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2019 FMX Out & About: Philadelphia CeaseAddiction - A Comprehensive

Public Health Strategy to Tackling the Overdose Crisis

• David O'Gurek, MD, FAAFP• Jonetta D. Gibbs, MS• Brandon R. Brown• Bryson Hoover-Hankerson• Steuart Wright• Mary Beth Hays, LSW• Kathleen Reeves

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ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

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David O'Gurek, MD, FAAFPAssociate Professor, Department of Family and Community Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Director of Urban Community Health, Center for Bioethics, Urban Health, and Policy, Temple University, Philadelphia, Pennsylvania

Dr. O’Gurek earned his medical degree from the Pennsylvania State University College of Medicine, Hershey, and completed a family medicine residency at Lancaster General Health in Pennsylvania. He practices comprehensive outpatient family medicine, as well as coordinating an office-based opioid treatment (OBOT) program for patients who have opioid use disorder. In his role as Director of Urban Community Health, he coordinates undergraduate and graduate medical education programs on social determinants of health and community health advocacy. He also serves as the director of Begin the Turn, a community-based, trauma-informed public health solution to address the overdose crisis. Dr. O’Gurek collaborates with Temple University’s faculty practice and the Temple Center for Population Health on creative methods to address the university’s community health needs assessment. Notably, he has partnered with the City of Philadelphia and its agencies to address the overdose crisis. He is a former chair of the AAFP’s Commission on Health of the Public and Science.

Jonetta D. Gibbs, MSMental Health Counselor, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Program Manager, Center for Bioethics, Urban Health and Policy, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania

Gibbs earned her master’s degree at Springfield College in Wilmington, Delaware, where she was inducted into the Pi Gamma Mu International Honor Society. She has experience providing therapeutic services for diverse clients in several modalities, including individual, group, couples, and family. Prior to her current position, she worked as an inpatient supervisor at Gaudenzia DRC in Philadelphia, Pennsylvania. She was also an outpatient counselor at Gaudenzia DRC, serving as a Vivitrol counselor and facilitating individual and group sessions for participants struggling with opioid and alcohol dependence. In addition, Gibbs provided services at CHANCES, an outpatient drug and alcohol treatment facility for women and women who have children. While employed by Dunbar Community Counseling, she provided treatment for adults and children experiencing challenges surrounding sexual abuse, domestic violence, post-traumatic stress disorder (PTSD), substance abuse, depression, and anxiety. Within Mercy Hospital’s Acute Psychiatric Unit, Gibbs provided short-term treatment for voluntary and involuntary patients who had a psychiatric diagnosis. She views medication-assisted treatment as a catalyst to long-term recovery and believes that treating participants with dignity and respect is a prerequisite to establishing optimal working therapeutic relationships.

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Brandon R. BrownTrainer/Consultant, BRB Consulting, Philadelphia, Pennsylvania

Brown is a graduate of Saint Joseph's Preparatory School and Temple University, both in Philadelphia, Pennsylvania. For more than 25 years, he has built a career as a national consultant/trainer/facilitator with a focus on challenging and strengthening individuals and communities by ensuring safe spaces in which young people can flourish. Some of his current and recent affiliations include working for the Lewis Katz School of Medicine at Temple University Center for Bioethics, Urban Health and Policy; serving as a Certified Trauma-Informed Practitioner/trainer with Lakeside Global Institute; and working as a facilitator for MENTOR. As a co-lead trainer for the Substance Abuse and Mental Health Services Administration (SAMSHA), he conducted training on the topic of engaging men and boys of color. Recently, he served as the interim director of diversity and inclusion at Saint Joseph's Preparatory School and provided technical assistance and capacity building for the Achieving Reunification Center. Brown is currently in his 13th year as the volunteer lead advisor for the Darryl L. Coates’ Sigma Beta Clubs of Philadelphia, working with boys of color ages 8 to 18. In addition, he serves in various local, regional, and national capacities as a member of Phi Beta Sigma Fraternity, Inc. Some of his past involvements include the Mayor’s Commission on African American Males; PhillyGoes2College; Philly Roots Fellowship Program; Black CAPs Philly; Project U-Turn; and Greater Philadelphia Mentorship Program.

Bryson Hoover-HankersonResearch Coordinator, Center for Bioethics, Urban Health and Policy, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania

Hoover-Hankerson earned an undergraduate degree from Tufts University in Medford, Massachusetts. He recently finished postbaccalaureate work in advanced core health sciences at Temple University in Philadelphia, Pennsylvania. Currently, he is a first-year medical student at Lewis Katz School of Medicine at Temple University. He is also serving as Community Service Chair for the Student National Medical Association (SNMA) and as an alumni liaison for the Temple University College of Science and Technology.

