Virginia Municipal League Conference October 6 th , 2019

1. Virginia Municipal League ConferenceOctober 6th, 2019 All Hands on Deck: Turning the Tide of the Opioid Epidemic By Cheri W. Hartman, Ph.D. Department of Psychiatry and Behavioral Medicine/Carilion Clinic

2. The United States of Drugs

3. A Call to Action: Look Up! Look Out! Roanoke Valley’s Collective Response • Beth Macy’s Dopesick spurred a “call to action” in the Roanoke Valley • Beth’s commanding stories captured the devastating impact of the opioid epidemic compelling the RV HOPE Initiative to respond • September 19th2018 60 people answered “YES” to an invitation to be a part of a “Collective Response,” spurred by the RV HOPE Initiative -- an effort to move our community’s conversation forward to foster better collaboration – too many of us were not looking up from our mop and bucket and were splashing our water on each other’s territory instead of seeing what we could accomplish together.

4. A Multi-sector Community-wide Problem Requiring All Hands on Deck All Hands on Deck including: (1) Law enforcement; First Responders; Judicial system (2) Local, state and federal government officials (3) Health and human services leaders (public, private sector) (for profit, nonprofit) (all levels of service providers along the continuum of care from harm reduction to residential care, medication-assisted treatment and AA/NA devotees) (4) Chamber of Commerce/business, Workforce development (5) Education (all levels: ongoing professional development) (6) Researchers; public health experts – data trackers (7) Faith-based community, general concerned citizens (8) Housing/homelessness/sober living (9) Persons in recovery, persons who suffered tragic losses

5. Dr. Rob Pack’s Turned the Tide in Tennesee through Common Core Values • Core Values that can help join people together – to bring them on deck • Core Values helped Dr. Pack win against stigma (people who don’t understand are NOT the enemy – myths ARE the problem); so tap into: • Compassionand capacity for respect = these become your stigma Busters! (educate and reduce misinformation about addiction) • Turn people’s passion into advocacyto stimulate investment • Don’t go it alone w/your little mop and pail- rely on collaborative relationships • Stewardship of our resources and energies; working efficientlyto bring timely solutions to the problem • Mutuality in decision-making, solutions with mutual benefit will endure • Objectivity: bring science on deck: evidence-based practice, quality results • Transparency in our actions and decision-making to build trust

6. What is the Roanoke Valley Collective Response? • A collaboration of community influencers working together for collective impact on sustainable solutions to substance use disorder in our community. • Aspires to tackle the root causes of the addiction crisis by influencing changes in policies, practices, social support, cultures and norms, resources, and capacity • Combines evidence-based practices with local insight and personal stories of persons with lived experience to develop, recommendand implement local but also comprehensive solutions to address every angle of the problem: prevention, treatment, overdose reversal, recovery, and child and family and community-wide support. • Seeks to re-chart the course – to Turn the Tide of the Opioid and Addiction Crisis in our community— we want to ensure that there is always for ALL a pathway to healthy and sustainable living for all of those affected by addiction.

7. Steering Committee Members: • Christine Baldwin, Administrator/Peer Recovery Specialist, Roanoke Valley HOPE Initiative • Lee Clark, Executive Director, Rescue Mission of Roanoke • Robert Natt, Business Development Director, IMPACT Lab, Radford University • Nancy Hans, MEd, Executive Director, Prevention Council of Roanoke County • Cheri Hartman, PhD, Trainer/Faculty, Department of Behavioral Medicine & Psychiatry, CarilionClinic, administrator of the Office-based Opioid Treatment Program (a gold standard OBOT program) • Kimberly Horn, EdD, Scientist/Professor, Fralin Biomedical Research Institute, Virginia Tech (Chair): a specialist in the collective impact best practices (worked with Dr. Rob Pack) • Amy Pierce,Western Virginia Regional Jail, works with treatment • Janine Underwood, Executive Director, Bradley Free Clinic (Chair) (mom of Bobby, who lost his battle to addiction as a very young man whose charm and promise, intelligence, potential were crushed by his disease) • Also, thanks to Program Assistant, Jill Pritts, AmeriCorps

