What does it take to galvanize a town’s leaders around taking coordinated action to reduce the opioid misuse problem? How do public health practitioners use behavior change strategy to advance decision-makers’ understanding of the root causes of opioid addiction, and encourage coordinated, community-wide implementation of evidence-based strategies to reduce the problem?

Public health consultant Liz Blackwell-Moore can tell you answers to these questions. Having devoted much of her career to preventing and reducing substance misuse as a nonprofit practitioner, in recent years, Liz has been guiding local and regional governments and NGOs wrestling with substance misuse issues, especially opioids. In 2017, she began working with the Greater Portland Council of Governments (GPCOG), the regional and municipal planning organization for the region surrounding Portland, Maine. With GPCOG’s team, Liz has helped several GPCOG member communities learn, assess their current response, and develop a coordinated strategy to address the opioid misuse problem across multiple sectors, agencies, and institutions.

The work with GPCOG emerged from a member mandate. “As GPCOG was implementing a strategic planning process with its member communities, one of the Council’s leadership groups chose the opioid misuse problem as their priority issue,” says Liz. At that time, the State of Maine had one of the highest rates of overdose deaths in the United States. “At the same time, the State had steadily been cutting funding for public health and prevention work and had cut Medicaid funding making less people eligible for insurance necessary to access treatment. So many communities were overwhelmed by the statistics, and the scale of the problem, but their leaders were not yet seeing the path in terms of how to manage the issue,” she explains.

Established as a regional transportation and community planning agency, GPCOG’s leadership team had little familiarity with building capacity around substance misuse issues. GPCOG’s Executive Director Kristina Egan began searching for this expertise, and as it happened, one of her employees knew of Liz and her work from years spent working as nonprofit colleagues together. For Liz, working directly with a network of local governments leaders feels like the most effective place to plug in. “In all of the years I’ve worked in public health, we’ve consistently had trouble reaching leaders and decision-makers on the issue of substance misuse. We could get into some individual schools; we could work with parent groups, some police officers and other concerned citizens; but we always had a hard time reaching the people who were in charge of the policies and budget,” Liz explains.

“GPCOG responded to their member mandate and elevated the issue,” says Liz. After the organization secured funding to support an educational and action planning effort, Liz and the GPCOG team engaged in a strategic planning process to assess what efforts were already happening within the region. Liz then developed and delivered a series of six once-monthly workshops that would bring foundational information about the root causes of opioid misuse to a broad Portland regional audience. The strategic planning process culminated in a workshop for municipal leaders from across the region during GPCOG’s annual meeting.

Liz designed the workshops specifically based on the patterns she’s seen in her work over many years. “Historically, government leaders haven’t felt it was in their purview to take action in response to the opioid problem, or to make active decisions about it. What I always say is that ‘opioid misuse is a community problem that requires a community solution.’ There are root issues that lead to the problem, and we must tackle those aspects of the problem in order to really solve it.”

Liz says that one of the most important strategies she uses to share this information is metaphor. She tells this story called “The Waterfall” to bring along her audience’s understanding of the issues in depersonalized way. Here is Liz’s telling of it:

“There is a community where there’s a waterfall and a river running through. In this community, there’s a group of folks who one day start to notice people falling over the waterfall. Very quickly they string up nets to catch people as they’re falling. Very soon they realize they can’t catch every person with the nets, so they send people downriver to pull those who are floating down out of the river. But pretty quickly, the community members realize that there are still people who are drowning and dying. As they are pulling people out of the river, the community members are sending the rescued people back into the community to reengage, connect, and find support. Eventually, they realize they need to start sending a team up river to find out why all these people are falling into the river in the first place. And in sending a team upstream, they observe that there’s a park right next to the river, and people who are playing there keep falling into it. The community members create a barrier to keep people from falling into the river. And slowly, as they’re doing all of these things, they’re also trying to relocate the park further away from the river’s edge.”

Liz says she uses this story whenever she begins a workshop, “to help people understand that this is exactly where we are in the opioid misuse problem; that we need direct action, while also needing to address the structural issues causing the problem in the first place. All of that has to be coordinated and happening at the same time to really be effective,” Liz explains. “This storytelling is a massive part of the work,” says Liz.