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Steuart WrightResearch Project Associate, Center for Bioethics, Urban Health and Policy, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania

Wright earned an undergraduate degree from the Fox School of Business at Temple University, Philadelphia, Pennsylvania. He recently finished postbaccalaureate work at Temple and is applying for matriculation in medical school in the summer of 2020.

Mary Beth Hays, LSWExecutive Director, Philadelphia Healthy and Safe Schools (PHASeS), Center for Bioethics Urban Health, and Policy, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania

Hays earned her Master of Social Work (MSW) degree from the University of Pennsylvania in Philadelphia. She is a Certified Play-Family Therapist and Professor of Play-Family Therapy from the Family & Play Therapy Center, Inc., in Philadelphia, Pennsylvania. A private practice therapist, supervisor, and educator with a focus in contextual therapy, she provides training locally and nationally on topics such as trauma, working with co-victims of homicide, contextual family therapy, and play therapy, including therapeutic modalities. For more than two decades, she has provided outpatient therapy and advocacy in both public and private arenas to children, adults, and families in the Philadelphia area, addressing issues including community and family violence, domestic violence, child custody, homicide, sexual/physical abuse, separation/divorce, and school-related problems.After spending more than 25 years working with children and families who have experienced trauma, Hays has been instrumental in contributing to the trauma-informed movement. She co-authored the chapter “Families That Experience Homicide” in Contemporary Families at the Nexus of Research and Practice, and she provides crisis response services after a violent or unexpected death to schools and communities within the Philadelphia area. She has acted as a mental health consultant for the Institute of Safe Families in Philadelphia and for the Physical Abuse Multidisciplinary Review Team at the Children’s Hospital of Philadelphia, as well as serving as a child development/parenting consultant for the Community College of Philadelphia, City of Philadelphia Public Assistance Office, and Easterseals.

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Learning Objectives1. Describe the importance of trauma and trauma informed

care in providing care to patients and communities struggling with opioid use disorder

2. Discuss critical elements of a community engagement strategy that includes prevention, harm reduction, treatment, and integration services

3. Identify community partners and opportunities to develop community-based solutions to addressing the overdose crisis and opioid use disorder within practice areas.

AES Poll Question #1Which of the following terms best describes the practice of refusing (a loan or insurance) to someone because they live in an area deemed to be a poor financial risk?

A. Racism

B. Discrimination

C. Gentrification

D. Redlining

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History– Health, Housing, & Policy

• Construction of canals and dams paved the way for industry in Philadelphia neighborhoods in 1820s

• Homes in the shadows of factories in a “walking city”

• Streetcar revolution in 1890s produced income segregation with poorest communities living in area around factories https://philadelphiaencyclopedia.org/archive/ind

ustrial‐neighborhoods/

History – Health, Housing, & Policy

• 1930s Post-depression Home Owners Loan Corporation (HOLC) property rating and Federal Housing Administration sought to maintain segregation in suburbs

• 1937 US Housing Act -Public Housing units arisehttp://www.urbanoasis.org/projects/holc‐

fha/digital‐holc‐maps/

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“The slums of Philadelphia are no accident. They are planned slums…the unregulated

tenement manipulators in their mad scramble for profits use the Negro as a pawn and use the middle class white

families as suckers, making them pay at both ends.”

Philadelphia Tribune, 1935

“Public housing policies played an especially important role in shaping the racial dynamics of the postwar city….Essentially, these housing projects solidified black ghettoization in the post war era.

Designed to prevent racial transitions and to maintain rigid color line in urban housing, the

massive housing projects also impelled working-class and middle-class blacks to newer second

ghetto neighborhoods.

Mohl R. Race and Housing in Postwar City: An Explosive History” 2001

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History – Health, Housing, & Policy

• mid-20th century -Factory closures and disappearance of industry

• Housing Act of 1954 called for urban renewal https://www.phillymag.com/citified/2016/03/22/philadelphia‐water‐lead‐flint/

History – Health, Housing, & Policy

• Philly’s most acclaimed renewal project focused on Society Hill– Before renewal, $454K annual property taxes

– By 1974, $2.47 millionGarvin A. The American City: What Works, What Doesn’t. 1996. McGraw Hill: New York.

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• Life Expectancy for child born in 2016 in Strawberry Mansion in North Philadelphia

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How Policy Shapes Health• Life expectancy for child born

in 2016 in Society Hill

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Estimated Deaths Attributed to Social Factors

Low education:  245,000

Racial segregation:  176,000 

Low social support:  162,000

Individual level poverty:          133,000

Income inequality:  119,000

Area level poverty:          39,000 

In comparison: 

Acute MI: 192,898

Cerebrovascular disease: 167,661

Lung cancer:            155,521

Estimated Deaths Attributable to Social Factors in the US. Galea S et.al. AJPH:June 16,2011;eprint.

