-------------------------------------------
Where to go? The beach resorts in Gran Canaria - Gran Canaria travel guide - Duration: 12:30.
In this video I want to give you a complete look and comparison of all the different holiday
destinations in Gran Canaria so you can pick the right one for YOUR holiday in Gran Canaria.
The first resort is the Bahia Feliz.
This you will find as the first resort when you drive South from the airport towards where
you will find most of the holiday resorts in Gran Canaria.
The Bahia Feliz is a small little holiday destination with just about 5 hotels or something
like that.
There are some stone pebble beaches and a sandy one just a bit outside the resort.
In the smallish shopping center here you will also find a selection of restaurants.
This place is great for a relaxing holiday in Gran Canaria but has no busy nightlife
or something if you are looking for that.
A bit further down but within walking distance for most people is San Agustin.
Some people will claim this is already part of Maspalomas, some will say it is not and
a completely different destination.
San Agustin is similar to Bahia Feliz as it has also only less than 10 hotels however,
San Agustin has some very nice sandy beaches and a bit more choice of bars, restaurants
and shops.
However, if visiting San Agustin and eating outside of your hotel I would very much advice
reading reviews before going into a place as many of the place I drank and eat served
Pepsi when asking for coke, served dripp coffee when asking for espresso and some even served
instant powder coffee for 3 euro price.
I am not saying other places in Gran Canaria, Spain or the world don't have this and maybe
I was just unlucky in picking places but I would just like to give you a quick warning
about this.
Especially be aware of this for the places next to the beach.
Otherwise San Agustin is a great place for a holiday on the beach.
Next up and within Maspalomas is Playa del Ingles.
By far the best known area in Gran Canaria and also the oldest and biggest.
This resort has been around since tourism started on the island about 50 years ago.
It is best compared to such places as Palma Nova in Majorca and Playa de las Americas
in Tenerife.
It's big, busy, pr people everywhere trying to get you into bars and restaurants, much
about the nightlife and 2 for 1 deals all day every day.
Most of the restaurants and bars you will find on the front line but also some very
large open air shopping centers spread out over the area.
The beach is a nice sandy beach and very long but depending on where you are staying, you
might need to take a lot of stairs up or down to get to it.
In some places they also have elevators going to the beach to make it more easy.
Playa del Ingles is great for people who want sun and beach but still all the comforts from
home like international pubs showing your football games and to speak your own language
and be understood.
In the resort you will find a mix from 1 star hotels to 5 star hotels.
Playa del Ingles is very big so I would advise you to have a quick look on Google maps or
something where your hotel is before booking if it is important for you.
Next to Playa del Ingles is the new Meloneras area.
Well actually it is not new but recently many new hotels have established themselves here.
All of these are very big hotels and all of them have great reviews and 4 or 5 stars.
One even has 5 star GL… so basically 6 stars.
It is much more quieter and relaxed there and a bit more upscale.
There are 2 great beaches like the beach of Maspalomas and the Meloneras beach, both are
on the outside of the resort but that is just 1 or 2 minutes walking from the center...
centrally there is no beach.
Meloneras is great if you want a nice relaxing holiday and you stay within the hotel most
of the time and once and a while like to go to the beach.
This area also has great all inclusive hotel options.
Next up is Arguineguin, this is just a typical small Gran Canarian village with just a few
hotels.
Pretty much everything here is Spanish but a large community of Norwegian people has
found there way here, especially pensioners who like to come here in winter.
There is a nice sandy beach and during my last stay they were even in progress to add
another beach.
A bit further down is Anfi, well known for the timeshare hotel there.
It has one of the nicest fluffy sandy beaches in this area and great relaxed vibe.
In the evening there are also live shows and mini disco each night in the harbor area.
Another big resort is Puerto Rico in Gran Canaria.
There are many hotels here on the side of the mountains in all price categories and
star ratings.
All of these are surrounding a centrally located shopping center where most of the bars, restaurants
and nightlife are in the evening.
The resort is very popular with Scandinavian people, especially in winter when the temperature
is still nice here compared to most Scandinavian countries at that time.
This resort has a nice beach and since recently there is now a walkway to the neighbouring
beach of Playa de Amadores as well, so if you want a change, it's just a nice walk
away.
This resort is great as it offers everything you could wish for on holiday however it is
not so big you would get lost.
Everything is easy to find because of the layout.
Keep in mind that depending on where your hotel is you might have to walk a bit uphill
or take a taxi each time.
Also, when I was last here there were a lot of people on the strip asking or advising
people to come join a timeshare presentation… so be aware of that.
If you have time and you are interested… do it, but it might take an entire day even
tho they say you can leave at any time.
This has nothing to do with Puerto Rico of course, just saying so you are informed.
Playa del Cura in Gran Canaria is a nice little chill resort for an "escapist feel" holiday.
There is just a few hotels here set up against the hill and a few in the front near the beach.
Just a small walk away is the new Tauro beach what has recently been constructed and added
sand to, to also have a sandy beach in this area.
There are not very many shops, bars or restaurants but enough.
Since you can find hotels here at very good prices compared to the more popular and well
known resorts in Gran Canaria it is also a great place to explore the island from by
car.
Also because of its central location between all resorts and great connection to the highway.
Taurito is best described as a mini Puerto Rico.
It has the same layout and nice beach.
All the hotels are set up against the mountain side with most of the restaurants and bars
in the center and beach in front.
In the center you will also find the water park, mini golf and all the nighttime entertainment
and mini disco for the public.
Next is Puerto de Mogan, well known for its postcard worthy houses in the harbour area.
This used to be a quiet little fishing village but recently has seen expansion and construction
of 2 very large hotels in this area.
Also construction of a large shopping center is on the way.
Puerto de Mogan is a great place, however I hope it does not get over commercialised
in the next coming year.
If you wanna visit here, I would visit as soon as possible.
On the other side of the island you will find Agaete, a typical spanish fisherman village
that has not been commercialised anything.
Also for this reason it is very cheap.
There are only 3 hotels here, 1 with pool and 2 city style hotels.
It's a really great and surprising place.
If you want to visit Gran Canaria but don't want the mass tourism, this is one of your
best choices.
Also from here it is easy to pop over to Tenerife with the ferry that arrives here.
Next up is Las Palmas or Las Palmas de Gran Canaria as some people call it.
This is the capital of Gran Canaria and the place where you will find most of the culture,
museums but also a great beach…
The Playa de las Canteras.
When I first visited Gran Canaria this was actually my first stop as I need to buy some
gear for filming in Gran Canaria.
While I was looking for the shopping center, getting a bit lost in the city, I suddenly
stood face to face with the Playa de las Canteras and could definitely not believe that a busy
capital could have such an amazing, long and awesome beach.
So if you are worried that since this is the capital, it is not a great place to have a
beach holiday… think again.
This beach is also very popular with surfers and surf schools.
On top of that there is also a great shopping center and prices here are often lower than
most European countries.
Be a little bit careful booking a hotel in this area tho as many hotels are not near
the beach, but further away on the other side of the city where there is more busy traffic
and less "holiday-ish vibe".
I really like however that Las Palmas is not know as a summer holiday destination since
because of this you won't find any PR staff trying to constantly sell you something or
try to get you into bars or restaurants.
If you want to find all my videos covering Gran Canaria even more easy, then don't
forget to subscribe.
Hope this video helped you and that you will have a great holiday in Gran Canaria because
of it!
All in all Gran Canaria has some great resort and holiday destinations, just make sure you
pick the right one for you.
-------------------------------------------
ESO Beginner Provisioning Guide - Become a Master Provisioner in the Elder Scrolls Online - Duration: 7:39.
Hello everyone, my name is Tianlein and today we talk about
all things related to the Provisioning Crafting Skill Line in the Elder scrolls Online
I will explain for what Provisioning is useful, show the skill line in depth, where you can
gather recipes and ingredients, where you can find a cooking station and how you can
level up your Provisioning Skill Line
If you are only interested in a specific topic please take a look in the description
So why should you think about to level up the Provisioning crafting skill?
