7 preventing the onset and/or spread of opioid use problems for their own population groups or areas of purview. The playbook seeks to provide the information that enables or contributes to the design and execution of such a strategic program, along with suggestions of how to measure its efficacy. It is important to underscore that the playbook’s contents represent a snapshot in time of our evolving knowledge on how to respond to the opioid crisis, while also identifying the research and evidence-gathering that still must be undertaken in order to make better-informed decisions. Our intent is to regularly update the playbook – most notably its plays – as we learn about new ideas and initiatives, and we welcome comments and contributions to keep it as current as possible. To provide input, please send an email to NIC@stewardsofchange.org. Many strategies have been proposed and many trials have been conducted as our nation has sought to fight this historic epidemic. We selected the 11 plays briefly summarized below because they appear to have traction by virtue of their perceived or actual positive value/impact. More-detailed versions of each play are in the full NIC playbook. The Plays – Summaries (Click on page number to read full version) 1. Remove the stigma. Page 27 Addiction is a disease. Educating the public, health care professionals, health care systems and plans, community organizations and law enforcement about that reality – and, as a result, about the need for prevention, detection and treatment with a comprehensive team approach – may be the most important component of any program to stem the tide of opioid use disorders. Efforts aligned with this play will seek to change the culture of interaction with those who have substance use disorders. The specific components include educational programs, small group discussions, seminars and training in specific approaches, as well as language that professionals (police, health care providers, etc.) should avoid. Example: The Toronto Drug Strategy Implementation Panel has published a report on its initiative to deal with the stigma problem. It includes recommendations for program content. 2. Reduce the risk of developing an opioid use disorder. Page 29 Research shows that there is a strong, lifelong correlation between adverse childhood experiences (ACEs) – including abuse and neglect – and a broad range of health issues, including substance misuse. In a policy brief, the Campaign for Trauma-Informed Policy and Practice reports a recent study that finds “over 80% of the patients seeking treatment for opioid addiction had at least one form of childhood trauma, with almost two-thirds reporting having witnessed violence in childhood.” The development of at least one play to address the incidence of ACEs, and their impact on the development of substance use disorders, is therefore a very important component of an effective prevention strategy. The goal is to better-understand, halt and/or reduce the extent to which ACEs influence the development of or lead to substance use disorders. (We want to acknowledge that addressing ACEs themselves will require a long-term, multidisciplinary approach that focuses on childhood, since that is when the trauma usually occurs.) Example: “Seeking Safety” addresses trauma-related problems and substance use at the same time. It is the most evidence-based model for people with both trauma and addiction. 3. Reduce the use of opioids for pain mitigation. Page 32 A clear consensus has emerged that one very important way to reduce the use and misuse of legal and illicit drugs is to control and limit opioid prescriptions for pain management. In a real sense, the eventual goal of this ambitious play is to change the culture of pain management. It requires a substantial educational effort for physicians and patients about the risks and cautions in opioid use for this purpose. Activities that have been successfully implemented (these are from the Chronic Pain Initiative in North Carolina) include promotion of a targeted toolkit for primary care providers, emergency departments and care managers; continuing medical education sessions on pain management; appropriate prescribing and  diversion control and continuing education for pharmacists on diversion, forgery and the use of Prescription Drug Monitoring Programs. Example: The California Statewide Opioid Safety (SOS) Workgroup promotes safe prescribing guidelines and disseminates educational materials, such as one for health care providers. 4. Reduce the supply of opioids from illegitimate sources. Page 34 Since most heroin and fentanyl originate outside the U.S., current counter-narcotics programming consists largely of federally driven efforts. This play suggests extending those efforts to the state and local levels by, for example: detecting and disrupting distribution channels for