 Just a second, I will pull my PowerPoint up. All right. So, as Marie mentioned, I am a postdoc with the North Central Regional Center for World Development, which is hosted by Michigan State University. But I'm actually, as a postdoc, hosted at NDSU. So I'm on campus in Fargo. And prior to my postdoc, I was a parent educator for the PFRC in Region 5 in Cass County. So I still feel like I'm part of the NDSU family, although maybe I'm now sort of like a weird cousin of sorts. And if you're not familiar with NCRCRD, it's one of four regional rural development centers that work collaboratively with extension across the country and really like to focus on issues that cross regional boundaries. And of course, the opioid crisis is one of those issues that definitely crosses a lot of those boundaries. All right. So, let's see if I can... Okay. So just to kind of give you a roadmap for the next 45 minutes or so, I will start out with touching on some of the background regarding cooperative extensions recent work in this arena and then talk about the crisis itself. So that'll include some statistics on different facets of the crisis, as well as important factors involved in opioid misuse, addiction, and overdose. The majority of our time will be spent on possible ways of addressing the crisis. So this will be information from the published literature, from relevant bodies of research on what are the possible avenues for solving the crisis, and more specifically, what are the most appropriate and effective ways for extension to be involved in addressing the crisis. And then finally, we'll finish up with some examples within the NDSU extension system of projects and programs that are related to substance misuse prevention that I think exemplify some of the ideas that I'm going to talk about today. Oh, and right before we begin, I did want to just very briefly give some definitions here because a lot of times you'll hear people say opiates and opioids interchangeably, but they're actually different terms. I'm going to use the term opioids because it's more of an umbrella term. So opiates are really the naturally derived products like heroin, codeine, and morphine, whereas opioids include opiates but also synthetic and semi-synthetic drugs. So some of the big synthetics that people know about would be oxycodone, fentanyl, and methadone. So just to kind of upfront clarify, I will be using opioids as the term. And so I did want to start with a little bit of background about why I'm even talking to you about this today, and that really is because of an initiative that was requested and sponsored by ECOP that started in spring of this year, and the NCRCRD and my supervisor, Mark Skidmore, coordinated that, and we formed the Extension Opioid Crisis Response Work Group, which was a team of extension professionals from all over the country, included people from all sections of extension programming. So a lot of people from FCS, from community vitality, some 4-H, some egg, and then different ranks. So people who are community-based educators, some administrative staff, and researchers, and so it was really a nicely balanced team that came together to work on these issues. And specifically what ECOP asked us to do, there's a lot of different things, but I'm going to cover kind of the main ones here, was first to identify existing activities in the land grant system related to substance use prevention and the opioid crisis, more specifically, to organize information and resources that were identified through surveys. So we actually sent out a survey, an extension behavioral health program survey to all extension, to all land grant institutions across the nation to collect that information. And then we do have on the website we've created a report on that. And then so really the goal here was to identify needs and opportunities for land grant institutions to help address the crisis. And then we developed a strategic framework to coordinate a system-wide effort. And all of this information is posted on an e-extension website that was created so that you can see what are these resources, what's this information we've collected, and the various documents. And then once it's ready, our final report to ECOP will get posted on there as well. And so just to give you an idea of what this website is like, I've included the link there. And there are different portions of the website that you might want to visit. The About Us just describes what's the composition of the workgroup. We also had an expert partners group. And so it lists who those people are and what their affiliations are. A little bit of history on how it all started. And then really though I think what would be more interesting to most of you would be the tab on shared extension programming. If you go into there, there are eight different programs that we identified as programs being used across the nation by land grant institutions that look like they would be the kind of programs that people could fairly quickly and easily implement in their own systems. And so if you click on one of the programs, you can see more details including a description of it and sort of how it would be classified according to these different things like response types and target audiences. And importantly, you can click on there are some links to find out more information on that specific program. But then there are also these YouTube videos because the center hosted a series of approximately one-hour webinars where we invited experts on these programs to talk about sort of the nuts and bolts of the programs. And so there are YouTube recordings of those that you can find