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Adverse Childhood Experiences (ACEs)

• 1998 study• CDC & Kaiser Permanente

– >17,000 Kaiser patients– Fairly homogeneous middle-class Americans

• ACE score ≥4 correlates with serious adverse health outcomes and increased risk for:– COPD 390%– Hepatitis 240%– Depression 460%

Suicide 1220 %Felitti VJ, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. AJPM 1998;14(4): 245‐58.

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http://www.philadelphiaaces.org

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Epigenetic Pattern of Disease

https://en.wikipedia.org/wiki/Epigenetics#/media/File:Epigenetic_mechanisms.jpg

Discussion

Housing, Policy, Poverty & Your CommunitiesAddressing ACEs and Trauma in your Practice

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From there to here: an overdose crisis awaiting action

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“When people talk about drugs, they assume people take drugs because they enjoy it,” Williams told the Toronto Star. “But really, it's no different from overeating or watching too much television or drinking too much. You take drugs to make yourself feel better, to fill a hole.”

‐Ricky Williams

‐Byline Damien Cox, Toronto Star, May 29, 2006

Map of African‐American segregation in Philadelphia. Maps constructed using the Philadelphia NIS NeighborhoodBase. © 2001–2014 Cartographic Modeling Laboratory at the University of Pennsylvania. All rights reserved. Data source: US Census, 2000.

Drug Policy

• 1970s War on Drugs

• Criminal justice system

• Institutional racism

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How might family physicians respond to the overdose crisis?

Harm Reduction Strategies

SEPsSISs

PRIMARYCARE

Intake/Assesment

Treatment Plan

PharmacologyMAT

Continuing Care

Behavioral

Therapy

Case Management

PeerSupport

Comprehensive Treatment FAMILY

CARE

VocationalRehabilitative

Services

PREVENTION

SOCIAL DETERMINANTS OF HEALTH SERVICESHOUSING FOOD LEGAL TRANSPORTATION EDUCATION

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Physician Responses to Overdose Crisis

• AAFP Position Paper

• AAFP Substance Abuse and Addiction Policy

• AMA Opioid Task Force Report

Limitations of Medical Response

• Relies heavily on current systems and infrastructures

• Fails to address barriers of historic institutional racism and failed policy

• Disease-specific model vs Trauma-informed model

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Adverse Community Experiences & Resilience

“No epidemic has ever been resolved by paying attention to the treatment of the affected individual.”- Dr. George Albee

https://www.preventioninstitute.org/sites/default/files/publications/Adverse%20Community%20Experiences%20and%20Resilience.pdf

Symptoms of Community Trauma and Overdose Epidemic

https://www.preventioninstitute.org/sites/default/files/publications/Adverse%20Community%20Experiences%20and%20Resilience.pdf

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Philadelphia CeaseAddiction

PHASeS

Begin the Turn

SMARRT

• Committed to defining and addressing the ethical challenges of urban health care, public health status, and policy

• Mission

– Education

– Research

– Clinical Care Deliveryhttps://medicine.temple.edu/departments‐centers/research‐centers/center‐bioethics‐urban‐health‐and‐policy/about

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Background

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Grounded in Harm Reduction Philosophy

• Meeting the person as an individual• Starting where the person is• Assuming the person has strengths that can be supported• Accepting small incremental changes as steps in the right

direction• Not holding abstinence as a necessary precondition of the

therapy before really getting to know the individual• Developing a collaborative, empowering relationship with the

person• The importance of destigmatizing those that use substances

Marlatt GA, et al. Harm Reduction, Second Edition, 2011.

Traditional Paradigm Trauma‐Informed Paradigm

Patients are sick, ill, or bad Patients have been hurt and are suffering

Behaviors are misinformed and misguided

Behaviors are survival skills developed to live through the trauma but are maladaptive in society

Patients can change and stop behaviors if they only had enough motivation to do so

Patients need support, trust, and safety to decrease maladaptive behaviors

Manage or eliminate behaviors negatively affecting health

Provide opportunities for individuals to heal from their trauma

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PHASeS

• Philadelphia Healthy And Safe Schools

• Vaccination arm

Trauma & Education

• One out of every 4 children attending school has been exposed to a traumatic event that can affect learning or behavior

http://tsaforschools.org/_static/tsa/uploads/files//child_trauma_toolkit_final.pdf

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https://www.nctsn.org/resources/creating‐supporting‐and‐sustaining‐trauma‐informed‐schools‐system‐framework

PHASeS

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Mary McLeod Bethune School

• Old York Road & Rising Sun Ave

• PreK-8th grade

• Over 700 students

https://bethune.philasd.org

Kenderton Elementary

• 1500 block of Ontario Street

• behind LKSOM

• K-8th grade

https://kenderton.philasd.org

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A Community‐Based Trauma‐Informed Response 

to the Overdose Crisis

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Building a Team

• Program Manager

• Outreach Workers (4)

