CAHNRS > Descriptive Transcripts > RURAL RESPONSES TO OPIOID USE from a non-profit perspective

RURAL RESPONSES TO OPIOID USE from a non-profit perspective

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>> I can't start video because the host has stopped it. >> I'm fixing that. One moment, please. >> Good morning or -- yeah, still good morning. And I have all these slides but -- >> All right, good afternoon and thank you for attending our monthly webinar series for the Rural Opioid Technical Assistance Collaborative. My name is Michelle Peavy and we are so excited to have Everett Maroon speak with us today. And let me just do a little introduction of Everett. So Everett Maroon, recent recipient of his master's degree in public health, is executive director of Blue Mountain Heart to Heart, a 501(c)(3) nonprofit based in Walla Walla, Washington. It's focused on HIV care and prevention and care and recovery for people with substance use disorders. He's engaged in regional and statewide efforts to increase pathways for recovery in rural areas and for stigmatized patient populations. Everett coauthored the Greater Columbia Accountable Community of Health's opioid demonstration project called the Opioid Resource Network and continues to be engaged in Medicaid transformation efforts in his region. He manages a regional site for naloxone distribution on a multi-year SAMHSA contract, is a co-manager of the first LEAD Diversion Program, LEAD meaning Law Enforcement Assisted Diversion. That's the first LEAD Diversion Program in Washington State, east of the Cascades, so the more rural area, of course, in our state, and manages the Medical and Opioid Medication Program at the Walla Walla County Jail. Blue Mountain Heart to Heart operates three fixed site syringe service programs and one mobile site, and two clinics offering low barrier buprenorphine prescribing across five locations in southeast Washington State. Everett is the 2021 NASW Washington Public Citizen of the Year and he also serves as co-chair for Washington State's LGBTQ Commission. So, so many qualities and experiences and knowledge that you bring, Everett, incredible that you're able to present for us today and I will turn it over to you. >> That's very kind of you. Thank you, Michelle. And I'm glad to see everyone can spend a little time with us today. I appreciate your time very much. Michelle and I talked a little bit before this. I'm going to have a hard time seeing questions as they come into the chat, but Michelle's going to keep an eye out. And so we'll do our best to answer questions during, but we're also going to have some time toward the end. So if there's a question you want to hang on to and then we can do a little Q&A at the end, that's fine too. So this is about rural responses to opioid use. We are going to talk a little bit about psychostimulant use and contingency management as an intervention for that, which I know is near and dear to Michelle's heart. But hopefully if there are any things left on the field that we need to get to by the end, you're going to ask me a question about it. So I'm going to try hard not to dwell on any one thing too long so we can do a real good overview. So that's me. That's the name of the agency and then this is a presentation to you. So here is, Michelle's going to talk for a couple of slides, a little bit about this technical assistance program. >> Right. So this comes to you via the Rural Opioid Technical Assistance Collaborative. It's a SAMHSA-funded effort for our region, Region 10, Washington, Idaho, Oregon, and Alaska. And we are funded by SAMHSA federal funds. And there's the disclaimer that the presentation is the responsibility of the authors and does not necessarily represent the official views of SAMHSA. >> Never represent the official views of SAMHSA, necessarily. OK. Very briefly, the history of Blue Mountain Heart to Heart is that it was founded in 1985 and then incorporated as a nonprofit, federal nonprofit in 1991. We began with 16 people who lived in Walla Walla who wanted to support folks who were dying of AIDS at the height of the crisis. And so this is really like glimpse number one of the counter-narrative to mainstream representations of what rural America is like. But it's not this backwards, you know, place where nobody supports anybody else and we're all beholden to some sort of ideology of not caring for each other. This is the height of the HIV crisis and these are people coming together to support loved ones. In fact, we saw a lot of people come down from the Tri-Cities back in the mid-80s and early 90s because people were afraid to talk to their family doctor about what was happening to their loved one. And so they knew they could come to Walla Walla about an hour away and get support here. So as part of our response to the HIV crisis and epidemic, we took on Syringe Exchange back in 1998 as an HIV prevention intervention. And I ran across the original intervention design description when we were like moving from one office to another some years ago. I think it had an estimate of exchanging like 3,500 syringes that year. Before COVID hit we had 577,000 syringes exchanged between our three SSPs. And this year, I think we're down to about 420,000, yeah, 422,000. It's definitely dropped off due to COVID. That's a switch to fentanyl where people aren't injecting or smoking. But we've been engaged in harm reduction for a very long time. And how harm reduction looks to us has evolved over time. So a running theme in my talk today is going to be when you are careful in analyzing gaps and needs, you wind up, you know, having really good ideas and conversations about programs to respond to those gaps and needs. And you can do that in an urban area but you can certainly also do it in a rural area. So in 2013, we held a board retreat. We were looking at this increase in substance use and people who were our clients coming into or participants coming into our SSPs, our syringe service program sites. And we couldn't really do anything for them. If they had HIV, we could give them all kinds of support. But if they didn't have HIV, maybe they had chronic hepatitis C. Oops, sorry, there's nothing we can do for you other than these limited services. So we wanted to turn that around. Again, we were seeing gaps in service and to us that was something that we could take on as an organization. So when I look at funding priorities for harm reduction programs, what I see kind of demonstrated in this logic model is we've got a pretty sturdy treatment silo or