9 will need to encompass a breadth of treatments, which may include both behavior modification and MAT. Evaluations of post-release substance use disorder treatments have generally shown positive results for reducing both relapse rates and recidivism. Example: Virginia and California have both developed expanded post-incarceration treatment programs, and SAMHSA, Substance Abuse and Mental Health Services Administration, offers a guide for improving such programs. 9. Reduce the risk of opioid-based treatment. Page 45 It is clear that the long-term use of opioids legitimately prescribed for pain management increases the risk of a patient developing a substance use disorder. A fundamental and widespread approach to the mitigation of this risk is to ensure that 1) both the prescriber and the patient fully understand the consequences of taking the drug and 2) the physician and the patient have a clear and unequivocal understanding of the conditions under which the prescription will be continued. In utilizing this strategy, the first step in reducing risk is to provide physicians and patients with the information they need. Literature, briefings to community groups and handouts in medical offices are all parts of an educational effort to ensure that every party is aware of the guidelines and constraints for using an opioid as a long-term medication. Some organizations are promoting the use of written doctor-patient agreements, which can be controversial. Example: The NH Board of Medicine has published strict rules requiring the development of written doctor-patient agreements. The NH Medical Society provides sample agreements. 10. Make provisions for safe disposal of unused opioids. Page 47 An estimated two-thirds of teenagers who have misused prescription drugs get them from their family and friends, so many practitioners believe it is important to clear out medicine cabinets at home that contain unused drugs, particularly opioids. Doing so is not as simple as might be expected, however, as regulations require that law enforcement take custody of discarded controlled substances. Many communities have organized annual drives during which people can give their unused controlled substances to the police, who then dispose of them in approved ways. Studies evaluating such take-back programs generally show positive outcomes, with recent research showing a more-positive impact for programs that allow drugs to be turned in at any time, rather than just once or twice a year. This play requires a methodology for collection and disposal, as well as a marketing/awareness effort to persuade people to participate. Examples: A variety of take-back efforts exist around the U.S. The San Diego Police, for instance, have set up boxes for drug drop-offs at any time. 11. Encourage the use of non-opioid formulations for pain management. Page 48 As it has become clear that long- term pain management using opioids increases the likelihood of substance use disorders, research has intensified on finding effective alternatives. Meanwhile, there are already significant, evidence-based alternatives that physicians are finding useful. The CDC offers recommendations that highlight and underscore the need to utilize alternative, non-opioid pharmacologic therapies to treat chronic pain. A strategy on this topic involves educating both physicians and patients on the options available and their consequences (strength, side effects, etc.). Health care providers can develop and set guidelines that call for the use of non-opioid alternatives. This strategy would include efforts required to stay current with the emerging research and development of new alternatives for pain management, including from the various aggressive research programs undertaken by the National Institutes of Health and the CDC. Example: The University of Tennessee Medical Center has developed a protocol of alternative pathways, giving priority to non-opioid treatments. The program is described in a video. Conclusion These plays reflect a broad range of current practices and thinking. Not all of them obviously will apply to every jurisdiction, and there will be further developments as innovative approaches are identified or created. It is our hope that this set of plays, as well as others as they are added, will provide ideas on which to base prevention-focused actions appropriate for specific communities. The body of research on this crisis makes it very clear that collaboration across agencies, organizations and sectors/domains is critical to enhancing the prevention of opioid use disorders. Our intent is to provide this playbook as a starting point, and then for it to become a living online resource and repository that can be refined and updated to provide promising and effective evidence-based ideas, approaches, practices and programs. Your comments and contributions will help to make this goal a reality.