Broward Restaurants (and hospitality industry) Educating Against Drugs

The Florida Department of Health in Broward County (DOH-Broward) is one of 67 Public Health Departments under the governance of the integrated Florida Department of Health (DOH). Although DOH-Broward is a state agency, it maintains a very strong partnership with Broward County Government, which is formalized in a core contract. The main administrative campus is located in Fort Lauderdale, Florida, with additional facilities in geographically accessible locations.  DOH-Broward is responsible for protecting, promoting and improving the health of the county's 1.9 million residents and over 10 million annual visitors. 

According to the U.S. Census population estimates for July 2021, Broward County is the 17th most populous in the United States, with over 1.94 million people and 9% of Florida's residents. 34.1% of residents are foreign-born.  Among Broward residents, 63.1% identify as White; 30.2% Black or African American including many who immigrated from Haiti, Jamaica, and other parts of the Caribbean, as well as Central and South America. 31.1 % of the population identifies as Hispanic or Latino. 37.5% of the population speaks a language other than English in the home.

Accommodations and food services is the third largest industry in Broward County, employing over 79,457 people. As of December 2017, full-service restaurants, limited-service restaurants, and hotels/motels accounted for 70% of the hospitality and tourism employment cluster in Broward County. The culture within this industry is stressful. Many workers may choose to use illicit substances to cope with the stress of the industry, including, but not limited to, customer interactions, chronic understaffing, high turnover, low wages, and occupational stress.

From January to June of 2020, a high percentage of overdose victims seen in Broward County emergency departments were employed in the hospitality industry. Not only are hospitality employees at higher risk for substance use, but the businesses themselves are a frequent site of overdoses. During that same period, almost one in ten overdoses happened within public companies, including restaurants, bars, hotels and motels, fast food restaurants, and other typical tourist attractions like casinos and commercial or entertainment establishments.  Data from FL Health CHARTS (Community Health Assessment Resource Tool Set) indicates that the age-adjusted rate of deaths due to unintentional injury by drug poisoning in Broward County more than doubled between 2015 and 2017 from 13.4 (250 deaths) to 27.1 (516 deaths) compared to the Florida rate of 22.6 in 2017. The 2020 Broward County rate was 33.7 (670 deaths) and Florida's rate was 32.9 (6,734 deaths).

The complex and evolving nature of the opioid epidemic highlights the need for an interdisciplinary, comprehensive, and cohesive public health approach. To combat this issue of substance use in the hospitality industry, the DOH-Broward Opioid Program implemented Broward Restaurants (and hospitality industry) Educating Against Drugs” (BREAD), which is an initiative to provide outreach and education to hospitality business owners and managers on the dangers of substance-use disorder (SUD).

Goal 1: By November 30, 2021, provide education on substance use disorder in the hospitality industry to at least 400 hospitality business owners/managers.

Objective 1.1: By December 31, 2020, develop a packet of educational materials to be distributed to hospitality industry owners/managers.

Objective 1.2: By December 31, 2020, through collaboration with South Florida High Intensity Drug Trafficking Area (SFHIDTA), develop a list of geographical areas to target for outreach based on overdose rates and drug-related arrest data.

Objective 1.3: By January 2, 2021, begin hospitality industry outreach visits.

Goal 2: By November 30, 2021, provide naloxone training and a naloxone kit to at least 400 hospitality business owners/managers.

            Objective 2.1 By January 31, 2021, DOH-Broward and the Broward Sheriff's Office (BSO) will enter into a contract for DOH-Broward to provide funding for BSO to purchase naloxone to distribute during outreach visits.

            Objective 2.2: By December 31, 2020, DOH-Broward and BSO will hold a planning meeting to create a protocol for outreach visits.

            Objective 2.3: By February 1, 2021, BSO will begin outreach visits with DOH-Broward health educators.

Goal 3: By November 30, 2021, 25% of hospitality business owners/managers will have a self-reported increase in SUD knowledge.

Objective 3.1: By January 31, 2021, develop a follow-up survey for hospitality industry owners/managers who receive a visit from health educators.