structure, infrastructure set up. It's about treatment and recovery. And then we've got a lot of prevention programs, a lot of them geared to youth, some of them geared to families, some of them geared to adults, some of them geared to veterans, you know, other kinds of identity communities or occupational communities where we know there's a higher risk of substance use in that occupation. But they're trying to prevent the thing from happening. But if you're in the middle, if you're kind of under that waterline and you're in use or you're in misuse or you're in use disorder, there's not a lot of program emphasis. But what's happening, it's not just like people are lost there, they are in a process of contemplation. If we think about the trans-theoretical model and moving them from pre-contemplation to contemplation to action, Blue Mountain Heart to Heart decided it wanted to be operating in that space. Again, it was a gap in service with a need that wasn't being met. So we have tried to look at, you know, what can we do to either support people through that trans-theoretical model? What can we do to help limit harm to them using principles of harm reduction and, you know, trauma-informed care, culturally competent communications and, you know, other kinds of social service or social work empowerment model interventions and supports that we can give to people? And then see, can we move them, you know, to a more stable place whether it involves recovery or not. Because there certainly are public health goals that we're invested in as an agency and as a staff and board that may or may not involve recovery. Even helping people, you know, move to a different modality of substance use may decrease, you know, incidence of some of the sequelae associated with injecting drugs, you know, if we're moving and they're smoking, if they're smoking 10 times a day and we move them to five times a day, what are we doing to increase stability and wellness for them? And as you all know, in public health, if we're decreasing incidence of disease to a component of the community, we're lowering the viral load for the whole community through that. So, those are some of our goals. But when we look at funding priorities, you know, what we were initially seeing was kind of, you know, funding on these polls and not really people who were kind of in the middle. So, we had an affirmative approach to try to change that and bring more money into that, more investment into that space. Our organization is set up to reflect this multi-layered and what you're going to see later, like a no-wrong-door service delivery to people. So again, this is a rural inclusive approach to how our staff are organized because as you'll see, they're organized around contracts. We may or, you know, I call them programs because one program may have one or more contracts supporting it. And to make, you know, rural organizations need to make sure that they're sustainable financially. And so, having many legs to your stool holding you up means that one thing can go away or be delayed, you know, or time out, but you have other supports under there so that you can keep the work going. So that is a big, you know, part of my strategy for being able to do work in the long term because what our stigmatized patient populations that we serve in HIV and in substance use disorder, what they really need are stable providers, right? It's really, it's so difficult when I hear from a client, "Well, I bared my soul to this counselor, you know, and I thought we're getting along great. But by the third appointment, she was gone and I had a new person and he wanted to know my whole life story again. And I just can't keep going through that. So I'm not going back." You know, once we lose trust with a client, it's really, really difficult to reclaim it. So, our goal is to have stability of the staff and stability of the programs so that as people are on a trajectory of increasing stabilization and wellness that, you know, they always have a staff to, that they know they can count on. So, one of the things that we do here is we set this organization up so that if someone's in jail with us and they start Suboxone and they're working with Amanda, the nurse, and Nadine, the physician assistant, and then they come out of jail, they can now be in our low barrier buprenorphine program. We're not saying, "Oh, well, too bad, you got to find another doctor." Or if they are, if they did walk in through our SSP to get onto Suboxone with us, you know, at one of our SSP sites and then they're arrested in a jail, it's still our medical staff that support them and continue that prescription while they're in Walla Walla County Jail. They can also be in LEAD and in another program. They can be in the Ryan White program for people with HIV and be in our low barrier MOUD program. If they're in our low barrier program and they say, "I also want to stop using meth," it is, you know, two doors away in the office to meet with our MSW who will get them onto the contingency management program. So I'll show you in a little bit, you know, kind of how that looks. But this is the program and staffing level and how we, you know, how we have kind of organized around what those potential individual needs are. How are we doing on questions? OK. >> We're good. We're all just in awe at what you've set up. So, thank you. >> OK, lovely. So if I look at -- so one of the things that I see happening, not just in rural areas but certainly in rural areas, stigma comes in to make people afraid to ask for help, even when they're dealing with the negative consequences of their opioid or stimulant use. And so many of our programs start off by being not just confidential but also anonymous. We don't need to know your name in order to give you a safer smoking kit. We don't need to know your name to give you a hygiene kit or Plan B or anything like that. We don't even really need to know who you are to do basic wound care with you, although we do start to get to -- as you can see, like it becomes kind of a higher engagement in care. Then I got this little gold line here for, you know, there's some things that we provide to you where we really now need to know information about you. So if we're going to provide a vaccine to you, we've got to report back to the state that we did it for that particular individual with that particular lot number and all of that. But what we've been working on is a trust relationship with people, right? So, they're moving on a path with us. All care is temporal, right? So all care happens