if you want to go watch them and learn a lot more about a specific program. And then of course the different resources and the ECOP final report will go on there. I believe there's a word version posted but it just, actually just yesterday reviewed the final formatted version. The Ohio State University is going to be publishing it for us so that should go out very soon. So definitely check out that website. All right, so we'll jump into some statistics here. And so this is an infographic from the Federal Health and Human Services Department with the most recent data on the epidemic. And as you can see it's not just one problem. There are a number of problems going on here that are interrelated. And I've added a few animations here to help you really appreciate the magnitude of the problem. And so here we go. So 11.4 million people misused prescription opioids in the last year. And that is almost equivalent to the combined populations of these five states that you see. So the combined populations of North Dakota, South Dakota, Kansas, Nebraska and Minnesota comes to about 12 million. So it's fairly comparable. And then over 42,000 people died from overdosing on opioids. And that's all types of opioids included together. And you can see below that's kind of parceled out into ones that are like the most common opioids that are prescribed versus synthetics versus heroin. But 42,000, just over 42,000. And that is roughly equivalent to the population of the city of Minot, which is where I grew up. So if you want to think about it that way, the entire city of Minot, that population, that's the number of people who died from overdosing on opioids. So some pretty heavy statistics there. To kind of bring it closer to home, one of the really major contributing factors to the crisis is really the over-prescribing. So high prescribing rates, which allows for availability of excess medication. So what often happens is that medication sits around. People put it in their medicine cabinets. They put it in their closets. They forget about it. So they've got all these pills sitting around. And nobody really notices if it goes missing because they forgot they even had it. So there's all this excess medication that can be easily diverted. And so when we look at the CDC keeps track of prescribing rates by county. So you can actually go to the CDC website and look for every state by county. And as you look at this, it's the rate per 100 persons. So if you see a number close to 100, that means that every single person in the last year, there are enough prescriptions that every single person could have had one. So as you look at this map, the top county is Ramsey with just over 100 prescriptions per 100 persons. So that would be categorized as a really high prescribing rate, potentially problematic for having all of this excess medication sitting around. Adams County, Foster, Eddie, Wells. So those are the top five. And there's sort of a little, you can see kind of towards the center of the state, there's sort of a little pocket there of really high prescribing rates. So that would mean that these are communities, these are counties where there's likely to be a lot of excess prescriptions sitting around. So I again encourage you to go to that website and take a look at more information about what's going on there. So it does look, you know, it obviously is a little bit alarming to see numbers over 100. But comparatively, if you look at other parts of the United States, it's actually pretty low in North Dakota and in most of the Midwest. It's really concentrated a lot more in the South, in Appalachia. So even though the picture looks pretty bleak here, this is really nothing compared to other areas of the nation. So as I mentioned, over prescribing is a big factor involved here. And I'm going to say more about that in a little bit. But I'm going to go through some different factors at different levels that have contributed in that play a role in the development of the crisis and also need to be considered when you think about addressing the crisis. And as part of the extension opioid crisis response workgroup, we completed a very thorough comprehensive literature review. And we organized that literature review largely using the eco-developmental model. So this is the framework we use to think about, you know, what are the important issues and how are we going to address them? And just to give a little background there, the eco-developmental model is really focused on risk and protective factors. So risk factors would be characteristics, and that could be at different levels. So biological, psychological, family, community, characteristics that proceed and are associated with higher likelihood of problem outcomes. And then protective factors are kind of the flip side of that, right? They're characteristics that are associated with lower likelihood of problem outcomes, or that would reduce the negative impact of a risk factor on problem outcomes. And these can vary quite a bit, the risk and protective factors, depending on developmental periods. So what you see for children is going to be a bit different than what you see for adolescents, and then different places in adulthood are going to have different risk and protective factors. And so really what I'd like to communicate here is that this model considers this really complex interplay of individual and contextual factors. So it's not a simple way of looking at the problem, but I think it really helps us understand how and why it's so difficult to address a complex issue like this. So when we think about individual level factors, one of the first ones that