GR_3_24_23

March 24, 2023

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00:00Donna and.
00:04Thank you Donna.
00:05Thanks to the Karasu lecture committee.
00:08It's it's such a pleasure to be to
00:10be back here to be back at Yale and
00:12New Haven to see so many friends
00:15and colleagues and I'm thrilled
00:17that we're able to do this at least
00:19hybrid with some people in person
00:21because I mean after I'm going to be
00:23talking about community approaches
00:24to treatment and to do that in zoom
00:27we've managed we've gotten by but
00:29we've lost a lot and the the power of
00:32people and the power of connections.
00:35Because that is really what what
00:37I want to focus on.
00:39So I'm honored to give the
00:42Carasau leadership lecture,
00:44you know, among other things.
00:47Professor Cara Sue is the cofounder and
00:51long time director of the Leadership
00:54Conference for the Tarrytown Leadership
00:57Conference for cheap residents.
01:00And so for over 50 years,
01:02said Nikki established that in 1972.
01:05For over 50 years,
01:07they've been training chief
01:08residents to be effective leaders.
01:10They do it experientially.
01:12They provide them training
01:14around conflict resolution,
01:15around strategic planning.
01:17I want you to think about
01:19the leveraged impact,
01:21the multiplier effect.
01:22Think about all the chief
01:25residents he's trained,
01:26they trained and then all the residents
01:29they trained and all the now practicing
01:31psychiatrists who were affected and
01:34all the patients and communities.
01:36So this enormous multiplier effect from,
01:41you know,
01:42from his intervention using social networks.
01:45Ohh.
01:47So when I started, let me.
01:52I got it.
01:53Yes, it's recorded,
01:54so I don't have anything
01:56to disclose and about.
02:00That's my team now at Howard,
02:03which is a huge group of people and
02:05it's at both at Howard and across
02:08a number of other institutions.
02:10When I, when I started here at Yale,
02:13I was very, very fortunate to,
02:15you know, join an established,
02:17small established group with her cleber,
02:20Charlie Reardon,
02:21rosalis programs and then to be
02:24part of this initial amazing
02:27cohort of Co faculty members.
02:29Including Bruce Rounsville,
02:32Tom Costin, Stephanie O'Malley,
02:34you know,
02:35Kathy Carroll and me and you know
02:38then I think we have helped and you
02:41know developed this program that
02:43the more I see it's like who would
02:46have imagined the ways that it would
02:49flourish and the types of programs.
02:50When I got to Howard,
02:53I was also really fortunate to
02:55be able to to be able to build
02:58on previous work and so I.
02:59I really didn't want to acknowledge
03:02how those now, unfortunately,
03:04the late Dean Robert Taylor,
03:07who had been the chair of
03:10the Pharmacology department,
03:11had been the Dean of the College of Medicine.
03:14Was a noted alcohol researcher,
03:18established the Alcohol Research
03:20Center at Howard, and it would,
03:23you know,
03:24focused on both genetics and increasing
03:29diversity in biomedical research.
03:31I was fortunate it was at
03:33the end of his career.
03:34I would have loved it had I gotten earlier,
03:37but benefited from meeting him.
03:39And then that team that I showed you,
03:41core members of it were people.
03:43He said, well, you ought to take over.
03:45The work that we've been doing,
03:46I have this great team and indeed he did,
03:48so we've benefited from that.
03:53OK, so here's what I want to
03:54talk about this morning. So.
03:57And it's the specific problem,
03:59but it's clearly embedded in larger ones.
04:02So opioid overdose death
04:03rates are skyrocketing,
04:05continuing to skyrocket in the United States.
04:08One of the four pillars of for reducing
04:11the deaths is to engage and retain
04:14persons with opiate use disorder
04:17and medication treatments. MUD.
04:20We've increased overall utilization of MUD.
04:25We certainly increased
04:27availability to it nationally,
04:30but still less than 25% of the people
04:33who need it receive it in a given year.
04:37And we should compare that to other places.
04:39You know,
04:40what's the benchmark is it's at least 50
04:42or 60% in many European Union countries
04:45and it's higher than that in some of them.
04:48And then that problem underutilization
04:51is particularly severe for African
04:55American and American Indian
04:57Native American communities.
05:00And so we want to what address,
05:02what accounts for the disparities and what
05:05can we do to address the treatment gap?
05:08And then in urban
05:11African-American communities.
05:12So this is what I'll do.
05:14I'll first go briefly through
05:16the four waves of the opiate of
05:19the overdose epidemic nationally.
05:22We'll talk about the changing demographics
05:25and then that persistent treatment
05:27gap and some of the efforts that have
05:30been made to expand availability.
05:32In a way you know Don alluded to
05:34some of the things we had done here
05:36to make treatment more available.
05:38And then I want to do a deep dive
05:40focus on what we've been doing
05:42on the District of Columbia.
05:43And what we've been doing there
05:46to address the problems including
05:48building community collaborations,
05:50qualitative research to gain a deeper
05:53understanding of the barriers and
05:55facilitators for engaging people
05:57in treatment and then developing
06:00and implementing a multi pronged
06:02strategy in partnership with Community
06:05resources to overcome the barriers,
06:08increase engagement and retention and
06:10treatment and support a healthy community.
06:16OK. So here this slide shows the four
06:19what we now think of as four waves
06:21of the opioid overdose epidemic.
06:23And you know what we see is
06:27that beginning in about 2000,
06:30there's this the black line
06:31up top is any opioid deaths.
06:33But what drove the epidemic during the
06:36first wave was prescription opioids,
06:38oxycodone and other prescription
06:42opioids beginning in about 2010, 2011.