Objective 3.2: By February 28, 2021, begin conducting follow-up surveys with hospitality industry owners/managers who have received a health educator visit.

From December 1, 2020, through November 30, 2021, the BREAD Team connected with 353 Broward County businesses. BREAD health educators, along with community partners from the South Florida Wellness Network (SFWN), completed 221 visits. Each visit included education on SUD and naloxone training, and kits. 89 % of the visited business received SUD training, naloxone training, and kits. As of November 2021, 520 naloxone kits were distributed to local business. Based on programmatic monitoring, 53 lives have been directly saved by this program and 54 referrals have been made by owners/managers to resources that were provided during the visits.

Opioid-related morbidity and mortality impacts quality of life and is very costly to individuals, employers, and medical systems. While the number of opioid prescriptions is decreasing, there is an increase in Florida's opioid drug overdose death rate, drug-related arrests, and overdoses. This suggests an increase in drugs such as opioids being obtained illegally. Substance-use negatively affects U.S. industries through workplace incidents (i.e., accidents and injuries), lost productivity, absenteeism, low morale, and increased illness. Nationwide, companies lose over $600 billion annually because of employee use of alcohol and illicit substances (Healthy People, 2020). The Centers for Disease Control and Prevention (CDC) reported the following statistics related to opioid use disorder and overdose in Florida for 2017 in a 2021 Morbidity and Mortality Weekly Report https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7015-H.pdf):

·                     Per capital cost of opioid use disorder: $1,476

·                     Per capita cost of fatal opioid overdose $1,786

·                     Per capita combined cost of opioid use disorder-fatal opioid overdose $3,262

·                     Case Count of opioid use disorder: 140,000

·                     Case count of opioid overdose: 3,245

·                     Cost of opioid use disorder (millions): $30,970.6

·                     Combined (millions): $68,444.3

·                     Value of statistical life lost (millions): $32,772.9

From January to June of 2020, overdose victims who were employed that were seen in an emergency department in Broward County were most likely to be employed in the hospitality industry. Not only are hospitality employees at high risk for substance use, but the businesses themselves are a frequent site of overdoses. During that same time period, almost one in ten overdoses occurred within public businesses/restaurants/hotels. These include restaurants, bars, hotels and motels, fast food restaurants, and other common tourist attractions like casinos and commercial or entertainment establishments.

The culture within the industry of food service is stressful. Many workers may choose to use illicit substances to cope with the stress of the industry including, but not limited to, customer interactions, chronic understaffing, high turnover, low wages, and occupational stress.

Nationwide efforts to stem the problem of substance use at work range from the implementation of workplace policies on alcohol use and employee assistance programs. There have also been other interventions focusing on reducing stress and providing food service employees with skills to cope and build resilience.

In 2014, the Center for Behavioral Health Statistics and Quality (CBHSQ) stated that full-time workers who used illicit drugs in the past month were generally less likely than those who did not use illicit drugs in the past month to be employed by an employer with a written policy on employee use of alcohol and drugs.

The Florida Department of Health (DOH) has collaborated with various agencies including the Florida Department of Law Enforcement (FDLE), the Prescription Drug Monitoring Program and the Agency for Healthcare Administration to create an Opioid Use Dashboard to publicly display opioid- and drug-related public health data at both the state and county level to provide high quality, comprehensive, and real-time data on overdose morbidity and mortality that are available to generate insight for action, and to drive prevention and response activities  Each surveillance system partner provides a different critical element to the dashboard. Opioid and drug-related deaths are identified by Florida Medical Examiners and investigated by the FDLE. The Dashboard includes the drugs which are identified as opioids by the FDLE Medical Examiners Commission which include the following: Buprenorphine, Codeine, Fentanyl, Fentanyl Analogs, Heroine, Hydrocodone, Hydromorphone, Meperidine, Morphine, Oxycodone, Oxymorphone and Tramadol.

