Connecting Social Services to Improve Harm Reduction

We talk with Dr. Sarah Spencer and Annette Hubbard of the Ninilchik Traditional Council to discuss how connecting social services like Child Protective Services, local food banks, police and sheriff departments with each other can lead to warm handoffs and improved outcomes for those struggling with substance use disorder. Learn how syringe access programs, open and honest conversations about recovery and medication-assisted treatment can significantly reduce the risk of overdose death, the leading cause of accidental deaths in the U.S., especially in isolated, rural communities where medical services are not always readily available.

Transcript

Dr. Sarah Spencer  00:00

Drug overdose is the number one killer of people under age 50 in this country, so if it is not your job as a primary care provider to treat the disease that is the number one killer of people under age 50, like, what is your job? That is your job. And so we have to be ready. Even if it's just providing emergency stabilization to those patients, we have to be ready as primary care providers.

Beth Brown  00:23

Welcome to Breaking Barriers in Rural Health, a limited series podcast from Mountain Pacific. We are sharing what is working in rural mental health and health care and discussing ways to replicate these successes. We're also shining sunlight where it's needed by identifying breakdowns and gaps in care. Ultimately, we aim to improve the health and well being of our health care communities, and anyone listening into this podcast. Now here's the latest episode in Breaking Barriers in Rural Health.

Amber Rogers  00:59

Welcome, everybody to our podcast. This is Amber Rogers, and we are here today with Breaking Barriers in Rural Health. I have several guests today. I have Kyla Newland. She is our pharmacist from the great state of Alaska. 

Kyla Newland  01:16

Hi, everybody. 

Amber Rogers  01:17

And then we have Dr. Sarah Spencer. 

Dr. Sarah Spencer  01:20

Hello. I live in Anchorpoint, Alaska, and I work in Ninilchik and Homer, Alaska. Originally, I grew up in Maine, but I've been working in Alaska since I got out of residency. 

Amber Rogers  01:31

Awesome. And we have Annette Hubbard. 

Annette Hubbard  01:35

Hi everybody, I reside in Ninilchik, Alaska, which is my tribal grounds and where my family's from, but I grew up in Anchorage, and I moved down here in 2016.

Amber Rogers  01:48

Awesome. Today we're going to talk about providing services in a very, very rural part of Alaska. Full disclosure, I'm from Montana, and I always thought that I knew what rural was. I grew up in a very small town in northeastern Montana, we were labeled as the middle of nowhere where I grew up, because in the lower 48, we are considered the furthest away from a metropolitan center. So my little town is considered officially the middle of nowhere. So it's labeled everywhere. It's like the capital of the middle of nowhere. But that all pales in comparison when you are actually talking to anybody from Alaska. So my son moved up to Alaska, and then whenever I visit with my co workers from Alaska, I am always humbled, because you guys actually live the rural life. And so you will always have stories that totally trump mine when it comes to living and breathing, what it means to live and work in rural areas. So can you share a little bit with our listeners, who perhaps have never experienced what it's like to serve and care for people in your very rural state of Alaska, a bit about your service area, and some of the challenges that you have when you're working with patients? And this is specifically about patients that are receiving drug and alcohol treatment services. And I'll start perhaps with you, Annette.

Annette Hubbard  03:35

Yeah, we've always got transportation and housing and employment even more so than in a more urban area. Pharmacy access. Where I live and reside, I'm halfway between two larger communities that have pharmacies, that have grocery stores, that have taxis. And so yes, there's just always always our barriers, everybody else's barriers we hear too. It's a big deal. 

Amber Rogers  04:03

But you just don't have roads. 

Annette Hubbard  04:05

We do! Actually, where we are you have roads and some of the other communities that we do some work with that are actually remote like you can only get in by a boat plane, they get their medications mailed in but they only get them mailed in on certain days. I really think that that's a very creative and strategic way to kind of address that situation. There's a mail-based pharmacy that does that for our tribal members that live in those kind of areas. But where we are at, we're on the road system and even then we're still limited because of reliable transport. Like a reliable, I feel like every day I drive in a distance like I at least run into like three or four cars that are broke down on the side of the road that honestly look like people have just been trying to keep it running. And so trying to find reliable, accessible transportation can be really difficult. 

