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Background: The opioid epidemic has disproportionately impacted areas in the Appalachian region of the United States. Characterized by persistent Medicaid nonexpansion, higher poverty rates, and health care access challenges, populations residing in these areas of the United States have experienced higher opioid overdose death rates than those in other parts of the country. Jefferson County, Alabama, located in Southern Appalachia, has been especially affected, with overdose rates over 2 times greater than the statewide average (48.8 vs 19.9 overdoses per 10,000 persons). Emergency departments (EDs) have been recognized as a major health care source for persons with opioid use disorder (OUD). A program to initiate medications for OUD in the ED has been shown to be effective in treatment retention. Likewise, continued patient engagement in a recovery or treatment program after ED discharge has been shown to be efficient for long-term treatment success.
Objective: This protocol outlines a framework for ED-initiated medications for OUD in a resource-limited region of the United States; the study will be made possible through community partnerships with referral resources for definitive OUD care.
Methods: When a patient presents to the ED with symptoms of opioid withdrawal, nonfatal opioid overdose, or requesting opioid detoxification, clinicians will consider the diagnosis of OUD using the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) criteria. All patients meeting the diagnostic criteria for moderate to severe OUD will be further engaged and assessed for study eligibility. Recruited subjects will be evaluated for signs and symptoms of withdrawal, treated with buprenorphine-naloxone as appropriate, and given a prescription for take-home induction along with an intranasal naloxone kit. At the time of ED discharge, a peer navigator from a local substance use coordinating center will be engaged to facilitate patient referral to a regional substance abuse coordinating center for longitudinal addiction treatment.
Results: This project is currently ongoing; it received funding in February 2019 and was approved by the institutional review board of the University of Alabama at Birmingham in June 2019. Data collection began on July 7, 2019, with a projected end date in February 2022. In total, 79 subjects have been enrolled to date. Results will be published in the summer of 2022.
Conclusions: ED recognition of OUD accompanied by buprenorphine-naloxone induction and referral for subsequent long-term treatment engagement have been shown to be components of an effective strategy for addressing the ongoing opioid crisis. Establishing community and local partnerships, particularly in resource-limited areas, is crucial for the continuity of addiction care and rehabilitation outcomes.
International Registered Report Identifier (IRRID): DERR1-10.2196/18734
The Appalachian region of the Eastern United States has been disproportionately affected by the opioid epidemic. In 2017, the death rate for opioid overdoses in Appalachian counties was 72% higher than that in non-Appalachian counties [
]. The number of opioid-related deaths in Appalachia has now surpassed the number of deaths from motor vehicle accidents [ ]. A Medicaid nonexpansion state, Alabama, is located in Southern Appalachia and has been particularly affected by the opioid epidemic. Since 2014, Alabama has led the nation with the highest rate of opioid prescriptions (107.2 prescriptions for every 100 persons), nearly two-fold greater than the national average [ ]. Following efforts implemented by the US Drug Enforcement Administration (DEA) in 2010 to decrease opioid prescription rates, the demand for more potent opioids such as heroin and fentanyl increased, resulting in an unintended increase in the number of overdose deaths nationally [ ]. This trend also occurred in Alabama, where there was a significant (11.1%) increase in the age-adjusted rate of drug overdose deaths from 2016 to 2017 [ ]. Jefferson County in Alabama is a hot spot for opioid use disorder (OUD) and its complications. An analysis of naloxone administration in 2016 revealed that Jefferson County had 48.8 overdoses per 10,000 persons, a rate significantly higher than the statewide average of 19.9 per 10,000 persons [ ]. In 2018, the Jefferson County Coroner's office confirmed 228 illicit drug deaths, 171 of which were because of an opioid overdose [ ].Patients with OUD often present to emergency departments (EDs) to treat opioid-related conditions, including nonfatal opioid overdose [
]. Persons with OUD are high users of ED services. People who inject drugs have been shown to use EDs over 3 times more frequently than the general population [ ]. Mortality after ED discharge following nonfatal opioid overdose has been shown to be as high as 5.5% within 1 year, highlighting a vulnerable population that may benefit from ED intervention [ ]. Beyond acute medical stabilization, ED interventions for this patient population have traditionally been limited to brief cessation counseling and referral for drug rehabilitation. Recently, a brief negotiation interview (BNI), the treatment of withdrawal with buprenorphine-naloxone as appropriate, and referral to treatment have been shown to be an effective strategy for OUD treatment. In a randomized trial comparing referral alone with BNI plus referral and BNI plus referral plus buprenorphine, ED patients randomized to the BNI plus referral plus buprenorphine arm had a nearly two-fold higher rate of retention in addiction treatment and significantly lower use of inpatient addiction services at 30 days [ ]. Despite this evidence, the widespread adoption has lagged. The implementation gap is particularly marked in Alabama, where, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) database and other publicly available data, only 2.18% (138/6342) of physicians had completed the Drug Addiction Treatment Act (DATA) 2000 waiver training, a requirement to prescribe medications for opioid use disorder (MOUD) such as buprenorphine [ , ]. Data elsewhere suggest that an even smaller percentage of X-waivered clinicians actively use their X-waiver to provide MOUD [ ]. The shortage of clinicians providing MOUD in Alabama is profound.Similarly, although the ED has long been recognized as the health care system's "front door," providing critical access and referral to primary care and specialty services, it often does not translate to effective linkage to substance use disorder (SUD) treatment. In Appalachia, an insufficient supply of behavioral and public health services targeting opioid misuse contributes to higher rates of opioid misuse and mortality in the region [
]. Engagement in long-term rehabilitation and MOUD, however, are an integral part of the recovery process for patients with OUD. Patients with SUD who are directly admitted to a treatment facility have been found to be 30 times more likely to enroll than those who were indirectly referred, as is most often the case in the ED setting [ ]. An additional important consideration is the resource-limited setting in which many EDs in non-Medicaid expansion states operate, particularly when considering treatment options for low-income, uninsured patients. Therefore, developing community partnerships that facilitate linkage to care is a critical component of OUD treatment after discharge from the ED.Objective
The overall objective of this implementation project is to increase the number of persons with OUD who present to either of 2 academic EDs in Jefferson County to receive MOUD and community treatment referral, thereby improving OUD outcomes in this region. We will accomplish this objective by initiating buprenorphine-naloxone in the ED, activating bedside referral services, and linking patients to longitudinal addiction care.
outlines the goals and objectives of this SAMHSA-funded public health intervention (SAMHSA Award #1H79TI081609). As the first ED-initiated medication-assisted treatment (MAT) program in Alabama, a resource-limited, non-Medicaid expansion state, we aim to demonstrate the feasibility and effectiveness of an ED-MOUD program in this region and identify barriers and potential solutions to expand access to MOUD further. We hope our experience will inform other resource-limited regions in the United States that may be seeking to improve access to MOUD and treatment options for persons with OUD.Goals for Jefferson County, Alabama | Measurable objectives |
Increase the number of clinicians with DATAa 2000 training to identify and treat patients with OUDb | Obtain DATA 2000 waiver training in at least 75% of EDc attending and licensed resident physicians by February 28, 2020. (25 UAB-EDd MDse by July 2, 2019; an additional 30 MDs by February 28, 2020). |
Develop and implement an electronic evidence-based induction and referral to treatment protocol initiated in the ED | Implement an electronic evidence-based order set to standardize OUD diagnosis, determine the need for buprenorphine induction, activate bedside referral services, and initiate outpatient MOUDf in the University and Highlands EDs by July 2, 2019. |
Operationalize the protocol to increase the number of individuals with OUD referred for MOUD | Treat and refer 272 individuals with OUD for MOUD over the 3-year project period (56 in year 1+108 in year 2+108 in year 3). |
Improve retention in care for individuals who have been diagnosed with OUD | Increase treatment completion rates by individuals with OUD throughout the program by 5%-10% each year (year 1=baseline). |
Decrease opioid overdose–related deaths | In collaboration with other community-based initiatives and public health interventions, decrease opioid overdose–related deaths in Jefferson County by 30% over 3 years. |
aDATA: Drug Addiction Treatment Act.
bOUD: opioid use disorder.
cED: emergency department.
dUAB-ED: University of Alabama at Birmingham Hospital Emergency Department.
eMD: Medicine Doctor.
fMOUD: medications for opioid use disorder.