comes to mind is going to be genes, of course, so genetic predisposition. And so genes account for between 40 and 60% of susceptibility to addiction in general, and genes are also important in thinking about different personality factors and other conditions that might make an addiction more likely. So things like an individual's temperament, like risk taking and impulsivity, and then also their risk of mental health problems and sensitivity to drugs. Another issue that is linked to genes is the comorbidity of disorders, and so comorbidity means you've got co-occurring disorders. So it's very common for people who have a substance use disorder to also have anxiety or depression or any number of additional psychological disorders. And that is partially because of genes, but then also some environmental features that can bring about both, which we'll get into. But an important thing here is that the comorbidity of disorders, it could be because of genetic factors that make both disorders more likely, but it could also be the substance use disorder could also be linked to attempts to use substances in a way of sort of self-medicating for anxiety and depression that's not being addressed through professional avenues. So it is entirely possible that somebody who has anxiety and depression then develops substance use disorder due to not having addressed those underlying problems. And then there are some demographic factors, and I'm not going to really get into that too much. But if you want to read more about that, that's in the literature review, and really the two big ones would be gender, that there are different patterns in misuse and in overdose and in the way that opioids affect people based on if they're women or men, or some of that is due to differences in biology, right? So biological sex and gender are both important to think about. But the big one really is race and ethnicity. So you'll hear the opioid crisis described as a white problem, and so really what we've seen is that the rates of misuse and overdose are much higher in white populations. But based on my reading of the literature, this really isn't an individual factor. It's an artifact of socioeconomic stratification that really has allowed white populations to have better insurance coverage and therefore greater access to the physicians who write the prescriptions. So really it's a testament to that systems level stratification that you see. But even when non-white patients have access, they're less likely to be prescribed opioids. So even if they have health insurance and see a doctor, they're still less likely to be prescribed opioids. So clearly there's a systems level thing going on there. In terms of family context and development, parental monitoring and involvement are huge. They are protective factors against adolescent opioid misuse, and then of course parental modeling is extremely important. So that's why organizations like Parents Lead are so important. And so obviously right now I have to give a little nod to my former colleagues in the PFRCs across North Dakota because if you want to solve the opioid crisis, you cannot do that without parent education. So there's my little tip of my hat to the PFRCs. Related to this would be adverse childhood experiences or ACEs. I just refer to them as ACEs. And ACEs don't occur exclusively in the family or home context, but that is the primary source of ACEs for most people. And I could say a lot about ACEs right now, but I'll try to keep it brief. But basically the original ACEs research identified 10 specific ACEs that you can broadly categorize into child male treatment. So that would include physical, sexual, or emotional abuse, and then physical or emotional neglect. So there's five that are categorized as child male treatment, and then five that would be categorized as household dysfunction. And so that includes witnessing a child or an adolescent witnessing domestic violence, having an adult in the home with a substance abuse problem, having someone living in the home with mental illness, having had a household member be incarcerated, and then lastly parental separation or divorce. So again, you can see how family education is important here to prevent some of these things from happening. And so then when we look at the impact of these ACEs, what we see is that particularly during early childhood, these ACEs impact neurodevelopment in ways that really make emotion regulation difficult and impact decision making for the long term. So ACEs are a common source for many health risk behaviors and chronic health conditions, and that includes mental disorders and addiction. So preventing ACEs or trying to sort of mitigate the effects of ACEs, that's really become a major focus in terms of a public health effort. Moving on to community level factors, social networks are an important aspect. So the size, composition, functioning of social networks impacts the local availability of opioids, especially prescription opioids. And when you see strong social and kinship networks, that actually can facilitate the possibility of diversion. So when people have strong emotionally close relationships, it's actually more likely that medication sharing will occur or diversion will occur. Importantly, these kinds of strong social networks are very prevalent in rural communities, and rural communities disproportionately, they are the places that are seeing opioid-related problems. For many factors involved here, there are higher prescription rates in rural communities, and a lot of that is due to higher rates of arthritis and then manual labor jobs. But even if you control for those