Strategies for Hope Conference

Strategies for Hope: Addressing the opioid crisis in rural communities.
May 17, 2019
Berkshire Community College, Pittsfield, Massachusetts

Random notes from a compulsive note taker

I attended this important conference and am a compulsive note taker. Most people, when the lecturer says, “Good morning,” will mumble back “Good Morning.” But, if one is a pre-med, when the professor says, “Good morning,” you write it down as it may appear as a question on an exam. I never unlearned that habit. These note may be of some value to others.Erik Garcia, M.D.: Homeless Outreach and Advocacy Program, Worc3ester, Massachusetts.
Stigma and shame play a big role in epidemics. HIV, opioid. It doesn’t matter.
There are 70,000 deaths in the US yearly from suicide. Over 40,000 deaths from opioids. In rural areas, a higher percentage of people are dying from opioids than in cities but this gets less attention.

Many who are addicted to opioids have a history of childhood trauma or PTSD. We need to pay attention to the power of words to change the language of addiction.

Jeffrey Foote, PhD.
He is the executive director of the Center for Motivation and Change, New Marlborough, Massachusetts. His goal is helping people help and helping families help. We need to change the conversation about substance-abuse. Nicotine kills over 1000 patients a day well opioids killed 40,000 or so a year (>100 a day).

There is collateral damage from opioid deaths. For every one person with substance abuse disorder, four family members are affected. Families then become isolated. They have to guard against what the stigma to does to their families.

Most families of addicts who die never come in contact with professionals. People leaving rehab, need to be on maintenance therapy and at the present time, many or not. When they get out of jail or rehab, looking to fix, they have lost their tolerance and many die.

Foote showed an amazing video and I need to try to get it.

He spoke about stigma. There was a recent JAMA article “Addiction 101, in Technicolor.” By Abigali Zuger, (JAMA. 2019 Jan 22;321(3):228-229) that began, “It was a sad, kind patient named Joel who taught me more than anyone else ever did about taking care of people who use drugs. His lesson consisted of a single sentence: “Never trust an addict.”

This kind of thinking promotes stigma. In what other profession than medicine do we tell those we are working with and for that we do not trust them. That’s one reason why most people don’t get or even seek help.

Foote’s group is developing tools to help families. Community reinforcements and family training.

How to help with understanding. There is not one simple answer; there are many, many answers. One size does not fit all.

He gave us a Scottish proverb,

They speak of my drinking,
but they never speak about my thirst.

The thirst is the deeper meaning that is often ignored. As physicians, we need to inquire about the thirst, the antecedents that lead to addictive behavior whether it’s nicotine, alcohol, or drugs. But when we learn or understand what matters to the patient then we will look at her differently. Understanding what is behind the behavior facilitates us to begin to help. Behaviors are complex. We need different strategies for different people. If we offer a variety of paths, they may choose one. If we offer just one path, they aren’t so likely to take that one.

Addicts are ambivalent. On one hand they want to change. On another hand on the other hand, they like what they have.

We have to let people know they are not alone. This means providing a safe environment. For teenagers who are having problems, this means teaching the parents to trust them enough to not monitor them to every second of the day and night

Dr. Katharine Callaghan, Assistant Professor of Obstetrics and Gynecology, University of Massachusetts Medical School
She is an obstetrician who deals with addicted pregnant women and mothers in Worcester.

Substance abuse during pregnancy:

5% opioids and street drugs,
10% alcohol,
15% tobacco.

The medical community has neglected addicted mothers for years. Seeking help in pregnancy can put a woman in jeopardy of losing her family including her kids to child protective services.

In pregnancy, continued use is not a problem for the fetus. The big risks are trying to withdraw drugs while pregnant. Abstinence treatment does not seem to work for this group and they should be maintained on methadone or Suboxone during their pregnancies. Methadone has been around for over 50 years and we know it is safe. Fetal opioid withdrawal is much less common than reported.

Christine Haley, LICSW, Massachusetts Department of Mental Health: Trauma is the gateway to addiction. A knowledge of a patient’s ACEs and traumatic experiences must be incorporated into a new care plan. This is called trauma informed care.

Individuals with a history of trauma are more likely to have chronic pain and to want to medicate that either from doctors, friends of the street. We need a trauma informed community. We have to be aware of the frequency of trauma and provide a safe place for our patients. You must sit with a person in the space that they are in.

She feels we should have a sign on our offices saying “You are entering a trauma informed community.” We should consider incorporating an ACE questionnaire into her intake forms.

Debbie Flynn-Gonzalez: Program Director, Hope for Holyoke Recovery Center. This was a powerful talk from someone who walks the walk. She is in long-term recovery from alcohol and opioids. It’s great to hear a first person narrative.

Engaging in conversations with others is helpful. Peer to peer support is very important. The big three things that patients need are “Transportation, Food, Child-care.” This can often be provided within a peer to peer system.

Your office has to be welcoming to families. It can be an extension of the family. We have to address the problem of transportation for a patient. To our offices, to the supermarket, maybe even to the movie theater with their kids.

Jennifer Michaels, MD, Medical Director, The Brien Center for Mental Health and Substance Abuse Services. She spoke about medication assisted therapy (MAT), namely methadone, Buprenorphine, Naltrexone.

She told us that the ER can now start patients on MAT and give them a three day supply to last until they can see a provider.

Sarah DeJesus, is the assistant director of Tapestry Health, Community Based Care.. It’s goal is to keep people safe and alive while they are using street drugs. She is certainly on the front lines and she gave an impressive presentation.

Joey Buyse: Program Director for Berkshire County – Living in Recovery, A peer-driven, peer led community. Their mission is to provide hope and support to those in recovery, as well as, all the family members and loved ones affected by addiction.. He and his group are recovery coaches. They help people with their lives. They are not providers in white coats in sterile offices. I wonder whether a medical doctor can be a “recovery coach.” Certainly they should be.

Cancer affects a person’s quality of life. In the same way, so does addiction. A recovery coach is not necessarily a professional but is there to support the patient.

Erik Garcia, MD. is a doctor who works with the homeless in Worcester. Homeless out-reach and advocacy. When you are treating addicts, you have to learn to say yes. You can’t find a million reasons to say “No” to their behaviors. We need to be nonjudgmental. He spoke of a program called L.l.FT. (I think)

How does trauma (ACEs) transform into chronic pain? And how do we address that? He mentioned the Peoples Medical Clinic in Greenfield, Massachusetts.

Summary: To me, this was an important and inspirational day. It left me with lots of things to think about. As a healthcare provider, many of my patients are not getting the type of help and services that were discussed today. Quite frankly, it’s a struggle for many to get into the system. There are clearly so many people who are available to help but there are blocks to get our patients to them. We just need to deal with them one person at a time.

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About David Elpern

The Online Journal of Community and Person-Centered Dermatology (OJCPCD) is a free, full text, open-access, online publication that addresses all aspects of skin disease that concern patients, their families, and practitioners. ​It was founded in 2012 by Dr. David J. Elpern, M.D. in Williamstown, MA. with technical help from Inez Tan.

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