Liz cites an oft-used tool developed by Frameworks, an organization devoted to identifying and sharing messaging shown to have the most traction in helping people understand, take action, and reduce stigma around substance misuse and addiction. Liz says Frameworks helped her realize that addressing stigma head-on by confronting the beliefs people hold onto, often unquestioned, can be threatening. Instead, Liz says, “we use metaphor because it brings the issue up a level by depersonalizing it, evoking a visual that is relatable. Plus, people love stories. But the context is essential—we have to help people understand the system in which that story is happening, the environment, the structures that surround it,” Liz explains. She then facilitates a process by which people in her workshop slowly begin to identify where they may have had misinformation, or where they had thought about this problem differently.

Sharing basic facts about the brain is another strategy Frameworks recommends for helping people understand addiction and youth substance use in a new way. Accordingly, when teaching, Liz shares simple information about brain development, and takes it a step further. “I also talk about the key risk factors that contribute to substance use disorder—early use of substances, adverse childhood experiences, and unresolved mental illness. I give context about why so many people get addicted and what happens in the brain. Many people think the problem is just that doctors gave out too many opioid prescriptions. But, in fact, people who had substance use disorders earlier in their lives are twenty-eight times more likely to get addicted to opioids prescribed to them by a doctor,” Liz says.

To develop its recommendations and create key messaging about brain development, Frameworks partnered with the Center on the Developing Child at Harvard University “because this is something the general public doesn’t understand very well,” Liz says. “When we presented the basics of brain development to city leaders, it completely shifted what they thought about the problem of substance misuse,” Liz explains. “Once you understand that relationships and environment are key contributors to how the brain develops, it’s easy to see how the brains of people who grew up with fractured relationships, or in environments where they experienced discrimination, abuse, or neglect, have brains that might be at more risk for substance use disorder.”

Following the region-wide workshops, GPCOG’s goal was to deepen its engagement with any community whose leader(s) experienced that shift in thinking as a result of Liz’s workshop series. “Once we’ve achieved that shift with someone, our next goal is to bring more intensive work to their municipality,” says Liz. At this point, our target audience then becomes the whole ecosystem of people in a town who shape practices and policies,” Liz explains.

Liz says that really deep thinking about behavior change is built into the entire process. “The goal here isn’t to just raise awareness about the problem. People already know what the problem is,” Liz explains. “Our fundamental goals are to move forward local leaders’ understanding about the root causes of substance use disorders, and ultimately, especially, to increase their adoption and implementation of evidence-based strategies that we know are impactful and will reduce the opioid misuse problem.”

From the outset, Liz looks for leaders who demonstrate interest, willingness, and commitment to bringing along their fellow leaders. Last year, the Town of Falmouth, Maine was the first such GPCOG community. “In Falmouth, it was easy. The town manager engaged in our workshops, and he got it right away,” says Liz. “The chief of police had already been championing substance use prevention work among young people. These are two very respected figures in their community, so we knew that if Nathan said ‘we are going to do this’, then people would show up. We completely trusted his leadership.”

Liz says the internal champion is someone who needs to see the possibility and the promise of a coordinated, cross-sector solution. “They need to be able to succinctly speak about a very complicated problem in a way that garners the support and actions of others. I can’t stress this enough,” Liz says. “The town manager in Falmouth understood this. With each person he engaged, he was able to show each colleague how they were part of the solution.”

The collaborative work in Falmouth has involved three phases:

• Education to build understanding and will among the ecosystem of decision-makers in that leader’s community—that is, the town manager, chief of police, school superintendent, recreation director, key direct reports, and the community’s elected officials including school board members, town councilors, state representatives and state senators who represent that town.
• Panel Discussion that involves five key decision-makers across that leader’s community engaging in generative dialogue about the problem and possible solutions, in a public setting. The panel typically involves leaders oriented toward prevention, law enforcement, harm reduction, treatment, and recovery. Discussion topics include what that town is doing currently, what gaps and barriers exist, and what each leader hopes their municipal colleagues will do in the future to support the effort.
• Action Planning that involves significant facilitation by Liz of three parts:

1. The School Practice & Policy Scan, which looks at what the town’s educational institutions are already doing related to substance use, misuse prevention, and intervention, including an assessment of practices for suspension, retention, detention, health and mental health supports, prevention curriculum, and more.
2. The Municipal Practice & Policy Scan, which is a review of existing policies and practices at the departmental level (i.e., recreation, police, school department, community development, etc.) that includes an assessment of training and capacity building for officers and employees related to substance use, misuse prevention, and intervention.
3. The Assessment and Characterization of Barriers, which brings to light things that might prevent progress (i.e., money, time, lack of awareness, prohibitive ordinances, etc.) and involves an extensive line of questioning in order to demonstrate to the town’s leaders the breadth of what’s necessary to really fix this problem, and to highlight the extent of things the town is already doing but didn’t before see as part of a comprehensive strategy.