06:47Began to see a spike in heroin related
06:51overdoses that then continued to increase.
06:54We were at that point decreasing the
06:57amount of prescription opioids out there.
06:59We were engaging in some primary prevention,
07:02better prescribing other
07:03parts of the pillars.
07:05But now heroin started causing a
07:09spike or continued overall growth
07:12and then beginning in the 2013,
07:162014 terrible introduction
07:18of synthetic opioids,
07:19fentanyl, car fentanyl,
07:21other synthetic opioids causing
07:24this enormous spike that's continued
07:26and then the 4th wave was the
07:30Co occurrence of stimulants,
07:32methamphetamine and cocaine.
07:33Contributing to this 4th wave
07:36of the epidemic.
07:39Along with that shift.
07:41In here to heroin and then synthetic
07:45opioids has been a shift in the geography.
07:49So whereas the prescription
07:51opioids hit first part because
07:53they were marketed to rural areas,
07:56out hit first and rural communities.
08:00The epidemic overdoses have increased,
08:03have gone increasingly rising increasingly
08:06fast in big cities and urban cities.
08:10And so, so we see this is the most recent,
08:14yeah, pointers up there.
08:16This is the most recent statistics and it
08:18looks at the opiate overdose death rates.
08:21That's Baltimore.
08:22That's the national average.
08:24And here's a series of other cities.
08:27Virtually all the big cities
08:28far exceed the national average.
08:30And overdose death rates.
08:33And this looks at different
08:36ethnic rich groups.
08:38You know what the difference is?
08:40Rural, urban, and in most groups
08:44they're comparable relatively.
08:46It's always higher now in urban.
08:48Except among non Hispanic,
08:50Hispanic,
08:51black people where the stark
08:53differences if you're non Hispanic
08:56black person living in an urban area,
08:59you're more than twice as likely
09:01to die of an overdose at twice
09:03the rate of overdose deaths.
09:05So this epidemic has moved
09:07from rural to urban.
09:12And it's also changed in terms of
09:15the complexion of who's dying of
09:18opiate overdose deaths. So the early.
09:23This is the beginning.
09:25And these are whites and OHS and
09:29American Indian or Alaska natives.
09:33Which has been a hidden population?
09:35Or hidden in the sense not hidden
09:36to people who are experiencing it,
09:38but hidden in the press, right?
09:40Who it or know that now that the
09:43overdose death rate has exceeded
09:45the entire time and grown at a
09:47faster rate American Indians,
09:49Native Americans than in whites?
09:52But beginning with the introduction of,
09:55you know, the heroin and then the
09:58synthetic opioids and most recently.
10:02It was Co occurring stimulants.
10:05The overdose death rate among black persons.
10:11Is African Americans has far
10:14outpaced that among whites,
10:17and the death rate now exceeds
10:18the death rates for whites.
10:20This is not a race that anybody wants to win.
10:25And what that means for the District
10:28of Columbia. Is this by 2021,
10:30this looks at overdose death rates,
10:33age adjusted per 100,000 persons and
10:36DC and the district is classified as a
10:40state by CDC and that's their CDC data.
10:44So Washington DC now leads every
10:48other jurisdiction in the country.
10:50And overdose death rates closely
10:52followed by West Virginia,
10:54which had been traditional epicenter.
10:57And then here are the rates.
10:59Elsewhere.
11:02And now let's look a little bit more
11:04closely at the district what's happening
11:06in the in the District of Columbia.
11:08So and and and here we just see
11:12this exponential growth you know
11:14rate the growth in overdose deaths.
11:17Basically tripled from 2014 to 2016,
11:21nearly doubled from 2016 to 2020,
11:24and it's grown substantially more since then.
11:28And this graph here shows overall number of
11:33opiate overdose deaths by year 2016 to 2020.
11:38It also begins to show the contributions
11:41of different of the different drugs and
11:45increasingly fentanyl has been the.
11:47You know, found that it's about
11:49now what 90% of the deaths are
11:52are related to synthetic opioids.
11:55But the second part is that the overdose
11:58deaths and the increase in overdose
12:00deaths occur almost entirely among black
12:03people and mainly older black males.
12:0785% of the overdose deaths in Washington,
12:11DC occur among black people.
12:14And about 3/4 of the deaths occur
12:19if 3/4 of those are among black men.
12:23So, so the death is highly concentrated
12:26out and they're older black males,
12:29although that is unfortunately
12:30also shifting so that we're seeing
12:32more and more younger people,
12:34but we'll tell you more and it's
12:36highly concentrated in this last
12:37graph looks at death rates by Ward and
12:39I'll show you for those who don't,
12:41I didn't know if the district
12:43wards until I got down there.
12:44But the death rates are highest
12:47in Ward seven and eight,
12:49and neighboring areas and Wards 5 and six.
12:55So where awards seven and
12:56eight and five and six.
13:018765.
13:04The White House, downtown DC,
13:08the red line, ohh,
13:11you know the people know the so, so there.
13:15And then this is the Anacostia River.
13:18So it's basically east of the Anacostia
13:21River and the area right across from it
13:25and what we look at in those wards and
13:27I'll show you just a couple of them,
13:29any health disparity statistics.
13:33They're the hardest hit,
13:34so this is infant mortality rates.
13:36Could be more maternal mortality rates.
13:39It's the same thing.
13:40The highest by far, you know,
13:4311 to 14 or 15 per thousand live births.
13:46That's just about as bad as
13:49the worst places in the world.
13:51It's not the worst in the world,
13:53but it's certainly out.
13:55It's not at all what you'd expect.
13:57It's not what you see in
13:58the rest of the district.
14:03Worth 7 and eight and those areas in five
14:07and six remain the most racially segregated.
