Health Guide 2017: Health centers take on opioid addiction

Community health centers in north-central Montana have received $350,000 in federal grants to use in the regional battle against rampant opioid abuse and to help treat people with mental health issues.

Bullhook Community Health Center in Havre and Sweet Medical Center in Chinook each received $175,000. The grants are part of $2.8 million in grants to 17 health centers in Montana and $200 million nationwide from the U.S. Department of Health and Human Services’ Health Resource and Services Administration.

The opioid epidemic has been federally recognized as a national crisis, and the Hi-Line, despite its geographical isolation or its national inconspicuousness, has not been spared from its ravaging effects. The need for care in the region, Bullhook CEO Cindy Smith said, is as great as it is anywhere.

“When these guys,” Smith said, referring to Licensed Clinical Professional Counselor and Licensed Addictions Counselor Misty Geer, Addictions Case Manager Sandy Derry and Nurse Practitioner Katie Olson — who is training to be psychiatric nurse practitioner as well — “don’t have enough slots to schedule the patients that are being referred, you know we have a big problem.”

The clinic’s backlog is an indication of two regional problems, Smith said. Geer is backed up two weeks before she can see anybody. That’s how bad care is needed and it is also a reminder of the continuing provider shortage in the region. Montana has, and continues to have, problems getting and hiring qualified employees in the mental health field, Smith said.

Despite statewide personnel issues, community health centers have been effective, and for that reason, Smith said, the government saw fit to arm them with more resources.

“They realize the impact and have seen data and outcomes from community health centers. So that’s why they give to community health centers,” she said.

Smith said Bullhook sees about 5,000 patients a year for about 15,000 visits.

Sweet Community CEO Dana Pyette said about 2,000 patients a year come through their health center at its Chinook and Harlem clinics.

Part of the grant money, Smith said, will be used to add staff so more people can get treatment faster. And although the backlog stretches for weeks, they still try to get patients seen by someone quickly.

“We try to get them in right away to see a case manager so at least somebody gets in touch with them and let them know we’re going to start working on this for them,” Smith said. “We want them to have access the minute they say they want help so we at least get them hooked up with somebody to talk to.”

A psychologist has already been hired and she will began work this month, Smith said. She will be the only psychologist at the clinic. Someone who is already working the health center in one capacity is being trained to be the second psychiatric nurse. And since an electronic medical records system has been implemented — all departments have access to patient records — a trainer is being brought in to teach employees how to best utilize the system. The goal is to insert patient information so it is accessible, as well capturable in the sense of being able to accurately determine the effectiveness, or lack, of treatment.

The grant money, Smith said, is to be evenly split between mental health and ubstance addiction counseling.

Pyette said the requirements for splitting the money between the two types of care apply to the Chinook health center as well.

Sweet Community will use some of the money to hire a licensed social worker and community health worker, Pyette said. In addition, the grant will also fund anti-stigma education and community education to raise awareness to the services provided by the health center.

The U.S. Department of Health and Human Services reports the majority of drug overdose deaths, more than six out of 10, involve opioids. Since 1999, the number of overdose deaths involving opioids — including prescription opioids and heroin — quadrupled. Overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths. The amount of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled from 1999 to 2010, yet there had not been an overall change in the amount of pain that Americans reported, the U.S. Department of Pulbic Health and Human Services reports. Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999.

Montana Department of Public Health and Human Service says 693 deaths in the state were attributed to prescription opioid poisoning between 2000 and 2015. From 2000 to 2012, the opioid-related death rate in the state, a chart on its website shows, exceeded the national average, with the 2008-2009 period showing the largest discrepancy. During that period, there were nearly eight deaths per 100,000 people in Montana related to opioids, whereas the national average was slightly over four.

The grant money shows faith on the part of the government that community health centers are effective, Smith said.

One of the changes in addiction treatment is changing the stigma attached to those who have a problem with drug abuse. Changing perception includes taking out the word addiction. The word addiction is no longer to be used, the staff at Bullhook said.

The Echo Institute says the key to success is a team-based approach in which the addiction is identified as a disease and not a character flaw.

“Substance use disorders are a chemical thing that happens in your brain. It changes your brain function. The old myth that you just have to be strong isn’t so effective,” Smith said. “The addiction is the disorder.”

“I think changing the stigma of the wording makes it more acceptable for people to understand,” Geer said. “This isn’t a choice, it’s more of a disease. The model before said it is a choice — ‘it’s all about willpower, you can make that change.’

“But people can’t do it on their own. They need support. They need help,” Geer said.

Labeling it a disorder is not an excuse to forego effort or dismiss personal responsibility, the group said.

“I think there is self-responsibility in every disease process, whether it’s diabetes or addiction. You have to be responsible and willing to get better,” Olson said.