factors, prescription rates are still higher in rural communities. We've got the manual labor jobs there. Outmigration of young adults. So young adults who have really excellent educational and vocational prospects tend to move out, and that results in aggregation of high-risk young adults. So young adults who don't have those kinds of opportunities tend to stay in the community. Economic stress is a major factor, so low wages, lack of upward mobility, and then a big one is automation of manufacturing, so fewer jobs in manufacturing. Lack of access to treatment and limited services. So this would be lack of access to services to address mental health, lack of access to treatment for substance use disorders, and then when treatment is available, limited services. So in particular, a lack of access to medication-assisted therapies such as methadone and buprenorphine, and lastly disparities in naloxone use. So naloxone is that lifesaving medication that can be given when somebody is overdosing to reverse the overdose, and it's used much less frequently in rural areas. And then when we think about broader social and cultural factors, the big one that comes to mind is mental health stigma. So that'd be general mental health stigma, which interferes with being able to talk about difficulties and seek appropriate treatment, but there's even more intense stigma around opioid use specifically. So substance use disorders, there's just even more stigma associated with substance use disorders. Over-reliance on law enforcement and the criminal justice system to solve the problems. So a more fruitful approach would be community-based solutions that engage multiple social systems and try to make use of community assets. And then there's a lack of appropriate treatment while people are incarcerated. So while they're trying to recover and be rehabilitated, they're not receiving the services that they need, and then sometimes they don't have an appropriate transition plan for release. And then, as I said, I'd come back to this one, the over-prescribing. So really this is about insufficient regulation of pharmaceutical companies. And I've got the little in-forum picture there of the Attorney General filing a suit against Purdue Pharma. So Purdue Pharma is one of the big names here. In the late 90s and early 2000s, the marketing and sales activities of pharmaceutical companies were really pretty intense. And in hindsight's 2020, as they say, but really like, wow, some pretty intense stuff here. So direct to consumer marketing of addictive medications, hiring of drug reps to work as detailers. So they were literally provided with prescriber profiles that had detailed information on the individual physician and then trained in being engaging and interactive. And so essentially like meeting with an individual and having a lot of information about them so that you can directly market. Bonus systems for drug reps who achieved certain levels of sales. And Purdue Pharma, in order to increase OxyContin sales, they had all expenses paid symposia for healthcare professionals. And that included staying at luxury resorts for the medical professionals who attended that. And then marketing materials and branded promotional items. And then this last one, really disturbing, 15,000 copies of an OxyContin promotional video that had not been submitted to the FDA for review. And it downplayed the risk of addiction and exaggerated the effectiveness of pain relief. So really a lot of what has caused the current crisis or the catalyst is the overprescribing that is a direct result of these marketing activities. So when we think about addressing the crisis, there are a lot of possible solutions and it's going to take multiple attempts at multiple levels. There's no easy fix. It's going to require a lot of different initiatives. And so I in the literature view have divided these into different types. And so demand side solutions are going to focus on people who are using, misusing or at risk of misusing an opioid of any kind. So really this is the consumer side of things. And its demand side is about once a medication has been dispensed. Whereas the supply side focuses on the people who do the prescribing, who manufacture or dispense medications. And then lastly we've got large scale policy changes that would be enacted through political channels. In terms of demand side solutions, pain management alternatives are one possible way of addressing it. So identifying alternatives to using opioids for pain management. So over the counter medications, that's a big one. There's some interesting research that suggests that the combination of ibuprofen with acetaminophen is more effective than oxycodone in treating certain kinds of pain. So over the counter medications are inexpensive, widely available and can be highly effective. And then so a note there is that opioids are indicated and well supported for terminal care. But there's not actually a lot of evidence to support the use of opioids for non-malignant chronic pain. So really we should be trying many different things before resorting to opioids. But instead what has happened is that that's what consumers are demanding at this point and that's what they want. And there's a lot of focus on appropriately treating pain. So people want to take a pill at this point. A lot of people want to just pop a pill and have it solve their problems. But we need to shift in thinking about how we manage pain. So some of the more alternative approaches, one of them is medical cannabis. So there's some interesting research here on medical cannabis products like pills and tinctures being effective