Provisioning allows you to create useful meals and drinks which increase your Health, Magicka,
Stamina, Magicka and Stamina Regeneration or other useful bonuses for a set amount of time
Especially if you are interested in playing dungeons, trials or PVP you want to be prepared
and have your own food or drinks
But in general it makes your adventures in Tamriel a lot easier if you don't miss this bonuses
When you dont want to invest so many Skillpoints, or you dont want to collect and store all
ingredients you can also buy from guild traders your food and drinks
You can't use food and drinks at the same time, since they do not stack
But you can use food or drinks at the same time with a experience potion
Now we take a closer look at the Skill Line
Recipe Quality will allow you to create green, blue, purple and legendary recipes
Recipe Improvement allows the making of up to level 19,29,39,49, Champion 50 and Champion 150 recipes
Gourmand is a really useful skill
It will add 5,10 and 20 minutes to the duration of any eaten food
Connoisseur is also a skill which is good to have
It will add 5,10 and 20 minutes to the duration of any consumed drink
that works also for crafted xp potions
If you plan to cook regulary for your Characters you should invest in the Chef and Brewer Skills
For every dish or drink you make you will create 1,2 and 3 extra servings without spending
additional ingredients
The Hireling will find for you ingredients
every 24 hours which you will receive via mail
With 2 skill points invested you will have a higher chance of receiving more ingredients
every 24 hours
and when you invest 3 skill points you can
receive every 12 hours a hireling mail
Before we are able to start to cook our first meal we have to find and learn cooking recipes
I believe at the moment you can collect up to 563 different recipes
At the start you can only cook meals with recipes between level 1 to 19
But if you increase your Provisioning Skill Line and invest into recipe improvement you
will be able to cook higher recipes too
You can find recipes as random drops in containers such as Cupboards and Chests
If you have some gold you can buy from guild traders recipes too
And for completing the daily Provisioning Writs you will recieve a random recipe depending
on your recipe improvement knowledge
Don't forget that you can buy the needed recipes
for the crafting writs from the chef and brewer in any pub in Tamriel
After you obtained your first recipes you need to gather the needed ingredients
In general provisioning ingredients can be found by searching barrels, baskets and crates
in Tamriel
Meat can be gatherd from various creatures throughout the world
For example from elk, deer, rabbits, goats, chicken and many more animals which you can
hunt in any overland zone
Grocers also sell ingredients, but have a limited selection and are also not cheap
If you have some gold you can choose the faster solution and purchase ingredients from the
guild traders
But if you take your time and just play the game you will acquire over time a lot of ingredients
If you want to start to cook you have to visit a cooking station
The Provisioning skill line is granted when you visit a cooking station the first time
You find cooking stations in many cities in Tamriel
But i will show you now some example cooking places in the starter zones
In Davons Watch in Stonefalls you can visit the The Watch House and The Fish Stink Inn
In Daggerfall in Glenumbra you find a cooking fire near the trademan's square
And In Vulkhel Guard in Auridon you can visit the Salted Wings Tavern to find a cooking place
In general you can find a cooking fire in camps, cities and inside houses everywhere
in Tamriel and they are easy accessible
Also you are able obtain a cooking fire for your house
You need 35 Master writs Vouchers to be able to purchase from the Master Mediator Rolis
your personal cooking station
Or if you have the coin you can buy with gold from the guild trader your personal cooking
station for your home
I believe you have to invest around 35 000 gold for a crafting station
But keep in mind that the market prices change all the time
Alternatively you can buy for 2400 crowns a cooking station for your house
Next we talk about how you can level up your Provisioning Skill Line
When you learned some recipes and gathererd the needed ingredients you can start to cook
meals and drinks at a cooking fire
Just by cooking you will earn Inspiration which will increase your Provsioning Skill line
You can also increase your skill line by learning recipes, doing daily crafting writs and master
crafting writs
And sometimes you can find books which increase your skill line too
If you reached Level 50 you reached the maximum level for the Provisioning Skill Line
In case you obtained already Champion Points you can increase your Inspiration gain
You have to invest 30 Champion Points into the Tower to unlock a 20% Inspiration boost
That will allow you to earn more Inspiration and level up faster all crafting skill lines
Also i would recommend you to take the time to do the daily crafting writs which not only
reward you with Inspiration, but give you also gold, useful materials and also cooking recipes
Keep in mind that you need a lot of storage space to store all the available cooking ingredients
If you have ESO plus you will not have any problem since all ingredients get direct stored
into your craft bag
Otherwise don't forget you increase your inventory and bank space, obtain storage chests and
if you still need more space you can use extracharacters to use their inventory as storage space
In case you play on PC i would like to recommend you the Addon CookeryWiz
CookeryWiz is a super helpful and an easy to use Addon which will allow you to see every
recipe available in the game
You can see what recipes your characters have
and do not have and you can share this information with other CookeryWiz users too
It allows you to browse all recipes at any time and it displays and calculates how many ingredients
you have to use to cook
and many more useful things
You can find the Addon link in the Video description.
Every Crafting Station in the Elder Scrolls online allows you to craft your own furnishings too
If you found and learned some Furniture Design Plans you can create beside of food and drinks,
also your own furniture at a Cooking Station
Visit any Cooking Fire and at the top right you can switch to the furnishings tab
Depending on the item you want to build you need to know multiple crafting skill line passives
and obtain many different materials
To be able to craft Furniture Designs you need Decorative Wax and other materials.
You can find Decorative Wax by looting barrels, baskets, urns, crates, cabinets, etc.
Hopefully you enjoyed my overview of the Provisioning Skill in the Elder Scrolls Online
Thanks for watching and it would be awesome if you subscribe, like or leave me a comment
Have a good day and until next time
Tschüss!
-------------------------------------------
Specific Protein Analyzer PA54 Operation Guide - Duration: 5:55.
For more infomation >> Specific Protein Analyzer PA54 Operation Guide - Duration: 5:55. -------------------------------------------
2018 Toyota RAV4 buying guide | Answers to top questions about a leading crossover - Duration: 7:26.
The RAV4 is now Toyota's top-selling vehicle, having last
year outsold the venerable Toyota Camry, itself the best-selling passenger car in the U.S.
for many years running.
It was the top-selling non-pickup in the U.S. in 2017.
And its popularity shows no sign of waning, with sales up more than 15 percent last year
— pretty good for a compact SUV that arguably birthed the segment.
Here you'll find all the information you need to make an educated buying decision if you're
considering a 2018 Toyota RAV4, including safety and reliability ratings, engine specs,
horsepower, fuel economy ratings and pricing.
And we'll summarize what Autoblog's professional auto reviewers think of the RAV4.
Is the 2018 Toyota RAV4 Safe?
The National Highway Traffic Safety Administration gives the 2018 Toyota RAV4 an overall crash-test
rating of five stars, giving it top marks for protecting the driver and passengers against
injury.
Breaking it down further, the RAV4 gets five stars in side-crash tests and four-star ratings
in both frontal crash and rollover resistance tests.
The Insurance Institute for Highway Safety, which also provides ratings for new vehicles
based on its own comprehensive crash tests, has given the 2018 Toyota RAV4 its "Top Safety
Pick" award.
It earned "good" ratings for five of six crashworthiness tests but a "poor" rating for passenger-side
small overlap crashes, which replicate crashes involving the front corner of a car.
(For an overview of the "hellish" small overlap test, see this behind the scenes article.)
IIHS gives the 2018 RAV4 a "superior" rating for front crash prevention and an "acceptable"
rating for headlights, its newest ratings measurement, and a "good" rating for its LATCH
anchors for child seats.
Ratings may differ for RAV4s from other model years, so be sure to visit the NHTSA and IIHS
websites to review ratings on the specific vehicle you're researching.
At the time of this writing, the 2018 Toyota RAV4 has not been included as part of the
widespread Takata airbag recall.
Is the RAV4 reliable?
J.D. Power most recently reviewed initial quality in the 2017 RAV4 – which is extremely
similar to the 2018 model.
It gave the RAV4 three out of five possible stars — "about average" — for overall
quality, overall performance and design, and predicted reliability.
Diving deeper, J.D. Power gave the RAV4 five stars for both overall mechanical quality
and body and interior mechanical quality, but just two stars for features and accessories,
and ease of using controls or other features.
A note about J.D. Power's methodology: we have some rather serious issues with the way
it weights serious and less serious reliability issues.
Find 2018 Toyota RAV4 pricing, information, and even ones on sale near you
In December 2017, Toyota issued a small recall of certain 2017-2018 model-year RAV4s, among
six other Toyota and Lexus models, for having incorrect load-carrying capacity modification
labels, which could prompt drivers to overload vehicles and increase the risk of a crash.
The company said it would notify owners and provide them with corrected labels free of
charge.
The recall affected fewer than 700 vehicles.
How much interior and cargo room does the RAV4 have?
The 2018 Toyota RAV4 seats up to five people, with 42.6 inches of front leg room and 37.2
inches in the backseats.
Passengers get 38.9 inches of head room in both the front and rear.
It boasts 38.4 cubic feet of cargo volume, or nearly twice that volume — 73.4 cubic
feet — with the rear seats folded down.
By way of comparison, the 2018 Ford Escape has 34 and 68 cubic feet, respectively, while
the 2018 Honda CR-V tops out at 39.2 cubic feet and 75.8 cubic feet.
Cargo volume decreases slightly in the RAV4 XLE Hybrid trim package, to 35.6 and 70.6
cubic feet, respectively.
What are the RAV4 engines and specs?
Both the LE and XLE models come equipped with a 2.5-liter four-cylinder, 16-valve engine
that generate 176 horsepower and 172 pound-feet of torque.
On the Hybrid models, total output nudges up to 194 hp.
What fuel economy does the RAV4 get?
Gas mileage ratings will vary depending on model and front- or all-wheel drive configurations.
The EPA rates the standard 2.5L four-cylinder model at 23 miles per gallon in the city and
29 on the highway.
Jump up to the LE or XLE packages and you'll get 23 mpg city and 30 mpg highway.
Opting for all-wheel drive takes those figures to 22/28 mpg, respectively.
Is there a hybrid RAV4?
The RAV4 is available with a gas-electric hybrid powertrain, with the LE Hybrid starting
at $27,235 and the top-of-the-line Limited Hybrid starting at $34,310.
Two hybrid trim packages slot in between those: the XLE Hybrid, with a $29,130 starting price,
and the SE Hybrid at $32,285.
Fuel economy is highest on the hybrid models, at 34 mpg in the city and 30 on the highway.
Does the RAV4 have AWD?
As mentioned previously, the 2018 RAV4 comes in either front- or all-wheel drive options.
All-wheel drive versions start at $25,910 on the LE trim package.
Hybrid models are only available with AWD.
What is the MSRP of the RAV4?
The 2018 RAV4 brings a starting MSRP of $24,510 for the LE trim and goes up to $36,250 for
the top-of-the-line Platinum.