Study Population
The population for this project includes patients seeking treatment for OUD who present to either of 2 University of Alabama at Birmingham (UAB) Hospital EDs located in Jefferson County. The University Hospital ED is a tertiary care academic ED with >70,000 annual patient visits in 2018, and the Highlands Hospital ED is an urban community ED with 30,000 annual patient visits in the same year. To estimate the number of persons potentially impacted by this public health intervention, we conducted an International Classification of Diseases, Tenth Revision, search of our electronic health record (EHR) from January 1, 2018, to December 31, 2018 [
]. We identified 2395 unique patients who presented to the ED to treat nonfatal opioid overdose, opioid withdrawal, or opioid detoxification. This prevalence rate, approximately 240 per 10,000 people, is above the national average of opioid-related ED visits [ ]. The mean age was 39.8 years (SD 12.4 years), and most patients were male (1432/2395, 59.79%) and White (1861/2395, 77.70%); 50.02% (1198/2395) of the patients were uninsured ( ).Characteristic | Value | |
Age, mean (SD) | 39.8 (12.4) | |
Male sex, n (%) | 1433 (59.83) | |
Race, n (%) | ||
White or Caucasian | 1860 (77.66) | |
Black or African American | 485 (20.25) | |
Other | 50 (2.09) | |
Insurance status, n (%) | ||
Privately insured | 380 (15.87) | |
Publicly insured (Medicare or Medicaid) | 817 (34.11) | |
Self-pay or uninsured | 1198 (50.02) |
The geographic catchment area for this initiative, Jefferson County, is the largest and most populous county in the state of Alabama, encompassing the city of Birmingham and 29 additional municipalities. Jefferson County has a total area of 1124 square miles and a population of 659,300, of which 44% are African American, 53% Caucasian, and 17% live below the federal poverty level [
].Admitted patients will be excluded from this study. Variability in inpatient treatment plans and logistical inability to consistently provide a warm handoff to a community partner (see Community Partnerships section below) make enrollment of admitted patients less feasible in our setting. Other vulnerable populations, including prisoners, minors, pregnant patients, or those unable to consent, will also be excluded.
Implementation Plan
Enrollment will occur in the ED 24 hours per day, 7 days per week. To be feasible in our context, the protocol developed by D'Onofrio et al [
] will be modified in the following ways: first, given the large number of patients who present to UAB EDs with a primary complaint of nonfatal opioid overdose, opioid withdrawal, or requesting opioid detoxification, these chief complaints will serve to identify patients with suspected OUD rather than a universal screening method. Emergency physicians' primary role in this project is to identify patients with OUD who may be eligible for ED-initiated MOUD and referral to treatment. If a patient meets 4 or more Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5), criteria (moderate to severe OUD), physicians will be asked to conduct a BNI to explore the individual's motivation to engage in treatment (see the Physician Education and Engagement section; DATA 2000 waiver training plus supplemental physician education encompasses DSM-5 OUD criteria and BNI training). The BNI typically takes ≤5 to 15 minutes [ ]. If the patient appears motivated, the physician will activate an order set within the EHR to notify the research staff in real time. Research staff will assess the patient for eligibility, conduct enrollment, and assist with linkage to care via direct communication with community referral partners. Physicians may provide a dose of buprenorphine-naloxone in the ED if the patient is in active opioid withdrawal (may be repeated if necessary for ongoing withdrawal symptoms) and will be asked to provide a buprenorphine-naloxone bridge prescription at the time of patient discharge from the ED [ ]. Patients provided with a buprenorphine-naloxone prescription will also be provided with in-person (from the provider) and handout instructions regarding buprenorphine induction and titration. Patients who are not eligible or who do not wish to enroll will be provided the appropriate existing standard of care, including a list of referral resources for OUD for self-access at the time of ED discharge.It must be noted that the prescription drug monitoring program (PDMP), a statewide controlled substance prescription database, is seamlessly integrated into the EHR at UAB and is now the standard of care in our hospitals. The PDMP for each patient is visible to all providers registered with the Alabama PDMP without the need to access an external website. A review of PDMP records before initiation of MOUD is an approach recommended by a recent American College of Emergency Physicians policy statement [
]. The PDMP will be consistently used for this study to (1) assist providers in the diagnosis of OUD, when applicable (eg, multiple overlapping opioid prescriptions from multiple providers), and (2) thoughtfully consider the treatment plan of patients who may return to the ED for MOUD refill prescriptions (see the Plans to Mitigate Risk of Diversion section).Clinical Protocol
To alert research staff to potential study participants, we developed a custom OUD order set in Cerner that delivers automated, real-time, electronic notifications to research personnel when activated by an emergency physician (
). A departmental protocol guides the initiation of the OUD order set by physicians at any time a patient meets the DSM-5 criteria for at least moderate OUD. Following the electronic alert, trained research staff, consisting of a research coordinator and/or research assistant, collaborate directly with the ordering the clinician and the patient to ascertain appropriateness for study inclusion. Research staff will assess patients for enrollment eligibility, complete the enrollment process, and facilitate handoff to community referral partners. If enrolled, research staff will also contact peer navigators to be dispatched to the bedside by the Recovery Resource Center (RRC)—a Jefferson County community substance abuse treatment coordinating center—to facilitate linkage to outpatient addiction treatment.UEDa opiate use disorder (initiated pending) | Order | ||||
Patient care | |||||
Communication order nursing |
| ||||
Communication order nursing |
| ||||
Medications | |||||
Buprenorphine-naloxone (buprenorphine [dosed with naloxone]) |
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Buprenorphine-naloxone (buprenorphine [dosed with naloxone]) |
| ||||
Discharge prescriptions | |||||
Buprenorphine-naloxone (buprenorphine-naloxone 8 mg-2 mg sublingual tablet) |
| ||||
Naloxone intranasal (take-home supply) | |||||
Buprenorphine-naloxone (buprenorphine-naloxone 8 mg-2 mg sublingual tablet) |
| ||||
Laboratory | |||||
Drugs of abuse profile (urine drug screen) |
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Comprehensive metabolic panel |
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Order urine pregnancy test for females aged 15-55 years |
| ||||
Consults | |||||
Consult to social services |
aUED: university emergency department.
bCOWS: Clinical Opioid Withdrawal Scale.
cTab-SL: tablet-sublingual.
dPRN: pro re nata (as needed).
eBID: bis in die (twice daily).
