Rx15 clinical tues_1115_1_porathwaller-robeson_2fan-lewis-noonan
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This document summarizes a presentation on prescriber attitudes and education regarding prescription drug misuse. The presentation features speakers from the Substance Abuse and Mental Health Services Administration, Centers for Disease Control and Prevention, and Canadian Centre on Substance Abuse. It discusses perceptions of prescription drug misuse among healthcare professionals in Canada, including challenges in identifying misuse, inadequate training and resources to address the problem, and questionable prescribing practices encountered by pharmacists. The goal is to inform physicians and providers of education tools being developed by CDC/SAMHSA to help them play a critical role in responding to prescription drug abuse.
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Rx15 clinical tues_1115_1_porathwaller-robeson_2fan-lewis-noonan
- 1. Clinical Track: U.S. and Canadian Prescriber Attitudes and Education Presenters: • Jennifer Fan, PharmD, JD, Substance Abuse and Mental Health Services Administration • Sarah Lewis, MPH, CHES, Centers for Disease Control and Prevention • Rita Noonan, PhD, Centers for Disease Control and Prevention • Amy Porath-Waller, PhD, Canadian Centre on Substance Abuse • Paula Robeson, RN, MScN, Canadian Centre on Substance Abuse Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, Tennessee Department of Health, and Member, Rx Summit National Advisory Board
- 2. Disclosures • Jennifer Fan, PharmD, JD; Sarah Lewis, MPH, CHES; Rita Noonan, PhD; Amy Porath-Waller, PhD; Paula Robeson, RN, MScN; and John J. Dreyzehner, MD, MPH, FACOEM, have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.
- 3. Disclosures • All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months. • The following planners/managers have the following to disclose: – Kelly Clark – Employment: Publicis Touchpoint Solutions; Consultant: Grunenthal US – Robert DuPont – Employment: Bensinger, DuPont & Associates-Prescription Drug Research Center – Carla Saunders – Speaker’s bureau: Abbott Nutrition
- 4. Learning Objectives 1. Express the critical role for healthcare professionals in responding to Rx drug abuse. 2. Analyze the challenges perceived by healthcare professionals as they play that role. 3. Inform physicians and provider networks of messaging and education tools being designed for them by CDC/SAMHSA.
- 5. www.ccsaca • www.cclt.ca Perceptions among Healthcare Professionals of Prescription Drug Misuse Amy J. Porath-Waller, PhD Director, Research and Policy (interim) Paula Robeson, RN, MScN Team Leader, Knowledge Mobilization Canadian Centre on Substance Abuse
- 6. Disclosures and Acknowledgements • Amy Porath-Waller, PhD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services. • Paula Robeson, RN, MScN, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services. • Funding: Alberta Health • Ethics approval: Health Research Ethics Board of Alberta, Community Health Committee The views expressed herein do not necessarily reflect the views of Alberta Health.
- 7. Learning Objectives • Express the critical role for healthcare professionals (HCPs) in responding to prescription drug abuse • Analyze the challenges perceived by HCPs in that role
- 8. About CCSA • Not-for-profit, arms-length from the federal government • Created in 1988 by an Act of Parliament with all-party support • Responsible for, and dedicated to, reducing alcohol- and drug-related harms • Sets a long-term vision, advances solutions and contributes to international dialogue on these issues • Primary funding from federal government; also from some provinces and territories, not-for-profit, private sector
- 9. • First Pan-Canadian strategy • 58 recommendations being actioned by seven implementation teams • Prevention • Education • Treatment • Monitoring and Surveillance • Enforcement • Legislation and Regulations • Evaluation and Performance Measurement • Two years of implementation phase completed First Do No Harm: Responding to Canada’s Prescription Drug Crisis
- 10. Perceptions of Healthcare Professionals • Dearth of research about HCPs’ roles in prescription drug misuse (PDM) (e.g., identifying, preventing, inadvertently enabling) – Focus has been on opioids and addiction – Studies generally qualitative in nature with small samples of physicians • Important to understand HCPs’ perspectives to: – Inform development of effective educational and prevention initiatives – Improve capacity of HCPs to address PDM
- 11. Study Objectives • To investigate perceptions of PDM among HCPs in one Canadian province • Specific perceptions the study explored include: – Extent and distribution of PDM – Clinical characteristics of PDM – Risk factors for PDM – Barriers to identifying PDM – Communication among HCPs about prescriptions – Strategies for prevention and intervention
- 12. Definition of PDM • Unintentional PDM includes using a prescription incorrectly, either because of misunderstanding instructions or a faulty memory (e.g., taking the wrong dosage) • Intentional PDM includes using a medication incorrectly for – Recreational use (e.g., to get high) – Therapeutic benefits (e.g., to help relieve pain, to improve concentration, to help sleep, to change one’s mood) The use of a medication for a medical purpose other than as directed or indicated, whether intentionally or unintentionally, and whether harm results or not.