Amber Rogers  04:55

So did you change the way that you're opioid treatment program looks to accommodate some of those challenges? 

Annette Hubbard  05:06

Yeah, we- 

Amber Rogers  05:06

Can you describe how how that looks maybe looks different for your treatment program than perhaps what other people have seen? And for those that don't know, maybe describe what the typical opioid treatment program looks like first. 

Dr. Sarah Spencer  05:23

Yeah, sure, I can speak to that. Well, first of all, opioid treatment program is also specific federal language. OTP actually means a methadone program, which is not us. So that language can be a little bit confusing. So we're officially an outpatient OBOT. So oh, by office-based opioid treatment, which is different than an OTP, or an opiate treatment program, which is a methadone clinic actually, like this dual language. So, like a little bit more detail about our area that we serve, and Alaska terms, we are considered really not that rural the town, you know, Ninilchik, our town has 800 people in it, we're 35, 45 miles from the nearest pharmacy, but that's actually not considered particularly rural in Alaska, because we do have a road that goes through our communities. So a lot of places we do serve patients who live across the bay from Homer in the native villages, like Seldovia and Nanwalek and Port Graham, where you have to fly in or boat in is the only way to get and those all have like less than 500. It's just a few hundered people that live in those villages. Most of our patients live on the road system, but doesn't mean that just because there's a road that they can get there. So most of our patients have some kind of significant transportation barrier. Either they don't have a working vehicle, or they don't have a valid driver's license, or maybe they do have those but they don't have money to put gas in their tank to drive like the 70, 80 mile round trip that it could be to either get to our clinic or to get to the pharmacy. So it's really telemedicine has been really critical. And we were doing telemedicine before COVID. That was something that we were already pretty familiar with before COVID. Because of the fact that, especially for our patients who do live in these rural those villages, it doesn't make any kind of financial sense for that patient to fly over and a lot of times they can't because the weather is just isn't good enough. You know, the weather, we have horrible weather, the plane can't fly for a week sometimes to deliver the mail even to give people their prescription. So it doesn't really make economic or financial or sense really in any way to try to actually get patients to our clinic that often. So a lot of times in a typical outpatient treatment program, when you're first starting someone say on medications, you might ask someone to come in person every week to your clinic, to get a urine drug screen and see them in person. And then we do medication counts, and even have random medication counts and random urine drug screens. But there is no way for our patients to get to our clinic or to hospital or to a pharmacy that often, it's just completely not feasible. And so you really have to make a lot of adjustments in the way that you practice, maybe that, maybe different from what you learned or what you did in a bigger community to make sure that patients don't lose access to care. Because that's really the most important thing with opioid use disorder is making care as accessible as possible, and not putting up any barriers because we know that especially for medications for opioid use disorder, interruption of those medications is very dangerous for patients. So we want to try to do everything that we can, when we're offering services to try to reduce those interruptions in medications.

Amber Rogers  08:36

Yeah, and that really illustrates the point that your treatment program's a little bit more unique than most.

Annette Hubbard  08:44

One of the big things that we did, I feel is changing kind of our mindset and our language. Like now, it's more we do addiction medicine treatment in primary care. So it's the same model of care as, that you can come in and get your blood pressure checked and get prescribed your medication for that week, right. And that language changing of we're an opiate-based treatment program or whatever, like we do substance use treatment and primary care. Number one, demographics, statistics and things state that, that that's where people get services, even mental health services, at their primary care. So that little bit of key language, you know, we've tried different models, you know, the program model of care where you do an assessment and things like that, that didn't work. And so we try to meet our patient's needs, which we're doing that anyways in general health care, so why not substance use treatment as well, right? So we're meeting them between the ethics and the guidelines and the laws and what they're trying to accomplish in their life. Also talking to them about what's safe and what's not safe truthfully, because what we're finding too is is that all the information that we're giving them, they come armed with their own facts of things that they have read on the internet, various websites and things peer-reviewed web sites so they know what's up. But they feel safe and comfortable with us to ask us the question like, if I do this, what will happen kind of thing.

Amber Rogers  10:07

When we talk about decreasing stigma, that's exactly what you're doing. You've already taken that whole stigma conversation, and you've already flipped it. Because there's no stigma. You've already eliminated it by saying, my doors are open to you. That my primary care is substance use disorder. It's opioid use disorder, it's stimulant use disorder, it's blood pressure control, it is everything. Primary care is the treatment of your entire body from head to toe.