Concomitantly, prompted by a nursing order in the OUD order set, the nursing staff will assess the presence and severity of opioid withdrawal symptoms using the Clinical Opioid Withdrawal Scale (COWS) [
]. If the COWS score is between 8 and 13 (moderate withdrawal), a 4 mg-1 mg sublingual dose of buprenorphine-naloxone will be offered to the patient for induction. The patient will be observed for 1 hour, and a second 4 mg/1 mg dose will be provided if needed based on symptomatic response and repeated COWS score assessment. If the COWS score is >13 (severe withdrawal), an 8 mg-2 mg sublingual dose of buprenorphine-naloxone will be offered for induction, and the patient will be observed for symptomatic improvement [ ]. Buprenorphine-naloxone administered in the ED will be stored in Omnicell automated medication-dispensing cabinets located in the ED for efficient access and delivery to patients in withdrawal. If the patient is agreeable to engaging in outpatient addiction treatment, a 10-day prescription for buprenorphine-naloxone, 8 mg-2 mg sublingual BID (twice daily), will be offered for take-home induction bridge to outpatient MOUD (10 days has been determined to be within the current average time to follow-up for local MOUD clinics). In addition, a take-home intranasal naloxone kit will be provided along with instructions on use and general overdose education ( ). The buprenorphine-naloxone prescription will be filled on site by the hospital pharmacy, allowing the patient to be discharged with the medication in hand. The take-home naloxone kit and supply of buprenorphine-naloxone will also be provided at no cost to enrolled patients. The study cost of buprenorphine-naloxone is US $6 per pill. The intranasal naloxone kits are provided free of charge to our department by the Jefferson County Health Department.Medical Clearance
Before buprenorphine-naloxone induction and activation of bedside referral services, patients will undergo routine medical screening and clearance consisting of a comprehensive metabolic panel, urine drug test (UDT), and a urine pregnancy test in female patients with childbearing potential. Although the only true contraindication to buprenorphine is a hypersensitivity reaction to the medication, dose modification in the setting of hepatic dysfunction will be considered. Urine drug screening will allow clinicians to detect patients who are malingering and/or seeking to divert buprenorphine-naloxone. Pregnant patients with OUD in active withdrawal or seeking addiction care receive a consultation for psychiatric addiction services in the ED. Preexisting institution-specific services offer focused monitoring and intervention for this specific population to minimize the risk of neonatal abstinence syndrome and miscarriage and optimize pregnancy outcomes [
]. As such, pregnant patients will be excluded from this study.Plans to Mitigate the Risk of Diversion
Only buprenorphine-naloxone, which has a lower risk of diversion than methadone, will be administered by ED staff per DATA 2000 waiver training regulations [
]. The Alabama PDMP will be checked before each buprenorphine-naloxone prescription (as described above). Each prescription's amount and duration will be documented in the EHR and communicated to the RRC and subsequently to the receiving Alabama Department of Mental Health (ADMH) certified treatment facility. Physician engagement and education (see Physician Education and Engagement section) include standard DATA 2000 waiver training, which encompasses UDT interpretation. Therefore, the UDT collection will be included in the OUD EHR order set, and result consideration will be advised per departmental protocol before administering or prescribing buprenorphine-naloxone. Likewise, consideration of the PDMP will be strongly encouraged for any provider prescribing buprenorphine-naloxone. No specific restrictions or guidelines will be provided during this study concerning either the PDMP or UDT analysis beyond the standard DATA 2000 training. Rather, they are additional resources available to our physicians for both OUD diagnosis and evaluation of suspected diversion.ADMH-certified facilities that receive OUD patients are required to independently develop, maintain, and implement diversion control plans. We will also limit the duration of the buprenorphine-naloxone prescription to 10 days, with an option for a subsequent as needed 7-day refill to balance 2 potential factors inherent to local substance abuse treatment referral: (1) waiting time before outpatient addiction services are available and (2) the risk of diversion associated with prescriptions of prolonged duration.
Despite linkage support and efforts, there may be occasions when a patient fails to link to outpatient MOUD. In these circumstances, the patient may return to the ED seeking reengagement in the program and a MOUD refill. In these instances, research staff engagement can be used to identify and potentially overcome specific barriers to the initial treatment plan. Recidivism will also be monitored. However, the decision to provide a return patient with a refill prescription will be determined on an individual basis and at the discretion of the prescribing physician.
Physician Education and Engagement
In the state of Alabama, 2 hours of opioid-specific continuing medical education are required every 2 years, which aligns with the goal of UAB-attending physicians to obtain DATA 2000 waiver training. In the months leading up to the project start date, the principal investigator provided brief presentations at monthly emergency medicine faculty meetings to describe the evidence supporting MOUD initiation in the ED—the high incidence of opioid overdose and death in Jefferson County—and advocate for the importance of a concerted initiative centered around the needs of patients with OUD. In addition, coauthors (LAW and JJH) developed 4 hours of didactic material to deliver to emergency medicine residents in a single, half-day format, including presentations, small group case discussions, simulations, and a presentation by leadership from the RRC. In an effort to encourage learner engagement and provide a general overview and introduction of the in-person didactic, we created and released a peer-reviewed podcast that is available on iTunes and Soundcloud [
, ]. Finally, as a public health intervention consistent with the mission and values of the UAB Department of Emergency Medicine, the Emergency Medicine Department Chair mandated the faculty completion of X-waiver training.Community Partnerships
The RRC is a local addiction coordinating center that facilitates intake assessment and substance abuse referral and placement for all-comers, regardless of insurance status. Following patient intake and assessment, the RRC uses local resources and networks to direct the patient to the most appropriate definitive MOUD continuing care option available. The engagement of the RRC as a local clinical referral partner in this project was a crucial initial step. Assisting individuals with substance abuse in navigating the treatment system is an RRC mission. Formalizing a referral process with the RRC as a part of this project fulfilled a critical need for our patients and helped them fulfill their vision as a valuable community resource. As described above, when an OUD patient is identified by ED staff, the RRC will be engaged by research staff to dispatch a trained peer recovery specialist to ensure a warm handoff between ED and RRC team members and initiate referral procedures for follow-up. A warm handoff is a direct transfer of care between 2 members of a health care team that typically occurs in front of the patient. This seamless transition in care has been shown to decrease the time to enrollment in recovery programs and improve recovery prospects [
]. Following study enrollment and contact by research staff, the peer recovery specialists meet directly with the patient in the ED, creating a direct personal link to the RRC for subsequent linkage to care steps. Peer recovery specialists or peer navigators are individuals in sustained recovery from OUD who have undergone a certification process involving 40 hours of specialized substance abuse training. Peer navigators are funded by the RRC, which is supported by the local county health department and the Birmingham Crisis Center. The peer navigators provide direct assistance to the patients to facilitate access and intake at the RRC (eg, physically accompanying them on the same day to RRC intake or sharing contact information to use next-day contact to ensure RRC follow-up). RRC staff will perform a detailed intake assessment, including the American Society for Addiction Medicine and Government Performance and Results Modernization Act (GPRA) assessments, and initiate a referral to an ADMH-certified treatment facility for the continuation of MOUD. ADMH-certified treatment facilities deliver comprehensive psychosocial services, including drug counseling, recovery support services, and behavioral therapies, in addition to medication. Within our local community, we currently have 4 inpatient facilities that provide opioid detoxification and rehabilitation services, including MOUD, comprising approximately 200-plus inpatient beds with varying wait times for intake (immediate to 1 week). In addition, we have 5 outpatient facilities, several of which overlap with the aforementioned inpatient facilities, with additional capacity for weekly (during new induction) and monthly (maintenance) MOUD services. Wait times for outpatient linkage averages 3 days to 2 weeks, depending on the facility.In addition, per RRC standard practice, peer navigators will continue to facilitate the patient's care until the patient has obtained MOUD clinic follow-up or the patient no longer wishes to be contacted by the peer navigator or is otherwise unreachable.
Letters of commitment from referral partners (see the Data Collection and Evaluation section) allowed communication between research staff, the RRC, and MOUD referral partners to be bidirectional. In addition, the UAB research faculty participate in the RRC oversight committee, which regularly engages community substance abuse treatment partners in the discussion and monitoring of local MOUD resources.
Data Collection and Evaluation
The GPRA of 1993, which was revised in 2010, requires SAMHSA grantees to collect and report performance data using standardized measurement tools [
]. GPRA tools gather extensive patient-specific information, including basic demographics, substance use and abuse, mental health and physical health functioning, and other key variables. The baseline GPRA data collection will be coordinated and completed by the dedicated research staff during the initial ED visit. In-person follow-up data collection interviews at 3 and 6 months postintake and at discharge from addiction treatment will be collected by a contracted third-party vendor, Community Tracking Services (CTS). Follow-up data (eg, current address and contact information) will be obtained through data-sharing follow-up efforts led by referral facilities, including the RRC. Discharge from addiction treatment as an event is technically determined by each respective MOUD clinic and will align with individual patient treatment plans. However, for this project's purposes, it will be defined as when the patient is no longer maintained on MOUD maintenance therapy, including concomitant psychosocial support services, and therefore no longer an active patient at the MOUD clinic.Contact barriers for obtaining follow-up data have been considered. Research and CTS staff will rely heavily on MOUD support partners and referral centers, namely, the RRC and the RRC peer navigators, to ensure accurate and up-to-date contact information for enrolled patients is maintained. In addition, contact information for family and friends will also be obtained with patient consent at the time of enrollment. MOUD clinic referral partners will also collect additional contact information.