- 13. Methods • Multidisciplinary expert panel with representation from professional colleges and associations • Short, anonymous, online survey consisting primarily of closed-ended questions • Data collected: November 13, 2013 to February 21, 2014 • HCPs were recruited from professional colleges and associations • Recruitment strategy included emailed invitations, advertisements in college and association newsletters and websites, and mailed postcards
- 14. Participants (n=1,063) • Nurses (61.1%) – Mean age: 47.7 – Years in practice: 21.6 – RNs: 93.9% – NPs: 4.5% • Physicians (9.3%) – Mean age: 48.9 – Years in practice: 21.0 – Family medicine: 63.9% – Emergency medicine: 12.4% – Psychiatry: 6.2% • Pharmacists (19.0%) – Mean age: 40.9 – Years in practice: 16.5 – Community pharmacy: 69.2% – Hospital pharmacy: 18.9% • Dentists (10.5%) – Mean age: 46.6 – Years in practice: 20.6 – General practice: 85.4% – Orthodontics: 5.2%
- 15. Clinical Presentation of PDM Behaviour indicating a patient is or was misusing prescription drugs • Scale from 1 (not at all) to 7 (definitely) Behaviour Mean (SD) Group Differences Altering the delivery of medication (e.g., snorting, injecting) 5.48 (1.39) Pharmacists > dentists* Prescription forgeries 5.47 (1.40) Pharmacists > nurses** Double doctoring 5.22 (1.32) Pharmacists > nurses** Doctor shopping 5.18 (1.31) Pharmacists > nurses*** Family or caregiver expresses worry 4.88 (1.29) None Use of medication is different than prescribed 4.76 (1.34) None Request replacement for lost or stolen prescription 4.56 (1.44) Physicians, pharmacists > nurses*** *p <.05. **p < .01. ***p < .001.
- 16. Clinical Presentation of PDM (cont’d) Behaviour Mean (SD) Group Differences Requesting that drug not be billed through routine insurance plan 4.54 (1.66) Pharmacists > nurses,*** dentists** and physicians*** Only requesting the opioid, stimulant or sedative portion of a prescription to be filled 4.40 (1.58) Dentists > nurses* Pharmacists > nurses*** Coming in early to refill prescription 4.37 (1.59) Physicians > dentists*, nurses** Pharmacists > dentists, nurses*** Requesting specific drugs 4.27 (1.47) Dentists > nurses* Frequent visits to prescribers 4.21 (1.84) Dentists > pharmacists** Nurses > pharmacists* Change reasons for returning to prescriber 4.20 (1.54) None Disproportionate pain/disability for presenting problem 4.18 (1.45) Physicians > pharmacists* Appear intoxicated 4.18 (1.46) Physicians > dentists, nurses** Pharmacists > nurses* Lack of improved function 4.16 (1.49) None *p <.05. **p < .01. ***p < .001.
- 17. Other PDM-related Patient Behaviours • States specifically what should be prescribed • Provides excuses as to why alternatives would not work Patients say they are “allergic” to all non-opioid pain relievers. They specifically know the name of and request [a] drug. • Vague about symptoms and medical history • Acts aggressively or in an intimidating manner Aggressive and threatening behaviour in the community when questioned about dosing. Threatening to report the physician to licensing body if pain isn’t treated as requested.