for chronic pain management. And of course less dangerous than opioids. Other approaches would include yoga, exercise and physical therapy. So those last three, yoga, exercise, physical therapy, those would not include taking a drug of any kind. Education on storage and disposal is really important. So you can see at the right here I've got the North Dakota Prevention tagline here, lock monitor take back. So there's a big health campaign right now for lock monitor take back. So really keeping medications secure while you have them, paying attention to what's going on with them or is medication disappearing? That shouldn't be. And then the big piece is disposing of them properly. So in order to do that, you need to have either permanent safe disposal sites in North Dakota. Most of, I think all of the county courthouses have safe disposal sites and drug take back events are another way of doing that. So having an actual community event dedicated to people bringing in their leftover medication to make sure that it gets safely disposed of. And then we have the realm of intervention and that can be divided into four different major categories. So you see on the right here we've got this picture taken from a National Research Council and Institute of Medicine document and it's the spectrum of intervention. So promotion and prevention would be more on the front end of things. Promotion would refer to trying to enhance individual competencies and capacities that function as protective factors. An example of this would be positive youth development approaches that attempt to promote optimal development or thriving by helping youth identify and pursue interests. Prevention is like promotion, so promotion and prevention are kind of linked, right? Prevention occurs prior to the onset of a disorder, but the main difference is between prevention and promotion is that prevention really explicitly and intentionally addresses risk factors. And then we've got treatment and maintenance. And so as the Extension Opioid Crisis Work Group completed our activities and took an inventory of different programs and activities of land grants across the United States, it was very clear that there's a lot more focus on promotion and prevention than on treatment and maintenance. So treatment would be an intervention for somebody who has a diagnosable disorder to either reduce their symptoms, manage the effects, and then if possible cure the disorder. Maintenance is really the long-term compliance with treatment goals, so that would be preventing relapse and recurrence. And so there are some institutions, there are some land grants that do some work, particularly with the maintenance part of it, but for the most part what we saw was a lot more focus on promotion and prevention. And then as a standalone, I did want to talk about community development. And the reason I wanted to really focus on this is because most of the demand side approaches focus on individuals and their microcontexts, so things like their schools, their families, their workplaces. But the research literature very clearly indicates that in order to solve this problem, we have to consider broader social contexts. So there are lots of economic conditions that are linked to opioid use disorder and then community capacity to address needs is really important. So economic development and community capacity building are essential aspects of addressing the crisis. Supply side solutions. Abuse deterrent formulations, that would be medications resistant to tampering. So there are physical or chemical barriers that make it difficult or impossible to misuse the medications. However, abuse deterrent is not equivalent to abuse proof and people who have a substance use disorder, especially if they're experiencing withdrawal, can find some fairly innovative ways to bypass those modifications. So this is not necessarily always the best solution. Training of medical professionals, obviously not really an area that extension can be involved in all that much, but still important. So in the literature it suggests that medical professionals need to receive a lot more training on social determinants of health and a lot more focus on pain management. And then in terms of treatment issues, more information on medication assisted treatment. Pharmacists as a point of intervention. So it's pretty rare for pharmacists to engage in screening and discussing misuse with patients, but they as the gatekeepers of these medications, they're the ones who dispense it. They're really at a critical juncture in this process where they really have that on the ground view of what's going on and can intervene if necessary. But unfortunately it doesn't happen very often and a lot of the issue is that they don't have the resources that they need to do that screening or the training or they don't feel comfortable. They don't feel like it's their role and so some of it needs to be empowerment of pharmacists to feel like, yes, they do have it right to ask these kinds of questions. And then lastly, prescribing guidelines and PDMPs. PDMP stands for prescription drug monitoring program. And so it's a database where prescription information can be tracked. So basically it tracks the not just who is receiving the prescription and the amounts or dosage, but who wrote the prescription. And in most states it's not a requirement to use PDMPs, it's voluntary, but the PDMPs allow for tracking of prescribing practices. So not only can they be used to provide information and kind of raise red flags about things like doctor shopping or if patients are running out of medications too quickly, they can also