Project data will be stored in a secure REDCap (Research Electronic Data Capture) database housed on UAB-encrypted servers [
]. Per requirements, project data are also entered and stored in SAMHSA's Performance Accountability and Reporting System, a web-based data entry, reporting, and technical assistance portal. Formal institutional review board (IRB) protocols and data use agreements have been executed between UAB and non-UAB partners to ensure confidentiality, human subject protection, and Health Insurance Portability and Accountability Act compliance. Written consent will be obtained according to federal confidentiality law and regulation 42 Code of Federal Regulations, Part 2, to exchange health information between UAB, the RRC, and ADMH-certified MOUD treatment facilities to coordinate care delivery. Program evaluation activities will measure (1) the fidelity of program delivery to the timeline, (2) delivery of DATA 2000 training as targeted, (3) data demonstrating implementation of evidence-based practices (eg, MOUD and peer support services), and (4) GPRA data collection. MOUD referral partners and CTS are permitted to collect and share data under the provision of a signed letter of commitment, which describes the respective data collection and sharing roles and responsibilities. Letters of commitment were included in the IRB protocol.The outcomes and measurable project goals are listed in
. Progress toward the first goal will be evaluated by comparing the percentage of documented DATA 2000 waivers with the census of ED physicians with current DEA certificates. Achievement of goal 2 will be assessed by electronically tracking when the protocols are used and the EHR review. Goal 3 will be evaluated based on GPRA interview data collected at the time of referral to the RRC. Goals 4 and 5 will be evaluated by comparing 3-month, 6-month, and discharge follow-up information from year to year. Goal 5 will also be evaluated by comparing opioid-related deaths at the end of years 2 and 3 from Jefferson County Coroner reports, with the average between 2014 and 2017 baseline years.Data Analysis and Management
Analysis of outcome data will include descriptive statistics, including tables that summarize quantitative data and the number of clients who complete treatment compared with those who do not. We will test for differences in a variety of demographic and socioeconomic variables, including racial and ethnic groups. Client data will be analyzed at the time of enrollment, 3 and 6 months post enrollment, and at the time of discharge from local substance abuse treatment facilities. Program outcomes will be monitored quarterly. Qualitative data will be analyzed according to the project evaluator's procedures, as appropriate for the variable collected.
Funded in February 2019, this study is in the active enrollment and data collection phase. The UAB IRB approved it in June 2019, and data collection and enrollment began on July 7, 2019. The project end date is projected to be February 26, 2022. As of February 2019, we have enrolled 79 participants. We anticipate the results of the public health intervention to be published in the summer of 2022.
Across the United States, the opioid epidemic continues to rage, disproportionately affecting particular areas of the nation, including Appalachia. Appalachia is characterized by a high poverty rate (16.3% as compared with 14.6% nationally) and limited access to subspecialty care (42% of the Appalachian population is rural compared with 20% of the national population), and Appalachian counties have more health care costs coupled with coverage and access disparities than the rest of the United States [
]. Alabama is a non-Medicaid expansion state, which further exacerbates these health care disparities [ ].These characteristics highlight the potential impact of an ED-based intervention for patients with OUD at UAB, the largest and only tertiary care academic medical center in the state of Alabama. They also highlight the necessity of collaboration and community partnerships for a public health intervention such as this to be successful. Many individuals who require addiction care comprise an underserved population with limited access to health care. Our local community partner, the RRC, coordinates care for over 1000 patients with OUD or SUD annually and refers their clients for MOUD, demonstrating an efficient model of care. The linkage of this community resource directly to OUD patients in the ED is critical to ensure continuity of care. EDs have previously served as effective venues to raise awareness of and linkage to care for similar stigmatizing and deadly conditions—specifically HIV and hepatitis C virus [
, ]. The successful implementation of the public health intervention described herein further demonstrates that the ED setting represents a unique opportunity to engage with the community and improve the health of the public [ ].Future Directions
As we implement the ED-MOUD protocol, a greater number of individuals with OUD will be identified and referred to treatment, increasing the demand for MOUD. As there is a shortage of addiction providers in our region, there is an urgent need to increase the number of clinicians with DATA 2000 training who can effectively provide MAT longitudinally in collaboration with UAB addiction specialists.
An integrated hub and spoke opioid treatment network was developed in Vermont, which may be appropriate for modification and application in our region [
]. In the Vermont model, hub clinics with addiction medicine expertise assess patients' medical and psychiatric needs at intake, induce patients with buprenorphine, and determine the most appropriate treatment placement. Once patients are stable on buprenorphine, they are referred to a spoke provider. Spokes have direct access to hubs for consultation, screening, and MOUD delivery, and transfers between spokes and hubs can be bidirectional. Any waivered physician can become a spoke provider, hoping that with the extra support of the hub, the MOUD capacity will increase. In Alabama, a non-Medicaid expansion state, we will need to modify the Vermont spoke and hub model to be financially sustainable. In Jefferson County, Federally Qualified Health Centers (FQHCs), community-based health care providers that receive funds from the Health Resources and Services Administration Health Center program, provide primary care services in underserved areas and have the potential to act as spokes in a modified Vermont model [ ].A recent additional grant from SAMHSA will enable the investigative team to establish a Provider Clinical Support System Data 2000 waiver training program at our institution along with a program to train primary care clinicians to deliver MOUD to patients with OUD. This program will facilitate collaboration with FQHCs in Jefferson County to provide addiction training, oversight, and consultation to expand primary care providers' scope of practice to include MOUD. In addition, we are developing a telemedicine-assisted consultation model to support primary care providers as they deliver care to individual patients. We hope that these additional training programs and models will expand MOUD capacity in Alabama, similar to the Vermont model.
We are also exploring opening a MOUD bridge clinic at UAB to manage patients between the time of identification in the ED and linkage to longitudinal addiction treatment. Such a clinic would also provide an opportunity to incorporate multidisciplinary engagement, including medical social workers and case management services, strategically identifying and addressing patients' social determinants of health to facilitate treatment of OUD. It will also provide a supervised venue for training physicians in the complexities of MOUD, equipping them to continue these addiction practices as they are subsequently hired throughout the state in rural communities.
Traditionally a niche reserved for psychiatrists or addiction medicine specialists, treatment of OUD with MOUD is expanding to emergency clinicians, primary care clinicians, and other health care providers. EDs are the tip of the spear where societal problems meet health care, and the intersection between the opioid epidemic and the emergency care system highlights this reality. Initiating MOUD in the ED is an evidence-based approach for improving health outcomes in OUD. Community collaboration is critical for developing a feasible, cost-effective, and sustainable approach to combat the opioid epidemic in resource-limited regions.
SAMHSA provided funding for this project. The funder predefined a standardized data collection instrument as a component of the data collected according to the GPRA, but otherwise, the funder had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.
Authors' Contributions
LAW is a core research and educational faculty member and a major contributor in writing the manuscript and cocreating the emergency medicine resident OUD education module. LL is an addiction medicine specialist and ED liaison for MOUD linkage support services; she also contributed to the manuscript's editing. JBR is an emergency research staff member and is integral in grant submission and current program and data maintenance. He also contributed to the editing of the manuscript. JJH created and codirected the emergency medicine resident OUD education module and contributed to the manuscript's editing. RMS is the core research faculty member responsible for logistical program implementation, and she contributed to the writing and editing of the manuscript. MCD is a core educational faculty member and created the podcast for the emergency medicine resident OUD educational module. JB provided patient demographic data and assisted in the creation of the custom ED EHR opioid order set. EPH is the project's principal investigator and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.