14:10Looks at proportion of the Population
14:12board seven and eight or 90% or more.
14:17African American have the highest
14:20unemployment, highest poverty.
14:21Most people living below you know,
14:25poverty line have the least health resources.
14:29These are clusters of all the
14:32various clinics and hospitals.
14:33There's now no hospital,
14:35General Hospital in Ward 7 or 8.
14:38There's no transportation
14:39to get out of there,
14:40and public transportation is terrible.
14:42These are food deserts.
14:44So these are really neglected areas
14:47that have been historically neglected.
14:53So the opiate fatality review board,
14:58out of office of the Chief Medical Examiner
15:01we've been looking at and who are the
15:05who's dying of the opiate overdose deaths?
15:07And here are some of the
15:09additional characteristics.
15:10At least up until a couple of years ago,
15:12which is the most recent stats
15:14that we've pulled together,
15:16about 88% produced heroin
15:18for more than 10 years.
15:21Nearly 60% had using for 25 years.
15:2522% had been using heroin
15:27for more than 40 years.
15:29Despite that incredibly long period of use,
15:33less than 20% had ever received
15:36any substance use treatment.
15:38From the records and these are estimates.
15:39We may have missed something.
15:41And as best we could tell,
15:42only about 10% had ever
15:44received medication treatment.
15:48So this pattern of underutilization
15:51of medication treatment. Is.
15:54Particularly stark for black or
15:58other minoritized populations.
16:01And now we'll do talk a little bit
16:03more about that. We know that.
16:06As of 22,019 was really the most
16:11recent data we can look at.
16:14Only about 17% of the 2.2 million people
16:18with past year opiate use disorder.
16:21Receive medication treatments
16:23for opiate use disorder.
16:25There's an additional set of people who
16:28are on medication treatment not using.
16:29They don't meet criteria any longer so
16:33that but 17% of people past year and
16:36that's much worse for black persons.
16:38You could look at it any number of ways here,
16:40just a couple of the key findings
16:43if you look at in Massachusetts.
16:45Pregnant women.
16:46They're all covered by one form of
16:48insurance or another, and a black,
16:51non Hispanic pregnant woman with
16:53opiate use disorder 30% less
16:55likely than her counterpart,
16:57White pregnant woman to receive
17:00medication treatment during pregnancy
17:02following an opiate overdose
17:04treated in an emergency room.
17:06Black patients are about half as likely
17:08as whites to receive medication treatment.
17:11Across primary healthcare systems,
17:13it's the same finding even in
17:16this the national based on the
17:18national Survey on Drug use,
17:20it's about a third black patients.
17:22But black people with opiate
17:24use disorder past year,
17:25about 1/3, is less likely to to
17:30receive medication treatment.
17:32In addition to that,
17:33when you look at retention,
17:34I'm not going to show you a slide.
17:36Retention is much lower for black
17:38persons with opiate use disorder.
17:40When they do enter treatment,
17:41they leave faster.
17:42And in the past several years,
17:45we've made gains nationally in the
17:47number and percentage of white people,
17:49patients who are staying on treatment
17:51for long enough period of time,
17:54you know, 180 days.
17:55It's gone in the other direction for
17:59black persons with opiate use disorder.
18:02Now we've done a lot here and I don't
18:04want to talk about all the efforts,
18:06but you know they're bringing
18:08medication treatments into primary
18:10care and office space settings,
18:12introducing it into emergency department
18:16initiated treatments or you know,
18:20developing Open Access clinics,
18:22being able to bring people in rapidly.
18:25We've expanded.
18:27MUD availability,
18:29so predominantly through office space.
18:32Buprenorphine these are.
18:34It's an older slide, but this is methadone.
18:37Methadone has remained pretty
18:39stagnant for a variety of reasons.
18:42But who's benefited?
18:44So up until about 2015, all the increased.
18:50Utilization essentially of buprenorphine.
18:53Was among white persons with
18:56opiate use disorder.
18:57And this is part of the reason,
18:59but it's, you know,
19:01it's just the one sign this is,
19:03I just pulled this off a few years back,
19:05the Internet.
19:06Pictures that were coming from
19:09advertisements from buprenorphine,
19:11buprenorphine clinics and buprenorphine
19:14manufacturers and the faces of
19:17the national advocacy groups.
19:20And I actually at that point did not see,
19:24couldn't find a single black person
19:28medication treatment now being shown.
19:32That's a little better now.
19:35OK,
19:36so I'm going to spend the remainder
19:38of the
19:39talk as promised talking about.
19:41What's happening in the district
19:42and what we've been doing there to
19:45to try to address this problem.
19:46So, so in the district in a good way,
19:49we've addressed the district some before I
19:52got there and some over the past few years.
19:55Many of the structural barriers,
19:57so the district expanded
19:59Medicaid and then for the.
20:0310% predominantly.
20:06That next Hispanic immigrants
20:07out who aren't eligible even for
20:10Medicaid or commercial insurance.
20:12The district provides free buprenorphine
20:15treatment through a drug assistance program.
20:19Eliminated copays and the requirements
20:22for pre authorization requirements.
20:24We've done a huge amount of
20:26training now the waivers gone,
20:28but we trained a large number
20:29of people to be waived.
20:31You know be able to prescribe buprenorphine
20:33many of them were we're doing it,
20:35ready to do it,
20:37interested in doing it.
20:38Every single federally qualified
20:40Health Center provides buprenorphine
20:43treatments out and we've initiated
20:46emergency department initiated.
20:49Medication treatment in every
20:52hospital emergency department.
20:54Despite that,
20:55the district ranks 32nd in the nation
20:58buprenorphine prescribing rates
20:59and is one way of looking at it.
