Sep 11, 2016

Fighting heroin in Cincinnati with money we already have and volunteers who are ready to start

A huge crisis. A new treatment paradigm. Now what do we do?


I live in Cincinnati, where over 300 people have overdosed this past week. People have been calling this a “bad batch” of heroin, but overdoses have also ramped up across southern Ohio, West Virginia, Kentucky, and in Ohio’s other big cities. This is not a “bad batch.” It’s a product evolution, and it is coming to your town soon.

Fortunately, our community response systems have reached a tipping point on policy. Police here are offering immunity to people who turn in their drugs and ask for treatment. Medication assisted treatment is supported as the norm. Earlier this week, I spoke at a Cincinnati City Council committee meeting to offer my take on what might help. I used to be an outlier on policy, advocating for harm reduction and medication treatment in a community that favored nonmedical 12-step approaches and abstinence based care. This week, people were nodding their heads as I spoke, and I was nodding in agreement as treatment program leaders spoke.

To put it bluntly, we have reached a Kumbaya moment on addiction policy. Naloxone, medication assisted treatment, and community support programs are mainstream concepts now. People agree that we need a system that provides these things. What we need now is action. This creates new issues — implementation issues. How fast can we implement a new systems paradigm? Where will the money come from? Where will workers come from?

Fortunately, in Ohio, the money and protocols are already in the system. Certain reforms that have already been worked out must be implemented several months sooner than planned. Ohio has been in the midst of a behavioral health finance redesign for several years. These reforms are scheduled to kick off in mid-2017. The redesign process will move the state’s behavioral health system much closer to a “pay-for-performance” finance model. It also adds coverage for some new services, including peer support. Given the overdose emergency we are facing today, it should be possible to pilot the new payment system immediately in the places where overdoses are raging. In practice, this means training up existing staff, and upgrading payment systems to use new billing codes. It won’t cost more to implement reforms early. Because every dollar invested in medication assisted treatment saves around $5 in other healthcare system costs, the question is not “how much more we need to spend.” The real questions are “how much do we want to save?” and “how fast can we start?”

Who is going to do the work? Cincinnati already has the human resources to implement reforms at scale. We have about 1250 primary care physicians in Hamilton County, where the City of Cincinnati is located. If just ten percent of them took on 30 medication assisted treatment patients each, they could stabilize 3,750 people this year. Next year, federal regulations will allow each of these doctors to expand their caseloads, and serve 100 patients each, for a total of 12,500 people. That is the entire population that needs treatment in Hamilton County today, stabilized in just two years.

Our region is fortunate to have sufficient healthcare infrastructure to implement the new paradigm. We have four large hospital systems, a dozen or more Federally Qualified Health Centers, and several networks of behavioral health providers. These provider systems already negotiate rates and treatment protocols with public and private insurance systems. If provider systems step up their game, they can work together to create what are called Accountable Care Organizations (ACOs) and Special Needs Plans (SNPs). These are legal structures and insurance arrangements that support collaboration and help finance the work. It takes leadership and some technical skill to put this together, but the models to accomplish this exist.

Like other communities in America, Cincinnati has no shortage of willing volunteers. Church groups and community organizations are looking for ways to address the social needs of people in recovery. Our hospital systems at the center of the new treatment paradigm already manage volunteers. The missing ingredient is action.

Feb 25, 2016

Mercy for Addicts

Pope Francis has recently declared a Jubilee Year of Mercy  If we care to give mercy a try, we can start with our brothers, sisters, and neighbors who are suffering and dying from addiction.

In the last few years we have learned that people who use heroin and other opiates are risky, traumatized, disordered, and distressed. They have pain, addiction, immaturity, and mental illness all mixed together. They are in deep trouble. They need rescue. They need treatment, safety, and support, not lectures, punishment, and scorn. They need mercy.

We can heal the sick, and offer treatment to everyone who needs it. Northern Kentucky treatment agencies receive 40 calls a day from people seeking admission to care. We can say yes to everyone who calls, and if half show up, that’s 20 people every day, 100 every week, 5000 in a year. That is everyone at risk of overdose death in Northern Kentucky, brought to treatment in one year. It is not that costly to fund that surge of treatment.

Most people who use opiates stabilize quickly with medication and day treatment, but they require support to recover long term. We can show these people mercy, and support them as they make progress in their lives. We can house the homeless, feed the hungry, and offer comfort to the afflicted. Treatment groups can team up with churches and volunteers to help people stay in treatment. Ordinary human trouble disrupts treatment. Guest rooms, church dinners, safe recreation, and basic friendship help people overcome loneliness, rejection, transportation issues, and relationship trouble, the top barriers to retention in treatment.

Don’t forget jobs. When people emerge from drug use they tend to be poor and unemployed. We can give alms to the poor by combining jobs with support. This is another way for volunteers and co-workers to pitch in.

A minority of people have great trouble stabilizing, even with treatment. They may be too immature, too traumatized, or just too far out of control. Many of the people in this last group become prisoners for their own safety. Some are in jail, others are in secure facilities. We can show these people mercy too, by offering them treatment and connecting them with community support as soon as they are ready.

Mercy is good public policy. It aligns with effective medical care for addiction. Why are we so stuck in suffering? Perhaps mercy is our greatest challenge.

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This post previously appeared in the Cincinnati Enquirer and Cincinnati Community Voices

Jun 1, 2015

Church groups challenge social service systems

I’ve been approached by a former student to connect her church group with resources to help congregation members improve their daily lives. I visited the church and met the pastor and other church leaders. It’s a small African American congregation here in Cincinnati. The issues of interest to the members are familiar to anyone who works with poor and working class families:

  • Education
  • Childcare
  • Jobs
  • Personal health
  • Chronic illness
  • Diet
  • Healthy families

A congregation choosing to improve the health of its members is no rare thing. People have always found ways to support each other in church organizations. Those in the so-called “helping professions” consider church groups a key “natural support.”

Unfortunately, we seem to know little about leveraging natural support relationships to improve health. The science plainly demonstrates our society’s failure to deliver success to the populations at the heart of social service mission. Service systems have directed countless dollars and resources at church groups in poor communities over the course of decades. Poverty, poor health, and trouble persist.

My hypothesis is that the American approach to health promotion and health improvement within church groups in high-poverty areas has been fundamentally incorrect. We treat natural supports as targets for professionals to manipulate. Congregations become the “primary target” of health interventions designed to reach intended “secondary targets,” meaning people with diseases or risk factors. Again and again, we measure the initial state of the target group, catalogue their troubles, and enumerate their risk factors and ailments. Later, we measure them again. At the end of our program, we announce that there has been some marginal statistical improvement. But that improvement never spreads to the population as a whole, and it’s hard to find actual living people who embody whatever improvement is announced.

What might we accomplish if we reversed the process? What might happen if we started with the desires and intentions of people in church congregations? What are their dreams? What are their strengths? What skills do they want to improve? What is the kind of life they envision for their children?

A population-centered starting point changes the direction of social service work. It turns the logic model inside out. What was once the “target population” is now the “action population.”  The local service system becomes the “primary target.” Changing the service system changes the health of the action population, and impacts the broader population. The “secondary target” becomes the overall social and economic environment.

And here’s what’s most important. Delivering good results on personal goals actually improves a person’s life. Not some straw man, or statistical sort of person. A real person, with a real life, with blood in the veins. A person who has relationships, and perhaps even children, who influences other people every minute they draw breath.

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Picture: WPA Church drawing
http://lva.omeka.net/items/show/139