Conflicts of Interest
None declared.
Emergency departments' medications for opioid use disorder induction flowsheet.
DOCX File , 49 KBReferences
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- Coroner/medical examiner department. Jefferson County, Alabama. URL: https://www.jccal.org/Default.asp?ID=236&pg=Coroner%2FMedical+Examiner [accessed 2019-10-09]
- Coutinho AD, Gandhi K, Fuldeore RM, Landsman-Blumberg PB, Gandhi S. Long-term opioid users with chronic noncancer pain: assessment of opioid abuse risk and relationship with healthcare resource use. J Opioid Manag 2018 May 02;14(2):131-141. [CrossRef] [Medline]
- Nambiar D, Stoové M, Dietze P. Frequent emergency department presentations among people who inject drugs: a record linkage study. Int J Drug Policy 2017 Jun;44:115-120. [CrossRef] [Medline]
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- D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. J Am Med Assoc 2015 Apr 28;313(16):1636-1644 [FREE Full text] [CrossRef] [Medline]
- Buprenorphine practitioner locator. Substance Abuse and Mental Health Services Administration. URL: https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator [accessed 2019-07-02]
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- Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, et al. Identification, management, and transition of care for patients with opioid use disorder in the emergency department. Ann Emerg Med 2018 Oct;72(4):420-431 [FREE Full text] [CrossRef] [Medline]
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- Coe MA, Lofwall M, Walsh SL. Buprenorphine pharmacology review: update on transmucosal and long-acting formulations. J Addict Med 2019;13(2):93-103. [CrossRef]
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- Ahmed OM, Mao JA, Holt SR, Hawk K, D'Onofrio G, Martel S, et al. A scalable, automated warm handoff from the emergency department to community sites offering continued medication for opioid use disorder: lessons learned from the EMBED trial stakeholders. J Subst Abuse Treat 2019 Jul;102:47-52 [FREE Full text] [CrossRef] [Medline]
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- Galbraith JW, Willig JH, Rodgers JB, Donnelly JP, Westfall AO, Ross-Davis KL, et al. Evolution and escalation of an emergency department routine, opt-out HIV Screening and Linkage-to-Care Program. Public Health Rep 2016 Jan;131(1_suppl):96-106. [CrossRef]
- Anderson ES, Galbraith J, Deering LJ, Pfeil SK, Todorovic T, Rodgers JB, et al. Continuum of care for Hepatitis C virus among patients diagnosed in the emergency department setting. Clin Infect Dis 2017 Jun 01;64(11):1540-1546. [CrossRef] [Medline]
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- Federally qualified health centers. Health Resources and Services Administration. 2018. URL: https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html [accessed 2019-10-23]
ADMH: Alabama Department of Mental Health |
BNI: brief negotiation interview |
COWS: Clinical Opioid Withdrawal Scale |
CTS: Community Tracking Services |
DATA: Drug Addiction Treatment Act |
DEA: Drug Enforcement Administration |
DSM-5: Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) |
ED: emergency department |
EHR: electronic health record |
FQHC: Federally Qualified Health Centers |
GPRA: Government Performance and Results Modernization Act |
IRB: institutional review board |
MAT: medication-assisted treatment |
MOUD: medications for opioid use disorder |
OUD: opioid use disorder |
PDMP: prescription drug monitoring program |
RRC: Recovery Resource Center |
SAMHSA: Substance Abuse and Mental Health Services Administration |
SUD: substance use disorder |
UAB: University of Alabama at Birmingham |
UDT: urine drug test |
Edited by G Eysenbach; submitted 15.03.20; peer-reviewed by J Hoppe, J Mihanovic, C Freiermuth; comments to author 21.08.20; revised version received 07.10.20; accepted 03.11.20; published 29.04.21
Copyright©Lauren A Walter, Li Li, Joel B Rodgers, Jennifer J Hess, Rachel M Skains, Matthew C Delaney, James Booth, Erik P Hess. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 29.04.2021.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.


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Treasury officials have given colleges the green light to tap into their coronavirus job retention scheme.
Speaking to FE Week, a spokesperson said staff who work in areas of a college that are not primarily funded by the government and who cannot be redeployed would be eligible for the scheme.
The news will come as a huge relief to college leaders, more than twenty of whom have shared with this newspaper their plans to furlough dozens, potentially hundreds, of staff.
Responding to an FE Week survey sent to senior college leaders, one said they have a proposal being presented to governors to furlough as many as 185 workers from departments across the college including "apprenticeships, nursery, estates, commercial services, health & safety, finance, HR, student services and marketing".
The finance director at a college in the East Midlands, who did not wish to be named, said the level of savings was still to be calculated but "without the government subsidising wages there would be large financial deficit, breach of banking covenants and redundancies".
And a vice principal at a college in the south west said they plan to start with furloughing 50 staff "in the very short term, but could extend to up to 300 staff" to save "potentially £100,000 in the first instance".
The coronavirus job retention scheme is a temporary scheme which will last at least three months starting from 1 March 2020.
The Treasury, due to have the scheme up and running by the end of this month, says "employers can use a portal to claim for 80 per cent of furloughed employees' usual monthly wage costs, up to £2,500 a month, plus the associated Employer National Insurance contributions and minimum automatic enrolment employer pension contributions on that wage".
But speaking to FE Week, a leading lawyer has urged caution, stressing "the guidance makes it clear that the government does not anticipate significant claims from publicly funded institutions".
Analysis of college accounts data compiled by the Education and Skills Funding Agency shows close to 80 per cent of FE college income comes from "funding body grants" (see table).
Ben Wood, partner at the law firm Eversheds Sutherland, said: "The criteria that HMRC will apply to applications from colleges for furlough payments are not yet known and there are potentially serious reputational risks if a publicly funded entity is perceived to be unfairly taking advantage of a taxpayer funded scheme.
"Having said that, in the face of depleting budget income there are obligations on governors and college leaders to look seriously at any potentially available mitigation."
Responses to the FE Week survey show many principals have already informed their college board of their furloughing decisions whilst others have sought approval.
David Hughes, chief executive of the Association of Colleges said: "College finances are on a knife-edge and many quick decisions are required by college leaders and their governing bodies. This decision is something that the principal would usually make under normal delegations.
"Because of the exceptional circumstances many leaders might engage their governing body if they can before making the decision.
"College governing bodies hold their principals to account for the effective operation of their college, including educational, financial and staff performance.
"Different governing bodies approach this task in different ways and with different levels of delegation. We're confident that college leaders and governing bodies will be approaching these decisions with care."
Just one of the 22 colleges that responded to the FE Week survey said they definitely did not plan to top up the 80 per cent government wage subsidy to 100 per cent for furloughed staff.
"What message would it send to those still being asked to work? Most people's costs have reduced as result of not travelling, lower mortgage rates etc so net difference should be marginal and manageable," the deputy chief executive of the college said.
The principal at a small college in the North East said they planned to furlough nearly 25 per cent of all staff, 36 out of 155, mainly direct apprenticeship delivery staff and administrative support.
But a spokesperson for the Department for Education stressed that it was not only Treasury guidance on the Covid-19 staff retention scheme that needed to be followed.
Colleges must, they said, have sufficient staffing resource in place to ensure vulnerable learners and the children of key workers are supported.
Advice from Ben Wood, a leading lawyer to colleges
"The starting point is that the job retention scheme guidance does not absolutely preclude colleges from applying but they should approach any applications with caution.
The guidance makes it clear that the government does not anticipate significant claims from publicly funded institutions.
Further, the criteria that HMRC will apply to applications from colleges for furlough payments are not yet known and there are potentially serious reputational risks if a publicly funded entity is perceived to be unfairly taking advantage of a taxpayer funded scheme.
Having said that, in the face of depleting budget income there are obligations on governors and college leaders to look seriously at any potentially available mitigation.