allow for tracking of the physician prescribing practices and can be used to identify physicians who might be engaging in unethical prescribing practices. So promoting or incentivizing provider use of the PDMPs would be, I think, would increase the effectiveness of the systems that are in place and then better information sharing capabilities is something identified in the literature. And then last we have our more grand scale policy changes. Medicaid expansion to ensure that economically vulnerable populations have access to the health care that they need. Health insurance coverage of medication assisted therapies, so not all insurance will cover things like buprenorphine, but medication assisted therapies are highly effective. Lifting federal restrictions to allow randomized controlled trials, examining medical cannabis as substitutes for opioids in pain management. So there's some interesting literature here coming out of states where medical cannabis is legal that demonstrates that when it is possible for chronic opioid users to instead switch to medical cannabis, they are able to completely stop using opioids and of course the cannabis products are safer. But because of federal restrictions, you can't do a true randomized controlled trial. You can't randomly assign people the conditions. So you can't engage in really the gold standard of research because of the federal restrictions. So people would like to be able to study this, not just for effectiveness, but also for safety, right? So that's one step in that direction. Modifying DEA regulations and processes to make it easier for physicians to prescribe buprenorphine. So as it stands, primary care physicians have to apply for DEA waivers to even be allowed to prescribe buprenorphine. And then there are restrictions on the number of patients that one physician can treat. So it's been suggested in the literature that there be some modification to this process that would make it more accessible for patients. And then lastly, shifting from prioritizing law enforcement and incarceration to prioritizing prevention, harm reduction and treatment. And especially when I'm talking about prioritizing, I mean putting the money there, right? So including a lot more funding in federal and state budgets for prevention. Because to date, a lot of the money has flowed towards treatment and the long-term maintenance stuff, which is definitely important. But if at some point we don't switch to greater emphasis on prevention, then we're going to have to keep putting money into treatment. So we really need to find ways to channel more money towards prevention. Okay, so the last important stuff here, extensions role. What role does extension play here? So the cooperative extension system is really uniquely positioned to address the crisis. A lot of that is because of the existing infrastructure in all states and counties. And diffusion of science with practice is our business. That's what we do, right? So we have the structure and the culture to do this. And extension agents in their communities often serve as change agents. In terms of the history of response, extension was involved in the rural crisis of the late 1980s. And at that time, it became clear that understanding mental health was an essential part of resolving the farm crisis of the 80s. And extension was definitely involved in addressing root causes of distress. So that would include economic changes, so helping people with work skills, right? Helping people manage with their economic pressures that they have. Extension agents out in the counties facilitated formation. And this is, I shouldn't mention, this is really just looking at extension, cooperative extension as a whole, not specifically NBSU. But just if you think about cooperative extension in general. So facilitating formation of community coalitions. Yes, we are working on farm and ranch stress again now, yep. And then recently there's been a lot more expansion of behavioral health programming within cooperative extension. And that includes substance use prevention. So mental health topics are receiving a lot more attention now than in the past. And there's a lot more emphasis on evidence-based programming as well as community level impacts. There are, however, some challenges involved here. First would be moving toward a common language. So particularly for community-based educators, they may not be well-versed in some of this information on what constitutes evidence-based. What would be evidence-informed, right? There are all these terms. There's a lot of jargon that's used by research scientists. And so the Journal of Extension, there are several articles in there that really discuss the need for greater professional development. That would help community-based educators be more proficient and comfortable in using this language and in identifying these kinds of programs. And then adopting evidence-based programs. So there are some issues here in terms of tensions between scientists and practitioners. Often there are different goals and priorities, especially when it comes to issues of fidelity of implementation and the ability to adapt the program to meet local needs. Knowledge, attitudes, and proficiency regarding evidence-based prevention programs. So this is something that could be addressed through professional development. I did want to just very quickly mention that one of the areas where attitudes are a bit of a bigger challenge is the world of 4-H, because of historical tension between positive youth development approaches and prevention approaches. So positive youth development tends to focus on promoting positive