8. What is our target community?

9. Roanoke Valley Collective Response PROGRESS TO DATE (one year anniversary): Founded Sept. 2018 12 Monthly Meetings 114 Organizations 215 Individual Stakeholders 6 Working Groups Prevention, Treatment, Child-Family, Crisis/Overdose Reversal, Recovery, Harm Reduction 8+ Sectors Healthcare, law enforcement, community support, business, faith communities, education, local government, and research Jurisdictions Roanoke City, Roanoke County, Salem City, Vinton, Botetourt County, Alleghany Co. and CraigCounty Collaborative Blueprint Draft Underway Asset mapping Underway

10. Resources in Prevention • CCoVA: https://communitycoalitionsofva.com • Local coalitions - RAYSAC, Prevention Council (trend data, multi-sector relationships, expertise in strategic planning)* • Trauma-informed Care (Adverse Childhood Experiences: risk factors) (Best Practices Court Systems team in Roanoke, BRBH, schools) • Community Conversations are being held throughout Roanoke – fighting stigma, dispelling myths, tapping into compassion and mobilizing volunteers

11. EducationCounters Myths/Stigma: Not MY Child …and provides objectivity Substance use disorders can happen in our own families: 55% of fatal Rx opioid overdoses in 2016 were females (unintentional ODs) in Virginia 2017 Youth Risk Behavior Survey revealed that in our Roanoke Valley among 10th and 12th high schoolers (HS) surveyed:* 10% of girls and 16% of boys used Rx drugs to get high. % of HS girls who ever used heroin has more than doubled since 2011 from 2.5% to 5.5% in 2017 (ave. across school systems) % of HS girls who used meth has almost doubled: 3.2% to 5.8% % of HS girls using cocaine has increased from 4.8% to 7.3% HS girls are as likely to drink alcohol as boys: 32% vs 33.9% We need to screen all youth about alcohol and drug use. Alcohol is still the #1 drug of choice among our youth. *Data collected by RAYSAC: Roanoke Area Youth Substance Abuse Coalition

12. Myth: Addiction Results from Moral FailuresMedical Science: Addiction Is a Chronic, Relapsing DiseaseWe Need to Understand the Brain to Understand Disease! Substance Use Disorders = Diseases (with powerful biological influences) Chronic, relapsing, progressive diseases The Opioiduse disorder responds to medication-assisted treatment (MAT) (medicines are helpful to making the therapy effective). Relapse happens, as in any chronic illness. Recovery– disease management – is possible but it’s a long term process.

13. Treatment Priorites • Priority Area 1: sharing data across systems to enhance patient care and care coordination yet protect patient privacy • Priority Area 2: Cross-Agency Collaboration (avoiding the dysfunctionality amongst the helpers caused by a failure to communicate across systems of law enforcement, child welfare, primary care vs. addiction treatment specialists, Emergency Department crisis care and the chronic care/treatment providers!) • Priority Area 3:Strengthened Continuum of Care/Transitions in Care: patients are most vulnerable at times of transition in care and post-discharge; patients need access to the best practices in care (treatment works – patients need access financially, geographically, physically/medically, psychologically: knowing that treatment works!) • Priority Area 4:MoreQuick Response Treatment Systems (urgent care centers for addiction, ED Bridges into Treatment) (deploy response teams to overdose events)

14. Resources for Treatment Referring to appropriate level of care: treatment needs to match patients’ needs ASAM Placement Criteria: six dimensions to consider ASAM Continuum of Care (levels of care) Communities need all levels of care on continuum with seamless systems to move from one level to another (from ED to treatment program; from detoxification into treatment, from residential into aftercare): most serious gaps are not only not having enough placements for care but we need to address gaps/time lapses b/w levels of care