The areas where colleges might have some prospect of accessing the job retention scheme are likely to be connected with lost apprenticeship and trading income where activities have ceased as a result of CV19.
I would suggest that if an application is going to be attempted there should be an audit trail that identifies: lost income streams as a result of CV19; individual roles that can legitimately be said to have ceased for CV19 reasons and which cannot properly be said to be publicly funded; an understanding of the letter and the spirit of the job retention scheme and its guidance – and that those principles have been carefully taken into account in putting the application together.
"I would recommend that colleges take a minimalist approach to accessing the scheme and have a plan B in case an application is not accepted by HMRC."

subset: commoncrawl


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See Miley Cyrus's Chill Night at the VMAs, vs, Her Wild One in 2015
Miley Cyrus attended the MTV VMAs on Sunday, and her appearance was jarringly different than the last two times she's been at the show. Despite skipping the red carpet, the singer performed her new single, "Younger Now," on stage. In addition to rocking an Elvis Presley-inspired outfit, she also worked the stage with the dancers from her music video.
The performance, as well as her entire night, is a far cry from the Miley we got used to seeing in recent years. In 2013, she basically had everyone's jaws on the floor when she put on a raunchy performance with Robin Thicke. And in 2015, she hosted the show and left very little to the imagination with her wild outfits, had that spur-of-the-moment feud with Nicki Minaj, and shared a joint with photographers.
But Miley's chill night shouldn't come as a surprise to her fans. The star has been vocal about recently quitting weed and getting back to her roots with her new album. She's also been back together with fiancé Liam Hemsworth for almost two years now, and while he wasn't at the VMAs, it's clear that their rekindled romance has had an effect on Miley's public persona. Keep scrolling to check out photos from her night vs. 2015 to see the crazy difference!


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Coming off back-to-back losses to Duke and Notre Dame, Syracuse almost picks up a road win behind Cole Swider's career-high
The Syracuse Orange men's basketball team came close to getting a big win but ultimately fell in overtime to the North Carolina Tar Heels by a score of 88-79 in overtime at the Dean E. Smith Center
This game started off as a dominant one for the Orange in the first half, shooting the ball above 50% from the field and from distance on fewer shot attempts from the Tar Heels. However, a tight second half with some late-game heroics from Caleb Love sent this game to overtime where Syracuse was outscored 15-6 by the Tar Heels to close out the game
Cole Swider led Syracuse in scoring despite the bitter loss collecting a career-high of 36 points on 14-21 shooting, 7-11 from 3. Buddy Boeheim had 14 points and 7 rebounds while Jimmy Boeheim added 10. Brady Manek led UNC with 22 points while Caleb Love came off the bench to add 21. Armando Bacot had 17 points and 18 rebounds.
Following the opening tip, Syracuse collected nine straight points in the opening two minutes of the contest. Syracuse's hot shooting wouldn't stop there though. The Orange ended up starting the game shooting a 6-7 while leading the Tar Heels 15-8 with 16:00 left to play.
Swider connected on 3-3 from the field and 2-2 from distance while Girard and the Boeheim brothers scored a bucket each.
After Syracuse called their first timeout of the game, the Tar Heel's knocked down two three-pointers to cut the Orange's lead to 17-14. After an offensive foul was called on Girard, the Syracuse defense crowded the paint forcing two missed shots allowing a Swider transition three for his third basket from a distance tonight and his 11th point.
Following some back and forth missed shots from both teams, Another pair of three-pointers from the Tar Heels brought them within two, resulting in Jim Boeheim calling Syracuse's second timeout of the game leading the Tar Heel's 22-20 with 11:06 left to play in the first half.
Following the timeout, UNC went on a 4-1 scoring run to tie the game up 24-24. Both teams played some lockdown defense forcing each other into non-ideal shot selections keeping the game intense for around two minutes until Syracuse called their third timeout of the game, still tied 24-24 with 7:28 left to play.
Following the Orange's third timeout of the night, they forced a Tar Heel into a trap near the corner of the court resulting in UNC calling their first timeout. Mickey Black then hit a three-pointer as the shot clock expired following the timeout to force a review, but the basket was ultimately waved off by the officials.
Both teams traded back to baskets to bring the score to 26-26, but Swider made a lay-up to put the Orange back in the lead while scoring his 15th point of the game.
UNC then got their first lead of the game following an R.J. Davis three and back-to-back dunks to take a 33-28 leading to a 30-second Orange timeout with 3:54 remaining in the first.
Armondo Bacot coming out of the timeout made a tip-in lay-up to put the Tar Heels up seven until Cole Swider was able to connect on back-to-back three-pointers to bring the game back into reach for the Orange.
Girard was able to make a jumper to bring the game back within three until Caleb Love was able to get a mid-range jumper to roll the right way to put the Tar Heels up five points. The first half ended with the UNC leading 41-36.
Cole Swider led all scorers with 21 first-half points on 8-10 shooting from the field and 5-6 shooting from distance. As a team the Orange got off to a good start in the first half, shooting 55.6% from the field on 15-27 shots and 50% from distance on 6-12 shots.
Coming out of halftime, Buddy Boeheim connected on a three from the top of the arc to bring Syracuse within two points from the Tar Heels. The Orange were then able to tie it up following Girard's first three-pointer of the game.
After two minutes of back and forth from both teams, Swider made another lay-up for his 23rd point of the game followed by a Sidibe tip-in to take a 46-42 lead before the Orange called their first timeout of the half with 16:20 left to play.
Following the first timeout of the half, the Tar Heels were able to make their first field goal of the half after starting 0-7 off a Davis three to bring the Orange's lead to a mere point.
Jimmy Boeheim was able to connect on consecutive baskets to put the Orange up 5, until the Tar Heels Brady Manek was able to get a three and lay-up to fall, tying the game up 50-50 before Syracuse called their second timeout of the half with 11:54 left in regulation.
9 seconds following Syracuse's timeout, Sidibe was sent to the line trying to connect on a lay-up. After sinking both, Davis sunk yet another three to give the Tar Heels a 53-52 lead.
Syracuse was then able to go on a 4-0 run until Bacot was able to make a transition dunk with contact, connecting on the free-throw and tying the game 56-56 before Syracuse called a 30-second timeout with 9:09 left to play.
Both teams scored two points each following the timeout until Bacot took the lead for the Tar Heels following 1-2 made free throws off a shooting foul.
Swider and Bacot then traded baskets on consecutive possessions until the Orange called a timeout following a Sidibe foul on Love with 6:43 left to play, UNC leading 61-60.
Love sank both free throws coming out of the timeout, but Cole Swider scored five straight points to give the Orange a 65-63 lead. Following another personal foul on Sidibe, Bacot got sent to the line where he sank both to tie the game up at 65.
After a minute of back and forth with no baskets for either team, Buddy Boheim got a mid-range floater to drop for the lead until Manek got a lay-up to fall to tie the game up at 67-67 before Syracuse called another timeout with 3:01 left to play.
Buddy Boeheim sunk two free throws off a Manek personal foul before the timeout for the lead until Love sank a three to regain the lead for the Tar Heels.
Buddy Boeheim on the next possession missed a shot near the basket only for Sidibe to get the tip-in to give the Orange a 71-70 lead with less than 90 seconds remaining before another timeout was called with just 15 seconds left to play.
Syracuse had possession of the ball following a Manek miss, only for Girard to turn the ball over on an inbounds pass to Buddy Boeheim. UNC then called a timeout after passing over half-court with 13.3 remaining in the contest.
7 seconds following the timeout, Love sank a deep three to give the Tar Heels a two-point lead only for Girard to tie the game up at 73 off a fading baseline jumper with 1.4 left to play. the Tar Heels were able to get a shot off from near half-court before the final buzzer sounded but it didn't fall sending this conference battle into overtime.
To start overtime off, the Tar Heels scored eight straight in just over two minutes to take a definitive 81-73 lead before the Orange called a timeout with 2:55 left to play.
