Addressing the Opioid Epidemic: Defining Cooperative Extension's Role

Approximately 130 Americans die from opioid-related overdoses each day (Centers for Disease Control and Prevention, 2017). Additionally, people in rural communities are more likely to overdose on prescription pain medications than people in cities, and opioid-related overdose deaths in nonmetropolitan counties are 45% higher than in metropolitan counties (Centers for Disease Control and Prevention, 2018; National Advisory Committee on Rural Health and Human Services, 2015). Cooperative Extension was designed to link land-grant college programs, grassroots needs, and national priorities (National Research Council, 1996). For over a century, Cooperative Extension has been a trusted source of information with keen influence and reach among rural communities (Elliott, 2015). Extension historically has offered programs that address both physical and psychological distress and, therefore, should be well positioned to contribute to addressing the nation's opioid crisis, especially with preventative strategies. Despite the fact that Extension is a trusted source of information and has become increasingly involved in opioid misuse prevention in some states, Mississippi State University (MSU) Extension specialists have been uncertain about the role Extension professionals should play in addressing the opioid misuse problem. MSU Extension professionals were certain that Extension needed to help other community-based and statewide agencies tackle the problem, but the best way to assist was unclear.

To better equip Extension to respond to this crisis, in 2017 a team of MSU Extension specialists sought and secured funding from the U.S. Department of Agriculture National Institute of Food and Agriculture to launch the PReventing Opioid Misuse In the SouthEast (PROMISE) Initiative. The first step in the initiative was to explore rural Mississippians' perceptions of the opioid epidemic and to identify community-supported primary prevention strategies that could be implemented by Extension professionals. It is important to note that primary prevention, in this case preventing opioid misuse before it happens, is the focus of this project because MSU Extension has a history of delivering community health education. As members of the PROMISE Initiative team, we report here on the formative assessment process we used to identify community members' perceptions of the opioid crisis and their methods for obtaining information about opioids, and we present an overview of our assessment findings.

An Introduction to the PROMISE Initiative Assessment Process

A needs assessment is crucial for Extension program development, specifically when novel and emerging program topics and delivery methods are involved (Kaplan, Liu, & Radhakrishna, 2003). The PROMISE Initiative team used both qualitative and quantitative formative assessment techniques to assess community members' perceptions of the opioid crisis and to define prevention strategies related to opioid misuse prevention. First, the PROMISE Initiative team held a series of nine 90-min community forums to explore the following topics:

• general perceptions of prescription opioid misuse,
• factors perceived to be easiest to change and most important in preventing prescription opioid misuse,
• efforts perceived to be the best for raising awareness about opioid misuse,
• perceived responsibilities of family members in preventing prescription opioid misuse, and
• perceptions of prescription drug take-back boxes.

A trained moderator facilitated the forums and used predetermined forum questions to guide the discussion, and a trained comoderator took notes during each forum. At the beginning of each forum, the moderator defined key terms in an attempt to establish a common understanding of terms related to opioid use and misuse. Extension agents from selected counties highly affected by opioid misuse recruited forum participants through telephone calls to past Extension program participants, one-on-one interactions with residents, social media posts, and newspaper advertisements. Our team audio-recorded, transcribed, and analyzed data from the engagement forums for key themes using NVivo version 12 (QSR International, 2018).

In addition to the community engagement forums, the PROMISE Initiative team developed a 164-item web-based quantitative survey that addressed the following topics:

• respondent demographics,
• perceptions of prescription opioid use and misuse and drug-securing behaviors,
• information seeking and scanning,
• willingness to use prescription drug take-back boxes, and
• history of prescription opioid use.

Survey participants were recruited via Qualtrics (Provo, UT, 2018), and data were analyzed in Stata version 15 (StataCorp, 2017) and SPSS version 25 (IBM Corp, 2017). Methods are described elsewhere in further detail (Robertson et al., 2019).

PROMISE Initiative Needs Assessment Findings

Preliminary reviews of the data demonstrated that forum and survey participants perceived the opioid crisis as a problem in their communities and recognized the importance of prevention strategies. Most participants noted that more awareness about and education related to opioid misuse prevention is needed. They also suggested that community-based agencies, such as Extension, can increase public awareness about opioid misuse prevention.

With the development of key prevention strategies emanating from the forum discussions, the quantitative survey findings, and additional resources available from the Centers for Disease Control and Prevention and the Food and Drug Administration, the PROMISE Initiative team is now developing messages related to each strategy that will become part of a statewide social marketing campaign. The messages will be distributed through Extension educational materials and Extension social marketing efforts and even embedded within existing Extension educational programs (e.g., Healthy Homes Initiative). Our team is also sharing these primary prevention messages with the State Opioid Response team at the Mississippi Department of Mental Health for use in their Stand Up Mississippi social marketing campaign. Our team will provide further reporting on the rigorous process used to develop the educational messages in future research reports.

Conclusion

Data from community forums and quantitative surveys are critical in developing locally relevant primary prevention messages that can be delivered and disseminated through Extension professionals in Mississippi. Because no data had been systematically collected on this topic in Mississippi prior to the needs assessment described here, our project was an important step in determining where Extension professionals fit into the prevention landscape. For states interested in conducting similar work, our team invites requests for forum guides and the survey instrument. They are available by request from the lead author.

Acknowledgments

The efforts of the PROMISE Initiative team and Mississippi State University Extension Service were supported by the FY17 USDA NIFA Rural Health and Safety Education Competitive Grants Program of the National Institute of Food and Agriculture, U.S. Department of Agriculture, Grant #2017-46100-27225, and the FY18 Substance Abuse and Mental Health Services Administration Rural Opioids Technical Assistance Grants #TI-18-022.

References

Centers for Disease Control and Prevention. (2017). Understanding the epidemic [Data file]. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html

Centers for Disease Control and Prevention. (2018). Preventing opioid overdose in rural America [Policy brief]. Retrieved from https://www.cdc.gov/ruralhealth/drug-overdose/pdf/Policy-Brief_Opioiod-Overdoses-H.pdf

Elliott, S. (2015, February 24). Cooperative Extension programs help strapped rural communities [Blog post]. Retrieved from https://www.usda.gov/media/blog/2015/02/24/cooperative-extension-programs-help-strapped-rural-communities

Kaplan, M., Liu, S., & Radhakrishna, R. (2003). Intergenerational programming in Extension: Needs assessment as planning tool. Journal of Extension, 41(4), Article 4FEA5. Available at: https://www.joe.org/joe/2003august/a5.php

National Advisory Committee on Rural Health and Human Services. (2015). Mortality and life expectancy in rural America: Connecting the health and human service safety nets to improve health outcomes over the life course. Retrieved from https://www.hrsa.gov/advisorycommittees/rural/publications/mortality.pdf

National Research Council. (1996). Colleges of agriculture at the land grant universities: Public service and public policy. Washington, DC: The National Academies Press. doi:10.17226/5133

Robertson, M. N., Williams, D., Seitz, H., Downey, L., Hardman, A., & Buys, D. (2019). The PROMISE Initiative: Who should give patients information on opioids? Journal of the Mississippi State Medical Association, 60(2). Retrieved from https://www.msmaonline.com/Public/Journal_MSMA/Public/Journal/JMSMA.aspx?hkey=313efbfe-0990-41ff-a032-27bd1ea43c31