Annette Hubbard  10:42

Exactly. 

Dr. Sarah Spencer  10:45

Absolutely. 

Kyla Newland  10:46

Yeah, I think that's really important to just normalize opioid use disorder, like people would treat diabetes, or heart failure or any of these chronic diseases, because that's what it is. 

Dr. Sarah Spencer  10:57

Yeah, absolutely. And I think that's one of the main reasons why the government got rid of all of these regulations around the market is that they want everyone to use it, they want to normalize it. Drug overdose is the number one killer of people under age 50 in this country. So if it is not your job as a primary care provider to treat the disease, that is the number one killer of people under 50, like, what is your job? That is your job. It's just as much your job as any other, like treating the most common is one of the most common diseases that people experience. And so we have to be ready. Even if it's just providing emergency stabilization to those patients, we have to be ready as primary care providers, especially in rural areas. And the good thing is, is that it's not really that hard. And honestly, as Annette said, like, we used to have, and you know I've been doing this for like 13 years now. And I've been working together for like seven or eight years. And in the past, we had these very structured, very outlined programs that you had to check all the boxes, and you had to fulfill all the requirements in order to participate. You know, what we found over time is that that works fine for patients who have a mild disease. But that is not at all helpful to people who have really severe disease. I mean, in some cases, it is some people thrive on really structured environments. But those people who are really struggling with the most severe disease, we really need to develop individualized treatment plans and meet them where they're at, just like we do with patients who have poorly controlled diabetes, and they're not exercising, and they're still eating sugar everyday, right? Just like we do for the person who's got severe COPD, and they're still smoking. Like, we still take care of them and offer them everything we can, whether they are still engaging in that behavior or not, because it's a really severe, life-threatening chronic disease. And so individualizing treatment like that, rather than making people try to fit into this box, has really helped really expand access to people who just weren't getting the treatment that they needed before.

Annette Hubbard  12:41

They also come with some compounded factors, right, like housing. So you're treating their substance use stuff, and housing and all these other things, which is totally different than what we're doing for somebody who has high blood pressure. It's a very different spectrum. It's a very different subset of things. And so how do you support somebody who their only housing is with other active users? Right? Do you just treat them? Do you treat that whole community within there? We talked to many different people along our travels with our services and things and we got a lot of amazing feedback from them. And it really helps they continue to be active in our clinic, and give us feedback and just staying connected to them, whether they're on medication or not. It's still a human being, and we still want to treat them that way. It's amazing.

Dr. Sarah Spencer  13:33

Yeah, I think like staying connected to and that's really great at staying connected to the people who aren't currently in care that just because they're not taking their medication doesn't mean that we can't support them in some way. And Annette's really great at staying connected with those people and hearing what their needs are and seeing in what ways that we can help them. Even if it's connecting them to other services, it may not be helping them navigate system that may not they may not be ready to come in for an appointment and take a medication, but we can still help them in some way. And then really just listening to them, like what are their needs, rather than kind of guess what we think their needs are. What is it that you need and what will be helpful to allow you to access treatment or improve your quality of life in whatever way that is, whether it's your health, your mental health, or your living situation or whatever, helping people improve their quality of life?

Amber Rogers  14:22

And for those that maybe aren't as familiar with some of the lingo for those that are hearing the words not currently connected to care, often that means receiving services at the clinic for some of the medications that assist with opioid dependence. That also means perhaps these people are receiving some harm reduction services. So as I understand it, you guys assist with some syringe services. Is that correct? 

Annette Hubbard  14:54

Yes, 

Amber Rogers  14:55

Access to syringes? I know that that can be controversial in some locations, you want to talk a little bit about that? Annette- 

Annette Hubbard  15:04

Sure.

Amber Rogers  15:04

Is that under your purview? 