Coming out of the timeout, Swider got fouled connecting on 1-2 free throws only for Manek to flush down a dunk. Swider wouldn't stop scoring though, draining his 7th three and scoring his 36th point of the game on the next possession to cut the Heel's lead to six.
Following a Syracuse defensive stop, Cole Swider put up a shot from distance only for Girard to bobble a ball that would have been an offensive rebound out of bounds to make it Tar Heels ball with 1:34 left to play.
After a personal foul on Love, Swider fouled out of the contest while Love sank both free throws to take an 85-77 lead.
Following two made free-throws from Jimmt Boeheim, Love put the dagger in this game making a scoop lay-up with contact for a successful three-point play after he made his free throw. After some back and forth, the Heels ran out the clock winning the overtime duel 88-79.
Syracuse was led in scoring by a career-high 36 point performance from Cole Swider on 14-21 shots from the field and 7-11 shots from distance. The Boeheim brothers combined for 24 points on 9-25 shooting from the field and 2-9 from three. As a team, Syracuse shot 49.2% from the field and 40% from three on 31-63 and 10-25 shots.
Up Next:
The Syracuse Orange looks to finish out their season this Saturday inside the Dome against the University of Miami Hurricanes at 1 P.M. EST.


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Genre: Blues/Rock
Mike Hawthorne – Bass/Vocals
Brian "Rugrat" Ketchum – Drums
Nathan Morgan – Guitar/Vocals
In 1980 Mike Hawthorne, Brian Ketchum, John Wright, Nathan Morgan and Dave Pipes formed the band Cyclops. We played what we liked…Led Zeppelin, Black Sabbath, Rolling Stones and our own twist of Blues/Rock originals. While in High School, we played most of the local premier venues like The Villa, Eli's, Scotties, Knight's of Columbus and any Keg Party that wanted an affordable rock band! We later reunited in the mid 1990's as a blues\rock trio in Atlanta as "Hogleg" with Mike Hawthorne on Bass and vocals, Brian Ketchum on drums and Nathan Morgan on guitar and vocals. Since we all grew up very near Thompson Park and often met up there, it is priceless to have the opportunity to jam at the park again. We look forward to seeing everyone!
Email: firstname.lastname@example.com
Phone: 770-789-0054


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Last updated on October 30th, 2020 at 02:53 pm.
Watch Full WordPress Blog Course here >>
As we agreed in the last post about our Video Blog, our video blog will be built upon WordPress. And your video source will be YouTube or/and Vimeo.
This post is about WordPress (WP) . Specifically WP for beginners . If you know about WordPress . And you have used it. And also know your way around it and what it can do, then skip to the next post by clicking the next button.
What is WordPress
WordPress is a CMS (Content Management System) . A CMS is a tool that you can use to build/manage a website. In WordPress' case, managing a website involves, creating pages, creating posts, installing plugins, changing website content, managing users and so much more.
Word Press can be used for creating any kind of website. These days, yes, any kind of website.
Whether it is a simple blog. An ecommerce website. A social Media Website. A forum. An LMS website. There are turnkey plugins and themes that give WordPress owners superpowers.
.com and .org
Before I go on, you must know that there is a hosted platform for WordPress . Where you can just go, create your account. Create your blog and you are set. This place is on WordPress.com .
Then there is WordPress.org. Where the open source WordPress is hosted. On this website you can download it and play around with it. Create your website on your local computer or on your Web Hosting account. Most Web Hosts already have WordPress on their system. And you can install it by the click of a button. Figuratively.
Henceforth I will be talking about self hosted WordPress from wordpress.org . Feel free to look at wp.com as well.
Why bother with WordPress
Without wasting a lot of time on so many words, the following are some reasons. Reasons based off of my experience with Word Press , why you should be interested in it.
WordPress is useful
No doubt ! Very useful. Over the past few years WordPress has been growing in popularity. Some businesses have even moved from their old website's CMS to WP (WordPress).
WP can do so much. Let's say you have an idea. And you want to try it out as fast as possible. May be it's some service you want to start offering. If you know WordPress, you can buy a domain and Hosting.
Then install WP. Create a home page, about page and contact page. And a service description page.
Share the page with some potential customers. Perhaps on social Media or via email. See if any of them bites.
For more examples like the one above, read this entrepreneurship post .
Equate the above example with a blog idea. Install WP and just start blogging.
WordPress is a growth Tool
You know, I wanted to add some points from here to the above part. The part about Word Press being useful. But I restrained myself.
So, here we go.
You've probably read it somewhere on this website, Word Press will give you superpowers my friend.
Over 27 thousand free plugins on WordPress.org. And there are even some more premium ones on places like codecanyon.net. Some of these plugins are turnkey plugins. Meaning that installing it, will make your website something else more powerful. For instance a Directory. A Fiverr.com like website. Or an eBay like Website . And so on.
Let's not forget about WP Themes. Over 10K themes all over the internet. I have underrated the number because I don't have a ballpark figure.
You may start as a video blog. Just posting your video tips and so on. Then end up a place where you sell your digital stuff. Or even a place where you and others sell their digital stuff.
You can grow your Word Press website into whatever you want.
WordPress Knowledge base is abundant
Right now just got to Google.com and type the word theme into the search box. I can assure you that over 80% of the results will be about WordPress.
Another one. Now go and type learn WordPress . I can guess there will be over 10 million results.
Whether you just want to learn to use the basic features in WP. Or you want to learn to build Word Press themes and plugins. There will always be a place for that. A course for that. A youtube channel. A vimeo channel. And so much more scattered websites.
WP knowledge is abundant. There are free and paid courses. Whatever you want to learn, you can learn.
You can learn WordPress via Skillshare (My Skillshare Account) . In this WordPress course , I used WordPress 4.3 . But WordPress has not changed dramatically. Still the same old system at 4.5.+.
WordPress is doable at your level
Start with what you know. You don't have to be intimidated by what you don't know. Do the things you can do. And learn the rest along the way.
There are things you will not be able to do. And there are things you will be able to do. Do the things you can. Seek help from others with more experience than you. And remember to keep learning and practicing.
We shall continue with our Video blog series in the next post .Where you'll know the kind of Video Blog it will be and you'll also get to know more about hosting.
For more on WordPress (I wrote them for you)


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Forth Valley Hospitals Move To Essential Visiting
Essential visiting arrangements are being introduced at Forth Valley Royal Hospital and the four community hospitals following a rise in the number of patients with Covid-19 in local hospitals and high rates in local communities across Forth Valley and the rest of Central Scotland.
Essential visits include:
- A birth partner to support woman during hospital visits, scans, during and after labour
- Visits from both parents to support a baby or child in hospital
- Visits to support a person receiving end-of-life care – to ensure they are able to spend meaningful time with their loved ones in their final days, weeks or months
- Visits to support someone with a mental health condition such as dementia, or a learning disability or autism, where not being present would cause the patient to be distressed
- Visits in situations when someone is receiving information about a life-changing illness or treatment
- Visits in situations where support from another person is essential for advocacy and wellbeing
Essential visiting arrangements will be applied flexibly and compassionately, and each patient's needs will be considered on an individual basis. Those providing spiritual care are not considered visitors and will be able to continue to support patients in local hospitals.
NHS Forth Valley's Director of Nursing, Professor Angela Wallace, said it had been a very difficult decision to take but was necessary to help protect local patients and staff given the current high levels of Covid-19 across Forth Valley and the rest of Central Scotland.
She said: "This difficult decision was taken following detailed discussions with our infection control, public health, clinical and nursing leads over the last week. We understand it will be very disappointing for local patients and families and we will keep these temporary visiting arrangements under regular review.
"We also recognise how important the support of local friends and family is to our patients and staff will do everything possible to help them stay in touch with loved ones through phone and video calls."