Use Autoblog's Smart Car Buying program powered by TrueCar to search out competitive local
pricing and savings on
the 2018 Toyota RAV4.
-------------------------------------------
L'urgentiste et guide de haute montagne Emmanuel Cauchy tué dans une avalanche à Chamonix - Duration: 3:32.
For more infomation >> L'urgentiste et guide de haute montagne Emmanuel Cauchy tué dans une avalanche à Chamonix - Duration: 3:32. -------------------------------------------
Guide your baby to flower with baby dolls - Dolls For Kids - Duration: 14:10.
Guide your baby to flower with baby dolls - Dolls For Kids
-------------------------------------------
L'urgentiste et guide de haute montagne Emmanuel Cauchy tué dans une avalanche - Duration: 3:29.
For more infomation >> L'urgentiste et guide de haute montagne Emmanuel Cauchy tué dans une avalanche - Duration: 3:29. -------------------------------------------
Webinar Using Data to Guide and Evaluate Responses to the Opioid Crisis Rhode Island's Drug Overdose - Duration: 1:03:47.
GOOD AFTERNOON, EVERYONE.
THANK
YOU FOR JOINING US FOR THIS
WEBINAR.
THE TITLE IS USING
DATA TO GUIDE AND EVALUATE
RESPONSE TO THE OPIOID CRISIS.
RHODE ISLAND'S DRUG OVERDOSE
DASHBOARD.
I'M YOUR HOST,
SUSAN, I AM THE EDUCATION AND
OUTREACH COORDINATOR FOR THE NEW
ENGLAND REGION OF THE NATIONAL
NETWORK OF LIBRARIES OF
MEDICINE.
I AM LOCATED AT THE
UNIVERSITY OF MASSACHUSETTS,
MEDICAL SCHOOL IN WORCESTER,
MASSACHUSETTS.
THIS WEBINAR IS
BEING RECORDED THOSE OF YOU WHO
REGISTERED WILL RECEIVE A LINK
TO THE RECORDING AND THE
PRESENTATION SLIDES SHORTLY
AFTER THE WEBINAR IS OVER.
IT
USUALLY TAKES ME MORE THAN A
COUPLE OF DAYS.
YOU KNOW, MAYBE
FIVE OR SIX DAYS TO GET
EVERYTHING ORGANIZED TO SEND OUT
THAT LINK.
AND, AGAIN, IF YOU
NEED CAPTIONING FOR THIS
WEBINAR, THE LINK TO CONNECT TO
THE CAPTIONING IS IN THE
CHATBOX.
THE WEBINAR SHOULD
LAST ABOUT 40-45 MINUTES.
AND
IF YOU HAVE QUESTIONS ABOUT WHAT
YOU'RE HEARING OR SEEING, JUST
JOT THEM DOWN AND WE'LL SAVE THE
LAST 10-15 MINUTES FOR YOU TO
ASK YOUR QUESTIONS AND WE'LL
HAVE YOU PUT THEM IN THE CHATBOX
FOR US.
FOR THOSE OF YOU WHO
AREN'T FAMILIAR WITH THE
NATIONAL LIBRARY OF MEDICINE,
OH, I'M SORRY, I FORGOT TO
ADVANCE MY SLIDES HERE.
HERE WE
GO.
I JUST WANTED TO TAKE A
COUPLE OF MINUTES TO GIVE YOU
SOME DETAILS ABOUT THE RESOURCES
THAT THE NATIONAL LIBRARY OF
MEDICINE HAS AVAILABLE ALL OF
WHICH ARE FREE.
THE NLM WHICH,
IT'S A SHORTENED VERSION TO
REFER TO IT. IS AN ACTUAL,
PHYSICAL BRICK AND MORTAR
LIBRARY LOCATED ON THE CAMPUS OF
THE NATIONAL INSTITUTE OF
HEALTH.
IT'S THE BIOMEDICAL
LIBRARY IN THE WORLD AND ONE OF
THE FEDERAL GOVERNMENT'S LARGEST
PROVIDERS OF DIGITAL CONTENT THE
LIBRARY IS OPEN TO EVERYONE THE
MISSION OF THE NLM IS TO ADVANCE
THE PROGRESS OF MEDICINE AND
IMPROVE PUBLIC HEALTH BY MAKING
BIOMEDICAL INFORMATION
ACCESSIBLE TO EVERYONE.
THE NLM
CARRIES OUT ITS MISSION THROUGH
A NATIONWIDE NETWORK THAT HAS
EIGHT REGIONS AND THE REGIONS
WORK WITH HEALTH SCIENCE
LIBRARIES PUBLIC LIBRARIES AND
INFORMATION CENTERS.
EACH
REGION HAS A PARTNERSHIP WITH A
REGIONAL MEDICAL LIBRARY.
AND
IT'S OUTREACH IS PROVIDED
THROUGH THE FREE ACCESS OF
ONLINE HEALTH AND MEDICAL
RESOURCES, FREE TRAINING AND
PROFESSIONAL DEVELOPMENT AS WELL
AS GRANTS FUNDING OPPORTUNITIES
THIS SLIDE IS A LISTING OF THE
SUBSTANCE USE DISORDER RESOURCES
WE HAVE ABLE -- AVAILABLE AND I
JUST WANTED TO GIVE YOU AN IDEA
OF HOW COMPREHENSIVE THESE
RESOURCES ARE.
SO THIS IS THE
SCREEN FROM THE FIRST BULLETED
RESOURCE.
AND IT'S AN EXAMPLE
OF HOW OUR RESOURCES, OUR FACT
SHEETS, INFORMATION ABOUT
PREVENTION, SAFETY AND
PRESCRIBING PATIENT MATERIALS,
REPORTS, AND SOME OF THE TOPICS
RELATED TO SUBSTANCE USE
DISORDER THAT WE HAVE RESOURCES
FOR, YOU KNOW, UNDERSTANDING
ADDICTION, MEDICATIONS TO TREAT
ADDICTION, PRESCRIBING,
PREGNANCY, NEONATAL, ABSTINENCE
SYNDROME, RECOVERY, DATA TRENDS
AND STATISTICS.
NOW I'D LIKE TO
INTRODUCE BRANDON MARSHALL WHO
IS OUR WEBINAR PRESENTER,
BRANDON IS THE ASSOCIATE
PROFESSOR IN THE DEPARTMENT OF
EPIDEMIOLOGY AT THE BROWN
UNIVERSITY SCHOOL OF PUBLIC
HEALTH.
HE WILL BE SHARING HIS
WORK WITH THE RHODE ISLAND DRUG
OVERDOSE DASHBOARD.
ALL RIGHT.
BRANDON I'M HANDING IT OVER TO
YOU.
>> EXCELLENT.
THANK YOU, SUSAN
SUSAN, CAN EVERYONE HEAR ME
OKAY?
AM I COMING THROUGH LOUD
AND CLEAR?
>> YES, YOU ARE.
>> GREAT, ALL RIGHT AND I'M IN
CONTROL NOW.
I AM HAPPY TO HAVE
THIS OPPORTUNITY TO PRESENT
TODAY AND SHARE SOME OF THE WORK
WE'VE BEEN DOING IN RHODE ISLAND
TO ADDRESS THE OPIOID CRISIS IN
OUR STATE.
WHAT I'M GOING TO DO
TODAY IS THE FOLLOWING, THESE
OBJECTIVES WILL FILTER THROUGH
THE PRESENTATION AND THEN I'LL
BE SURE TO LEAVE SOME TIME FOR
QUESTIONS AT THE END.
I WILL
TALK A LITTLE BIT ABOUT NATIONAL
AND THEN FOCUS ON OUR STATE
SURVEILLANCE SYSTEM TO TRACK AND
RESPOND TO THE OVERDOSE EPIDEMIC
AND THROUGHOUT THE PRESENTATION,
WE'LL BE LEARNING ABOUT STRATEGY
TO IMPROVE THE COLLECTION
ANALYSIS AND DISSEMINATION OF
OVERDOSE RELATED DATA.
I'M
DIRECT AS SUSAN MENTIONED THE
RHODE ISLAND'S SYSTEM, WE'VE
LEARNED A LOT I THINK ABOUT WHAT
OUR BEST PRACTICES FOR
COMMUNICATION OF OVERDOSE
RELATED PUBLIC HEALTH DATA SO
I'LL SHARE SOME OF WHAT WE'VE
DONE TODAY AND I'M HAPPY
AFTERWARDS ALSO TO FOLLOW UP
WITH SOME ADDITIONAL RESOURCES
IF THAT'S HELPFUL FOR FOLKS.
SO
JUST TO GET A SENSE OF THE BIG
PICTURE FOR NOW, WHY WE'RE
FOCUSING ON OVERDOSE IN THIS
WEBINAR.
THIS IS A GRAPHIC FROM
THE NEW YORK TIMES ACTUALLY THAT
SHOWS YOU HOW THE NUMBER OF
PEOPLE WHO HAVE DIED FROM DRUG
OVERDOSE IN THE UNITED STATES
HAS INCREASED ESSENTIALLY
EXPONENTIALLY OVER THE LAST TWO
OR THREE DECADES.
THE NUMBERS
IN THE SLIDE WERE MADE FOR 2016
WERE PRELIMINARY AND NOW BEEN
FINALIZED AT 64,000 PEOPLE
LOSING THEIR LIVES TO OVERDOSE
IN THE UNITED STATES IN 2016 AND
THAT WELL EXCEEDS AS YOU CAN SEE
THE PEAK NUMBER OF GUN RELATED
DEATHS THAT WAS OPENED IN 1993
AND THE PEAK NUMBERS OF HIV
RELATED DEATHS OBSERVED IN 1995
SO I OFTEN TELL MY STUDENTS HERE
AT BROWN THAT THIS COULD BE AND
VERY WELL BE THE EPIDEMIC OF
THEIR GENERATION.