Annette Hubbard  15:06

Yeah. Sometimes we have somebody who is just getting into care. And they're working on decreasing use, whichever. So we do ask them, what's your preferred method of use. And if they are still actively injecting or actively smoking, we definitely work to get them connected to services in our community that offer safe supplies. In Alaska, there's an agency that does mail-based distribution. And so you just go to this website, login, your address, they'll mail you Narcan, they'll mail us syringes, any supplies that you order, and they're, they're awesome. Then there's also in our area, Dr. Spencer helped start up a local syringe access program. And sometimes that does mean getting people connected to that service and letting them know when it is and where it is, and, and helping get them coordinated through there. So I do a lot of harm reduction education, and Megan's Place is something that's very near and dear and personal to our hearts. It's a place for people who use drugs by some people who use drugs, we have a spectrum of volunteers that volunteer there, from nurses, to doctors, to peers, people who used to use the exchange, and now just want to be a part of it, because it's, for some people, it's, they say that it's the one place that they can come and just be human. And work on that. And the mail-based one is through the Alaska Native Tribal Health Consortium. And they have a website, www. IKnowMine.org. But for people down in the lower 48, just so you know if you are in need of supplies, www.NEXTDistro.org. Most states, NEXT Distro is very helpful and can work with you on that. And they do mail-based as well.

Amber Rogers  16:57

They do. And they also offer a lot of materials and available resources for those about how to receive services for those materials. There's so many good reasons to do harm reduction. You can't recover if you're dead. 

Annette Hubbard  17:15

Yeah. And we just think about- Like, I'm also in recovery from alcoholism. And you know, this is like the growing frustration about safe injection supplies, right? But when I met with somebody with that resistance about like handing out stuff. But I, as an alcoholic, can go to the bar and get drunk and pass out. And I know that I'm gonna make it, I'll make it home, right? If the bartender the like, there's that community within there. And so what makes me as somebody who's in recovery from alcoholism better than somebody who's in recovery from meth use, or benzo or you know, like, if we're all talking about addiction, and basically, the symptoms are all the same. It's just the substance that you use is different, why can I go and probably more than likely be safe, I made it out lucky, like everywhere can be a safe injection site, not just the bars. And so for me, I really had to work with my resistance to thinking about working in a safe access supply. But I saw the magic that happens. And I saw the relationships and I saw it actually changing people's lives. And I got passionate about it. And when you think about your own story and the ways in your life, that harm reduction has been present in your life, and I'm not just talking about condoms and seatbelts, I'm talking about all that stuff. It helps you get into the mindset in evening the playing field, right? And address your own stigma. You have to address your own stigma before you can even walk out that door to help anybody.

Dr. Sarah Spencer  18:46

Yeah, and I think to like think about harm reduction, harm reduction doesn't just belong in a syringe access program, or in a family planning clinic or something, you know, harm reduction. It's a part of health care, it's sort of the lowest entry level part of health care, it is health care. Handing someone safe injection supplies, a Narcan kit, teaching them about safer injection practices, testing them, offering them prep all of these things, it is a 100% health care. So, it is part of treatment. Treatments in health care is about improving people's quality of life. And, if you can, reducing their morbidity and mortality. And it's the entry level of that. We already do incorporate it into a lot of other ways that we serve people in health care, so making sure that we're offering that for people who use drugs as well. And not just in the syringe access programs, but in our regular primary care practices as well. 

Amber Rogers  19:36

Yeah, I mean, prevention. It's number one. Think of all the infections and all of the other downstream effects that you're preventing. I mean, you do it because you care about other fellow people, but you're also saving a boatload of money, even if you want to put cold hard facts and figures to it. It just makes sense.

Dr. Sarah Spencer  19:56

And I think it really it really helps to build that sense of trust and that therapeutic relationship with that patient that they know that you're there for them. And it's safe to talk to you about their drug use, and that you're going to help them in whatever way you can. Whether they're using drugs or not, whether they're wanting to stop or not, no matter what they're doing that you're there to help them to improve their life in whatever way that they are ready to do that. Being president, like volunteering for a syringe access program, or offering harm reduction supplies in your practice are ways that you can make that connection and really connect with that patient base, which is the people that really need you most that aren't getting services. Right now, the national statistic is that people who use harm reduction services like syringe access programs are five times more likely to seek treatment services, we've absolutely seen that in our area. I think one year that we looked, I think it was like 2020, or 2021, half of all of our referrals in some way were related to our local syringe access program, whether it was my friend who went to the program told me or I heard about it there. So, they're an incredible opportunity for people to make those safe connections to health care and enter into treatment, if that's what they're ready to do.