21:02With that expansion of Medicaid
21:04between 2016 and 2018,
21:06treatment capacity just based
21:09on the number of buprenorphine
21:12providers increased by 5500 patients.
21:15But there are only 132 more patients
21:19on Medicaid receiving buprenorphine
21:22treatment in 2018 than in 2016.
21:25And the clinics like one of our partner
21:29FQHC's, had about 100 out of they.
21:33They figured they could treat
21:35at least 600 patients.
21:37So so why aren't?
21:39Patients who aren't people with
21:41opiate use disorder coming for it.
21:49This. You know, I used to think this
21:51humbled me because I used to think
21:52if we build it, they will come.
21:54Alright, the guy had slides about it.
21:57That was, you know, the question if we
21:58just build the capacity, people will come.
22:00And to some extent it was true, but here
22:03we hit the limits of where it's not true.
22:06So when I first got there or,
22:08you know, because I was brand new,
22:10I needed to learn, I needed to meet people.
22:11And so I started my own,
22:14learned this thing here, Connecticut
22:16Mental Health Center and, you know,
22:18the community coalitions and how do you,
22:21you know, get in the app foundation.
22:23So we met with community leaders,
22:26including faith leaders, health centers,
22:29other service providers,
22:30sort of attending community forums and then
22:34we assembled from Ward seven and eight.
22:36A Community Advisory Board
22:38and this has been an amazing,
22:40fabulous group of people.
22:42A pastor of a large church,
22:44director of the faith-based Community Center.
22:47And advisory Neighborhood Health Council
22:50director, community outreach workers.
22:52Peers in recovery.
22:55And started meeting regularly with
22:57them to say how are we going to
23:01address this problem and and they
23:03have Co lead the research and program
23:07development from the from the very start.
23:12And I think I was a little impatient
23:14internally when I started because
23:16I was ready to do something.
23:17But this is a problem.
23:18We got to do something and they said
23:21we need to understand it and and
23:23I have grown to absolutely trust
23:26this process because.
23:28We're doing better than we would have.
23:29We would have failed terribly
23:32and they've had great ideas.
23:34So immediately just with the cab with
23:36our Advisory Board started telling
23:38us remember I I started being able to
23:41do this because I got one of these
23:43heel initiative grants on opiates and
23:45I told them what we were going to
23:48do on opiates and it had to focus on
23:51opiate use disorders in this you know,
23:54hard hit area.
23:55And the first thing they said is look.
23:57Communities have strong,
23:59deep roots and strengths.
24:01Don't come in here and just focus
24:03on our problems.
24:04Come in here and figure out what
24:06our strengths are and build on
24:09them and strengthen the community.
24:10Second was don't come in here
24:13and just focus on opiates.
24:15And we don't trust you or you know,
24:18what's this sudden shift?
24:20Why now is there the sudden interest
24:23in opiates and a shift to view the
24:26problems of medical and not criminal?
24:27We've been going to jail for years for
24:30drug problems and now people want to
24:32come in and a public health effort.
24:34Why now only when white people are
24:36dying of overdoses, this change happened.
24:38To the people in charge of the funding
24:41and policies and priorities do the
24:44researchers or treatment providers need?
24:46Really care about us.
24:50Those are.
24:51Themes and questions that resonate deeply,
24:55as we'll see from interviews
24:58and focus groups
25:00that we did. So this don't focus
25:02on treatment and recovery only and
25:04don't certainly don't focus on or
25:06focus on treatment and recovery,
25:08don't focus on medications. Yeah.
25:11My view was we can get people to take
25:13the medications will save a lot of lives.
25:15I still think that.
25:16But people aren't interested
25:18just in the medications.
25:20And that's just another way for
25:22pharmaceutical companies to make
25:23money off of us again, that.
25:25Deep mistrust.
25:26Distrust of the medical system is part of,
25:31you know, the roots of the problem,
25:33and we'll see more from the
25:35interviews around it.
25:36And then focus on drug addiction generally,
25:39not just on opioids.
25:41And don't focus only on drugs.
25:44This problem doesn't occur in isolation.
25:47The disparities economic and housing
25:50problems, insecurity, transportation,
25:52limited healthcare services,
25:54trauma.
25:54And I personally struggled with
25:56this because I don't have any
25:58expertise in many of those.
26:00And what they challenge me said,
26:01OK, you bring your expertise,
26:02but join us in the larger struggle.
26:05And play with the expertise,
26:07but don't think that that's
26:09going to be alone enough.
26:10And so we need allies and we need,
26:13you know,
26:13we need you to be thinking about it.
26:15And then they set out and created about
26:18a really powerful vision statement.
26:20Ward seven and eight to be healthy,
26:23thriving communities where residents
26:25experience freedom from problems
26:27with substance use and addiction.
26:30And a mission you know we're
26:32to increase access to effective
26:34recovery and treatment services,
26:36reduce stigma and deal with the
26:38root causes of unhealthy drug use.
26:41They also came up with this fabulous
26:44logo that connects the wards and
26:47the district in this puzzle and
26:50and the Better Together name
26:51that wasn't where we started.
26:55And the first thing they
26:57challenged us to do and suggested,
26:59which got some medical students
27:01and residents, that was created.
27:02Community asset map. What's here?
27:04What's in the community?
27:06And and then.
27:08Two of our medical students
27:10and Morgan Medlock,
27:12who's been on our faculty developed
27:15some geospatial modeling when looking
27:18at assets over overdoses with a view.
27:21Eventually, you know as we got into a closer
27:24view of where overdoses were occurring,
27:26you might be thinking about where
27:29the really local resources that we
27:32might tie into to address hotspots.