- 18. Other PDM-related Patient Behaviours (cont’d) • Reports maximum amount of pain, but inconsistent symptoms Rating pain level to be 10/10 as in severe, but vital signs are normal and patient appears to be comfortable (i.e. breathing normally). • Uses manipulative behaviour Patients (initially) tend to be very “friendly” or chatty to stay on your good side and keep you distracted. • Talking too much Overly talkative about meds.
- 19. Patient Risk Factors for PDM • History of substance abuse • Recent or active illicit drug use • Suicidal ideation • Chronic pain • Recent or active alcohol use • Psychiatric disorders • History of sexual abuse
- 20. Challenges Identification of PDM in Patients • Patient tendencies – Lack of patient honesty • HCP tendencies – Lack of communication with the patient and his or her family – Insufficient time with patients – Lack of communication with patients’ other HCPs – Lack of access to chronic pain or addiction specialists – Reluctance to inquire about PDM with patients
- 21. Challenges Inadequate Training and Resources • Overall, HCPs did not think they were effective in preventing or addressing PDM (M = 3.62, SD = 1.46) – Nurses’ ratings were lower compared to those of physicians, dentists and pharmacists – Pharmacists’ ratings were lower than those of physicians • Only 26% of HCPs felt they had adequate support for preventing or addressing PDM • On average, HCPs who felt they had adequate support reported it was effective (M = 4.71, SD = 1.16)
- 22. Challenges Prescribing Practices • Pharmacists indicated that during the past three months they were very likely to have encountered the following prescribing practices: – Medication was prescribed to a patient that the pharmacist suspected was misusing the prescribed medication – Medications were prescribed that should not be taken together (e.g., sedatives and opioids) – Medication was prescribed to a patient who, in the pharmacist’s opinion, probably does not require the medication – Increases in medication that were made too quickly
- 23. Challenges Interdisciplinary Communication • Opioids most frequent topic of communication among HCPs, compared to other categories of prescription drugs • Positive interactions between the groups were generally reported (except interactions between physicians and pharmacists) • Pharmacists reported that during the past three months they were likely to have encountered a situation where a physician – Was difficult to reach directly by phone – Did not promptly return calls – Was not receptive to concerns – Did not communicate or was not willing to share the therapeutic plan
- 24. Effective PDM-related Strategies • Better connections with other HCPs (e.g., chronic pain and mental health) • Improved access to a provincial prescription database • Clinical guidelines for the management of high-risk patients • Increased support for the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain • Improved understanding of – Reporting protocols – How information is used, tracked and shared
- 25. Conclusions • Similarities and important differences in HCPs’ perceptions • HCPs did not feel effective in preventing and addressing PDM • Minority (26%) felt adequately supported to prevent or address PDM • Communication issues exist between pharmacists and physicians
- 26. Implications • Inform development of a multidisciplinary screening tool • Provide additional support for HCPs – Education and training in PDM risk-management and prescribing practices – Improved access and connections with pain, mental health and addiction specialists • Consider electronic health record system improvements to help improve communication and collaboration • Conduct research – Effectiveness of interventions to improve pharmacist-physician communication
- 27. Contact InformationAmy J. Porath-Waller, PhD Director, Research and Policy Division (interim) 613-235-4048 ext. 252 Aporath-waller@ccsa.ca Paula Robeson, RN, MScN Team Leader, Knowledge Mobilization 613-235-4048 ext. 267 Probeson@ccsa.ca Canadian Centre on Substance Abuse 500–75 Albert Street Ottawa, ON K1P 5E7 @CCSAcanada • @CCLTcanada
- 28. Prescription Opioids U.S. Prescriber Attitudes and Education Sarah Lewis, MPH, CHES Rita Noonan, PhD Jennifer Fan, PharmD, JD
- 29. SAMHSA/CDC Presenters CDC National Center for Injury Prevention and Control: • Sarah Lewis, MPH, CHES Health Communications Specialist • Rita Noonan, PhD Health Systems and Trauma Systems Branch Chief Substance Abuse and Mental Health Services Administration: • Jennifer Fan, PharmD, JD Public Health Advisor
- 30. • Sarah Lewis, MPH, CHES, Rita Noonan, PhD, and Jennifer Fan, PharmD, JD, have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services. • The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention and shall not be used for advertising or product endorsement purposes. Reference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the United States Government or the Centers for Disease Control and Prevention.