• Clinical Manager/Physician Assistant

• Case Manager

Obtaining a Unit

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Location, Location, Location

F & Allegheny

Somerset&

Kensington

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Who we are

Social Support Services

Street‐basedCare

PublicEducation

Community Advisory Board

• Modeled after FQHC

• Mission-driven compass for efforts

• Hiring Board

• Evaluative component

• Eyes and Ears/Boots on the Ground

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Outreach• 429 connections (July 25, 2019)

– 222 patients

• 73% male

• Drug(s) of Choice

– 89.3% opiates

– 23.5% crack/cocaine

– 18.2% K2

• 68.5% active insurance

• 78.3% interested in medication treatment

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EMERGENCY DEPARTMENT

TRUST Clinic

Treatment Center of Excellence

Inpatient consultsWarm Handoffs

Respite & Housing Development

SMARRT

• Social Medical Addiction Response and Resilience Teams – Under development– Will utilize and leverage opportunities from

current social services and support• CureViolence• Farm to Families• TRUST

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Philadelphia CureViolence

• Violence as a public health issue– Community mobilization

– Youth outreach

– Public education

– Leadership involvement

– Criminal justice participation

http://www.philaceasefire.com/about.html

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Farm to Families

Farm to Families

• Public health approach to food insecurity issues

• High rates obesity, cardiovascular disease, and diabetes in N Philadelphia

• Brings low cost, fresh produce to families

• Rx can be obtained from doctor

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https://www.giving.temple.edu/s/705/giving/16/interior.aspx?sid=705&gid=1&pgid=8804

TRUST Clinic (TEMPLE RECOVERY USING SCIENTIFIC TREATMENTS)

• Fully Integrated into a FM Clinic

• ~10 MAT patients per day

• 143 active MAT patients

• Buprenorphine Induction/Maintenance

• Routine Drug Screening

• Lab Testing

• SDoH Screening 

• Level of Care Assessment

• CRS Counseling/Groups

• Social Work Services

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TRUST Clinic (TEMPLE RECOVERY USING SCIENTIFIC TREATMENTS)

Before Funding

MAT appointments available 2, 1/2 day

sessions a week

MAT appointments available 5, 1/2 day sessions a week +

walk-in hours

Primary care office staff supporting

everyone

Dedicated case manager, medical assistant, front-desk and CRS

team

No recovery group sessions

Monday/Thursday from 1 to 2 p.m.

Hot Meals Served!

No dedicated funding for patient

services

Housing, food, transportation, cell

phone and pharmacy assistance available.

2 month wait time for a new patient

appointment

New patient appointments

scheduled within 2 business days

Sparse community ties for

OUD treatment

Working in tandem with outpatient offices

and community resources.

Before FundingAfter Funding After Funding

Unique Features

• Direct Contracts for Patient Services:

– Housing

– Transportation

– Pharmacy

– Food

– Phones

• 2 Group Therapy Sessions/Week

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TRUST Clinic (TEMPLE RECOVERY USING SCIENTIFIC TREATMENTS)

Total Visits 2,758

Total Unique Patients Seen 368

% Male 68%

% Medicaid 80%

Avg Age 43

Avg Visits per Patient 7.5

% Appts Cancelled 18%

% Appts No‐Showed 13%

Avg PCP Visits (past 12 months) 4

Avg ED Visits (past 12 months) 3

Avg Admits (past 12 months) 1

Avg # of Med Classes 5

We’ve seen a 2% reduction in the readmission rate of patients with OUD who were discharged from the Temple EDs/Hospitals, regardless of reason for admission, when comparing FY’18 and 

FY’19.

TRUST Clinic (TEMPLE RECOVERY USING SCIENTIFIC TREATMENTS)

10 spoke sites were selected as the initial cohort for the PaCMAT program.  Including 

FQHCs, city clinics, and nonprofits.

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Break Out Session/Discussions – 45 mins

Begin the Turn Room C/Mobile Unit

PHASeS Room D

Closing Thoughts

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“One of the first objectives for family physicians is to understand the living conditions patients face when they leave our office or when they leave

the hospital."

Steve Woolf, MD

Language Matters

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People & Communities have been and continue to be hurt

• Check our implicit and explicit biases

• Seek understanding

• Do ”with” NOT “to”

Practice Recommendations

• Our current overdose crisis is grounded in institutional racism and failed policy

• Public health problems require comprehensive public health solutions

• Individual and community level trauma is common, particularly in communities with high rates of overdose and overdose deaths

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Practice Recommendations• A lot about who we are, and what we do, are

because of things that happened to us• Prevention includes a multimodal strategy

built on optimal healing environments• Harm reduction and treatment efforts must be

individualize and patient-centered with an emphasis on cognitive and behavioral components

Questions