27:35And then get more input.
27:39And this is where I'll spend sort of the
27:41bulk of the remainder of the time talking
27:44about the interviews and focus groups
27:46that we've done with community leaders,
27:49advocates, outreach workers,
27:51healthcare workers,
27:52persons with lived experience or in recovery
27:57or currently using and family members.
28:00And now we sort of created these artificial
28:03buckets and that's how we recruited people,
28:06but of course.
28:08Community leaders, healthcare workers
28:09have a lot of lived experience,
28:11so to some of the family members,
28:13so there's people speak with
28:16multiple hats and identities,
28:18but those are the buckets
28:20that we recruited them in.
28:22We worked with the CAB to develop an
28:26interview guide community how opioids,
28:28other substances affect the community.
28:32Power of people view people
28:33don't be used disorder.
28:35How do they view treatments,
28:36including medication treatments?
28:37What makes it harder or easier
28:40for people to get treatment?
28:42What could make it better?
28:45We enter,
28:45we did the audio tapes and transcribed
28:49all the interviews and then.
28:51First time in my life I've been
28:54really learning qualitative
28:55research methods much more used to
28:58randomized clinical trials and.
29:00The data analysis is easier on the RCT,
29:04but so we've developed codebooks,
29:07I'm immersed in the transcripts
29:10it's thinking about and and we've
29:12been moving from rapid coding to
29:15try to come up with plans quickly
29:17and then formal coding so we
29:20can be able to publish it.
29:22So across the interviewee
29:26participant categories.
29:28Really identified 5 main themes identified,
29:32you know,
29:33some not surprising but powerful
29:34and how they played out.
29:36Stigmatizing views about persons with
29:39opiate use disorder are prevalent.
29:41Even among many community
29:43leaders and health care workers.
29:45And they keep people away from treatment.
29:49There's incredibly powerfully strong
29:52negative views about medication treatments.
29:56And I was surprised by this because
29:57I knew there were some here that I
29:59didn't think we had that I don't
30:01know if we did these interviews
30:02what it would be like.
30:04New Haven,
30:05but I thought we had done a better
30:07job talking about what it was
30:09like and a corollary of that,
30:11that the only real treatments are
30:1312 step and abstinence base and
30:16long term residential treatments.
30:19And then a sad aspect was a
30:22real sense of nihilism.
30:24Nothing can be done.
30:27I don't know how to intervene.
30:28Nothing can be done successfully
30:30to get anyone into treatment or
30:33to help them remain in treatment.
30:35And the last was what I think of as the
30:38importance of social networks, peers,
30:41trusted, credible messengers and getting
30:44messages out and people into treatment.
30:47So I'll give some snippets
30:49of the transcripts.
30:51What people were saying.
30:53So stigmatizing views.
30:54There was a medical provider.
30:57Ohh. And the general question,
31:00how would you describe the community?
31:02Entitled. They just kind of want.
31:06What they want, when they want. Ohh,
31:10my research assistance was talking to them,
31:13you know, as they've read some of
31:16these comments they say. If I knew.
31:19The people felt that way about me.
31:21I wouldn't go and it's horrible.
31:24Medical assistant is a different one,
31:26describing patients with opiate use disorder.
31:29They're sneaky.
31:30They play with the system,
31:31the system, the Suboxone system.
31:34I'm pretty sure all of us feel like this.
31:36Why are you in this program?
31:37You should.
31:37You should act as if you're not going to.
31:39You're not going to take
31:41this program serious.
31:42Then you should get out.
31:44Another medical provider and
31:45we're really tell you the truth,
31:48I still don't trust them.
31:50I feel like there's too much
31:51potential dangers for having
31:52this prescription in their hand,
31:54and I don't want any questions
31:56with my name on that prescription.
31:58A community leader, I mean,
32:00they act like zombies.
32:02Lack of motivation. It's just an eyesore.
32:05It's something that those who don't
32:07use drugs, we don't want to see it.
32:09And.
32:10We could spend, you know,
32:12a long time reading other statements.
32:14These are very, very prevalent views.
32:18And we also heard the impact.
32:21You know what's it like when you're
32:23on the receiving end of that?
32:25So there was a person who lived
32:27experiences doing PR outreach.
32:29But if you're always putting them down,
32:30they're going to feel like,
32:32hey, this is all I'm worth well,
32:33and I'm going to do go and get high.
32:37Or another person,
32:38a community leader now have lived experience.
32:41I got treated real bad and methadone clinic,
32:45they put me down,
32:46made me feel bad about myself,
32:48told me I wasn't going to be one,
32:49I was going to be one of the ones
32:51who wasn't going to make it.
32:52There was a couple of staff like that.
32:54Not just one,
32:54you know Park as I was so angry
32:56because I got there and then noted.
32:58But there was a counselor who believed in me,
33:01motivated me, helped me stay clean.
33:06And that had a big impact.
33:07And then later in the interview
33:10this person down doing community
33:12leader who was working with one of
33:15her people came to her agency to
33:17try to help her get some housing
33:20assistance and she describing it.
33:21She said, well,
33:22a lot of times people be embarrassed
33:25about being in a situation.
33:27You'd be so afraid that people
33:28are going to judge you.
33:30And the way that Lady talked to her,
33:32so she was hearing the other,
33:34you know,
33:35the person on the other end of the
33:37phone, the way that Lady talked to her,
33:39it discouraged her.
33:41Community leader who's a teacher will
33:43get some other quotes from her and
33:45a little bit on some other issues.
33:47If it's their child,
33:48their cousin or whatever,
33:50they want them to get help,
33:51but they also don't want anybody to see it
33:53because there's stigma attached to it, like,
33:55Oh my God, the child was a drug problem.