- 31. Session Overview This session will: • Discuss the current state of prescription opioid abuse and misuse; • Review provider and patient attitudes, beliefs, and education surrounding prescription opioids; and • Provide an introduction to a new education campaign from the SAMHSA and CDC.
- 32. Learning Objectives At the conclusion of the session, participants will be able to: 1. Express the critical role for healthcare professionals in responding to Rx opioid abuse. 2. Analyze the challenges perceived by healthcare professionals as they play that role. 3. Inform physicians and provider networks of messaging and education tools being designed for them by SAMHSA/CDC.
- 34. Rates of prescription opioid sales, deaths and substance abuse treatment admissions (1999-2010)
- 35. EDUCATION CAMPAIGN SAMHSA/CDC joint venture campaign to target messaging and educational tools for providers and patients
- 37. Research Shaping the Campaign • Environmental Scan –Past and Present Campaigns to Reduce Rx Opioid Misuse –State, Federal, and Non-Profit Organizations • Prescriber online training modules and webinars • Web and social media campaigns, largely focused on youth
- 39. Research Shaping the Campaign • Environmental Scan – Effective Messaging Strategies • Use of multiple media channels combined with the distribution of a free or reduced price product • Health communication interventions presented as social marketing campaigns are more successful
- 40. Research Shaping the Campaign • Focus Groups – Audiences • Physicians • Consumers • Allied Healthcare – Locations • Washington, DC • Atlanta, GA
- 41. Campaign Tools and Resources • What? – Fact Sheets – Brochures • Where? – Campaign website for providers and consumers • How? – Partnerships with national and regional agencies and organizations
- 42. Preliminary Results • Focus groups for each of the 3 target audiences were held in March of 2015, in the DC and Atlanta metro areas. • Participants were asked to provide feedback on early drafts of campaign materials. – Feedback was incorporated into new drafts and those materials are currently being finalized. • Participants also discussed their existing knowledge of prescription opioid misuse along with content areas about which they wished to learn more.
- 43. Preliminary Results (cont.) • Terminology – “Pain Meds” or “Painkillers”, instead of “Opioids” • Experience with Alternative Therapies – Complementary instead of Replacement – Yoga, Acupuncture, Exercise, Chiropractic – Issues with time and access • Current Experience with Rx Opioids • Receiving Information
- 44. Preliminary Results (cont.) • Content – More visual appeal – Fewer words – Highlighting specific information instead of general overview • Design – Less clinical, more eye-catching • Titles and Taglines
- 45. Next Steps • Finalize material development • Launch campaign website • Engage partners for promotional plan • Implement campaign activities • Evaluate reach
- 46. Clinical Track: U.S. and Canadian Prescriber Attitudes and Education Presenters: • Jennifer Fan, PharmD, JD, Substance Abuse and Mental Health Services Administration • Sarah Lewis, MPH, CHES, Centers for Disease Control and Prevention • Rita Noonan, PhD, Centers for Disease Control and Prevention • Amy Porath-Waller, PhD, Canadian Centre on Substance Abuse • Paula Robeson, RN, MScN, Canadian Centre on Substance Abuse Moderator: John J. Dreyzehner, MD, MPH, FACOEM, Commissioner, Tennessee Department of Health, and Member, Rx Summit National Advisory Board
Editor's Notes
- Are we required to include Johnathan? I took them out but we can put them back in if required. [no, I think we are ok leaving them out. In the Technical Report they did not have any potential conflicts of interest]. Contractors: Jonathan Brown, Ph.D. and Aarin Frigon, M.A., CHRP, Applied Solutions & Consulting
- Note importance of language. FDNH – not PDM, PDA but rather reducing harms associated with psychoactive prescription drugs PDM not PDA for study – consultation of stakeholders Describe the First Do No Harm strategy to reduce the harms associated with psychoactive prescription drugs in Canada Present key findings from a study of Alberta healthcare professionals’ perceptions of prescription drug misuse (PDM). Describe challenges reported by healthcare professionals in responding to PDM Describe the practice implications for healthcare professional related to their critical role in responding to PDM
- -note that most studies have focused on opioids and have been conducted with physicians -most studies have been qualitative in nature with small sample sizes -studies have mostly been focussed on addiction
- HCPs included physicians and surgeons, dentists, pharmacists, registered nurses and nurse practitioners First known comprehensive study examining these variables among these 4 healthcare professional groups
- - Project adopted an integrated KT approach - Draft survey was pilot tested -Pilot test conducted through 2 online focus groups and consisted of 3 pharmacists, 3 nurses and 1 dentist. Expert Panel to inform the development of the survey and interpretation of findings. Members on the panel included representatives from Coalition on Prescription Drug Misuse National Advisory Council on Prescription Drug Misuse College of Physicians and Surgeons of Alberta Alberta College of Family Physicians Alberta Dental Association and College Alberta College of Pharmacists College and Association of Registered Nurses of Alberta Canadian Centre on Substance Abuse
- -These behaviours received a mean rating of 4 or higher -Several of these behaviours were rated higher by pharmacists compared to some of the other groups
- Participants reported other patient behaviours they felt were associated with PDM:
- Gender and age were rated as lower risk factors.