Amber Rogers  21:04

The power of caring, right? 

Dr. Sarah Spencer  21:07

Unfortunately, so many rural areas don't have any kind of organized harm reduction services, we were the first rural syringe access program in Alaska, that was in 2016. There's one more right now in Bethel through their native health system there that they just started like two years ago. And then there's the mailorder, one that started like three years ago. But most rural places in America really don't have direct access to harm reduction services. And it's a lost opportunity to connect with people. So you know, when you're working in a rural practice, and you don't have the service locally offering those to the patients, even if you don't keep syringes in your clinic, the handout or you can write a prescription for syringes for someone, you can talk to them about safe injection practices, you can prescribe PrEP, like there's all these things that you can do without there being a syringe access program, and you should talk and you should offer those to patients because they're terrified ask their doctor because they're saying they want to stop using drugs, but they're struggling. And they don't want to admit maybe that they're still injecting and so really being upfront about that, like, "Hey, do you need injection supplies?" and not judging people for that, so that you can really make sure that they know it's safe to have that conversation and ask for those health services. 

Amber Rogers  22:12

Yeah, again, it's so powerful just to even be able to have that conversation with people and not be I don't know what the word is. Just be open, just be vulnerable to it, or open to it. 

Dr. Sarah Spencer  22:28

Yeah, I think people are scared. I think one of the biggest stigmas around that is being enabling right, like providers are scared that if I'm going to offer someone injection supplies, then I'm saying that they should use drugs, right? Which is not at all what it is, you're just asking them "Do you need this medical service that's going to help reduce your health risk for this activity that you're engaged in?" right? So normalizing that that like it's a very valid health care service, and incorporating that into health care to reduce that stigma? Because I think it's just as hard for the patient to ask that question about syringe access, it's probably even harder sometimes for the provider, because it feels like it just somehow feels wrong, you know, to offer that when you're actually helping the patient dramatically to reduce your health risk. But it's it can be an uncomfortable conversation until you engage in it and practice it. And it becomes much more comfortable and more natural, but it's not a kind of thing that most doctors are comfortable with talking with their patients about.

Annette Hubbard  23:22

And yeah, I think about like when I'm doing my intake or my meet and greet or sitting down with somebody, I've got my laptop open and I'm you know, "How do you use them?" And then they're like, "I injected." I'm like, "Okay, well, what's what is your plan? Like? Do you want to stop using opiate like, what do you want to do?" And I'm like, well, but they mentioned somewhere whenever they're actively injecting, and they have no plans on discontinuing some other injectable material, right? Approaching that but then there be there's sometimes they're just- a lot of times, they're just shocked. Nobody's ever asked that question. Wherever they're at. Sometimes they travel very hard. They can get them but they're, but they're stigmatized by it. By where they have to go to ask pharmacies, they're going to pharmacies to ask for syringes who were advertising syringes, but they you know, their name goes on a list. And so then we were just like, I mean, "Do you want them?" Like, "Here's a pack." But it changes the whole relationship and the dynamic. And I'm a second with with Dr. Spencer, like it can get uncomfortable sometimes like, but it's not my place. I have to remember that. Like we're impacting each other's life, but the outcome of each of our lives is different. And so again, like that makes it easier. I'm just here to support you the same that I would do to Dr. Spencer as a friend. But no matter what we're here, and it can be really hard because we've definitely along the way we've we've lost patients, people that we've known. And I always think like I know that they were trying, it's not "I shouldn't have given them that pack of syringes." It's always "I know that they were trying," and we celebrate them and the things that they were going through up until that moment, and that's just what we do.

