June 19, 2019 | Announcements | SAMHSA's GAINS Center Health Service Psychologist, Certified Group Psychotherapist | Operations Director, Behavioral Health Services, Mercy Health Q: You have received recognition for the collaborative approach you have taken in leading a regional response to the opioid epidemic in Cincinnati. What are some of the key components of this approach, and can you share any information about its impact to date? There are a few key components to the work that we pursued over the last 3.5 years. In January 2016, we started with the idea of a collaborative approach to addiction medicine. The first step was to understand that our goal was to mainstream addiction treatment into the general delivery of health care. This idea extends from the broader goal of behavioral health integration for mental health conditions; given the nature of the opioid epidemic and increasing mortality, we narrowed the focus to addiction. Inertia was a major challenge to overcome in this space. Inertia in this case is the idea that mainstream health care has not fully participated in the delivery of addiction medicine or the treatment of folks with substance use disorder (SUD). This is not out of malice; rather, it is an entrenched idea—if this is how things have been done forever, we’ll continue to do them this way without an intentional vision for change and a strategy to execute on that vision. Mainstreaming addiction treatment into the general delivery of health care would do a lot of things: It would allow patients to have more robust access to treatment It would open the door for a more comprehensive continuum of care It would reduce stigma, both for clinicians and for patients with SUD Treatment has to be comprehensive and include emergency, inpatient, and residential components, as well as placing a heavy emphasis on outpatient care. And it needs to include the use of all medications approved by the FDA for the treatment of patients with SUD. That understanding then leads to another key component—understanding addiction and SUD as chronic medical conditions that warrant a healthcare response. To some audiences, that may be fundamental and self-evident, but because of inertia, mainstream medical care and various other disciplines have not had that understanding – until now. Thanks to the collective efforts of many in Cincinnati, we believe that we have turned the corner on this concept and believe that the treatment of patients’ SUDs falls just as much into mainstream health care’s wheelhouse as would the care of patients’ other chronic medical conditions, like heart disease or diabetes. Those are the primary components to our thinking around this, but the idea that truly helped us understand the scope of work in front of us was the realization that if you need treatment on demand through a comprehensive system of care that is integrated into the general delivery of health care, no single provider would have the capacity or knowledge to do it alone, and certainly not with any measure of urgency. [Note: Visit findlocaltreatment.com to see one vehicle for connecting people with an on-demand treatment network, in use in Cincinnati.] To develop a collaborative approach, we then must determine who is doing good work within this space, which then opens up additional questions: What is good work in this space? What is quality addiction treatment? How do you operate once you’ve identified collaborators? How do you integrate your clinical operations in such a way that the patient can move seamlessly from one level of care in this comprehensive system to another, in an on-demand, seamless fashion, including between organizations? How can you ensure that a patient can be treated well not just from a clinical standpoint, but from a compassion and integrity standpoint, as well? An example from our work that illustrates this idea of collaboration was patient waitlists. During one of our initial routine collaborative meetings, we had a group discussion around waitlists—who was holding waitlists, who was not holding waitlists, and who had open capacity? We were fortunate that folks were honest and forthright with each other. We talked through why certain providers held waitlists, what we could do about them, and worked with those that had open capacity to move patients from one provider to another. The concrete takeaway from that discussion was that we labeled waitlists as death lists, which sounds morbid, but we have a mortality crisis here. We understand there is more than enough work for everyone in the community to be as busy as they want to be, and by labeling the waitlists as death lists, we are providing a visceral cue of what we’re dealing with to incite action. Q: As a psychologist by training, how do you see your role (versus the roles of others, such as sheriffs or government leaders) in leading institutional or systemic responses to mental and substance use disorders in the community? I’m a clinician by training. In a lot of our work, we have used the term of wheelhouses (i.e., something that is within your area of expertise)—what falls into your wheelhouses, how do you understand and deliver upon what falls into your wheelhouse, etc. Another step is to partner with folks who have different wheelhouses to ensure that the efforts you’re all engaging in are cohesive. Additionally, it is important to make sure you aren’t stepping out of your wheelhouse into things you do not understand or cannot impact as well. Part of it was understanding the breadth of our wheelhouse. If we were to go by what we have done historically, we would say, “well, addiction treatment is not really in our wheelhouse. Therefore, we don’t have much to do with it,” and our story