The Players at the Task Force Table

Charts fly across the screen. Graphs depicting overdose rates, numbers showing government spending, lists of our own efforts spark discussion, back and forths, reminders that people are dying. This Substance Use Disorders Task Force (SUDTF) is a window into MAHEC’s broader efforts in public health –researchers, next educators, next to providers teaching, learning, problem-solving. Our internal Substance Use Disorders Task Force (SUDTF) stands as MAHEC’s central team that streamlines and organizes our opioid and substance use related efforts. What this really means is that the SUDTF is a group of crazy passionate, dedicated, and driven doers who have a million ideas and projects to help improve the lives of their patients and their communities.

As a member, I began as a confused yet amazed fly-on-the-wall taking notes on words I didn’t understand– the preverbal acronyms that could have been computer code, the nuanced language of a medical practice. I wasn’t sure how each other were linked, whose responsibilities were whose, why was there so much data? The second month of my Fellowship, I thrown the responsibility of leading the team’s meeting which was a rough trial run in organization and management. How was a supposed to tell these big-name opioid players that they needed to stop talking so we could get to the next agenda item? Guiding the group in this discussion was challenging and rocky; I forgot to include introductions, there was a classic technology snafu, I didn’t successfully adhere to the agenda etc.

However, things have improved since this point.

I’ve finally been able to differentiate the players into their different, important roles.

The Education Team: manage and create programs to educate providers and community members on treating chronic pain and substance use disorders. They work with other community practices to ensure they are treating patients with evidence based medicine.

The Family Medicine Office Based Opioid Treatment Team (OBOT): provide medication assisted treatment along with primary care to patients. Many of the providers also serve as speakers and educators for the education team.

The Obstetrics Office Based Opioid Treatment Team (OBOT): provide substance use treatment to women who are pregnant. They also serve as speakers and educators for the education team. Both of the OBOT teams serve as community leaders in this work to many of the surrounding counties.

Research Teams: conduct community based and patient centered healthcare research. They also provide research support to our provider and education teams.

Population Health: collaborate with community organizations in an effort to address social determinants of health.

Community Affiliates: There are many public health professionals as well as community affiliates from MAHEC and other organizations that work directly in the community to address the opioid crisis.

Throughout my time at MAHEC, I collaborated on projects with nearly everyone on the task force. I’ve worked with the research teams on qualitative research, the education teams on pain and substance use disorder education programs, the population health teams on community engagement, and the providers on a myriad of projects related to patient support and education. Within the past year, these players have passed legislature, published breakthrough research, provided education across the state, received grants, and continually built robust treatment services.

Each player and team has their own skills, goals, efforts, schedules. They have their own ideas, thoughts, and strategies. But each MAHEC SUDTF member is bound by the same philosophy –we are here to help our patients. Their dedication and commitment to their communities, patients—people—is inspiring and motivating. I feel immensely privileged to work alongside these individuals and am grateful for the lessons they have taught me thus far.

How to Mitigate an Epidemic When it isn’t an Epidemic: MAHEC’s Efforts to Serve a Country in Crisis

The United States opioid crisis has been titled the “Opioid Epidemic” by the CDC and picked up by media drawing attention to the growing number of 600,000 people who have died from drug overdoses in the past 10 years. Vox has even claimed it as the, “epidemics of epidemics” attributing this largely to the over prescription of prescription opioids and now deadly impact of synthetic opioids like Fentanyl1. 100 times more potent than morphine, Fentanyl, which is mixed with heroin because it is a cheaper and stronger alternative, has led to increasingly to more overdoses and subsequent deaths.

MAHEC is among healthcare clinics across the country attempting to address this crisis that is seemingly out of control. As a healthcare education center, MAHEC serves the 18 westernmost counties of North Carolina and trains providers and community members on safer opioid prescribing, teaches how to treat opioid use disorder (OUD), and leads community discussions on the current state of the opioid crisis, amongst many other talks. As part of the education team, I help speakers comb over new literature on opioid and pain treatment to be disseminated to learners of our programs. Most of the literature is from 2017 and 2018 indicating the recent push from the medical community to more adequately address the crisis, but there is still so little we know about adequately helping patients with pain and addiction.

