitoring process measures like the number of hospitals/ healthcare providers alerted; number and type of agencies/org mobilized; referral health care systems identified; and number and percentage of patient communication sent
• Monitoring patient population outcome measures. For example, the number of patients encountered on the day of an action, number of naloxone kits disseminated, number of patients receiving flyers and resource info, number of patients connected with a new healthcare provider, number of emergency room visits from displaced patients, number of fatal and non-fatal overdoses among displaced patients
• Contacting and convening regular briefings with state response partners like the state licensing boards, PDMP, Medicaid, etc.
• Releasing information and follow up communications with response partners and the general public, when appropriate
• Reviewing data to continuously assess patient risk. For example, in addition to the two data sources mentioned earlier—PDMP and Medicaid claims data—the state response team may also consider using other payer data, medical examiner and coroner data, and emergency department/syndromic surveillance data.
• Hosting after-action reviews to debrief response activities and develop or update a state’s response protocol for responding to these events.

For more information about the Opioid Preparedness work from ASTHO and ORRP, please visit our websites which are listed here. For more specific information about state trusted contacts and their role, please visit this FAQ page developed by ORRP. Finally, if you are interested in learning more about how state trusted contacts plan for disruptions in opioid prescriptions and the other partners that are involved in response efforts, please check out our first and second trusted contacts training module. Thank you!