MUCH LIKE
HIV/AIDS WAS SOME DECADES AGO.
THESE NUMBERS ARE SO LARGE IT'S
HARD TO GET A SENSE OF WHAT THAT
LOOKS LIKE SO ANOTHER WAY TO
LOOK AT THIS IS GEOGRAPHICALLY
AND THIS IS USING DATA FROM THE
CDC AND THAT'S AT THE COUNTY
LEVEL THE RATE OF OVERDOSE DRUG
DEATH HERE IN 1999.
YOU CAN SEE
HOTSPOTS POPPING UP IN WEST
VIRGINIA, PARTS OF NEW MEXICO
AND NORTHERN CALIFORNIA.
THIS
IS WHAT OVERDOSE LOOKED LIKE IN
2015 AND THE SITUATION HAS
GOTTEN ACTUALLY SIGNIFICANTLY
WORSE SINCE THIS MAP WAS
GENERATED.
WE SEE HIGH RATES OF
OVERDOSE, REALLY ACROSS THE
NATION.
THIS IS AN ISSUE THAT
TOUCHES ESSENTIALLY EVERY
COMMUNITY ACROSS THE UNITED
STATES, RURAL COMMUNITIES, URBAN
COMMUNITIES, RED STATES, BLUE
STATES, WE ALL NOW I THINK ARE
FACED WITH ADDRESSING THE
OVERDOSE CRISIS.
NONETHELESS,
YOU CAN SEE REGIONS OF THE
COUNTRY THAT ARE MORE HEAVILY
EFFECTED THAN OTHERS.
WEST
VIRGINIA, OTHER PARTS OF
APPALACHIA, OHIO, THE SOUTHWEST,
NEW MEXICO, AND ALSO HERE IN NEW
ENGLAND.
IN ADDITION TO
GEOGRAPHICALLY THE OVERDOSE
EPIDEMIC EFFECTS ESSENTIALLY
EVERY AGE GROUP.
THIS SHOWS THE
AGE GROUP SINCE 1999.
OVERDOSE
USED TO BE A PHENOMENON THAT
AFFECTED PEOPLE IN MIDDLE AGE.
YOU CAN SEE IN 1999 THE HIGHEST
RATES WERE OBSERVED IN THE EARLY
40S, LATE 30S.
OVER TIME THE
EPIDEMIC HAS INCREASED IN ALL
AGE GROUPS BUT MOST DRAMATICALLY
IN THE 25-34 YEAR-OLD AGE GROUP
AND WE'RE ALSO NOW SEEING
INCREASES IN EVEN YOUNGER
TEENAGERS AND YOUNG ADULTS THAT
IS TREMENDOUSLY ALARMING AND
DRIVEN PRIMARILY BY THE DRUG
SUPPLY IN THE UNITED STATES.
FENTANYL IS AN OPIOID CUT INTO
DRUGS AND INCREASES THE RISK OF
DEATHS QUITE DRAMATICALLY AND
NOW WE SEE PEOPLE UNFORTUNATELY
DYING OF OVERDOSE MUCH EARLIER
IN A DRUG USE TRAJECTORY THAN WE
USED TO SEE BACK IN THE EARLY
2000S AND JUST TO FINISH THIS
SECTION NOW I PULLED HERE THE
STATES WITH THE HIGHEST RATES OF
OVERDOSE IN 2015 AND 2016.
IN
2015 HERE IN RHODE ISLAND WE
WERE ACTUALLY FIFTH HIGHEST.
NOW AS YOU CAN SEE IN THIS SLIDE
WE'VE DROPPED TO 10TH AND THAT
ISN'T SO MUCH A REFLECTION OF
SIGNIFICANT DECREASES IN OUR
STATE.
RATHER OTHER STATES
INCREASING FASTER THAN US.
YOU
CAN SEE DRAMATIC INCREASES IN
DRUG OVERDOSE IN VIRGINIA THE
HARDEST HIT STATE IN THE
COUNTRY, OTHER STATES AND THE
DISTRICT OF COLUMBIA SEEING A
DOUBLING OF DRUG OVERDOSE IN
JUST ONE YEAR AND YOU SEE THIS
DIPPED SLOWLY AND DROPPED IN THE
RANKINGS OVER TIME IN RHODE
ISLAND SO WITH THAT BACKGROUND
IN TERMS OF THE NATIONAL SCOPE
OF THE EPIDEMIC I WOULD LIKE TO
DRILL DOWN NOW INTO HOW OUR
STATE IS ADDRESS THING CRISIS.
IN EARLY 2015 OUR GOVERNOR
CONVENED A TASK FORCE WHICH
CONSISTS OF THE NUMBER OF
STAKEHOLDERS FROM VARIOUS STATE
AGENCIES, MEMBERS OF THE PUBLIC,
COMMUNITY ORGANIZATIONS AND
PRIVATE INDUSTRY.
AND THEY, IN
TURN, TASKED AN ACADEMIC
RESEARCH TEAM TO AUTHOR A
STRATEGIC PLAN.
MINE WAS
FORTUNATE ENOUGH TO BE PART OF
THAT STRATEGIC PLAN, THAT WAS
DEVELOPED IN 2015 AND WAS
RELEASED AND ENDORSED BY THE
TASK FORCE LATER THAT YEAR.
I'M
NOT GOING TO GET INTO STRATEGIC
PLAN IN GREAT DETAIL.
I'M GOING
TO FOCUS ON THE DATA AND THE
DASHBOARD TO DRIVE TARGETING OF
OUR RESOURCES AND UNDERSTANDING
OUR EPIDEMIC BUT TO GIVE YOU
40,000 OVERVIEW THE STRATEGIC
PLAN FOCUSES ON FOUR PILLARS,
WHERE WE CAN FEEL WE CAN MAKE
THE BIGGEST DIFFERENCE IN TERMS
OF REDUCING MORTALITY AND SAVING
LIVES.
PREVENTION REFERS TO THE
PREVENTION OF HIGH RISK
PRESCRIBING PRACTICES, HIGH RISK
OPIOID DOSES OR HIGH DOSE
OPIOIDS AND CO-PRESCRIPTION OF
OPIOIDS AND BENZODIAZEPINES.
RESCUE INCREASING ACCESS TO
NALOXONE.
I WILL TOUCH ON THAT
LATER.
WE ARE PUTTING A LOT OF
ACCESS TO TREATMENT.
PRIMARILY
MEDICATIONS FOR ADDICTION
TREATMENT AND THESE INCLUDE
MEDICATIONS SUCH AS METHADONE
AND MORPHINE.
WE ARE A NATIONAL
LEADER IN PEER BASED RECOVERY.
WE HAVE CREATED A SIGNIFICANT
NUMBER OF PEERS WHO HAVE
EXPERIENCED ADDICTION
THEMSELVES, ARE TRAINED AND
CERTIFIED AND ARE DEPLOYED
THROUGHOUT THE STATE TO MEET
PEOPLE WHEREVER THEY, WHEREVER
THEY ARE AND MAYBE AT RISK FOR
OVERDOSE BE THAT.
EMERGENCY
DEPARTMENTS OR PRISONS OR OUT AT
THE STREET AND THEY MAKE CONDUCT
WITH THOSE FOLKS AND TRY TO
ENGAGE THEM WITH SERVICES.
SO
THAT'S JUST A BRIEF OVERVIEW OF
OUR PLAN.
ANOTHER IMPORTANT
COMPONENT OF THE PLAN WHICH I'LL
FOCUS ON NOW IS THE CREATION OF
A PUBLIC DASHBOARD WE RECOGNIZE
VERY EARLY THAT WE WANTED TO BE
ABLE TO PUBLICLY TRACK THE
STATE'S OVERDOSE EPIDEMIC AND
HOW TO ADDRESS THIS.
WE SPENT A
LOT OF TIME ASSURING DATA
QUALITY AND CREATING DATA
MANAGEMENT SYSTEMS SUCH THAT WE
COULD TRANSFER DATA IN NEAR
REALTIME ANALYZE AND IT PRESENT
IT TO STAKEHOLDERS IN THE
PUBLIC.
WE'LL TALK ABOUT THAT
HOW WE DID THAT TODAY.
FIRST OF
ALL I'LL FOCUS ON JUST THE GOALS
OF THE OVERDOSE DASHBOARD.
THESE WERE IDENTIFIED THROUGH A
STAKEHOLDER ENGAGEMENT PROCESS
AND THROUGH THE DRAFTING OF THAT
STRATEGIC PLAN.
THE INITIAL
CONCEPTION THAT I HAD FOR THE
DASHBOARD WAS THAT IT WOULD BE A
SURVEILLANCE TOOL.
WE WOULD
JUST USE IT TO TRACK OVERDOSE
RELATED EVENTS OVER TIME.
IT
BECAME OBVIOUS, VERY QUICKLY
THROUGH THAT STAKEHOLDER
ENGAGEMENT PROCESS THAT PEOPLE
NEEDED MORE.
THEY WANTED A
CENTRALIZED RESOURCE FOR
INFORMATION ON WHERE TO FIND
RESOURCES, WHERE TO BUY
NALOXONE, TO SEEK TREATMENT IN
THEIR COMMUNITIES AND --
HISTORICALLY DATA EVEN IN A
SMALL STATE LIKE RHODE ISLAND
HAD BEEN VERY SILOED.
