addiction

The table below from the CDC illustrates what we hear all the time on the news and in our communities: drug overdose deaths are on the rise. It’s both heartbreaking and shocking! Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids. Escape from chronic pain, caused by a myriad of physical ailments, often initiates the journey to overuse and addiction.

Rather than focusing on the enormous and incredibly complicated routes to opioid addiction, this newsletter will take this opportunity to shine a light on some of the people, communities and projects that are working to make a difference. Once again, our mantra at the Foundation, “it’s a whole-person, whole-community thing,” holds true. Solving this issue is not possible by a single person or a single agency/institution; it’s about how we all can work together.

Rural communities are particularly vulnerable to this issue for a variety of reasons. Access to care, access to pain management, and the number of heavy labor occupations inherent in the economy of these communities have all been linked as reasons for increased opioid use. Research has also shown that prescription drug use in some rural areas is an embedded part of the culture, as they are often prescribed them to maintain a steady workflow in heavy labor occupations.

The Foundation houses The NC Rural Health Leadership Alliance, a group that works closely with the National Rural Health Association (NRHA) on a variety of issues. In February, NRHA provided testimony to the United States Senate Committee on the Judiciary regarding mental health and substance abuse issues in rural America. The following is a summary of the comments and recommendations from NRHA:

Rural Americans in need of substance abuse treatment services and behavioral health care will find that access to care can be limited.
Even with rural telemedicine services improving access to mental health care, 60 percent of rural Americans live in a mental health professional shortage area.
Rural Americans are forced to travel significant distances for care, especially specialty services such as mental health services and pain management.
With rural hospital closures, rural Americans are farther away from emergency care, as well as options for the ongoing treatment that is essential for successfully treating substance abuse.
The differences between rural and urban settings, culture and resource availability means the solution for rural America must be uniquely tailored to this population.
Treatment programs must be available locally and should be tailored to the unique needs and characteristics of rural Americans. Treatment programs must be able to leverage the health care providers in the community while using tele-health and other resources to bring new providers into the community.
The implementation of models to engage rural communities in addressing opioid issues must be supported. Broad community coalitions, including schools, law enforcement and medical providers need to be a part of the rural solution.
Evidence-based prevention programs tailored to the needs of rural communities must be identified and developed.
Implementation of harm reduction strategies must increase. Harm reduction is an essential part of dealing with the existing problem and will require training of both law enforcement and first responders. It will also require administering interventions known to reduce the harm of drug use including needle exchange and naloxone.
Use of evidence-based prescribing guidelines need to be promoted. Pain management is an important component of health care. However, measurement of hospital and physician quality must balance the need to address patient’s legitimate pain with the need to avoid misuse and diversion of pain medications.
State prescription drug monitoring programs (PDMPs) must be strengthened.
Use of substance abuse treatment as an alternative to incarceration for opioid users must expand. Those facing substance abuse or mental health crisis may wait years before seeking treatment from a professional, especially in rural America where the stigma discourages people from seeking treatment and views addiction as moral failure.

For the complete testimony from NRHA to the U.S. Senate Committee on the Judiciary, visit: http://connect.nrharural.org/blogs/erin-mahn/2016/02/22/nrha-submits-testimony-on

An enormous thank you to all the people engaged in this work every day. At the end of the day, success comes from the work done by communities, their citizens and the people who need their help.

-Maggie Sauer

CEO & President

Erin Hultgren, a Bernstein Fellow and Program Manager at Gaston Family Health Services (GFHS) is currently assisting with a behavioral health initiative that will improve and expand the delivery of substance abuse services and Medication-Assisted Treatment (MAT) to underserved populations with opioid use disorders. This initiative is funded by the Health Resources & Services Administration (HRSA) through their recent Substance Abuse Service Expansion, which awarded a total of $94 million in funding to health centers across the United States. GFHS was one of seven centers in North Carolina and one of 271 centers across 45 states to be awarded.