Data from FL Health CHARTS, indicates the count of unintentional injury deaths by drug poisoning in Broward County more than doubled between 2015 and 2017 from 250 deaths to 516 deaths or an age-adjusted rate of 13.4 (2015) to 27.1 (2017) as compared to the State rate of 22.6 in 2017. The FDOH Opioid Use Dashboard between 2015 and 2017 for Broward County demonstrated the following: Opioid-involved non-fatal overdose emergency department visits increased from 522 to 1,842; Opioid-involved non-fatal overdose hospitalizations increased from 414 to 729; and Emergency Department visits related to opioid overdose increased from 7.3 per 10,000 visits to 30.5 per 10,000 visits.

FDLE provides data on arrests attributed to possession or sale of illegal drugs. From 2015-2017, the number of drug arrests has declined. In 2015, there were 8,991 total drug arrests in Broward County. Of those arrests, 8,639 were adults and 352 were minors. The number of total drug arrests decreased by 14% to 7,696 in 2017. The number of adult drug arrests decreased by 16% to 7,299 in 2017, and by 16% to 297 in minors.

Opioid-related morbidity and mortality impacts quality of life and can be costly to individuals and medical systems. While Florida's opioid drug overdose death rate is increasing, the number of opioid prescriptions is decreasing, and there is an increase in drug-related arrests and overdoses. This suggests an increase of drugs/opioids obtained illicitly, not through prescriptions.  The complex and evolving nature of the opioid epidemic highlights the need for an interdisciplinary, comprehensive, and cohesive public health approach. In order to combat this issue of substance use in the hospitality industry, DOH-Broward created and implemented the Broward Restaurants (and hospitality industry) Educating Against Drugs (BREAD), an initiative to provide outreach and education to hospitality business owners and managers on the dangers of SUD.

BREAD provided outreach visits to owners/managers of hospitality businesses, including restaurants, bars, hotels/motels, movie theaters, and night clubs. The goal was to educate the owners/managers on: 1. naloxone, what it is and how to administer it,  2. the dangers of SUD, 3. the importance of promoting a workplace culture that supports sobriety and does not glorify substance use, 4. how to recognize when an employee may have a SUD, and 5. how to help to link employees in need to treatment and resources.  We employed two health educators to conduct these visits, and they partnered with a deputy from BSO who provided the naloxone and naloxone training. A toolkit of educational materials was developed that can be left with the owners/managers, as well as a naloxone kit. The toolkit included information on the dangers of SUD, how to recognize when someone may have a SUD, how to talk to an employee with a SUD and help them connect with treatment, and a guide to local treatment resources.

The health educators collected data on their visits, including the number of businesses they contacted, the number who receive a naloxone kit, the number that accept a visit, the number that reject a visit, and the types of questions and feedback received during the visit.  A follow-up survey was developed and conducted one month after the visit. The survey collected data on whether or not they have used the naloxone kit, level self-reported knowledge and attitude change from owners/managers and any actions taken by owners/managers with their staff, including referrals to treatment programs in the resource guide provided at the visit.

The Florida Prescription Drug Monitoring Program, Electronic Florida Online Reporting of Controlled Substance Evaluation Program (E-FORCSE), was created by the Florida Legislature in 2009 to encourage safer prescribing of controlled substances and reduce drug abuse and diversion within the state of Florida. DOH-Broward utilized the E-FORCSE Dashboard to identify overdose morbidity and mortality rates, generate insight for action, and drive prevention and response activities. Dashboard data identified the type of drugs used in overdose cases. Drugs characterized as opioids by FDLE Medical Examiners Commission include: Buprenorphine, Codeine, Fentanyl, Fentanyl Analogs, Heroine, Hydrocodone, Hydromorphone, Meperidine, Morphine, Oxycodone, Oxymorphone, and Tramadol.