33:59And then, of course, there's, you know,
34:01the stigmatizing attitudes push people out.
34:04But there's also a clear sense that.
34:07Ohd. If you've got somebody
34:10who's positive and receptive,
34:12that's what welcomes you.
34:13And so my doctor had a positive impact on me.
34:16His impact, I think, was the greatest of all.
34:20And people, they don't want to
34:21come into a place where people.
34:24See, they're not in recovery.
34:25This is another the stigma.
34:26They're afraid of being rejected,
34:29looking weak.
34:32So, so here's now just some
34:34of the what we heard about.
34:37How people see medication treatments.
34:42Person with lived experience.
34:43All you're doing is 1 drug
34:45and going to another drug.
34:47That's all. But nothing,
34:48nothing stopping you from wanting heroin.
34:51So once you start taking the methadone,
34:52you have to drink it every day.
34:54It's basically it's another drug.
34:56Another person who lived experience
34:58methadone is heroin and another form.
35:01It's addictive. It hurts your body.
35:02It's a little worse than heroin too,
35:04in terms of your bone structures.
35:06Here's your bones down and then it starts up.
35:09I think Suboxone works because don't
35:13have the addictive effects to it.
35:15But most of the people sell Suboxone too.
35:17You can sell a shot.
35:20I know both sides,
35:21so one side is saying it's not addictive,
35:23but the other people use it for getting high.
35:29More about from another community leader.
35:32These are the people who want to
35:33be the I want to be the advocates.
35:35And they went on methadone.
35:38Some of them can never get off the methadone.
35:40Their bones cannot function.
35:41Their bodies blew up, they become dead.
35:44They're not productive in society.
35:46I don't agree with you using
35:48a drug to get people off.
35:50And another community leader.
35:52I've seen methadone as a way
35:54of legally maintaining it.
35:55It's almost like how you treat animals,
35:58getting medication as a crutch in a way
36:00that prevents us from realizing it,
36:01tapping into that strength as a people.
36:05So we heard that in the medical clinics too,
36:09who've been clinics.
36:11That are providing medication treatment.
36:13So there there are some strong advocates,
36:15but there are also a lot of people that
36:18patients can come in contact with like.
36:20Nurse like with methadone,
36:21you trade 1 high for the next.
36:24Now they hooked on methadone.
36:25What you want them to do is to live a
36:27normal life, not addicted to anything.
36:30Another medical assistant.
36:31Sometimes patients, they'll just get it.
36:34So just to sell it.
36:37It said not much we can do about that.
36:41Family members echo.
36:43Over from people, you know the same thing.
36:47It's the same thing. People chase it.
36:50Gets you high, messes your teeth up.
36:52The teeth and the bones is.
36:55Powerful.
36:56In some ways it's more dangerous
36:58because people look at it as if it's
37:00not the same thing and there's a.
37:02Person with her own lived experience
37:04is one of the lead family describes
37:07herself one of the lead family mental
37:09health people in the community.
37:11I have a problem with methadone.
37:13I have a problem with harm reduction
37:15in order folks to recover the
37:17need to be abstinent.
37:19Yeah,
37:19they shouldn't be continuing to do drugs.
37:24This is how one aspect of this is the
37:27medical mistrust or distrust of medicine.
37:30We had heard that from the from
37:32our Community Advisory Board.
37:33But then. Heard it over and
37:36over again from the interviews.
37:41You know, giving one drug for another,
37:43it's more of a political thing with
37:45this money and pharmaceutical and
37:47some agencies that know they can make
37:49money off methadone or suboxone.
37:52It's more harmful than good, but I get it.
37:54People want to make money.
37:55It's all about the money.
37:58Ohh somebody called it the treatment
38:01industrial complex so it was
38:04worried about making it easier to
38:07get access to it from any doctor.
38:10Doctor's abuse.
38:11Their right to describe it, I think
38:13they have used the medical treatment program.
38:16And people who are just skeptical
38:18with all sorts of medications.
38:20Not too big on it.
38:21People always go to that first,
38:23like they just want to throw it at
38:25somebody instead of talking to them.
38:27Trying to understand anything.
38:28And of course this is this level
38:31of medical mistrust we all saw
38:34around COVID vaccinations and,
38:35you know, how difficult it was in
38:39some communities to be able to get,
38:41you know, high vaccination rates.
38:49Part of the problem was what they
38:52had seen with methadone programs.
38:55There are only three in the district,
38:57highly concentrated.
38:58They're highly stigmatized,
39:00they're large out and people passing by.
39:06Don't see the successes?
39:08Of methadone treatment,
39:09they see the people who are hanging
39:11out all day and so they gives this view
39:14and we heard over and over you know,
39:17what they people had seen and what
39:19they don't want in their community.
39:22You know, I think medication
39:23treatment is a good thing,
39:24but I think people abuse it.
39:26They spit it back out and then sell it.
39:28They get high.
39:29All kinds of stuff is going on over there.
39:32You get them all over the place,
39:34nodding, making drug transactions.
39:36It's a mess.
39:37You see 30-40 people standing around.
39:40They're just always busy
39:41because they want that high.
39:42That teacher and I'll talk
39:44about her one more time,
39:45but mention when she talked about
39:47a methadone clinic that she passes
39:49on her way to work and all these.
39:52People here, people are high.
39:53They're clearly on something.
39:55And I'm like, Oh my God,
39:57I don't want that in my community.
39:59But how do we fix the people?
40:01It doesn't seem good that you have
40:03a whole group of people addicted to
40:06something in the same place at the same time,
40:08because it's nothing good bound to happen.