IT WAS
DIFFICULT TO SHARE AND
IMPORTANTLY LINK DATA THROUGH
THE -- ACROSS AGENCIES AND SO
WE'VE CREATED WAYS TO ELIMINATE
THOSE SILOS THAT I WILL TALK
ABOUT TODAY.
WE WILL ALSO USE
THE DASHBOARD FOR EMERGING
ISSUES AND AS I MENTION THE
FINAL GOAL WAS TO TRACK OUR
ACTION PLAN TO HOLD US
ACCOUNTABLE TO MAKING SURE WE
ARE MAKING PROGRESS WHERE WE ARE
PUTTING RESOURCES AND MONEY
INTO.
A LOT OF PEOPLE ASK ME
WELL, WHAT DID THIS ACTUALLY
TAKE TO ACCOMPLISH THIS?
OTHER
STATES AND REGIONS ARE
INTERESTED IN THESE DASHBOARDS
SO I LIKE TO BE UPFRONT ABOUT
WHAT RESOURCES WE NEEDED TO
ACCOMPLISH WHAT I WILL BE
SHOWING YOU THROUGHOUT THE
PRESENTATION.
FIRST OF ALL A
LOT OF CONTENT EXPERTISE.
FIRST
RESEARCHERS SUCH AS MYSELF AND
AS COMMUNITY BASED ORGANIZATIONS
THAT WORK WITH PEOPLE THAT ARE
EFFECTED BY OVERDOSE AND
EXPERIENCING ADDICTION.
THEY
WERE REALLY CENTRAL TO
DEVELOPING THE DASHBOARD AS
YOU'LL SEE IN THE MESSAGES WE
PRESENT.
SO WE REALLY WORKED ON
FOSTERING COMMUNITY
PARTNERSHIPS.
WE CONVENE A DATA
WORKING GROUP TO START TO
UNDERSTAND WHAT THE SILOS WERE
AND HOW WE COULD ELIMINATE THOSE
SILOS TO SHARE DATA MORE
SEAMLESSLY AND THAT TOOK A LOT
OF DIFFERENT EXPERTISE.
IT ALSO
TOOK SKILL SETS IN TERMS OF
ANALYSIS AND DATA VISUALIZATION
AND WE COLLABORATE HERE AT
BROWN.
WE HAVE DATA SCIENTISTS
THAT WORK ON THE WEBSITE AT
BROWN BUT THEY WORK CLOSELY WITH
THE DOH AND OUR DEPARTMENT OF
BEHAVIORAL HEALTH TO VISUALIZE
AND UNDERSTAND THAT DATA.
AS
YOU'LL SEE, WE USE A LOT OF
DIFFERENT DATA MANAGEMENT AND
SOFTWARE TOOLS.
MANY OF OUR
VISUALIZATIONS ARE DONE IN A
SOFTWARE CALLED TABLEAU WHICH IS
A BUSINESS ANALYTIC SOFTWARE
PROGRAM.
IT'S VERY WEB-FRIENDLY
AND AS YOU'LL SEE VERY
INTERACTIVE AND DOES A GOOD JOB
AT COMMUNICATING HEALTH
INFORMATION.
WE USE MAPPING
TOOL TO DISPLAY INFORMATION
GEOGRAPHICALLY.
PEOPLE LIKE TO
SEE INFORMATION AT THEIR TOWN
LEVEL.
HOW IS OVERDOSE
EFFECTING MY COMMUNITY AND WHAT
CAN I DO TO ADDRESS IT SO WE TRY
THROUGH OUR MAPS TO BE AS LOCAL
AS POSSIBLE IN THE PRESENTATION
OF THE DATA.
THE WEBSITE ITSELF
IS JUST BUILT IN WORDPRESS
THERE'S FAIRLY EASY WEBSITE TOOL
TO BUILD SOMETHING LIKE THIS AND
THEN SOME OTHER DATABASE
SOFTWARE SUCH AS SQL AND I WILL
TALK ABOUT STRONGHOLD WHICH IS
OUR SECURE COMPUTING ENVIRONMENT
A LITTLE BIT MORE.
THE FUNDING
FOR THIS A LOT OF PEOPLE ASK ME
COMES FROM THE CDC.
WE WERE ONE
OF THE STATE TO RECEIVE A
PREVENTION DRUG OVERDOSE FOR
STATE'S GRANT AND A SUPPLEMENT
AS WELL AND SO THE FUNDING FOR
THIS PROJECT ACTUALLY COMES
THROUGH THAT CDC GRANT AND I'M
HAPPY TO AFTERWARDS, GIVE PEOPLE
SOME IDEA OF HOW MUCH IT
ACTUALLY COSTS US TO BOTH BUILD
THE WEBSITE AND TO MAINTAIN IT
YEAR OVER YEAR.
SO JUST TO
HIGHLIGHT A LITTLE BIT ABOUT HOW
WE ELIMINATED SOME DATA SILOS
THAT EXISTED HERE IN RHODE
ISLAND.
ALL OF THIS DATA OF
COURSE IS VERY SENSITIVE ON
OVERDOSE DEATHS AND TREATMENT
RECORDS WHICH I'M SURE MANY OF
YOU KNOW ARE SUBJECT TO A LOT OF
FEDERAL LAWS IN AND ARE HIGHLY
SENSITIVE INFORMATION.
WE USE A
RESOURCE HERE AT BROWN CALLED
STRONGHOLD THIS IS A SECURE
COMPUTING AND STORAGE
ENVIRONMENT FOR ALL BROWN
RESEARCHERS TO ANALYZE SENSITIVE
DATA.
IT MEETS THE SECURITY
ENVIRONMENTS AND CONTROLS FOR
HIPAA AND MANY OTHER FEDERAL
REGULATIONS SO STRONGHOLD ALLOWS
US TO ACTUALLY TRANSFER
INDIVIDUAL LEVEL DATA FROM THE
STATE HERE TO BROWN, AND THEN DO
A LOT OF INTERESTING THINGS WITH
IT.
WE CAN ANALYZE IT WITHIN
THE STRONGHOLD ENVIRONMENT AND
ALSO LINK THE DATASETS TOGETHER
I'LL SHOW YOU THE BENEFITS OF
THOSE LINKAGE PROJECTS IN A
MOMENT AND THIS IS REALLY HOW WE
ELIMINATED SOME OF THESE DATA
SILOS WAS THROUGH THIS COMPUTING
INFRASTRUCTURE.
EVERYTHING IS
KEPT IN THE STRONGHOLD LOCKDOWN
AND MEETS ALL THESE FEDERAL
REQUIREMENTS.
WE ALSO HAVE IOBS
AND OTHER POLICIES WE DEVELOPED
WITH THE STATE FOR EXAMPLE
AROUND SHARING SMALL NUMBERS
THAT WE ADHERE TO SO WE DON'T
INADVERTENTLY DISCLOSE DATA
OCCURRING IN TOWNS FOR EXAMPLE.
AS I'LL TALK ABOUT NOW,
STRONGHOLD ALSO ALLOWS US TO
CONDUCT DETERMINISTIC LINKAGES
BETWEEN DATASETS USING
IDENTIFIERS SUCH AS NAMES AND
DATES OF BIRTH AND THAT'S
ALLOWED US TO EVALUATE SOME
INTERESTING PROGRAMS AND TO
CONDUCT SOME GREAT RESEARCH
WHICH I'LL TALK ABOUT NOW.
SO
ONE FOCUS FOR US IS PEOPLE WHO
ARE RECENTLY RELEASED FROM THE
CORRECTIONAL SYSTEM.
WE WERE
ABLE TO LINK OUR STATE'S
CORRECTIONAL RECORDS WITH OUR
OVERDOSE DEATH DATASET TO
IDENTIFY HOW MANY PEOPLE ARE
RELEASED FROM OUR PRISON/JAIL
SYSTEM AND ARE DYING WITHIN ONE
YEAR AND AS YOU CAN SEE HERE
THIS FIGURE SHOWS YOU THE DRUG
OVERDOSES OVER TIME IN BLUE AND
THE NUMBER OF PEOPLE IN THOSE
TOTAL DEATHS WHO ARE RELEASED
FROM OUR CORRECTIONAL SYSTEM
WITHIN ONE YEAR OF OUR DEATH AND
AS YOU CAN SEE ABOUT 12-15% OF
ALL OVERDOSE FATALITIES OCCUR
WITHIN THE CORRECTIONAL SYSTEM.
THAT'S AN ISSUE FOR US AND MANY
OTHER STATES AS WELL SO WE
DEVELOPED AN INNOVATIVE PROGRAM
TO ADDRESS THAT DATA.
WE'RE THE
FIRST STATE IN THE NATION TO
PROVIDE MAT, AND NALTREXONE TO
ALL INDIVIDUALS IN THE
CORRECTIONAL SYSTEM WHO ARE
INDICATED FOR THESE THERAPIES.
THERE'S UNIVERSAL SCREENING FOR
OPIOID USE DISORDER AND
INITIATION OF THESE TREATMENTS
FOR PEOPLE WHO WOULD LIKE THESE
THERAPIES.
AND THEN THESE
PEOPLE ARE PROVIDED WITH
REFERRALS AND ACCESS TO
COMMUNITY BASED SERVICES WHEN
THEY'RE RELEASED.