Dr. Sarah Spencer  24:58

When we think about like services that we're offering to people that continue to use drugs, harm reduction isn't also just about supplies like syringes or Narcan. But also like medication can be a form of harm reduction. So we know we certainly have some patients who are low. There's a lot of different ways in which that can be right. Sometimes patients say I want to stop using opioids, but I'm not really ready to stop using meth. So the idea of you think, you know, I think it's just old fashioned, as people come into treatment that they'll stop using everything. Well, it's not, there may be one particular drug they're using that is causing them problems. Whereas another drug that they're using is not something that they feel is causing them problems right now that they're ready or willing to stop using right now. Or maybe ever, which is fine. So medications can help people to stop using opioids, even if they're not ready to stop using other drugs, but also some people, maybe they're not 100 percent ready to completely stop using it because they want to, but they're just struggling and they just they just can't. And so that medication, even if they're not able to stop using fentanyl, most of our patients are using fentanyl. They're trying to stop using fentanyl, that medication like buprenorphine can keep those patients safe, it can keep them alive so that when they do use fentanyl, that they're less likely to have an overdose also less likely to experience withdrawal symptoms in between their use. So it can dramatically reduce their mortality risks, even if it doesn't result in them stopping using those drugs. And so we really make sure that people know we do a lot of long acting injectable buprenorphine in our clinic, which really helps to reduce barriers in a lot of ways. Because people, they can come in once a month or once every six weeks to get an injection of buprenorphine. They don't have to worry about getting to the pharmacy every week, they don't have to worry about coming to frequent appointments, they know that no matter what drugs they're using, they can get their injection no matter what if they show up and they want their injection that they can get it and it's easy for us to do it even to squeeze the men for walking appointments for that. So that really can help to reduce mortality, even if people aren't able to completely stop using.

Amber Rogers  27:00

Really low barriers. Make it as easy as possible. 

Dr. Sarah Spencer  27:06

Yeah. And I think the long-acting injectables are really great. Like they have been also in psychology, you know, like the long-acting antipsychotics, and now we're having the long acting PrEP and treatments, you know, for HIV infection that are long-acting. It really can reduce the barriers to folks who just really struggle with connecting with care with a frequency or taking a daily medication is so hard. It's hard for everyone and the more issues you have in your life with mental health issues with homelessness, with substance use, financial barriers, transportation barriers. All of those things make it increasingly hard to take a daily medication. You know, luckily, these innovations come out in medicine, that we're able to offer long-acting injectables, it can really help to reduce those barriers for the patients who really are the most vulnerable patients. So we really utilize those medications a lot for those folks. We offer people all of the options. But honestly, most of our patients, I would say at least four to five of our patients maybe are three or four patients who come to us and maybe they're specifically asking for long-acting injectable buprenorphine when they're calling about access to care. 

Annette Hubbard  28:10

Yeah, that's what their voicemail says, "Hi, this is so and so and I'm calling to get on sublocade. Call me back."

Dr. Sarah Spencer  28:17

Because they've heard from their friends like "This helps me to feel better. This is like, you know, you you need to get on this medication." So we don't, we don't need to advertise our services. It's all word of mouth, through other people and patients in the community that talk to each other and share that experience, which is so much more valuable to them. And I can explain to you all day long as a doctor's point of view, why I think that this is a great medication, much more meaningful for it to come from another person with lived experience that has actually gone through that to say that this was really helpful for me and you should go see a doctor to get medication to help.

Annette Hubbard  28:50

Because they're probably not sitting around watching TV waiting for the commercial to come up. "Have you thought about-" you know? They're, they're talking and they're communicating with each other? Yeah, all it takes is one.

Amber Rogers  29:02

Well, and I think that that brings us back to kind of community as a whole, as well. And I know that you guys know each other in Alaska there, through your connection through community coalition's. And I think that different community connections can bring about partnerships between like minded community organizations, community partnerships, and that can include people from all walks of life, that can be people with lived experience, people from the law enforcement community, people from clinics, people from everybody from a library. Yeah, yeah. All you know, all kinds of people. So can you talk a little bit about your particular community coalition? Who were your partners? What kind of strengths do those individual organizations bring to the table and what are some of the things that you've been able to do, perhaps that are unique to your people there to serve your community there in Alaska. 