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FLORIDA (RPT) – A Florida man was arrested at his home last Tuesday after police received an anonymous tip regarding his involvement in a string of unnecessarily harsh and vindictive manuscript reviews. On the scene, police found thirty pounds of lemons and a thesaurus with all synonyms for the words "insufficient" and "evidence" underlined.
The man was then identified as Reviewer 3 and confessed to his role in countless paper rejections in journals spanning numerous fields of study. Regarding his motives, he offered, "After I was kicked out of high school for [redacted], I needed something to pass my time. It was either this or loitering outside the Kwik Stop with Enus and Colter."
When asked how he managed to become a frequent reviewer at so many high-impact journals without any experience or academic credentials, he replied, "They'll let just about anybody review these things."


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References & Citations
Computer Science > Data Structures and Algorithms
Title: Approximation Algorithms for Continuous Clustering and Facility Location Problems
(Submitted on 30 Jun 2022 (v1), last revised 1 Sep 2022 (this version, v3))
Abstract: We consider the approximability of center-based clustering problems where the points to be clustered lie in a metric space, and no candidate centers are specified. We call such problems "continuous", to distinguish from "discrete" clustering where candidate centers are specified. For many objectives, one can reduce the continuous case to the discrete case, and use an $\alpha$-approximation algorithm for the discrete case to get a $\beta\alpha$-approximation for the continuous case, where $\beta$ depends on the objective: e.g. for $k$-median, $\beta = 2$, and for $k$-means, $\beta = 4$. Our motivating question is whether this gap of $\beta$ is inherent, or are there better algorithms for continuous clustering than simply reducing to the discrete case? In a recent SODA 2021 paper, Cohen-Addad, Karthik, and Lee prove a factor-$2$ and a factor-$4$ hardness, respectively, for continuous $k$-median and $k$-means, even when the number of centers $k$ is a constant. The discrete case for a constant $k$ is exactly solvable in polytime, so the $\beta$ loss seems unavoidable in some regimes.
In this paper, we approach continuous clustering via the round-or-cut framework. For four continuous clustering problems, we outperform the reduction to the discrete case. Notably, for the problem $\lambda$-UFL, where $\beta = 2$ and the discrete case has a hardness of $1.27$, we obtain an approximation ratio of $2.32 < 2 \times 1.27$ for the continuous case. Also, for continuous $k$-means, where the best known approximation ratio for the discrete case is $9$, we obtain an approximation ratio of $32 < 4 \times 9$. The key challenge is that most algorithms for discrete clustering, including the state of the art, depend on linear programs that become infinite-sized in the continuous case. To overcome this, we design new linear programs for the continuous case which are amenable to the round-or-cut framework.
Submission history
From: Ankita Sarkar [view email][v1] Thu, 30 Jun 2022 08:12:17 GMT (489kb)
[v2] Wed, 6 Jul 2022 08:55:14 GMT (37kb)
[v3] Thu, 1 Sep 2022 19:01:05 GMT (492kb)
Link back to: arXiv, form interface, contact.


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Falconets and Bayelsa Queens goalkeeper Omini Oyono, in this exclusive interview with ANTHONY NLEBEM, talks about how she started her football career, playing at the U-20 Women's World Cup, her ordeal at the Istanbul airport and more
Welcome back from the U-20 Women's World Cup. How would you describe the experience?
It's a dream come true for me. With all the training I had growing up, my goal was always to play at the FIFA World Cup, and having that exposure now is a thing of joy.
You conceded three goals in four games at the World Cup in Costa Rica. Is it a performance you are proud of?
Honestly, I am not proud of my performance in Costa Rica. I feel I should have done better, especially the mistake I made against Canada; it hurts me so much.
How did you feel about keeping two clean sheets in the tournament?
That was my goal going into the tournament, we aimed to play in the final, but unfortunately that did not happen. I feel very bad.
You girls reportedly slept on the floor at the airport in Turkey after missing your flight. What was the experience like?
That was not a good experience, it was a shame for me to sleep on the floor at the airport, but we had no choice at that moment but to accept it.
We learnt that you had to pay $18 to have your bath at the airport, with some players unable to pay and couldn't have their bath. Were you affected?
It was not an easy thing, from when we departed from Costa Rica to Colombia, then to Turkey. To take your bath, you had to pay $18. Let me tell you the truth, I did not have my bath and most of us did not have our bath for three days. None of us could afford to pay $18 for a shower, so we stayed for days without having our bath. But some of the officials, like the backroom staff, who could afford to pay the $18, had their bath.
Is it true you girls washed your kits yourselves in Costa Rica?
No, we did not wash our kits ourselves. We only dropped our kits off after training at the laundry, they will come and pick them up, wash them and return the kits to us.
What's your next step as a footballer, after the U-20 Women's Cup?
My dream is to play outside Nigeria and show the world my talents, but first I need to first improve on the areas I am lacking to become a better goalkeeper.
Some of your teammates were invited to the Super Falcons for the recent friendlies against the USWNT. How soon do you think you can break into the senior team, which has experienced keepers like Chiamaka Nnadozie and Tochukwu Oluehi?
I'm very happy for them to have been called up to the Super Falcons, they deserve it. I was expecting that because they did very well at the World Cup in Costa Rica. My prayer is for us to progress to the senior team. For me, I believe it's a matter of time and grace, if others can break into the senior national team, I believe I can too.
What's your impression of women's football in Nigeria?
Female football is growing fast in Nigeria. Now you can play an away game and win, not like the usual home wins alone. Teams can now get away wins, which was very difficult in the past. The league is tough, with talented players. If you are not strong enough, you can't play in the Nigerian league, because everybody wants to play.
Were you born with a silver spoon?
I was never born with a silver spoon; I was born and brought up in Ughelli in Delta State.
When did you start playing football?
I started as a secondary school player, just normal school football, nothing serious then. I had an appendix operation when I was in Delta State and my mum said I should go to Cross River, my state of origin, so I could recover fully. I went to Calabar, and that was how it started. A friend invited me to the stadium and introduced me to the coach of Pelican Feeders team. That was how I started playing football. From Calabar, I moved to Lagos with Local Queens, where I spent a season with the team. Then I joined Abia Angels; later I moved to Kogi where I played for Confluence Queens before joining Bayelsa Queens.
Most parents usually kick against their daughters playing football. Did your parents stop you?
My mum was not in support of me playing football because she doesn't want me to look like a guy. But my dad was in full support, he loves football and knows many Nigerian coaches and that made it very easy for me.
Who was your role model footballer while growing up?
I was inspired by former England women's goalkeeper, Hope Solo. The first day I watched her game, I said to myself I wanted to be like her. Then I was not taking my football career seriously, so I started watching her games. I was inspired by her. Interestingly, it was my dad that told me about her and urged me to watch her.
Why did you choose to be a goalkeeper?
I started playing football as a right-back, when I was with Pelican Feeders in Calabar. But one day, we went for training and my coach saw my reflexes in between the posts and converted me to a goalkeeper. He bought me hand gloves and jerseys and asked me to join the goalkeepers, and since then, I have been a goalkeeper.
What are your best and worst moments as a footballer?
My best moment was when I played against Cameroon at their home last year in one of the qualifiers for the World Cup, and that was top-notch for me. I was everywhere all through the game, coordinating my defence, and making saves. My worst moment was when I played against Edo Queens in 2020, when I conceded a very cheap goal, I don't think I ever conceded a cheap goal like that in my career.
Which striker gave you the toughest time so far?
The list is much, but I will talk about two. I remember when I was in Kogi, there was Charity Ruben, who now plays in Israel. When she was with Bayelsa Queens and Ibom Angels, I was scared of her shooting. And there was also Joy Igbokiri, who now plays in France. When she was also in Bayelsa, she took advantage of any little space to score. They are fantastic strikers who will give keepers headache any day.
What are your ambitions as a footballer?
My biggest ambition is to make money, come back home and build a football academy in my state. My state is blessed with so many football talents, but many of them are wasting away, nobody to groom them up, they are just hoping to make it one day. If not for God, I would still be at home.