- I am not sure if this is the best spot for this slide. I did move it from a later spot in the original slide deck.
- -In contrast, physicians did not report any concerns with interactions with pharmacists. -Its unclear whether physicians are aware of these communication issues that pharmacists are reporting. These results are consistent with other studies that have investigated pharmacist-physician communication.
- Strategies perceived to be very helpful in preventing and addressing PDM in patients
- -education and training could include point of care tools and clinical guidelines
- Paula, you should add yourself to this slide as well
- In a period of nine months, a tiny Kentucky county of fewer than 12,000 people sees a 53-year-old mother, her 35-year-old son, and seven others die by overdosing on pain medications obtained from pain clinics in Florida. In Utah, a 13-year-old fatally overdoses on oxycodone pills taken from a friend’s grandmother. And a 20-year-old Boston man dies from an overdose of methadone, only a year after his friend also died from a prescription drug overdose.
- These are not isolated events. Each day, 44 people in the United States die from prescription opioid overdose. Deaths from prescription opioid overdose have quadrupled since 1999, in lockstep with increasing sales of these drugs. In 2012, US retail pharmacies dispensed more than 259 million opioid prescriptions – enough to give every adult their own bottle of pills. Yet there has been no change in the amount of pain people say they experience. Opioid poisoning and overdose now costs more than $20 billion each year in direct health care and productivity costs. Nearly two million Americans abused prescription opioids last year.
- Educational initiative aimed at increasing awareness of signs and symptoms of prescription opioid misuse and abuse, and appropriate solutions, for three target audiences: Prescribers Allied Healthcare Patients Prescribed Opioids
- Little is known regarding the effect of education on prescription drug abuse. There is a dearth of research assessing the best methods of education and information distribution, particularly as it pertains to prescribers. Although clear guidelines have been established for the assessment of abuse risk and monitoring of patients prescribed opioid analgesics, the impact of these guidelines on physician behavior has been limited. Chou R, Fanciullo GJ, Fine PG, et al. 2009. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 10(2): 113-30; Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abbboud P-AC, Rubin, HR. 1999. Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement. JAMA 282(15): 1458-1465; Hayward RSA. 1997. Clinical practice guidelines on trial. CMAJ 156: 1725-1727; Woolf SH. 1993. Practice guidelines: a new reality in medicine, III: impact on patient care. Arch Intern Med (153): 2646-55. Therefore, we conducted an environmental scan regarding existing communications to reduce prescription opioid misuse to find campaigns and trainings were often implemented by state and federal agenices, and non-profit organizations. Some examples include: National Institute on Drug Abuse’s PEERx teen campaign with website, blog and social media channels. National Association of Boards of Pharmarcy’s AWARxE is a web-based information center on prescription opioid safety – includes a user forum, RSS feed, resources for pharmacists, and social media involvement. ONDCP Partnership for Drug-Free Kids’ Above the Influence campaign targets teens and addresses a range of topics, including drug (prescription or illicit) abuse, through internet, TV, and print advertising, as well as social media.