DOH-Broward partnered with SFHIDTA to identify areas with high overdose rates and/or high arrest rates for drug-related charges to prioritize outreach to businesses in those areas. After identifying priority businesses, the following activities were implemented:

·         DOH-Broward hired a team of health educators to provide outreach

·         Health educators received specialized training on SUD and prevention topics

·         The BREAD Team developed an educational toolkit and educational materials about the dangers of SUD, the importance of promoting a workplace culture that supports sobriety, recognizing when an employee may have a SUD, and how to connect employees in need to SUD treatment resources

·         DOH-Broward developed and implemented a follow–up visit survey to determine the effectiveness of the outreach education

·         The BREAD Team held meetings with SFWN to coordinate site visits and naloxone training for owners/managers

·         Conducted outreach and visits to identified hospitality industry businesses 

From December 1, 2020 – November 30, 2021, the BREAD Team connected with 353 Broward County businesses. The BREAD Team health educators with community partners from SFWN completed 221 visits. Each visit included education on SUD and naloxone training and kits. 89 % of the visited business received SUD training, naloxone training and kits. As of November 2021, 520 naloxone kits were distributed to local business. Based on programmatic monitoring, 53 lives have been directly saved by this program and 54 referrals have been made by owners/managers to resources that were provided during the visits.

Opioid-related morbidity and mortality impacts quality of life and is very costly to individuals, employers, and medical systems. While the number of opioid prescriptions is decreasing, there is an increase in Florida's opioid drug overdose death rate, drug-related arrests, and overdoses. This suggests an increase in drugs such as opioids being obtained illegally. Substance-use negatively affects U.S. industries through workplace incidents (i.e., accidents and injuries), lost productivity, absenteeism, low morale, and increased illness. The National Council on Alcoholism and Drug Dependence (NCADD) estimates that SUD costs employers $81 billion annually through lost productivity and absenteeism, turnover and recruitment costs, workplace accidents, health care expenses, and disability and workers' compensation. The CDC reported the following statistics related to opioid use disorder and overdose in Florida for 2017 in a 2021 Morbidity and Mortality Weekly Report https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7015-H.pdf):

·                     Per capital cost of opioid use disorder: $1,476

·                     Per capita cost of fatal opioid overdose $1,786

·                     Per capita combined cost of opioid use disorder and fatal opioid overdose $3,262

·                     Case Count of opioid use disorder: 140,000

·                     Case count of opioid overdose: 3,245

·                     Cost of opioid use disorder (millions): $30,970.6

·                     Combined (millions): $68,444.3

·                     Value of statistical life lost (millions): $32,772.9

The DOH-Broward BREAD initiative is an original program, and the department has been unable to find another jurisdiction that has implemented a program that specifically targeted the hospitality industry. This innovative program has been recognized as a 2022 TaxWatch Productivity Award Winner.  Harm reduction initiatives have been applied in the past. According to the CDC, as of 2013, 55% of U.S syringe service programs (SSPs) had implemented overdose education and naloxone distribution (OEND). In 2014 and 2015, researchers with the Veteran's Administration (VA) Palo Alto Health Care System evaluated the feasibility of VA's distribution of naloxone to Veterans at risk for an opioid overdose.

This practice had 3 goals with multiple objectives as listed below:

Goal 1: By November 30, 2021, provide education on substance use disorder in the hospitality industry to at least 400 hospitality business owners/managers.

Objective 1.1: By December 31, 2020, develop a packet of educational materials to be distributed to hospitality industry owners/managers.

Objective 1.2: By December 31, 2020, through collaboration with SFHIDTA, develop a list of geographical areas to target for outreach based on overdose rates and drug-related arrest data.

Objective 1.3: By January 2, 2021, begin hospitality industry outreach visits.

Goal 2: By November 30, 2021, provide naloxone training and a naloxone kit to at least 400 hospitality business owners/managers.

            Objective 2.1 By January 31, 2021, DOH-Broward and BSO will enter into a contract for DOH-Broward to provide funding for BSO to purchase naloxone to distribute during outreach visits.

            Objective 2.2: By December 31, 2020, DOH-Broward and BSO will hold a planning meeting to create a protocol for outreach visits.

            Objective 2.3: By February 1, 2021, BSO will begin outreach visits with DOH-Broward health educators.

Goal 3: By November 30, 2021, 25% of hospitality business owners/managers will have a self-reported increase in SUD knowledge.