outcomes through building competencies, but then prevention really focuses on deficits and avoiding negative outcomes. But it's really important to note that both approaches are useful and necessary and that they're not incompatible or mutually exclusive. You need both. And then lastly, organizational capacity. So system openness to change is really important to consider. The port for evidence-based prevention within the organizations. Happing and human resources, of course. When we surveyed land-grant institutions across the country, a lot of institutions said we don't have the staff on the ground to deliver programs. We don't have experts in these areas. They just don't feel that they have the human resources that are required. And that is related to shrinking budgets, of course, which I don't really need to launch into a spiel about that. I think you all probably understand how that impacts human resources and how difficult and challenging it can be to even think about adding new programs when you're trying to just maintain, in a lot of ways, the programming that you have. And a lot of institutions across the country said that organizational capacity is really the problem, that they care about the crisis, they want to do something to help, but they just don't feel they have the capacity at this point. I have a few suggestions really identified through the literature that community-based educators should all have a basic level of behavioral health knowledge and skills. And I realize that that takes funding, that takes training, right? Professional development requires money. So my recommendation here is that, at a minimum, you have the responding to distressed people publication on hand for quick reference. So if you don't have that in your office, it should be fairly easy for you to obtain a copy. Prioritizing high-quality programs. So you've got to have good implementation and outcome evaluation for that. And I think that the PAIRS system is really a step in the right direction there to be able to track that information and demonstrate if programs are having their intended effects and if not, why? Why not? Addressing both risk and protective factors would be important. Multiple contexts and multiple portions of the lifespan. So really, that's a good question. Did all agents automatically receive the series of publications? I'm not sure, but I think that would be helpful to get those publications into the hands of all of the county staff. Oh, okay. Sorry, I got distracted by the comments. Capacity issues. So learning about innovative, highly impactful ways to deliver programs. So one example is Prosper, which is explained very in depth on the extension website. So I think that's definitely something to look into. So there's my little blurb about Prosper. So if you go to the website, you'll be able to read about that. And making use of Pivot to search for funding opportunities. So NDSU has a subscription to Pivot, which is basically a platform you can use to do customized searches for grant opportunities. It's really neat. If anybody wants to talk to me about that later, I definitely love Pivot. Okay. So very, very quickly, I just want to give a few examples where I think NDSU Extension is doing a great job. And these are some projects and programs that are on the right track. So the Mackenzie County Coalition, which is chaired by Marsha Helen Sauce. This coalition really focuses on prevention of underage drinking. And they have been able to do a number of systems, a number of PSE, policy systems, environmental change activities. So implementing card readers in bars and places where you buy alcohol to make sure that IDs aren't fake. Anyone who's under 35 has to be carded, cameras installed in and behind bars. Anyone selling alcohol, having to complete safe server training. And importantly, I want to emphasize that the community coalition model can be and has been applied to opioid misuse. It just happens to be the case that in North Dakota, we have a much larger problem with underage drinking and with binge drinking would be a big issue. So if there is a county, though, where the issue is more opioid misuse, then this county coalition format is a great way of addressing that, including multiple players bringing people to the table who all need to be in on that conversation and who can really combine their resources and expertise to make some of these important changes in their communities. I wanted to highlight this. This is actually, it was a small grant that has been awarded to a team, which is led by Amber Letcher at SDSU, but Megan Scott is part of this team. And the program itself, stepping up, it's social emotional learning for rural middle school youth. So they're going to be collaboratively delivering this program in a multi-state region. And it's a prevention program that their outcome that they're focused on is suicidality, so suicidal thoughts. But these kinds of skills and factors are involved in many, many other mental health issues. So this is a great example of a cross-state collaboration that focuses on prevention and use of evidence-based programming. So I highlighted at the bottom there that they've got a pretty exceptional plan for research. In addition to using an evidence-based prevention program, they've got a great plan for how they're going to evaluate it. And then lastly, the mental health training on Ivan. So I believe this is an annual training that different topics get discussed annually. And the most recent one, there was a section on emotional stress on the farm. So I think that is a very important one that's relevant to the opioid crisis. If you didn't