40:10It's a recipe for disaster.
40:12And she very nicely compared
40:13it to having a bunch of second
40:16graders standing on line and the
40:18types of interaction.
40:19But you know that we're,
40:20we're it's just hard to
40:22maintain some sense of order.
40:30Don't think I'll go through
40:31all of you know the there's,
40:34you know, they're mixed views.
40:35The the predominant focus
40:38was methadone's the worst.
40:39And buprenorphine has some people who are
40:43supportive of it is interesting to me,
40:45one of the people who's a buprenorphine
40:48provider who says all Suboxone is great.
40:52But it's and it's it's really difficult to
40:55have a sustained remission without Suboxone.
40:59So I guess you could believe
41:01in remission with methadone.
41:03I don't like methadone at all.
41:05I've yet to encounter people on
41:07awake or thriving on methadone.
41:10It puts the people,
41:11it puts a damper on people and
41:13their personalities.
41:14Ohh, so there's a split which is
41:17the good medication and which is
41:19the bad one and then there's some
41:22just very strong whatever works or.
41:25And then one outreach worker who
41:27I thought this is my educator you
41:30know this is how Suboxone works
41:31and this is how you do it.
41:33And and then talking about you know,
41:36even how you engage somebody,
41:38you'd really be amazed at how many
41:41people are interested in Suboxone.
41:43Due to the fact they start realizing they
41:45have grandkids that they want to be around,
41:47so he's a sort of first responder
41:50to overdoses in the community
41:52and this we're walking,
41:54that's the hardest time to
41:56get somebody into treatment.
41:57He engages them.
41:59You have to stop using,
42:01but you could stay alive and you
42:03could do the things you want to do.
42:06So if we think that it was just
42:09our interviews that we got some
42:10bias sample this last year,
42:12that every quarterly there's
42:13a live long DC summit,
42:16about 200 people who were community leaders,
42:18people who are healthcare workers,
42:20anybody who's interested in opiate overdose.
42:22And they are pulls it together.
42:24Last year because of things we
42:26were finding that, you know,
42:28I gave a talk about the myths of
42:30medication treatment, but before I did it,
42:32we surveyed the respondents and so,
42:36you know, nearly half.
42:37The naltrexone is the most effective
42:39treatment because it's not an opioid,
42:42so can't use an opioid to treat an opioid.
42:45Again,
42:47about 4546% method medication treatment
42:49can have long term adverse impacts on health,
42:52bone deterioration,
42:54teeth falling out.
42:56And 40% medication treatments
42:59used for short term treatment.
43:02So this is generally subscribe views.
43:07This is connected with this abstinence
43:09only is long term residential treatments.
43:13That's what worked for me and that's
43:14the only thing that's going to work.
43:19Keep on time. I know there's no time at all.
43:24And then this is really.
43:26You know the what I found part of
43:29what I found so sad about this,
43:31the sense the treatment is not going to
43:33work for anybody that's not ready for it.
43:35We've been threatened, locked up.
43:36We can still continue to use
43:39until an individual is ready.
43:40I don't care how much you treatment
43:42you put in front of them, it's always
43:45on the person to be tired and fed up.
43:48Community leader, Faith Leader said.
43:50We don't have the tools to pay attention to
43:53because there are tools that that could have,
43:56we're not equipped.
43:57We don't know how to deal with their pain and
44:00people saying so take these as suggestions.
44:03I've never seen a program or an
44:05agency that will support a person that
44:08has a family member that's using.
44:10Oh, so so how does this, you know, play out?
44:15Nothing can be done.
44:16So here's a person talking about her cousin.
44:18It was a known secret,
44:20but people don't know how to
44:22tackle the situation.
44:22Well, it's not affecting me.
44:25You know what,
44:26nothing to do with intervening.
44:29And then she said, I'm not a professional.
44:31So in that sense,
44:32when it's somebody familiar,
44:34people don't really want to listen.
44:36I find that so.
44:37But like I said, it was.
44:39Just like, you know, try not to look at
44:42a car accident so you're driving by.
44:45Even though you see, you know,
44:47it's horrific, you know,
44:48there's bodies on the street
44:49and the cars on fire.
44:51You're like, well, just be desensitized.
44:53I'm just sensitized.
44:54So it happens and let me go and,
44:57you know, let me go about my day.
44:59Some more could have been done.
45:02And I'm not saying no one cared.
45:03As far as mother, Father.
45:05It's sad for his children.
45:07He had five daughters,
45:09a lot of them,
45:10four of them are still in school.
45:13I believe in my heart.
45:14I believe that had they had support services,
45:18this could have been negated.
45:20Died alone in a hotel room.
45:23And then that teacher.
45:27Toward the end of the interview,
45:29she suddenly remembered.
45:30She said. And I don't know why.
45:32How I forgot this pick up blocked it off.
45:35It's going to start a
45:36whole another conversation.
45:37My neighbor across the street.
45:40She was addicted to painkillers, opioids,
45:42and because of it she killed her baby.
45:45What happened was baby was crying,
45:47probably with some persistent withdrawal,
45:49and so she crushed up some of her pills
45:52to give to the baby to quiet her down.
45:55And I'm not sure what could have
45:57been done because I didn't know
45:58that was an issue for her, for her.
46:00But then she said her mother knew
46:03Ohh but didn't want to recognize it.
46:05But she did mention something.
46:07The baby was born addicted and and then
46:11she remembered another overdose death.
46:14Occurring right around the corner from her.
46:17Ohh. I'm told my neighbor's granddaughter,
46:20maybe about a month ago died
46:22of a drug overdose.
46:233rd House almost at the corner,
46:25exactly where she was living and.