Objective 3.1: By January 31, 2021, develop a follow-up survey for hospitality industry owners/managers who receive a visit from health educators.

Objective 3.2: By February 28, 2021, begin conducting follow-up surveys with hospitality industry owners/managers who have received a health educator visit.

DOH collaborated with FDLE, the Florida Prescription Drug Monitoring Program, and the Agency for Healthcare Administration (AHCA) to create the E-FORCSE Opioid Use Dashboard for opioid and drug-related public health data at the state and county level. This dashboard provides high quality, comprehensive, and real-time data on overdose morbidity and mortality to generate insight for action and to drive prevention and response activities. 

Each surveillance system partner provided critical elements to the dashboard. BREAD utilized data from DOH-Broward's Overdose Data to Action (OD2A) collaboration with Florida Medical Examiners to identify opioid and drug-related deaths investigated by FDLE. DOH-Broward provided funds to the South Florida Wellness Network for the purchase of naloxone kits which were provided during training and outreach visits. 

The Florida Prescription Drug Monitoring Program, E-FORCSE, was created by the Florida Legislature in 2009 to encourage safer prescribing of controlled substances and reduce drug abuse and diversion within the state of Florida. DOH-Broward utilized the E-FORCSE Dashboard to identify overdose morbidity and mortality rates, generate insight for action, and drive prevention and response activities. Dashboard data identified the type of drugs used in overdose cases. Drugs characterized as opioids by the Florida Department of Law Enforcement (FDLE) Medical Examiners Commission include: Buprenorphine, Codeine, Fentanyl, Fentanyl Analogs, Heroine, Hydrocodone, Hydromorphone, Meperidine, Morphine, Oxycodone, Oxymorphone, and Tramadol.

DOH-Broward partnered with SFHIDTA to identify areas with high overdose rates and/or high arrest rates for drug-related charges to prioritize outreach to businesses in those areas. After identifying priority businesses, the following activities were implemented:

·         DOH-Broward hired a team of health educators to provide outreach

·         Health educators received specialized training on SUD and prevention topics

·         The BREAD Team developed an educational toolkit and educational materials about the dangers of SUD, the importance of promoting a workplace culture that supports sobriety, recognizing when an employee may have a SUD, and how to connect employees in need to SUD treatment resources

·         DOH-Broward developed and implemented a follow–up visit survey to determine the effectiveness of the outreach education

·         The BREAD Team held meetings with SFWN to coordinate site visits and naloxone training for owners/managers

·         Conducted outreach and visits to identified hospitality industry businesses 

This program is scalable and may be applied to different settings, agencies, and departments such as law enforcement, EMS, and other health care facilities.

DOH-Broward received grant funding of $114,728 for this twelve-month project.  Budget included:

Personnel:  $55,176 for 2 FTE Health Educators, .1 FTE Human Services Program Analyst and .1 FTE Program Manager; Associated fringe benefits costs of $9,429; $5,338 in collocated expenses ($2,737.39 per FE x 1.95 annual FTE); mileage reimbursement for the Health Educators (200 miles/month @ 0.445/mile) $1,068; contract with BSO for $17,000; cell phones ($50 x 12 months) $600; Printing materials $5,000; laptop computer $1,800 and indirect (29.90% of salary and fringes $64,605) of $19,317.

According to a CDC MMWR 2021, the cost estimate per case of fatal opioid overdose includes all opioid-related overdose deaths regardless of intent (intentional, unintentional, homicide, or undetermined), based on the value of a statistical life were as follows: health care associated costs: $5,545; lost productivity: $1.443 million; and importance of statistical life: $10.1 million.

As of November 30, 2021, 53 lives were directly saved by the BREAD Program. Cost components of fatal opioid overdose, the project was responsible for cost savings in millions of dollars:

·         Savings in health care associated costs for 53 overdose reversals: $5545 x 53 = $293,885

·         Savings in lost productivity for 53 overdose reversals: $1.443 million x 53 = $76,479,000

·         Savings in value of statistical life for 53 overdose reversals: $10.1 million x 53 = $530,000,000

·         Total Savings for past year= $606,772,885

DOH-Broward practices rapid cycle quality improvement used to achieve improved outcomes in all our activities. We used multiple measures to evaluate the program, including SMART goals and process measures, such as the number of businesses contacted, the number who accept an outreach visit, the number who reject an outreach visit, and the number who complete a one-month follow-up survey. DOH-Broward's Overdose Data to Action Program Evaluator delegated 5% of their time to evaluating BREAD.