Annette Hubbard  30:08

We do have a local recovery coalition, it recently changed. It's now All Things Recovery, I think. It used to be called the Opiate Task Force. But we wanted it to just be more general and broad. And we were just a table of solution seekers. So we didn't want to call it the Opiate Task Force, which is a whole bunch of money got dumped out for for opiate funding, right. Like, let's be a recovery coalition, like let's get things going, let's start talking about solutions and make it all recovery, mental health, substance use domestic violence. There's people who are at that table, who are involved in this task force, since I think that they meet quarterly. I'm friends with a coalition leader. She's also a peer support, who works for us as well. She's fantastic. We love her to death, this keeps coming to my brain. And I mentioned it to the one of them the other day, about back in 2019. Everybody got together as a community at a church, you remember this, when we got together? It was it was the whole community. And it was churches, and it was the local councillors and the medical and the ER. And we came up with a vision, like a community solution to these issues. And a lot of things came up out of it about mobile addiction treatment, and the mobile crisis model, right, the Crisis Now model and things like that. And it was fantastic. And then COVID hit, so nothing got done. But I want to do it again. So I made the proposal to them again, because we just did another needs assessment. And that's a whole mass, right. But the coalition, I feel like helps break down the silo. And it helped increase the communication, I was just talking to talking to the nurse at another clinic today about getting somebody into our clinic. And so it put faces to names of the community members that we're hearing all this weird little chitter chatter about all these people that were doing all these things. So that happened number one, and it created a more cohesive environment and community. And just kind of helps shed light on some things that might be radical, that probably aren't your radical we can all do as a small part of the bigger picture, right? So now it makes it easier when I'm like, "Oh, you have an appointment, hang on, let's just call them," right? Like, it broke down that barrier. So we can just be like, "Hey, I got your person, they're here, we're taking care of them." And it built more trust in the community around some things. 

Dr. Sarah Spencer  32:23

Even in a small community, even though you feel like you kind of know everyone, you really don't know what is going on in each individual organization. They're serving your population by different areas, you know, the food pantry viewpoint, and the criminal justice and the police department and the homeless shelter in the emergency room and the family medicine clinic and the Child Protective Services, right? They're all potentially interacting with people who need treatment for substance use disorder. But unless you all know each other, and you all know what other services each other organization provides, and know how to help that patient easily transfer between agency to agency, you know, people just get lost in the shuffle of all these agencies that I have to deal with. So I think really that community coalition, the biggest thing is making those connections between the organizations understanding how each organization operates and what services that they provide. And that allows patients to kind of to really have that no wrong door of if I show up at Child Protective Services, or I show up at the food bank, or you know, I get arrested, People at each of those organizations know how to get me treatment services, if that's what I'm trying to do. They know how to do it quickly and easily. And to provide the warm handoff versus just giving you a like list of like, here's where you can call these places, if you want to treatment, you know, it's that warm handoff makes all of the difference. We're dealing with a patient right now who just showed up from out of town that a pregnant patient who has you know, high birth and said it at multiple different agencies in town at the hospital and one of the clinics and miss an appointment with another clinic and then just showed up in labor this morning. So as all knowing each other, the clinic, the hospital, the other clinic, the hospital and our clinic all knowing each other and then all being able to talk immediately over the phone about this patient and coordinate their care in real time makes a huge difference. And you really have a lot of that flexibility, you have more flexibility, I think in a small town to kind of make those personal connections that makes all the difference for people when they're looking for help that if no matter where you go. Any social service agency is going to know how to get you the help that you needed to get it quickly.

Amber Rogers  34:36

That's awesome. 

Kyla Newland  34:37

Yeah, I was thinking that exact same thing that you're talking about all the barriers to being in a rural area that then advantage to that community connections. It's a lot easier to make those and maintain those that it would be in an urban area I guess. 

Dr. Sarah Spencer  34:53

And there's also like a lot less bureaucracy. We don't have big councils we have to go through in a lot of ways because the number of people are smaller. Like, the financial barriers are also smaller to providing for our syringe access program. We have like, all volunteer, grassroots all donations funded, it's much easier if you're in a town of 2000 people, and you need to just provide syringes for a dozen people or 20 people, that's a pretty inexpensive project,. It doesn't take a lot of, you know, you can get these little micro grants and things to fund these projects. And you don't have to go through big issues with zoning and codes. And...

Annette Hubbard  35:25

Yeah, the zoning I was gonna say that's, that's a huge thing that's off of our table. That's really nice with the future of health care with like mobile stuff. Like we could just park it and pull it right like because, because we're not a city. So we don't have to deal with stoplights and things in we do have to deal with a lot with like, not in my backyard. But we know whose backyard like we know. I mean, you can do it in my backyard. That's totally fine. I'm so and I haven't, you know, I don't have any covenants or zonings, or any, you know, and so so it really does open the doors in certain places, for sure. 