AND THIS
PROGRAM REALLY STARTED IN 2016
AND HAS -- WE'RE STARTING TO SEE
THE SUCCESS OF THIS PROGRAM NOW
THIS IS AN ARTICLE RELEASED JUST
IN FEBRUARY A COUPLE OF WEEKS
AGO IN PSYCHIATRY WE USED THAT
RECORD LINKAGE WHICH I TALKED
ABOUT TO LOOK TO SEE OVER TIME
AGAIN HOW MANY PEOPLE ARE
RELEASED FROM OUR CORRECTIONAL
SYSTEM AND ARE EXPERIENCING AN
OVERDOSE DEATH WITHIN A YEAR OF
RELEASE.
WE DID A PRE AND POST
EVALUATION HERE.
THE FIRST
26 -- FIRST 6 MONTHS OF 2016 THE
PROGRAM WAS IMPLEMENTED AND YOU
CAN SEE THE NUMBER OF PEOPLE WHO
DIED OF AN OVERDOSE AND THIS
DECREASED SIGNIFICANTLY BY 65%
JUST IN THAT SHORT PERIOD AND WE
BELIEVE THAT'S LARGELY
ATTRIBUTED TO THE MAT PROGRAM IN
OUR CORRECTIONAL SYSTEM AND THAT
65% INCREASE IS ACTUALLY LED TO
A 12% OVERALL DECREASE IN DRUG
OVERDOSE DEATHS STATEWIDE SO
THERE'S ONE PROGRAM APPEARS TO
BE MAKING IMPORTANT INROADS INTO
OUR DRUG OVERDOSE EPIDEMIC HERE
IN RHODE ISLAND AND A LOT OF
THIS AGAIN RELIES ON THE DATA TO
UNDERSTAND THE PROBLEM AND THEN
AS WE'RE NOW DOING, EVALUATE ITS
SUCCESS AND THERE'S A PROGRAM
NOW TO EVALUATE THIS PROGRAM IN
MORE DETAIL.
SO THAT'S SORT OF
HOW WE DO IT. AND IN THE NUTS
AND BOLTS OF THE DASHBOARD, AND
I WANTED TO HIGHLIGHT BEFORE I
GET INTO SOME EXAMPLES OF WHAT
IS ON THE DASHBOARD ITSELF IS
MANAGING QUALITY AND CONSTANTLY
IMPROVE THING -- IMPROVING THIS
TOOL IS VERY IMPORTANT TO US.
YOU CAN COMMENT AND PROVIDE US
WITH FEEDBACK ON THE WEBSITE AND
THAT ALLOWS ONGOING MONITORING
AND I UPDATE THE TASK FORCE WITH
HOW TO OBTAIN FEEDBACK ON THE
WEBSITE ITSELF AS WELL.
I WANT
TO HIGHLIGHT THAT ONE ISSUE WE
HAD TO DEAL WITH WHEN WE FIRST
STARTED THIS STRATEGIC PLAN WAS
THAT WE WERE RECEIVING A LOT OF
DATA AND AS SORT OF DUMPED UPON
US ONTO ANALYZE AND THAT'S NOT
REALLY EFFECTIVE TO --
UNDERSTAND HOW WE'RE RESPONDING
TO AN OVERDOSE EPIDEMIC OVER
TIME.
WE REALLY NEED STANDING
DATA SHARING AGREEMENTS TO
SUPPORT FREQUENT DATA REFRESHES
AND WEBSITE UPDATES SO DATA IS
TRANSFERRED TO US THROUGH
STRONGHOLD ON A SET SCHEDULE.
IT DEPENDS ON THE DATASET IN
QUESTION FOR OVERDOSE DEATHS FOR
EXAMPLE WE RECEIVE THAT
INFORMATION MONTHLY AND THAT
ALLOWS US TO KEEP ON TOP OF THE
EPIDEMIC AND MAINTAIN IT'S
USEFULNESS IN CLOSE TO REALTIME
HOW WE'RE DOING AND WHERE THE
EPIDEMIC IS. AND FINALLY
ANOTHER THING WE LEARNED THROUGH
OUR STAKEHOLDER ENGAGEMENT
PROCESS AND SOME ADDITIONAL
EVALUATIONS WE'RE DOING
CONDUCTING QUALITATIVE
INTERVIEWS WITH PEOPLE WHO HAVE
OVERDOSED AND WHO MAY HAVE
OPIOID USE DISORDER IS AN
EMPHASIS ON CLEAR VISUALS, PLAIN
LANGUAGE AND DATA FOCUSED
MANAGING IS REALLY EFFECTIVE FOR
US.
YOU'LL SEE OTHER OVERDOSE
PREVENTION WEBSITES WHICH ARE
VERY DRAMATIC, VERY SHOCKING,
THEY HAD PICTURES OF DEATH AND
DESPAIR AND THOSE WERE NOT SEEN
AS EFFECTIVE BY PEOPLE WHO ARE
AT RISK OF OVERDOSE.
PEOPLE
REALLY WANTED PROFESSIONAL
FOCUSED MESSAGES THAT WAS ACTION
ORIENTED WHAT CAN I DO IN MY
TOWN OR MY FAMILY TO HELP
ADDRESS THIS EPIDEMIC?
SO THAT
FOCUS ON DATA FOCUS MESSAGING,
ACCESS FOCUS MESSAGING IN PLAIN
LANGUAGE PERMEATES THE FEEL OF
THE ENTIRE WEBSITE SO WITHOUT
FURTHER ADO I WILL SHOW YOU THE
FRONT PAGE, THE LANDING PAGE OF
THE WEBSITE CALLED PREVENT
OVERDOSE.
YOU CAN SEE HERE
AGAIN, THERE IS A CLEAN LOOK,
NOT A LOT OF DRAMATIC IMAGES AND
SORT OF NEUTRAL COLOR AND VERY
CLEAR MESSAGING AS WELL.
AND
BOXES BELOW THAT HAVE -- THAT
PROVIDE AUDIENCE SPECIFIC
INFORMATION IF YOU'RE A FAMILY
OR FRIEND, SOMEONE AFFECTED BY
OVERDOSE, A FIRST RESPONDER OR
SOMEONE WHO NEEDS HELP THERE'S
RESOURCES SPECIFIC TO THOSE
GROUPS.
SO THIS TALK IS ABOUT
DATA.
SO I'M GOING TO FOCUS THE
REST ON THE DATA WE GET AND WHAT
WE DO WITH IT.
THIS IS A
SUMMARY OF THE DATA THAT
POPULATES THE DASHBOARD, PREVENT
OVERDOSE.
I TALKED A LITTLE BIT
ABOUT OUR OVERDOSE DEATH DATASET
WHICH WE RECEIVE MONTHLY FROM
THE MEDICAL EXAMINERS OFFICE
HERE IN RHODE ISLAND AND WE LINK
THAT DATA TO THE RHODE ISLAND
DEPARTMENT OF CORRECTIONS WHICH
I SHOWED YOU ALREADY.
WE ALSO
TRACK EMERGENCY DEPARTMENT
VISITS FOR OVERDOSE IN 2014 I
WANT TO SAY, THE RHODE ISLAND
DEPARTMENT OF HEALTH PROMULGATED
A REGULATION THAT ALL ED
DEPARTMENTS, EMERGENCY
DEPARTMENTS HAD TO REPORT
SUSPECTED OVERDOSE CASES WITHIN
48 HOURS OF THEIR OCCURRENCE.
THAT'S CALLED THE 48 HOUR
REPORTING SYSTEM.
HOSPITALS
MUST REPORT THESE WITHIN 48
HOURS.
THAT DATA IS COLLECT BY
THE RHODE ISLAND DEPARTMENT OF
HEALTH SENT TO US ON A BIWEEKLY
BASIS, ANALYZED BY MY TEAM AT
BROWN AND THEN UPLOADED ONTO THE
WEBSITE AND THAT'S PROBABLY THE
MOST, I WOULD SAY CLOSE TO
REALTIME DATASET THAT WE HAVE
ARE THOSE EMERGENCY DEPARTMENT
VISITS.
WE ALSO WORK WITH THE
RHODE ISLAND DEPARTMENT OF
HEALTH, LOOKING AT DATA ON
TREATMENT ADMISSIONS THROUGH THE
STATE, ALL LICENSED SUBSTANCE
USE DISORDER TREATMENT
FACILITIES, PROVIDE THIS TO THE
DEPARTMENT OF HEALTH AND WE
ANALYZE THAT DATA AND PRESENT IT
TO THE WEBSITE.
WE CARE A LOT
ABOUT PROMOTING, IMPROVING
ACCESS TO MEDICATIONS FOR
ADDICTION TREATMENT OR
MEDICATION ASSISTED THERAPIES,
MAT AND THAT DATA COMES FROM A
NUMBER OF DIFFERENT SOURCES THE
PDMP, AROUND PRESCRIPTIONS, OUR
DEPARTMENT OF HEALTH, WITH
OPIOID TREATMENT PROGRAM.
UTILIZATION.
AND ALSO
INFORMATION, FEDERALLY, FROM
SAMHSA ON PHYSICIANS WHO ARE --
PROVIDERS I SHOULD SAY WHO ARE
ABLE TO PRESCRIBE THIS IN OUR
STATE.
NALOXONE DATA IS THE
FINAL ONE.
THIS IS RATHER
TRICKY.
NALOXONE IS DISTRIBUTED
THROUGH MANY DIFFERENT SOURCES
SO WE'VE HAD TO WORK WITH A LOT
OF DIFFERENT INSTITUTIONS TO
BUILD A ROBUST NALOXONE
DISTRIBUTION INFRASTRUCTURE.