Aiming to use best opioid treatment practice, MAHEC has two substances use specific treatment services –the perinatal substance use program which treats pregnant women who have substance use disorders and the office based opioid treatment services which provides family medicine patients with medication assisted treatment (MAT) for opioid use disorders. Both of these programs provide behavioral health services as well as medication in order to help patient’s combat addiction by reducing cravings and withdrawal symptoms. As part of the clinic teams, I help with program logistics, development, and research. These roles include community outreach, creating education materials for patients and other providers, and scribing patient documentation.

MAT helps patients curb their withdrawal symptoms, it eases their nervous symptoms anxiety and urges to use. The analogy we use in clinic is that MAT is to people with substance use disorders like insulin is to people with diabetes. It helps regulate your body to a normal state. This analogy has helped me combat my own harbored bias and medicalize addiction as a disease. The providers a work with state, almost as a mantra, that addiction is a “chronically relapsing disease.” Relapse is part of the disease—it is expected that patients will struggle for the first few months while in treatment because this disease is so difficult to combat.

The biological, medical model for addiction is only one piece of understanding addiction. People who struggle with addiction are also surrounded by others who are using. Even if you are on MAT you may go home to your parents or partner using, which can be incredibly triggering and stressful. Evidence has shown that addiction also has an unclear but definitive genetic component, meaning that if you have a family history of addiction, you have a greater chance of having addiction yourself. And historically addiction has existed disproportionality in communities of color and in poverty. While the opioid crisis initially impacted poor, rural, white communities, it has grown to have broader implications in urban areas and across racial groups2. Medicalizing the rise in opioid addiction and opioid related deaths is incredibly important because it emphasizes the notion that addiction is a chronic relapsing disease that can be helped through medication and therapy. But more broadly addiction stems out of communities harboring significant trauma, stress, and other social determinants of health.

Many of our patients have extensive trauma histories and family histories of addiction. Trauma causes anxiety and fear, putting your body in fight or flight mode. When the body is in constant fear, maybe because of an unstable family situation or even insecure housing or nourishment, the body can get stuck in fight or flight mode. High stress, high anxiety mode. Especially if someone has never been taught healthy coping mechanisms, they can often turn to substances to help calm their nervous systems and get a break. Patients have told me that their first time using an opioid was “the first time the felt normal.” This trauma often exists in communities of poverty and can carry on through generations.

Unlike other “epidemics,” the opioid one isn’t virally catching. And going into this fellowship and as I learned more extensively about addiction as a disease, I did not fully grasp why the language of “epidemic” could be problematic. But providers, researchers, and patients themselves have shown me that addiction cannot be solved by a cure all medication or even a simple behavior change like washing your hands. In order to more fully support patients with addiction, within the medical setting, patients must, at minimum, be provided with behavioral health and social resources that mitigate their psychosocial stressors. Using the word Epidemic can leave out the psychosocial pieces of addiction –its existence due to poverty, trauma, stress, anxiety.

MAHEC has shown me how one organization can target the crisis through different avenues like clinical practice, population health, community and provider education, and community engagement. However, the opioid crisis is another crisis in a long time of addiction crisis that have persisted throughout United States history. We need more robust efforts that target systemic inequalities so that we don’t see another crisis in ten years.

 

  1. Nilsen, E. (2018, March 06). America’s opioid crisis has become an “epidemic of epidemics”. Retrieved from https://www.vox.com/2018/3/6/16453530/america-opioid-crisis-epidemic-bacterial-endocarditis-hepatitis-c
  2. Peñaloza, M. (2018, March 08). The Opioid Crisis Is Surging In Black, Urban Communities. Retrieved from https://www.npr.org/2018/03/08/579193399/the-opioid-crisis-frightening-jump-to-black-urban-areas
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