small town limitations. big city...
TRANSCRIPT
SMALL TOWN LIMITATIONS.
BIG CITY PROBLEMS.
A model for changing the structure and focus of treatment
as a response to the opiate crisis in rural areas.
The question we all
have to answer…
What did you do when the wave hit?
Opiate use has increased dramatically
over the past decade. The demographic
has changed too.
• Much of the increase may be attributed to a rise in
rural areas
• Majority of first-time users are white.
• Over 80% of new users now live in rural areas.
Opioids• Heroin, not prescription drugs, account for majority
of increase in rural areas.
• Change in cultural perception of drug vs. prior
generation.
• 3 Deadly Factors: Available – Potent – Inexpensive
• Fentanyl
Community Composition
• Higher unemployment rates
• Lower educational attainment
• Poorer overall health status
• Greater social/emotional isolation
Challenges to addressing substance
use disorders in rural areas.
Social/emotional isolation becomes a
major barrier to prevention and treatment
• In absence of family – often fractured due to
addiction – there are few social supports
• Limited number of support groups (AA/NA/Drop-in)
• No public transportation
Limited Service Resources
• Absence of basic needs: detox beds, shelters, sober
housing, community case management, food pantry
• Healthcare: overburdened ER, limited behavioral
health services
What We Were
RecoveryServicesRecoveryServices
CMHCCMHC
IndividualTherapy
IndividualTherapy
GroupTherapyGroup
Therapy
Suboxone
What We Are
IOP
Partial Hospitilization
Program
Outpatient
Co-OccuringDiagnosis Unit
Inpatient
RecoveryServicesRecoveryServices
Community Mental Health
Center
Community Mental Health
Center
DrugCourt and Probation
DrugCourt and Probation
IndividualTherapy
IndividualTherapy
GroupTherapyGroup
Therapy
Suboxone
Vivitrol
Broaden Access and Services
Care must be ACCESSIBLE and
INTEGRATED with a
SINGLE POINT OF ENTRY and a
FLUID CONTINUUM
Focus on where people ARE not
where we would like them to be.
Dictum of AA : Addiction Leads to…
• Jails
• Institutions
• Morgue/Death
Where are they?
• Courts
• Police
• PCP Offices
• Emergency Room
• Med/Surg /Psych Units
Response:
Institutions
• Integrated clinician to identify, treat, refer – ER
• Hospital Clinicians – Med/Surg, Psych
• Community Navigation for follow-up
Jails
• Development of regional Drug Court System
• Probation referrals
• Police Initiative – Gloucester model
• Vivitrol initiative in jails – f/u in community
Death
Emergency Room
The central point of crisis should be
the central point of care
• Patients with co-morbid conditions (medical and SA)
have 77% higher ER revisit rate
• Patients routinely sent out after OD with nothing but a
list of detox units that are inaccessible and often full
ER Response
• A study of patients discharged from ER after
Narcan show increased potential for fatal overdose
• Immediate linkage or Treatment on Site
• Clinicians and Navigators stationed in ER
• Ambulatory detox in the ER (buprenorphine) – Yale
Study
How to Capture and Contain
• Time is of the essence
• Patients with SUD given an appointment 2 weeks later have only 30% chance of successfully making the appointment
• Life-threatening condition – risk of OD changed dramatically due to unknown potency (Fentanyl)
• MAT – immediate access
Treatment• Accessible
• Single Point of Entry
• Adjust modality and level of care in a seamless, shifting manner built around nature of illness and not nature of program
Accountability• Stabilization Arms
• In-house Psychiatry - Co-Occurring disorder
• Drug Testing – LCMS – individualized and frequent• Report from Drug Court grads that testing was a
primary factor in maintaining recovery
Relationships
• Community – Judges, Police, EMT, Parent Groups
• Staff with the “5 Cs”
• Craft
• Character
• Charisma
• Confrontation
• Compulsiveness
A responsive healthcare system should be
like a spider’s web – touch it anywhere
and the whole system responds.