- The Community Preventive Services Task Force and Community Guide Branch conducted a systematic review of twenty-two health communication campaigns designed to deliver messages to influence health behaviors of target audiences. Although the campaigns reviewed did not include campaigns to specifically address prescription drug abuse, studies included evaluated the effectiveness of the combination of communication of health-related information through multiple media channels with the distribution of a free or reduced price product, and determined that these campaigns were effective in changing health behaviors. Further, the strength of the findings suggested that health communication interventions presented as social marketing campaigns are more successful than those that are not in initiation and maintenance of a targeted behavior change. CDC Community Preventive Services Task Force, Community Guide Branch. Health Communication and Social Marketing: Health Communication Campaigns That Include Mass Media and Health-Related Product Distribution – Task Force Finding and Rationale Statement. October, 2011. http://www.thecommunityguide.org/healthcommunication/RRcampaigns.html. Accessed 11/21/2014. CDC Community Preventive Services Task Force. Combination of Mass Media Health Campaigns and Health-Related Product Distribution is Recommended to Improve Healthy Behaviors. American Journal of Preventive Medicine, 2014; 47(3): 372-374.
- Focus groups were held in early March, allowing participants to provide feedback on the look and feel design aspects of campaign materials, along with general content of materials. Participants were also asked about their current knowledge of prescription opioids and what information they would like to acquire. Focus groups were segmented by prescribers, allied health care professionals, and patients currently taking opioids and their family members. One focus group was held per audience in DC, and one focus group was held per audience in Atlanta, for a total of 2 focus groups per audience.
- The campaign will create and display online digital content for the three target audiences, through a centralized campaign website. A promotional plan will allow campaign staff to engage partner organizations to spread the word to their membership and associates.
- *Possible slide insertion after this, to discuss prelim data from focus groups
- While the full reports are still being finalized, a few key themes emerged from the focus groups: Terminology: Participants did not generally use or choose to use the words “opioids” or “opiates.” For some there was a negative stigma attached, for others there was fear of theft. Most consumers reported using the words Pain meds or painkillers, and prescribers reported similar for their patients. Many used the word Narcotics or the generic or brand name for the specific prescription. Some also mentioned the street/slang names for the drugs. Experience with Alternative Therapies: While most patients reported having tried alternative options, they were used in a complementary capacity, not as replacements for the pain meds. There was a feeling that these options were easier for certain groups of people with the time and resources. Most commonly mentioned were yoga, acupuncture, chiropractic, and exercise. Current Experience with Rx Opioids: Patients reported having chronic pain conditions and seeing pain specialists. Some reported being physically dependent, but not addicted. Prescribers discussed the issue of doctor shopping. Some were unaware of the existence of a PDMP in their state. Some reported knowing about it but not using it. Dentists admitted to not using it and possibly overprescribing as a result of treating acute pain. Allied Health providers (pharmacists and nurses) felt that there was little they could do when faced with misuse. They try to educate and pharmacists do have the ability to turn people away but have a difficult time judging the situation. Information Channels: Most people obtain their information online. Participants felt that pharmacists and packaging should be utilized more as sources of information. Pharmacists said they would LOVE for people to ask for information, but that oftentimes the retail system has time limitations. Prescribers rely on their state licensing agencies and medical conferences for updated information about policies, research, and PDMPs.
- Content: When shown draft versions of our campaign materials, participants overwhelmingly felt that the information should be more concise and with more visual interest. They mentioned specific topics that could be turned into easily accessed and absorbed information (such as infographics). Some topics mentioned were Safe Storage, Dangers of Mixing, and Common Street Names for Opioids. Most felt that they were aware of general information about opioids, but that the mortality data was eye-catching. Prescribers and Patients alike discussed the high volume of paperwork received by patients as being a potential barrier. Reinforced the idea of making materials engaging and visually appealing. Design: Our initial design was considered too clinical. All groups suggested increased visual aids and color, along with fewer words. Designers began working again after these initial reports. The color red was generally disliked for this campaign. Titles and Taglines: Most groups liked the word Understand or Understanding for use in titles or taglines, instead of Initiative, Awareness, or Education. Understand was considered the most straightforward and accurate, as many people are already “aware.” Similarly, they liked the tagline “Reduce the Risks” instead of “Know the Risks,” because many prescribers and patients already know the risks but could work more towards reducing them.