would have been over. Instead, we expanded the view of what our wheelhouse is. We reframed our work as being within the treatment realm, and then, more specifically, within the acute care realm. We then partnered with addiction providers to supply specialty care. When I was in graduate school, the SUD treatment class was an elective, and I did not take it. I was never one to consider myself a specialist, and there is no such thing as an addiction psychologist anyway. Five years ago, if you told me I would be working in the addiction space, I wouldn’t have believed you. As a psychologist, what I’ve come to understand in my role is that the application of assessment and intervention skills learned in the traditional setting (e.g., individual therapy, group therapy, couples therapy, family therapy) can be just as effective in addressing systems change, including within organizations. We have done a lot of work within the health system to improve how we think about and respond to patients with SUD, and so our role as psychologists can be broader than clinical care delivery. Our clinical training serves as the foundation for those more extensive efforts. Q: You have talked about the presence of cultural bias against mental illness and SUDs in some communities. In your experience, what can organizations do to ensure that people from all cultural perspectives feel comfortable in accessing behavioral health care? With SUDs, our philosophy to expand access is to mainstream addiction treatment into the routine delivery of health care. If we look at folks with chronic conditions who are struggling to manifest their treatment plan (e.g., exercise or eat the way they’re recommended to), we typically do not put extra barriers in front of those patients. Similarly, we do not establish motivational requirements for patients with physical health conditions to achieve before providing treatment. In physical health care, there is an expectation both at the organizational level and the clinician level that we will be compassionate to folks who are struggling. This philosophy should extend from primary care treatment to behavioral health treatment. When we talk about patients with SUDs, we should provide care as we would do for anyone with any chronic disease. That includes having a comprehensive system of care, making treatment available on demand, and treating patients with dignity, compassion, and respect. We should provide individuals with SUDs all the different forms of aid that we possibly can with the hope that we’ll be impactful. An organizational understanding that we expect compassion for all individuals, no matter their health or behavioral health condition, is a good way to get started. Q: The opioid epidemic has prompted a public health response in many communities, which has been contrasted with the more criminal justice approach that occurred and still occur in response to other epidemics. How can we foster a public health response to all substance use disorders as we address the opioid epidemic? Mortality is something, regardless of its cause, that we have a collective responsibility to act on. When we have something that is causing mortality at the scale that we see in the opioid epidemic, we have to think, if it was anything else, what would our response look like? If a plane full of 200 people were to fall out of the sky every day, how many days would it be before the airports would be shut down until it got solved? Fostering a public health response to the opioid epidemic will give you a foundation to address all SUDs with a public health response. Not every community has welcomed or adopted a public health response to the opioid epidemic; there’s still considerable work to be done in that regard. Even in communities that have a robust public health response, like Hamilton County, Ohio, where Cincinnati sits, we are growing our public health response with regards to data—converting data into action—as well as expanding harm reduction strategies. The way to foster a public health response to SUDs is to be comprehensive in how we address the opioid epidemic, which would build an infrastructure to address future substance use epidemics, especially as we see a rise in the use of amphetamines and stimulants. The challenge to a given community right now is to reflect: have you truly fostered the growth of Narcan distribution, syringe exchange, and point-of-care testing for blood-born pathogens? What is the community’s dialogue around supervised injection sites? That’s a controversial one, even here in Cincinnati. You can look at Philadelphia and see the challenges they’ve had in trying to push that forward, and despite local energy to do so, there’s potential legal challenges. Q: Name one thing that you wish every person would do to help reduce the stigmas associated with mental and substance use disorders. Carry naloxone. A broader answer to address stigma is to educate yourself and to not rely on assumptions or anecdotes. Be curious, be inquisitive, and do your own research. There are countless sources of information online—SAMHSA has a wealth of information online about this topic, including the Treatment Improvement Protocols (TIP), the TIP Series Quick Guides, and online guides in the SAMHSA store. These resources can help you learn about mental and substance use disorders, what causes them, and more. Before we close out, I would like to say that as an organization, we could not have done this alone without our collaborators. I would like to express our deep appreciation for those who have collaborated with us in recent years. We truly believe that collaboration is the way forward in this, and that no one can do it alone. Thank you for this opportunity.