Amber Rogers  35:58

So, yeah, well, this has been awesome. So let's end on a high note, shall we? Just as a spin off, what's a word or phrase that summarizes how you feel at the end of the day, when you've been working with clients that currently are using drugs?

Annette Hubbard  36:19

I have one that comes to mind. And I use it all the time with my PowerPoint presentations. And I really hope that I don't mess this up. That people don't care how much you know, they want to know how much you care. And I have this other one, it's okay, if you don't want to do this work, it's okay that you don't want to do this work. There are way more people who want to do this work than don't. So give them to us. Build relationships with us, the outreach workers and the medical providers. But don't shun people. And don't say like, "I'm not going to treat you because you smoke pot, I'm not going to treat you." "I just need my birth control man," right? Don't. So it's okay that you don't, I totally get it. It's- days, this job is really, really hard, emotionally and mentally in more ways than I can count. And I did not want to do this, but it is the most rewarding thing. And I'm so grateful for my mentors, for Dr. Spencer, and pharmacy reps that have educated me. But more than anything, I'm so grateful for the people that I've worked with and for whether they're still with us or not. And I've had the glorious opportunity to meet beautiful human beings who just broke it down and made it real for me. And I do this continue to do this in honor of them. Because that's what they that's what they were doing. They just got caught in the crossfire. It's been a very emotional year, I needed this for me, I can say with losing quite a few. And, and it really sucks. It really sucks. But you gotta understand addiction. And you gotta understand the world and put yourself in people's places. Because life's not easy. And they're just doing the best that they frickin can with what they have. So don't be a jerk. Don't be a jerk. Don't be a jerk. That's what, that's what harm reduction is. It's just not- and I'm using a very nice polite, politically correct word. Don't be that guy. Do not be that guy.

Dr. Sarah Spencer  38:28

Yeah, you know, I think the Harm Reduction Coalition or a lot of them have there's, you know, these stickers that say "I love people who use drugs." Yeah... You got me all teary. Oh, god, that's so bad. I can't watch other people cry. Because then I cry, that's the worst. 

Annette Hubbard  38:46

It's been a rough month for us. We've lost pat- we've lost a few. We've lost quite a few in this last month. And we love them to death and their families and we're there to support their families. Because, because they need us too. 

Dr. Sarah Spencer  39:01

Yeah, I think that's I would say that that's the biggest misconception about this field is that these are difficult patients, right? You're my favorite patients, referred patients, whether they're using drugs or not, right, it doesn't matter. They're my favorite patients. And really, because it's just different, you know, when we think of like, oh, I don't want to I don't want to track these difficult patients to my practice. I don't have time for that. You're thinking of behaviors of someone with untreated substance use disorder, who doesn't feel safe around you who's trying to do whatever they need to do to help themselves. And so when you offer them the help, and you offer them a safe place, they're incredibly honest people they're incredibly grateful. You can't help everyone but the people that you do help you get to see them completely transform their lives. Honestly, in my opinion, because I'm a primary care originally I'm family practice trained and I, I did everything. I deliver babies in the emergency room. I did all that for like the first five years of my practice, and I can tell you that nothing has been more rewarding and satisfying than working with people who use drugs, for sure. So that would I say would be the one thing I would say is that this is a great population of patients to work with. You just need to make it a safe and welcoming place for them to come talk with you and to help. 

Amber Rogers  40:20

Oh, I don't think I can top that at all. 

Annette Hubbard  40:24

That's our most favorite thing about it. It just makes sense. So sorry for taking up all the time on that. Our 10 minute, like, hey, like this can happen. But like, you should help your people with addiction, you should do it. 

Amber Rogers  40:43

You have ambassadors out there. So I hope this message resonates with all kinds of future doctors and nurses and caseworkers and social workers and peer supporters out there to get out there and spread the message. So, thank you for sharing. Thank you for being role models. And thank you for being on our podcast. With that, go forth and do the good work that you're doing in your community.

Dr. Sarah Spencer  41:14

Thank you for inviting us, it's been great talking with you guys today.

Beth Brown  41:24

Thank you for listening. Be sure to subscribe to Breaking Barriers in Rural Health and learn more about Mountain Pacific at www.mpqhf.org