“They don’t choose to be diabetic, but they can make changes,” Geer added. “It’s about choices, too. So, if you’re aware that you have this and you’re still making counterproductive decisions, you’re not going to be successful, or get anywhere.”

Motivation plays a role, Geer said, and for that “there’s all different kinds of skill building that we can do to help people understand what they are suffering from.”

The damage some people have incurred from the abuse is irreversible, Derry said. Some have developed cognitive delays or dementia.

“You can rebuild pathways and learn different skills and tools, but it’s always going to be some degree of damage,” Geer said.

Getting to the root of the problem, the reasons why someone turned to drugs is also part of treatment.

Reasons for abuse are many and when treating, it’s important find out what caused someone to develop drug problems. Sometimes, the women said, the drugs throw them into mental health. Other times family history can be a contributor — the environment in which they were raised. And then there’s trauma.

“Trauma as a child is huge,” Derry said.

One of the major changes in treating mental health and substance abuse issues has been the implementation of the collaborative care model, or, as the Bullhook staff call it, “wraparound treatment.”

“Before, you had medical here, behavioral here, mental health here, substance counseling over here,” Smith said. “Now … everyone is starting to talk together.”

In 2009 the National Council for Community Behavioral Healthcare issued “Behavioral Health/Primary Care Integration and the Person-Centered Health Care Home,” a report that summarized a collaborative care model to delivering mental health and substance use services in primary care service and primary care service in mental health and substance use settings. The Echo Institute says that more than 40 percent of patients with substance use disorder seeking treatment also have a mood disorder.

An example of how the care model would is implemented is provided in a mock report written by the American Psychiatric Association Academy of Psychosomatic Medicine:

John is a 48-year-old man visiting his primary care physician for a follow-up to manage hypertension. During the visit, John’s depression test is in the moderate range for major depression. John was treated by Dr. Stevens months ago for depression and is on a daily dose of 20 milligrams of fluoxetine. This is John’s first visit since the collaborative model has been implemented.

Dr. Stevens talks to John during their appointment before introducing him to Ms. Cook, a behavioral health specialist, who is available in the clinic to meet patients as they go from appointments at the request of any clinic staff.

Ms. Cook discovers that John has recently moved out of his house and is separating from his wife. He is staying with a friend and has had a difficult time making it on time to work. He often goes to bed late and sleeps in, missing his alarm and calling in sick. Ms. Cook shares some of that information about John with Dr. Stevens, who then increases John’s fluoxetine to 40 mg a day. She also engages him in behavioral activation strategy to improve his mood.

Five weeks later, the consulting psychiatrist, Dr. Brown, notices that John’s depression score hasn’t changed. Ms. Cook tells Dr. Brown that John stopped taking the fluoxetine the week before because it was making him jittery. The psychiatrist recommends switching John to another medication, sertraline. Ms. Cook passes the information on to John’s primary care physician, Dr. Stevens, through the electronic health record. Dr. Stevens then writes a prescription for the sertraline the next day and John agrees to try it. Ms. Cook goes over the side effects with John and then gives him her’s and the psychiatrists’ contact information in case he has any problems.

“By constant communication and sharing of tasks, the collaborative care team can work at their optimum level of efficiency and competence and share in the management of patients in a coordinated fashion,” the report says.

The Bullhook staff talked about reasons opioid abuse has gotten out of control.

Olson said opioids became a huge issue when pain became one of the vital signs.

“It started with doctors who said ‘If you are in pain, you shouldn’t ever be in pain — let’s treat it so you shouldn’t ever have pain,’” Derry said.

“We put it in the forefront of our treatment and people are under the impression they shouldn’t have any pain — and that’s just not realistic,” Olson said.

But the shift, she said, has begun.

“We want to better control your pain so you can function. The different scales we use are not 0 out of 10 pain. It’s more, ‘Can you go spend time with your kids and see your family and feel better and function?’”

Different ways of managing the pain is another aspect of trying to curb opioid prescription, ways which can include physical therapy, meditation, acupuncture and yoga.

Other ways to curb use may include prescribing less.

“Instead of getting a prescription for 30 days, maybe you only get it for a week,” Derry said.

It’s important, the group said, that when reducing the amount of drugs prescribed it is done wisely, so as not to create another problem by trying to eliminate one.

“If you cut the drugs too much, those who do really have chronic pain will go to their dealer and get heroin,” Olson said.

Encouraging doctors and nurse practitioners to prescribe smarter is the way to go, they said.

“We have drug screens, pill counts, contracts that say if we suspect you’re not taking the pills the way it’s prescribed we can check,” Olson said.

The Bullhook employees said the approaches are working.

Montana DPHHS reports the death rate numbers began to improve during the 2012-20 time period and ever since they have steadily declined and have been lower than the national average. In 2015, the absolute number of deaths from opioid analgesics, 35, was the lowest in nearly 15 years, DPHHS reports.