participate in that, you can go watch the recording and learn more about that. I think that that is a really helpful video conference. Oh, concluding thoughts. Promotion and prevention seem to be more the area where extension can and should be involved. It aligns well with the mission and history of the land grant system. Addressing the crisis requires all extension program areas to work together. So it's tempting to think about mental health and behavioral health as within the realm of FCW, right? But when we think about, especially in rural areas and areas where farming and ranching are the dominant forms of economic activity, it's the A&R agents a lot of the time who are having the greatest interaction with our clients and who are in a position to really help people who might be in distress to find access to services, right? So it needs to be a coordinated effort across all extension program areas. Capacity is a challenge for many institutions. So ECOP and partner organizations are working on forming a response network that's sensitive to this. And then lastly, NDSU Extension, I think y'all are doing great work. So keep up the great work. And if you're interested in learning about additional ways to do more specifically with the opioid crisis, go visit the extension, the extension website and take a look at some of the information on there. And with that, we've got a few minutes for questions. And if you want the references for any of this, I can send you. You can email me directly and ask about a particular portion of the presentation or if you just want all of them, definitely feel free to contact me with follow-up questions. And I can get you those references. So with that, does anybody have questions? Allison, this is Jody. I have a quick question. Hey, so maybe this is what Lynette is referencing in the chat pod there. I read yesterday part of the farm bill that there's a piece that was designated for opioid issues in rural areas. It's in this new farm bill. So does anybody know if there's something more than what Lynette's reference here addresses? I'm not sure about that. That's a good question. Is Lynette still on? Yeah, she is. Maybe Lynette can speak to that? No? Okay. Anybody else? I can do a little more digging into it. I'm just curious. Oh, okay. She's going to respond. Just give her a minute. Yeah, disposal is definitely an issue. Oh, I've seen some interesting articles about on the coasts that there are muscles that are testing positive for opioids. You know, shellfish testing positive for opioids because medications are not being disposed of properly. So can you hear me? This is Lynette. Yes. Okay, good. Thanks. Sorry, I didn't have my headphones on. But yes, good question, Jody. There has been money in the past for rural health and safety grants. And that's part of the one that Megan has that Allison referenced earlier. There's other larger rural health and safety grants that have been given nationwide through extension. I believe and they've always come through extension. I believe that there was more money put in the firm bill for things like this and I'm going to go back and look. But there's just a lot of different things they're really trying to do and put into whether it's the firm bill or other operational dollars for extension for research around this issue. Whether it's mental health, opioid use, I mean, it's just become such a huge deal. And so there's becoming more money. We haven't gleaned through all the details on the firm bill yet, but I think that then there's always been some dollars in this regard. So we're hopeful. The message that I, the little note that I mentioned too was that there is a, it's called a solid waste management grant program. And it's really all about water quality. And so when we think about all of you that are working, especially in the agriculture arena and the water quality issues, natural resource issues that you're dealing with, there is a grant. There's a big grant out there that I'm going to forward on to everyone. And again, it's probably something you would partner with a specialist on if you wanted to make this happen. It's for communities with less than 10,000 in population. But we just learned that there's extra points that will be given if there's some type of take back program with pharmacies or on opioids because of the solid waste that they're adding to the water supply. And so it's been kind of an interesting read and something more interesting to kind of learn about, but it's just becoming such a big issue. And so we're concerned. There are lots of concerns. And so there will be extra points with this USDA grant. So if you've got any ideas or thoughts or some creative way that maybe partnering with a specialist on, wow, this would be something we should do for our region that I'll forward it on. Terrific. Thank you, Lynette. This is Marie. For Allison, is there any last question for Allison? If there comes questions, I'm sure Allison, you'll be fine with them reaching out to you as well. Absolutely. Yeah, I want to thank you for sharing this wonderful research and helping us better understand the opioid problem in the U.S. and here in North Dakota what we as extension professionals can help with and do in our roles. So thank you so much for sharing that this morning. And thank you all for being on the call. It will be, it is recorded and so look forward under our long term downloads with FCW Webinar Wednesday. And we'll be back again after the new year. Our next webinar will be January 16th. So look for some information to come out for that. So thank you all for being part of this this morning. Thank you.