Health educators collected qualitative data during their visits, such as questions asked by the business owner/manager, information requested by the business owner/manager, and any anecdotal information shared by the business owner/manager.

Outcome Based Performance Measures

·         Number of owners/managers contacted by health educators

·         Number of owners/managers who are willing to meet with health educators

·         Number of owners/managers who are unwilling to meet with health educators

·         Number of owners/managers who participate in naloxone training

·         Number of owners/managers who refuse naloxone training

·         Number of owners/managers who complete a follow-up survey one month after the health educator visit

·         Number of owners/managers who report increased knowledge of SUD following the visit, as assessed by the follow-up survey

·         Number of owners/managers who referred an employee to a resource on the provided resource list

·         Number of total referrals made by owners/managers to the resources on the resource list

·         Number of owners/managers who report using the naloxone kit received

Outputs

·         Educational packet on substance use disorder in the workplace

·         Educational pamphlet or flyer on substance use disorder in the hospitality industry

·         Educational pamphlet or flyer on talking to your employees on substance use disorder

·         Local resource guide to treatment and recovery programs and groups

From December 1, 2020 November 30, 2021, the BREAD Team connected with 353 Broward County businesses. BREAD health educators along with community partners from SFWN completed 221 visits. Each visit included education on SUD and naloxone training and kits. 89% of the visited business received SUD training, naloxone training and kits. As of November 2021, 520 naloxone kits were distributed to local business.

Due to the COVID-19 pandemic, DOH-Broward continued the BEREAD Program through virtually. We started contacting many of the local businesses which were temporarily or permanently closed, impacting our performance level during quarter 1 of the project. Due to the short life of the award and the position's instability, a health educator resigned at the beginning of quarter 4. We shifted the funds to support her salary and SFWN allowed them to take over all outreach activities. However, we did achieve 88.25% of our goal by contacting 400 businesses.

Based on programmatic monitoring, 53 lives have been directly saved by this program and 54 referrals have been made by owners/managers to resources that were provided during the visits.

Opioid-related morbidity and mortality impacts quality of life and is very costly to individuals, employers, and medical systems. While the number of opioid prescriptions is decreasing, there is an increase in Florida's opioid drug overdose death rate, drug-related arrests, and overdoses. This suggests an increase in drugs such as opioids being obtained illegally. Substance-use negatively affects U.S. industries through workplace incidents (i.e., accidents and injuries), lost productivity, absenteeism, low morale, and increased illness. The National Council on Alcoholism and Drug Dependence (NCADD) estimates that SUD costs employers $81 billion annually through lost productivity and absenteeism, turnover and recruitment costs, workplace accidents, health care expenses, and disability and workers' compensation. The CDC reported the following statistics related to opioid use disorder and overdose in Florida for 2017 in a 2021 Morbidity and Mortality Weekly Report https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7015-H.pdf):

·         Per capital cost of opioid use disorder: $1,476

·         Per capita cost of fatal opioid overdose $1,786

·         Per capita combined cost of opioid use disorder and fatal opioid overdose $3,262

·         Case Count of opioid use disorder: 140,000

·         Case count of opioid overdose: 3,245

·         Cost of opioid use disorder (millions): $30,970.6

·         Combined (millions): $68,444.3

·         Value of statistical life lost (millions): $32,772.9

The DOH-Broward Opioid Program received a grant from the University of Baltimore with funds from the Office of National Drug Control Policy in the amount of $114,728 for this twelve-month project.  DOH-Broward has recently applied for expanded funding through this funding opportunity to provide outreach visits to owners/managers of hospitality businesses, including restaurants, bars, hotels/motels, movie theaters, and night clubs.