There are three important aspects of the work that Liz highlighted as she explained it. First, action planning cultivates accountability across multiple stakeholders. “We make sure there’s a point person responsible for each to-do item, and dates and timelines for completion. The local stakeholders coordinate their meetings, which we don’t attend. This is how we know our impact is sustainable, when the effort becomes owned by the town,” she says.

Second, Liz describes the action planning as “holding up a mirror”. She explains: “A lot of the work is me facilitating an exploratory conversation, and mirroring things back to them. I say ‘look at what you’re already doing here.’ What I’m offering is fresh eyes, refinement, coordination, tweaks. I’m filling gaps, really. This is not ‘major overhaul’ kind of work. I think the clients find it empowering in many ways—it’s really a series of a-ha moments, ‘the ball is already rolling, there’s stuff we’re already doing’ it’s just that they hadn’t really viewed what they were doing through the lens of preventing and responding to substance use disorders,” she says.

Third, Liz says, is knowing the language and framing that will help your audience. “You really have to show people the good stuff first. What we’re working to create is really, really big. People need something to hold onto; it can’t feel too overwhelming,” Liz says. She’s careful to avoid using “crisis” language. “I say ‘opioid misuse problem.’ In a crisis, people feel totally overwhelmed, and they have no idea how they can possibly be part of the solution. So, I show people what they’re already doing, where the gaps are, simple things they can do to address them. Of course, I put some ‘reach’ things on their list, too, aspirational things,” Liz says.

But Liz says that many of the suggestions on the action plan are “things they could do tomorrow. Most of the stuff doesn’t take additional money. The resources already exist, they just need to plug into and connect them,” Liz explains. Over time, some things will take resources. “The problem in this town is not so huge… in a bigger city like Portland, it would take more resources and capital because the problem is so acute. But Falmouth’s population is just 14,000, so the work feels do-able, in part, because it’s a smaller community.”

In terms of initial outcomes, Liz says her team has utilized a simple pre- and post-workshop survey to help GPCOG assess how their workshops are being received, and to measure overall project impact and progress. She summarizes examples of early progress in three categories:

1. Shifting attitudes – Liz says Falmouth has shown an increase in the number of conversations focused on getting more people involved in general, and specifically, heightened interest in recovery residences. “Historically there has been a good deal of resistance to the idea of recovery houses. There’s stigma and fear about people having a past criminal history, and regarding a group of seven to eight men living together. Before, only code enforcement had been interfacing with the folks in recovery residences. Now, the town manager is setting the tone, saying: ‘you belong here; how can we be helpful to you so you can stay?’”
2. Catalyzing connections – The Town of Falmouth has shown how powerful a convening initiative can be in terms of connecting things already existing but were previously not widely known. “Both the middle school and high school administrators and staff had been talking about restorative practices in place of suspension and expulsion—neither team knew about the other team’s efforts or interest. Now, the two schools’ staff have created a working group, and they’re already advancing a major sea change in both schools over the next academic year.”
3. Seeding new partnerships – Small groups working directly on issues that have long been taboo are growing new partnerships. The Portland Recovery Community Center has begun connecting with churches that wanted to do more, especially programming for young people and for families. The Portland Needle Exchange, a harm reduction organization, has been expanding its needle collection program beyond Portland proper. “They’ve been great in raising visibility of the problem, helping people understand it better, and recognize that people who use drugs deserve our empathy and our support,” says Liz.

Behavior Change Analysis

As a public health consultant, much of what Liz does is focused on ripening the hearts and minds of decision-makers to prepare them for behavior change. As her initial work with Greater Portland Council of Governments demonstrates, along with the successive work with leaders across the Town of Falmouth, Maine, when people are presented with new information and new ways of thinking, they become most ready to change their behavior in positive ways.