WE
WORK WITH THE DEPARTMENT OF
HEALTH, OTHER AGENCIES, THE
DEPARTMENT OF CORRECTIONS
DISTRIBUTES NALOXONE TO RELIEF
FEES: COMMUNITY BASED
ORGANIZATIONS.
WE ALSO DO
ACTUALLY RECEIVE INFORMATION ON
NALOXONE DISTRIBUTION FROM THE
THREE LARGEST PHARMACY CHAINS IN
RHODE ISLAND AS WELL.
SO I
WANTED TO MOVE NOW AND TALK A
LITTLE BIT MORE ABOUT OVERDOSE
DEATHS.
BOTH AT THE NATIONAL
AND STATE SYSTEM I'LL TALK ABOUT
WHAT THE SURVEILLANCE LOOKS LIKE
NATIONALLY.
REALLY THE BEST
PLACE TO FIND NATIONAL OVERDOSE
SURVEILLANCE IS FROM THE
NATIONAL CENTER FOR HEALTH
STATISTICS AT THE CDC COLLECTS
INFORMATION ON VITAL RECORDS
THROUGH THE NATIONAL VITAL
STATISTICS SYSTEM OR NVSS AND
THIS PROGRAM IS A COLLABORATIVE
PROGRAM THAT WORKS WITH ALL
FIFTY STATE TO RECEIVE DATA FROM
STATES VITAL STATISTICS OFFICES
ON DEATH RECORDS.
AND CAUSES OF
DEATH.
THEY HAVE A SEPARATE
WEBSITE NOW ON PROVISIONAL
OVERDOSE DEATHS AS I WILL TALK
ABOUT THEY IMPROVED THE
TIMELINESS OF THIS REPORTING
SYSTEM.
SO I ENCOURAGE YOU
AFTERWARDS TO GO TO THIS WEBSITE
AND LOOK MORE AT THE NATIONAL
STATISTICS ON DRUG OVERDOSE
DEATH THROUGH THIS PORTAL.
SO
TO TALK ABOUT THE SYSTEM A
LITTLE BIT MORE, STATE VITAL
REGISTRATION OFFICES SENDS DEATH
RECORDS TO THE NATIONAL CENTER
FOR HEALTH STATISTICS.
THESE
DEATHS ARE REPORTED BY THE
JURISDICTION IN WHICH THE DEATH
OCCURRED.
SO I SHOULD CLARIFY
THAT, OFTEN IN RHODE ISLAND, WE,
WELL, NOT OFTEN BUT SOMETIMES WE
HAVE AN OVERDOSE HAPPEN
OUT-OF-STATE BUT IS TRANSPORTED
TO ONE OF OUR HOSPITALS AND THE
DEATH IS PRONOUNCED IN RHODE
ISLAND THAT WOULD BE COUNTED AS
AN RHODE ISLAND OVERDOSE AND
REPORTED TO THE NATIONAL SYSTEM
TO OUR DEPARTMENT OF HEALTH.
CAUSES OF DEATH ARE CODED
ACCORDING TO THE IDC GUIDELINES
BOTH ON THE DRUG THAT CAUSED THE
DEATH AND ALSO THE MANNER OF
THAT DRUG OVERDOSE DEATH BE THAT
AN DIDN'T, INTENTIONAL, A
HOMICIDE OR SOMETIMES
UNDETERMINED.
ONE OF THE MAJOR
ISSUES WITH THIS SYSTEM IS THAT
THERE'S A SIGNIFICANT LAG TIME
BETWEEN WHEN THE DEATH OCCURRED
AND WHEN DATA ARE AVAILABLE FOR
ANALYSIS NATIONALLY.
THIS USED
TO BE AROUND 12 MONTHS BEFORE
DATA WAS ACTUALLY SUBMITTED,
ANALYZED BY THE NCHS, ANALYZED
AND THEN PUBLISHED.
THOSE
PROVISIONAL ESTIMATES, AND THAT
PROVISIONAL WEBSITE I SHOWED IN
THE PREVIOUS SLIDE NOW REPORTS
PROVISIONAL ESTIMATES EVERY SIX
MONTHS SO THAT'S ABOUT SIX MONTH
DELAY IF YOU GO ON THAT WEBSITE
YOU MIGHT SEE DATA THROUGH SAY,
AUGUST OR SEPTEMBER.
A COUPLE
OF LIMITATIONS OF THIS DATASET
IS THAT NOT ALL JURISDICTIONS
RECORD THE DRUG THAT CAUSED THE
OVERDOSE IN THE SAME WAY.
SOME
JURISDICTIONS JUST SIMPLY SAY
THIS DEATH WAS AN OVERDOSE OF
ACUTE DRUG TOXICITY.
A RECENT
PAPER CAME OUT THAT LOOKED AT
THIS PROCESS STATE BY STATE AND
FOUND THAT STATES ACTUALLY VERY
TREMENDOUSLY IN THE DEGREE TO
WHICH THEY REPORT THE SPECIFIC
DRUGS THAT CAUSED THE OVERDOSE
DEATH.
WE DO THE BEST IN RHODE
ISLAND ALMOST 100% OF OUR DEATHS
ARE CODED AS HAVING SPECIFIC
DRUGS THAT CAUSED THAT FATALITY
ONLY AROUND HALF THE TIME IN
SOME OTHER STATES.
SO YOU MIGHT
HAVE SEEN IN THE NEWS LAST YEAR
THAT THIS DOES RESULT IN AN
UNDERESTIMATE OF DRUG SPECIFIC
FATAL OVERDOSES THE TOTAL NUMBER
OF OVERDOSES MAY STILL BE
ACCURATE BUT IF YOU DRILL DOWN
AND LOOK, FOR EXAMPLE, AT HEROIN
RELATED OVERDOSES THOSE MAY BE
UNDERREPORTED IN JURISDICTIONS
AND THAT'S SIMPLY A FUNCTION OF
THE WAY THAT THE CASES ARE CODED
BY LOCAL VITAL RECORDS OFFICES
AND THEN REPORTED TO THE
NATIONAL CENTER FOR HEALTH
STATISTICS.
SO TO GET AROUND
SOME OF THESE ISSUES, BOTH
TIMELINESS AND THEN ALSO TO GET
MORE DETAIL ON THE DRUG OVERDOSE
DEATHS, WE WORKED DIRECTLY WITH
THE OFFICE OF THE STATE MEDICAL
EXAMINER, THE OSME.
THEY ARE
CHARGED WITH INVESTIGATING ALL
UNNATURAL DEATHS AND SEND US
THEIR DATA AS I MENTIONED ON A
MONTHLY BASIS AND WE WORK WITH
THE RHODE ISLAND DEPARTMENT OF
HEALTH TO ANALYZE THOSE CASES
AND LOOK INTO MORE DETAIL INTO
WHAT CAUSED THOSE DEATHS, THE
CHARACTERISTICS OF THE DECEDENTS
AND EVEN THE EXACT ADDRESS TO
WHICH ALL OVERDOSES OCCURRED.
IT'S A VERY RICH DATASET TO DO
SOME INTERESTING DATA LINKAGES.
THE STANDARD SYSTEM I SHOW SORT
OF IN THIS CIRCLE THE MEDICAL
EXAMINER WILL ALSO ONCE THEY
INVESTIGATE THE DEATHS, SEND
THAT INFORMATION TO OUR STATE
OFFICE OF VITAL RECORDS WHICH
WILL UPDATE THE DEATH
CERTIFICATE AND THEN SEND THE
DEATH CERTIFICATE TO THE CDC
WHICH CODES THAT DEATH ACCORDING
TO IDC-10 GUIDELINES AND THAT
INFORMATION GOES BACK TO THE
LOCAL JURISDICTIONS AND THE
FINAL DEATH CERTIFICATES ARE
RECORDED.
SO, AGAIN, THIS IS A
RATHER SLOW PROCESS THAT TAKES
6-12 MONTHS.
WE ARE ABLE TO GET
THE DATA MONTHLY BY WORKING
DIRECTLY WITH OUR MEDICAL
EXAMINERS OFFICE.
WE WILL FOCUS
ON HOW WE USE THIS DATA.
ONE
WAY IS BY LOOKING AT THE DATA ON
A MONTHLY BASIS.
WE CAN UPDATE
OUR OVERDOSE DEATH NUMBERS MORE
FREQUENTLY SO THIS IS OUR
EPIDEMIC OVER TIME IN RHODE
ISLAND FROM 2009 AND THE MOST
RECENT DATA I PULLED LAST WEEK
THE 2017 DATA INCLUDES
JANUARY-NOVEMBER SO WE'RE ON A
THREE MONTH DELAY IN REPORTING
DRUG OVERDOSE DEATHS AND THAT'S
SIMPLY BECAUSE DRUG OVERDOSES
TAKE SOME TIME TO INVESTIGATE AT
THE MEDICAL EXAMINER'S OFFICE.
THEY HAVE TO INVESTIGATE WITNESS
TO DETERMINE IF THAT OVERDOSE
WAS ACCIDENTAL OR INTENTIONAL.
SO THAT DELAY IS STILL PRESENT
AND WE'VE BEEN ABLE TO GET OUR
STATISTICS MORE FREQUENTLY THAN
MANY OTHER STATES.
WE STILL
HAVE DECEMBER TO GO TO CLOSE OUT
THOSE CASES BUT PROJECTION WE'VE
DONE LOOKS LIKE WE'LL FINISH
2017 AT AROUND PERHAPS 305-310
WHICH DOES REPRESENT ABOUT AN 8%
DECREASE SINCE 2016.
