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.