With its initial series of six monthly informational workshops, Liz and the GPCOG team made the work TIMELY by presenting GPCOG’s member leaders with stories, facts, data, language, and context about the opioid misuse problem, symptoms of which have been causing such urgent desire for solutions among GPCOG’s municipal leaders, and so many others across the country. “We talk a lot in the public health field about ‘finding the door’—creating the point of entry people want to walk through,” Liz says. Liz and the GPCOG team promote their workshops by zeroing in on exactly what is most top of mind for members of their audience. “They’re very willingly walking through that door and attending our workshops because everyone in their administration is freaking out about opioid misuse and overdoses, and they all want tools and answers,” Liz says.

Related to timeliness, Liz and her team use the concept of SALIENCE by recruiting workshop attendees with the promise of gaining information about a problem that is one of their greatest concerns, “and then, once they’re in the workshop, we present a much larger and interconnected body of information to give them a complete picture.”

Liz also described using the concept of PRIMING in the way she presents workshop attendees with “more than what they were expecting when they walked through the door,” Liz says, “and that’s by design. They’re thinking addiction and overdoses. To move them from panic to action, we need to take them through an exploration of the root causes of those issues, such as ACEs (Adverse Childhood Experiences), trauma, and restorative practices. We prime the audience members by providing foundational information, and build to ultimately help them see why those early life experiences can be such a big deal,” she says, “and from there, they are on the path toward empathy and taking action.”

Liz and her client team also made their workshops SOCIAL to prime the room for connecting, relating, and relationship building. “We mixed up the group by doing assigned seating at the tables. We offered dinner. Once the teams identify some of the things they could put into their action plan, our team facilitates a group prioritization process. So, then everyone goes up to cast their individual vote, and by design, the meeting is over at that point. So many people stood around and talked awhile afterwards; the fact that folks met other people who were new to them was done by design, and that does encourage attendees to speak with other people, and come away with fresh ideas.

The GPCOG team works to convey a compelling story that can then be picked up and shared by a local stakeholder MESSENGER, that is, someone who is respected, trusted, and well-liked. The messenger is someone who uses the messaging and the metaphor as their own to paint the picture—showing each person the problem, and how each person fits into the solution to that problem.

Conclusion

In a short period of time, Liz and the GPCOG team have shown incremental but certain progress in changing attitudes and behaviors among leaders in Falmouth, Maine. The team is increasingly gaining traction with leaders in other communities across the Greater Portland region, too. As with many public health initiatives past and present, behavioral economics frameworks are key to developing an effective messaging strategy in response to the opioid misuse problem. To learn more details about the work in Falmouth and the next steps the community is taking in the neighboring town of Gorham, please visit this recent article published in the Portland Press Herald.

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The theoretical basis for the Behavior Change Blog Series is informed by two mnemonic frameworks shown in detail below. The MINDSPACE framework is a list of the elements that inform cognitive biases and human behaviors, while the EAST framework is a list of directives that are derived from MINDSPACE and help inform strategies for influencing behavior change in humans. These two frameworks were established by the Behavioural Insights Team (BIT), a social enterprise based in the United Kingdom.

 

MINDSPACE Framework	EAST Framework
Messenger – We are heavily influenced by who communicates information to us.	Make it Easy – Harness the power of defaults, reduce the ‘hassle factor’, simplify messages.
Incentives – Our response to incentives is shaped by predictable mental shortcuts such as reference points, aversion to losses, and overweighting of small probabilities.	Make it Attractive – Draw people toward preferred behaviors, design rewards and sanctions to maximize effect.
Norms – We are strongly influenced by what others do.	Make it Social – Show people the norm, use the power of networks to encourage and support, encourage people to make a commitment.
Defaults – We “go with the flow” of pre-set options.	Make it Timely – Prompt people when they are most likely to be receptive, consider immediate costs and benefits, help people plan their response.
Salience – Our attention is drawn to what is novel and also to what seems relevant to us.
Priming – We are often influenced by subconscious cues.
Affect – Our emotional associations can powerfully shape our actions.
Commitments – We seek to be consistent with our public promises, and to reciprocate acts.
Ego – We act in ways that make us feel better about ourselves.