The additional grant money will enable GFHS to expand behavioral health and substance abuse services to serve its patient panel as well as extending services to both pregnant women and people living with HIV/AIDS and opioid addiction. Through its history of collaborative work with the Gaston County Health Department (GCHD), GFHS will work with GCHD and other community partners to identify pregnant and parenting women and HIV+/AIDS patients who need a more integrated approach to their opioid addiction including primary care, behavioral health, MAT and counseling services. Identification is only the first step. The ultimate goal of GFHS is to not only identify these patients, but also provide them with the integrated care they need to achieve and sustain recovery.

Additionally, GFHS will enhance their existing integrated model by:

Increasing the number of patients screened.
Connecting identified patients to treatment.
Hiring additional behavioral health providers to connect patients with access to MAT treatment.
Providing training and education for providers on best practices for opiate prescription.
Working with patients and community members on the availability and use of opioid antagonists.

As the HIV program manager for GFHS, Erin’s primary role in this initiative is to increase screening and education regarding the availability of testing and treatment for patients with or at risk of HIV/AIDS and Hepatitis C, both associated with opioid use disorders. Erin will work with behavioral health staff to update risk assessments to include questions regarding sexual health, HIV and Hepatitis C risk. Since integration and coordination of services is key to success, Erin will coordinate services between GFHS and health departments in the area to ensure patient’s have access to HIV testing and clinical services regardless of ability to pay. Although she’s new to the work of opioid addiction, she believes that an integrated care approach is the best way to provide support for these substance abuse issues.

“As we move forward, I think collaboration and communicating between partners will be our largest challenge and biggest asset,” she says. “Education will be critical – educating primary care providers, working with ERs, changing protocols, etc. Opioid addiction has far-reaching consequences and it will take all players at the table to conquer this public health crisis.”

For more information about Gaston Family Health services and their unique integrated care approach, visit http://gfhs.info.

The Center of Excellence for Integrated Care (COE) is a program of the Foundation that works with health providers across the state to integrate primary care and behavioral health services. COE’s model of integrated care is well-suited for substance abuse issues, which can harm both the mental and physical well-being of a patient. COE Director Cathy Hudgins says that “integrated care provides those struggling with addiction an opportunity to be treated as a whole person.”

The COE helps organizations develop their ability to provide integrated health care. One of their longstanding partners is Family Service of the Piedmont (FSP) in Guilford County.

The primary care provider for FSP is Anthony Steele. Steele is a nurse practitioner with a certificate in family medicine and psychiatry. He has spent 16 years serving individuals with addiction. He says he’s a “one-stop-shop” for patients because he has the training to address their physical and mental health in one setting. In the time that the COE has been working with FSP, Steele has assisted in building exemplary integrated care services.

We asked Steele a few questions to understand how he uses the integrated care model to help patients suffering from addiction.

When did you realize that you wanted to work with addiction?
I was done with inpatient healthcare. I needed to do something different. When I came in 16 years ago I knew nothing about addiction. But guess who were the best educators? My patients. They were the ones who taught me about the disease. They even taught me how to change my language when speaking to clients. I had to really adjust. Because when you’re looking at a patient and you’re calling him or her an addict, it’s one of those things that just makes them cringe. ‘No, I’m not just an addict. My name is John,’ or, ‘my name is Suzie.’

I also had to work on my perception and how I addressed individuals. I had to look at them as a patient and as a client. This is someone’s son. This is someone’s daughter. This is someone’s brother. In treatment we always want to keep people alive. Every day you see someone alive is a success. Then you work on developing tools to help them stay alive. You work on helping them build resources and you meet them where they are. Within the first month of working with addiction I became engrossed with learning about the disease process and I thought if not me, then who?

What’s encouraging about your work?
When I have a patient come in who’s been using 10 bags of heroin a day and then within a week of treatment, they are looking at me in the eye, they are taking a bath, and they are beginning to see changes in their life. When you see a pregnant mother who’s been using every drug under the sun get stabilized and she’s now able to have a normal labor and delivery. When I see those patients, I know this is where I need to be.