46:27Who she was connected to and for
46:30the most part I know if something
46:32happens in a house and contrasted.
46:35Without saying, but, she said.
46:38You know,
46:38but we've got this person with Alzheimer's.
46:41Ohh, he's been lost a few times
46:43and he's wandered off and.
46:45So, you know, as a neighborhood now,
46:47we keep an eye out for them.
46:49So there's some diseases that people know
46:51how to watch out for, some they don't.
46:55So.
46:56And there's a terrible impact
46:58on family members.
47:00Power.
47:06So the last part of the interviews is,
47:10you know, we've been trying to build on is.
47:13You know that that there is some wisdom
47:15who can connect and how to connect.
47:17There's a lot of wisdom around that with
47:20an accepting view and with persistence.
47:22People saying maybe not they don't hear
47:24the first time or the second time or
47:26the 5th time, but at some point and
47:28then they'll say, well now I'm ready.
47:30So as long as you don't keep pushing
47:32them away or closing yourself off.
47:37And the need for people to be you know,
47:41peers out there to get the support
47:45or see people successful or. And or.
47:53Alright, so I'll spend the last part of
47:56the talk just talking about where we've
47:59moved in terms of some interventions
48:02that we've been piloting and that
48:04I think we're about to start and.
48:07A larger multi site randomized study that
48:11looks like we'll get funding for or and so.
48:16We need to, you know,
48:17counter the misunderstanding
48:19about medication treatments.
48:21We need to counter the negative
48:23beliefs about it out,
48:25and we need to somehow be able to
48:28address the stigmatizing views or.
48:33And certainly need to counter the.
48:36Nothing that can be done.
48:38To encourage treatment.
48:43So working with our Community Advisory Board,
48:46they came up with, you know,
48:48the community is the cure and really
48:50thinking obviously this isn't going to
48:52be a simple intervention, it's not good,
48:54it's not like a simple single cure,
48:56but there's I think of it as multi
48:59pronged collaborative interventions
49:01with trusted community resources,
49:04credible messengers.
49:06So, so we're working with as you
49:09see a faith-based Community Center
49:11with the peer working out of there,
49:15but don't isolate or establish clearly
49:17you're not going to establish a large new
49:19drug treatment program in the Community,
49:21work the existing resources.
49:25And then out of those community centers
49:27have them help work on developing
49:30the anti stigma campaigns and be
49:32advocates for medication treatment.
49:34So to try to create equivalent of a movement,
49:37people who use it educate them, ask them,
49:40pay for them to create anti stigma campaigns,
49:45to learn about medications,
49:46to create medications can be
49:49helpful campaigns to do educations,
49:51train them to do it and because
49:54then they become.
49:55Credible messengers and spread the
49:58word into their cloud networks.
50:02Now we're providing,
50:03we've been piloting this now
50:05for the past year,
50:07medication treatment on site.
50:10In this fabulous DC Dream Center
50:14and we do it with a peer based in
50:17the Dream Center and telemedicine
50:19to prescribe the buprenorphine and
50:21the pier we've trained up to do
50:24some interventions and counseling.
50:25And part of the counseling that the
50:28peer is doing is to train the patients.
50:31About how medications work,
50:33opiate addiction,
50:34how medications work so that they can.
50:37First understand it and want to use
50:41it information model to be able
50:43to counter some of the negative
50:45attitudes that they face and say
50:47why are you still on that?
50:49And three,
50:50potentially help educate and
50:52engage people in their networks to
50:55bring other people into treatment.
50:58It goes back and work Stephanie
51:00and I have done a long time ago on
51:04AIDS outreach and interventions
51:06the most effective.
51:08Programs,
51:08the ones that didn't use just the
51:12credible messenger giving talk but
51:15that engage peers in response driven
51:18sampling or you know in having one
51:20peer make a message and bring somebody
51:23others in and creating this network
51:26effect that had both the most cost
51:29efficient and most effective approach.
51:31So we're trying to both increase the
51:34treatment and build on that approach
51:36and this is a little storyboard that
51:38or people have developed for what
51:40we're trying to do and it it's a.
51:44Basically starts off with a big
51:46program or a little person versus help.
51:50Is closer to closer you,
51:53closer to your care in small places.
51:57It's comfortable, close,
51:58trusted in your community.
52:02So where you live,
52:05it looks like your community.
52:07And then this shows this is our
52:10little area and the DC Dream
52:12Center where we've been providing,
52:14that's miss Daphne,
52:16our peer outreach worker out.
52:18She's out doing some community education.
52:21We've got a couple of peers and
52:24health educators out in the community
52:26talking about the program and engaging
52:29people trying to bring them in.
52:32We have power.
52:34Developed their own sets of.
52:37Liars and we've.
52:40We've worked.
52:41The district was running
52:45large campaigns around Narcan.
52:48Out and then they moved into
52:49campaigns about treatment,
52:50but all the treatments were
52:53residential drug free treatments.
52:55And so we started helping them
52:56develop and working with the
52:58communications people campaigns
53:00that would talk about medications
53:02and tried to help message it based
53:04on what we were hearing because
53:06they were starting off here.
53:07Are you ready to stop and stay stopped?
53:10And the answer is you're ready to
53:12get help and you know you'll better.
53:16So come up with I think a reasonable.
53:18Campaign.
53:18These will have a small effect,
53:20but they'll have an effect.
53:23And the idea is you can we create
53:25a cumulative effect with multiple.
53:28Interventions.
53:31So that's our team once again.
53:35Think about our own network of of people and.
53:41Thank you for this opportunity
53:43to be back here and talk about
53:45the work we've been doing.
53:47Right. And I think we've got a
53:51little bit of time for questions.