WHICH IS
CERTAINLY NOT A HUGE SUCCESS.
WE HAVE A LONG WAYS TO GO HERE
IN RHODE ISLAND BUT I BELIEVE
SOME OF OUR EFFORTS ARE STARTING
TO PAY OFF SUCH AS OUR JAIL,
PRISON, MAT SYSTEM.
SO THIS IS
THE KINDS OF THINGS WE CAN DO
WITH SUCH A RICH DATASET.
WE
HAVE WHERE THE FATALITIES OCCUR
OUR TEAM AGGREGATES THAT DATA TO
THE ZIP CODE AND THE TOWN LEVEL
IS ABLE TO PREVENT THAT
INFORMATION GRAPHICALLY ON OUR
WEBSITE.
THIS FIGURE SHOWS YOU
THE NUMBER OF OVERDOSES.
THE
YELLOW INDICATES MORE.
THIS WAS
GENERATED IN TABLEAU.
YOU CAN
GO OVER TOWNS AND IT WILL GIVE
YOU THE TOWN AND THE RATE AND
THEN THE FIELDS IN THE BOTTOM
ALLOW YOU TO TOGGLE THE GRAPH ON
THE WEBSITE AND YOU CAN CHANGE
THE YEARS, YOU CAN CHANGE THE
MAP TO COLOR THE MAP BY ACCOUNTS
OR RATE TO REALLY DRILL DOWN AND
ALLOW YOU TO SEE IN YOUR TOWN
WHAT THE RATE AND NUMBER IS YEAR
OVER YEAR AND WE'VE HAD A LOT OF
GOOD FEEDBACK ON THIS.
PEOPLE
LIKE TO KNOW WHAT THE OVERDOSE
EPIDEMIC LOOKS LIKE IN THEIR
TOWN.
I'LL SHOW BRIEFLY A
COUPLE OTHER EXAMPLES OF HOW WE
USED THE DATA.
I WANT TO FOCUS
ON SOME OF THE NALOXONE AND
TREATMENT MAPS NOW.
THIS IS
ANOTHER MAP WE PUT TOGETHER
WHICH WE CALLED AN NARCAN TOOL.
WE COLLECT INFORMATION ON
NALOXONE DISTRIBUTION FROM MANY
DIFFERENT SOURCES SO WE HAVE A
FAIRLY GOOD IDEA OF HOW MANY
NALOXONE KITS EACH TOWN IS
RECEIVING EACH YEAR.
WE HAVE
COMMUNITY PHARMACIES, WHAT HAVE
YOU.
WE'RE ABLE TO OVERLAP THAT
NALOXONE ON THE OPIOID OVERDOSE
DEATH AT THE TOWN LEVEL AND
COMPARE THOSE NUMBERS.
SO THIS
MAP SHOWS YOU A RATIO.
THE
NUMBER OF OVER -- NALOXONE KITS
THAT EACH TOWN RECEIVED DIVIDED
BY THE OPIOID OVERDOSE DEATH SO
THAT'S THE RATIO.
AND THEN THE
MAP ALLOWS YOU TO SET A TARGET.
SOMEWHAT OF AN ARBITRARY TARGET
IN THIS CASE IT'S TWENTY.
IN
THIS TOWN LET'S SAY IT'S TWENTY
KITS FOR EVERY DEATH.
THIS TOWN
GIVES YOU A LOOK AT WHICH TOWNS
MET THAT TARGET.
SO PROVIDENCE
HAS VERSUS OTHER TOWNS THAT HAVE
NOT MET THAT TARGET, MORE
YELLOW.
IF YOU TOGGLE OVER YOU
WILL SEE HERE IN THE SOUTHWEST
PART OF THE STATE 235 KITS WERE
DISTRIBUTED IN 2017.
THIS WAS A
PRETTY RURAL TOWN AND THERE WERE
SIX OVERDOSE DEATHS FROM
JANUARY-SEPTEMBER ACCORDING TO
THAT TARGET NO MORE IS NEED.
IT'S NOT THE TARGET THAT IS
IMPORTANT HERE.
IT'S MORE A
TOOL TO PROVIDE COMMUNITY BASED
ORGANIZATIONS, INFORMATION ON
TOWNS THAT ARE UNDERRESOURCED
COMPARED TO THEIR OPIOID
OVERDOSE BURDEN AND TARGET OR
DEPLOY RESOURCE TO ENSURE EQUITY
OF NALOXONE DISTRIBUTION ACROSS
OUR STATE.
FOCUSING HERE ON THE
TOWNS THAT ARE YELLOW.
WE ALSO
HAVE A LOT OF TREATMENT
INFORMATION ON THE WEBSITE.
SO
THIS IS A SCREENSHOT OF OUR
TREATMENT PAGE.
WE HAVE A
HOTLINE TO GET REFERRED TO MANY
TYPES OF RESOURCES.
WE HAVE
INFORMATION ON DETOX,
OUTPATIENT, RESIDENTIAL, MAT AND
OTHER PEER TO PEER PROGRAMS
ACROSS THE STATE.
ALL OF THIS
IS DISPLAYED IN A MAP.
SO
PEOPLE CAN LOOK TO SEE IN THEIR
TOWN WHERE ARE THE TREATMENT
CENTERS WHAT, IS PROVIDED, WHAT
INFORMATION, WHAT THEIR HOURS
ARE, WHAT THEIR NUMBERS ARE AND
SO FORTH SO THIS IS AN EXAMPLE
THAT WILL PROVIDE LOCAL
INFORMATION TO TREATMENT
RESOURCES AT THE TOWN LEVEL.
I'LL JUST SPEND A COUPLE OF
MINUTES NOW SHOWING EXAMPLES OF
SOME OF THOSE OTHER GOALS.
ONE
WAY THAT WE USE THE WEBSITE IS
TO COMMUNICATE EMERGING HEALTH
ISSUES.
OVER 60% OF DEATHS ARE
DUE TO FENTANYL.
SO THAT'S A
HUGE CRISIS IN OUR STATE.
THERE'S A LOT OF RESOURCES ON
THE WEBSITE SPECIFIC TO
FENTANYL.
THERE'S INFOGRAPHICS
THAT CAN BE DISTRIBUTED THROUGH
OUTREACH TEAMS OR IN OTHER
VENUES SUCH AS A SHELTER.
WE
DEVELOPED INFOGRAPHICS THAT HAVE
CLEAR MESSAGING AROUND WHAT
SOMEONE CAN DO IN THE EVENT OF A
FENTANYL OVERDOSE.
CARRY
NALOXONE.
DON'T USE ALONE AND
CALL 911.
ARE REALLY THE
MESSAGES RIGHT NOW THAT WE'RE
TRYING TO GET OUT TO FOLKS.
BOTH TO PREVENT FENTANYL AND
REALLY ALL OPIOID OVERDOSES.
AND FINALLY, I'LL SHOW YOU AN
EXAMPLE OF HOW WE USE THE
WEBSITE TO TRACK OUR ACTION PLAN
SO IF YOU GO TO THE TRACKER
ACTION PLAN PAGE ON THE WEBSITE
YOU'LL SEE A REALLY CLEAR
INFOGRAPHIC THAT DESCRIBES WHAT
WE'RE TRYING TO DO WHICH IS SAVE
LIVES.
OUR GOAL WAS TO REDUCE
OVERDOSE DEATHS BY ONE-THIRD IN
THREE YEARS.
WE'RE NOT THERE
UNFORTUNATELY I THINK LARGELY
DUE TO THE EMERGENCE OF FENTANYL
WE'VE SEEN INCREASES YEAR OVER
YEAR AND NOW PERHAPS A
STABILIZATION OF THE EPIDEMIC IN
RHODE ISLAND OR EVEN SMALL
DECREASES BUT NONETHELESS THAT
ORIGINAL GOAL IS MADE CLEAR ON
THE WEBSITE TO PEOPLE CAN ENGAGE
WITH THAT MISSION AND THEN WE
TRACK OUR PROGRESS.
SO AS I
MENTIONED THERE ARE FOUR PILLARS
TO OUR ACTION PLAN.
ONE OF THEM
IS TREATMENT.
WE WANT TO
INCREASE ACCESS TO MEDICATIONS
FOR ADDICTION TREATMENT.
WE
WORK WITH STATE AGENCIES TO
UNDERSTAND HOW MANY PEOPLE ARE
RECEIVING THESE DRUGS SO HERE WE
WORK WITH THE PROGRAM IN THE
DEPARTMENT OF BEHAVIORAL HEALTH
TO UNDERSTAND MONTH OVER MONTH
HOW MANY PEOPLE ARE RECEIVING
THESE THERAPIES AND THIS
DASHBOARD PROVIDES YOU WITH A
QUICK TOOL TO SEE, OKAY,
MORPHINE, WE ARE SEEING
INCREASES.
SO FAR IN 2017, THE
NUMBERS HAVE NOT BEEN FINALIZED
BUT AROUND 4600 RHODE ISLANDERS
ARE ACCESSING THIS PER MONTH.
IN CONTRAST, METHADONE HAS SEEN
YEAR OVER YEAR INCREASES AND WE
ACTUALLY ACHIEVED THAT GOAL TO
ACCESSING THIS DATA LET'S US
UNDERSTAND WHAT
WE'RE
WELL
AND
NEED IMPROVEMENT.
WHAT ARE
THE
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