How does integrated care help you serve individuals with addiction?
We look at the whole picture. We do a comprehensive assessment when people come in. We have screening tools that look at depression, anxiety, trauma, addiction history, and physical health issues. When a patient comes in, they have bared their souls to us, and it’s a judgment-free zone. It just makes sense for us to treat the mind, the body, and the soul. If a patient is struggling with opioid addiction, but also high blood pressure and diabetes, I’m not going to ignore those physical issues. I’m not going to send them to another primary care doctor that doesn’t know them or who may prescribe other medications that could get the patient into trouble. It’s important to be mindful of not causing a relapse.

If we don’t begin to address the fragmentation of care, then our opioid addicted individuals will continue to be stigmatized. We need providers that know a patient’s history, won’t judge them, and will meet me where they are. Some of these patients don’t have their basic needs being met. When you add addiction on top of that, their addiction takes precedence over food and shelter. That’s why we help clients get their cravings under control, and then we work on the other aspects of life. Let’s get you gainfully employed. Now let’s work on relationships with your family so you can be supported on that road to recovery. Instead of disconnecting the head from the body, my goal is to connect it all together.

[box type=”bio”] “If we don’t begin to address the framentation of care, then our opioid addicted individuals will continue to be stigmatized.”[/box]

How does addiction tie in with other health issues?
People who have addictions have the same chronic medical issues that anyone else has, but they might be highly elevated because they aren’t typically treated. If you look at most statistics, more than one in five adults have a co-occurring mental health and substance abuse issue. And so it just makes sense to figure out how to treat them in a collaborative perspective.

One thing I’ve noticed is that dental care is much needed and sought after. A patient who’s addicted to opioids, one of their side effects is dry mouth. If you have dry mouth you aren’t producing enough saliva, and then bacteria grows and your teeth decay. But if you’re in active addiction, you’re not going to be worrying about brushing your teeth. It’s a perfect storm for dental problems. If I have dental issues, they effect my self-esteem, and now I have self-doubt, now I’m depressed, now I’m isolated. And it continues that cycle of relapse and recovery, relapse and recovery. Oftentimes our patients are also IV drug users which opens up the risk for Hepatitis C transmission with potentially shared needles. They may not know or have any symptoms, so they keep sharing needles, snorting drugs with dollar bills and having unsafe sex.

Why do you think that integrated care for opioid addiction isn’t more widely used?
Sometimes I think it’s a comfort level. Most medical programs don’t give you a lot of training in substance abuse and mental health. In primary care you maybe get one to two week’s rotation in substance abuse, and that’s it. You’re taking on the responsibility of something you really don’t know much about. And sometimes in primary care, if you don’t ask about addiction, you don’t have to deal with it. Some primary care providers do want to deal with it, but guess what? They are limited in terms of where they can refer patients. The amount of money that’s available for substance abuse treatment compared to all the other diseases is a drop in the bucket. If I’m a primary care provider and I screen for addiction, where can I get this patient into treatment? The hospital is limited and here in Guilford County we only have one in-patient detox facility, which is also limited. I think there might be 15 beds.

In your opinion how do we better address this epidemic?
We’ve got to do a better job with screening and treatment. You really need to meet the patient where they are. But once we screen for it, we also need funding to cover the cost of these patients who need this service. We have to stop ignoring the issue. Because it’s here, and it’s prevalent. Until we take a very hard look at this disease, we are going to continue these vicious cycles of chronic relapse and people dying on the streets. Most people look at it as a character flaw. We in the addiction world know that it’s not. This is a disease of the brain that needs to be dealt with like any other disease. You don’t tell your diabetic, ‘you’re obese so we aren’t going to treat you.’ No. You work with that patient where they are. Oftentimes with our addicted individuals, we just don’t have that same tolerance.

It’s STILL About Whole-Person, Whole-Community… Opioid Abuse and Addiction

[box type=”bio”] “If we don’t begin to address the framentation of care, then our opioid addicted individuals will continue to be stigmatized.”[/box]