Panel 4: Public Health Response from Urban to Rural Communities

The Role of Public Health

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“We have an obligation to keep people alive.”

– Bassett

The final panel focused on the public health response to the opioid epidemic, from urban to rural communities.

While the overall statistics on opioid-related overdose deaths across the U.S. describe the gravity of the situation at large, examine them more closely and the disparities among the communities most affected come into starker clarity, often overlapping with and underpinned by major inequities in social opportunity, the panelists said.

“Opioids are not an issue that we sought out, but that sought us out,” H. Luke Shaefer, PhD, said in describing how his colleagues have come together to focus on intersections between poverty and the opioid epidemic. Shaefer is director of the Poverty Solutions initiative at U-M, and an associate professor of public policy and social work.

Low-income Americans in vulnerable communities bear the greatest burden from the opioid epidemic, which is “both a cause and consequence of poverty,” Shaefer said, pointing to the association between increases in poverty and unemployment rates and increased rates of opioid-related hospitalizations as one example.

The opioid epidemic has grown from a much broader context of economic vulnerability, structural challenges, and unmet needs for social services, Shaefer maintained. Highlighting socioeconomic barriers such as the lack of affordable housing, substance treatment facilities, and employment services may provide insight to the disparities within the opioid epidemic, he said.

With low-income communities coping with an unstable job market, adverse childhood experiences, and an inadequate safety net, Shaefer wondered, couldn’t we as a society consider devoting more resources toward different kinds of aid?

“I encourage us to ask the question of whether or not the opioid crisis is only the most deadly example of a broader set of phenomena that we have to address,” Shaefer concluded.

Intersections Between Poverty and the Opioid Epidemic

Debra Furr-Holden, PhD, talked about statewide efforts, many initiated at the community level, to reduce opioid-related harm. Furr-Holden, an epidemiologist with expertise in addiction epidemiology, prevention science, behavioral health equity research, interventions and policy, is a C.S. Mott Endowed Professor of Public Health and the Interim Director of the Michigan State University College of Human Medicine Division of Public Health.

Her major takeaway message? “We have to do better at working together.”

Furr-Holden described MSU’s Opioid Prevention and Education Network, or OPEN-MSU, which has been working with 20 community health organizations across the state in collaboration with the AmeriCorps Vista program to increase the capacity of local stakeholders to address the opioid epidemic.

She also emphasized the need for identifying leverage points to build synergy across existing opioid prevention and intervention efforts, and working collaboratively to address gaps in current opioid prevention efforts.

Statewide Efforts to Prevent and Reduce Opioid-Related Harm

Conference Co-Chair Mary T. Bassett, MD, MPH, director of the Harvard FXB Center for Health and Human Rights and the François-Xavier Bagnoud Professor of the Practice of Health and Human Rights at Harvard, described the ADEPT response to the opioid epidemic, which encompasses these points:

  1. Keep people Alive
  2. Follow the Data
  3. Media campaigns to Educate
  4. Take care when Prescribing opioids
  5. Effective Treatment everywhere

“A public health approach to the opioid crisis may be hard to do, but it is not rocket science,” Bassett asserted.

Bassett pointed to the state of Massachusetts’ Chapter 55 law as the “gold standard” model for how to integrate multiple data sources (across 10 government databases in all, including criminal justice, prescription drug monitoring, clinical service, and public health sources) on opioid fatalities to effectively determine where to focus prevention efforts.

But while Massachusetts has successfully reduced overall overdose deaths two years running, it still remains among the top 10 highest states for these fatalities, and its progress has been uneven, with opioid-related deaths among blacks in the state continuing to rise, particularly among black men.

Bassett talked at length about the persistent stigma around providing help for people using drugs, including harm reduction methods. “We need to be in a place where we can say, ‘I’m proud of my son, he’s in recovery.’”

“It’s absolutely unfathomable that only 20% of people with substance use disorder are in treatment,” and not always effective treatment at that, Bassett said. “No one should have to have treatment interrupted by incarcerations,” she added.

She also pointed to the disparities in opioid fatality reductions as a reminder to look to past epidemics that affected primarily minority communities that were “not greeted with the empathy that we’re correctly seeing now,” and to keep the focus on compassionate care for all who are currently affected by the opioid crisis. “We need to keep a lens on the racialization of addiction, and we need to take action,” she concluded.

Intersections Between Poverty and the Opioid Epidemic

Khaldun moderated the panel discussion, which addressed how to effectively involve affected communities in sustainable solutions.

As academics and public health officials, “probably the biggest mistake we make with community is that we already know what we want to do, we have everything all figured out, and then we go and we try to sprinkle everything around and make it work,” Furr-Holden said.  “We have to value the voice and the role that the community plays in the process at the outset,” she said. “If people can’t own it, it can’t be sustained.”

The panelists discussed ideas for social policy changes that could help boost employment and economic opportunity while also reducing the risk of substance use, and also examined the disparities within the overall progress in reducing opioid deaths.

“We live in a world where we place a hierarchy on the value of human life, and if we don’t address that, we’ve really failed society,” Furr-Holden said, noting the importance of stratifying data by race and other social determinants to reveal persistent inequities in outcomes.

“My wish would be that we had more people going straight to treatment, and actually bypassing the criminal justice system altogether,” Bassett said. “We really have to accept that this is a chronic, relapsing condition,” in which those on parole or probation who experience relapse deserve the same access to effective treatment as those with chronic heart failure and diabetes, she said.

The panelists also talked about expanding support for community health worker models – including finding sustainable funding for them – and with it, creating more job opportunities within the communities that the programs seek to serve.

Khaldun noted the successes of community health workers throughout programs Detroit, emphasizing that workers “really need to be from the community and have a shared experience with those communities that we’re trying to support,” while Bassett noted that community health workers need to be compensated appropriately and treated as professionals, not volunteers.

The panelists spoke about ways to address the particular challenges that justice-involved populations face related to access and outcomes, as well as the problem of finding sustainable funding sources for evidence-based programs in general.