15. ASAM 5 levels of care with gradations

16. HOPE Initiative| Directory of Resources along continuum of care • Key: OP: Outpatient care: Case mgtlcase management counselingcounseling; psychiatry peer support MAT medically assisted treatment (MAT) intensive outpatient therapy (IOP); day treatment; partial hospitalization program (PHP) transitional housing: sober living detoxresidential treatment Treatment for no cost or for the uninsured

17. SBIRT = Screening, Brief Intervention and Referral to Treatment (culturally sensitive approach to early identification and how to facilitate readiness and successful referrals) • Evidence-based “tools” to screen for: • early identification of substance misuse, • brief interventions using motivational interviewing skills starting where patient is; • referral to treatment warm handoff best practices lead to treatment engagement ASAM considers this a .5 level of “care” -- it is often used to reduce harmful use before an SUD develops.

18. Medication-Assisted Treatment: OBOT Programs found on VA DMAS website OBOTs offer outpatient comprehensive care integrating recovery supports into treatment through peers, care coordination to address medical co-morbidities, housing, legal, child welfare, transportation, employment, insurance, family engagement and education; MAT is combined with therapy(medication-assisted therapy). At least 50% remain in continuous course of treatment; others dropout, some get referred to higher levels of care, some return later. If a patient remains in treatment (MAT) for two years they are twice as likely to survive their disease. ARTS Initiative in Virginia (in 2017) made these programs possible: it led to the creation of approximately 100OBOTs in VA.

19. Other priority areas: • Child and Family Supports • Comprehensive Harm Reduction • Recovery Supports • Strengthening Our Crisis Intervention Systems

20. Peers As Key Community Resources: Replace Shame with Hope • Peer recovery specialists* have been trained to help our patients believe in themselves, have hope for successful treatment, and facilitate basic skills for navigating life in a drug-free way to achieve and sustain recovery • Offer community-based support groups • Workin hospital settings to serve as a connector to treatment; RV HOPE is staffed by peer recovery specialists • Peers = powerful stigma busters!

21. Summary of Treatment and Integrated (Peer) Recovery Resources • Roanoke Valley HOPE Initiative at the Bradley Free Clinic: resource directory for treatment (rvhopeinitiative@gmail.com) • SBIRT training: cwhartman1@carilionclinic.org (Cheri Hartman) • Tele-consultation/free CMEs—education on best practices in OUD field (Virginia’s Project ECHO: jean.hoyt@vdh.virginia.gov) • Care coordinator of Carilion’s office-based opioid treatment program (540- 981-7027) – information on OBOT care coordination • ARTS (Addiction and Recovery Treatment Services) Initiative of Virginia’s Department of Medical Assistance Services (DMAS) has a manual: SBIRT billing, office-based opioid treatment program requirements/billing/ attestation procedures for Medicaid members (www.dmas.virginia.gov) (directory of OBOTs, ASAM continuum of care: facilities at various levels

22. Other Resources • http://curbthecrisis.com/treatment/ • Information on what to look for to find quality care in treatment • Rob Pack at ETSU and Dr. Kim Horn at Roanoke’s Virginia Tech Carilion Research Institute have both inspired collective responses to act on your common core values to Turn the Tide of the opioid epidemic: https://www.etsu.edu/cph/pdam/ Governor’s Advisory Commission on the OpioidEpidemic meets regularly – convened by the Secretary of Public Safety, Brian Moran, and Secretary of Health and Human Services, Dr. Dan Carey Feel free to contact me for more information about MAT and establishing an OBOT program; SBIRT – for early identification and early intervention best practices and to connect with other Roanoke resources that can be used to Turn the Tide and get All Hands on Deck!

23. Contact information • Cheri W. Hartman, Ph. D. • Office-based opioid treatment program administrator in the Department of Psychiatry and Behavioral Medicine/Carilion Clinic • cwhartman1@carilionclinic.org • 540-981-7099 • 2017 S. Jefferson St Roanoke, VA 24014

24. The United States of Drugs