over a span of time. And when you're building trust with people then, you know, you can earn their confidence that you're not going to, you know, traumatize them because they've shared something that made them vulnerable, like their name or where they live or whose family they're from. And that can be a really big barrier in rural areas where people are routinely subjected to healthcare providers who know a lot about their family history and their own individual history. They may have a partner that had them as a student in kindergarten. You know, I mean, that thing happens here all the time. There's no real anonymity in some of these areas. Now, so when we get into contingency management and prescribing medications for them then we're in a full-fledged, you know, case management and medical management, you know, enrolled status with people. I see a question. I know federal funding can be difficult for harm reduction that goes beyond syringes. How do you find your safer smoking kits? Well, we have a great partnership with the State Department of Health and we have also found ways with some public-private partnerships like NASTAD, the National Alliance of States and Territorial AIDS Directors. I always have to look up in the top left corner to remember that name. You know, AIDS United, some other, you know, foundations will support the costs of things like glassware and foils that we would give out in safer smoking kits. We certainly don't ever use federal funds against a restriction in those funds. And so, you know, I think safer smoking kits are particularly hard to fund because politically they're controversial. People yell crack pipe at folks and, you know, the Biden administration ran away from that when they came out with funding that did allow that a year and a half or so ago. But I think -- you know, and they're costly, like it's more expensive to get a glass pipe than it is to get a pack of syringes. But I think there is some loosening up of funding for some of those things because I can show that we had a huge rebound in transactions at our SSP sites when we started distributing safer smoking kits in the summer of '22. We were very low on our transaction levels and our, as I said earlier, our syringe volume has really fallen off since fentanyl took over, you know, the underground drug market during COVID. If you're not motivating people to come in to your program, you can't deliver any service to them. So if you want to see engagement, you've got to provide things that they need. And, you know, anybody could come in who needs a sleeping bag or a tent. They may not actually need your other services. But if you're doing something that you know your target population needs really badly then you could help encourage the engagement. So, you know, I'm happy to talk about exactly where the funding comes from but I think DOH is moving more toward supporting some of those purchases of those supplies. This is that no-wrong-door approach. So we've got a client and what we try to do as staff is identify what their needs are. They're very good at telling us, you know, some of what their needs are. And sometimes by probing and having, you know, a trauma-informed and helpful discussion, you can identify other things that they need too. So when we look at our -- you know, the blue, the bright blue pieces are really the programs and the strategies and then the light blue are all of those activities and services and resources we can bring to bear. So no matter what it is somebody needs, you know, we can come with, you know, a variety of things that wind up feeling kind of customized to the individual. Help us stay an agile organization at the same time and, you know, help us really get to that relationship building with them so that they say, "OK, well, I'm not ready for, you know, contingency management today but I'd really love support with housing and getting re-housed. I'd really love to talk to your care coordinator to deal with some of these medical bills that I have. For the last time, I tried recovery and now I owe, you know, thousands of dollars to some for-profit provider," or something like that. So, you know, in us doing any kind of work on behalf of that client and helping show them that like they deserve to have a better and more stable life, and they're capable of doing these things, by using a shared decision-making process with them and using direct, supportive, empowering communication with them, you know, they wind up identifying a whole host of things that they really want to work on with us. So that no-wrong-door approach has really helped us get to some pretty good outcomes for some of our clients. OK. In general, when I think of models of care that are available in rural areas for stigmatized populations, it doesn't look very different than what list I might put together in an urban center, right? We still have, you know, a whole host of different kinds of care that we can bring in. Where it starts to look different is, for rural communities, is in who's doing what. It's not as common out here. Even if you're thinking about like an FQHC that does a lot of things under one roof, they might not have a board that says, "Yeah, we're going to go for it and have a harm reduction, you know, SSP." And, you know, maybe they'll do naloxone distribution but they don't want to do syringes or safer smoking kits. But you do have somebody that can do that. Maybe you've got someone else that is doing peer-based recovery and they've got a couple of groups going and maybe have a smart recovery group and maybe there's, you know, a housing program, supported housing or something that has a good counselor available. What it looks like in rural areas is you're putting pieces together from multiple organizations. So people coming in and, you know, aligning around a goal is something that I see happening in rural areas that really is to the benefit of the whole community because we're helping people who are otherwise delaying care, avoiding care, and then things are getting worse for them as they do that. And again, I think prevention models are pretty robust in many places but they're not necessarily linked in to people who are already facing, you know, overusing their medications or who have begun to turn to street drugs or illicit manufacturers for things. And there are other programs where like maybe someone is doing behavioral therapy, but if they think that you have started using again and it's like the third or fourth time, you know, they cut you off. So, trying to get people into alignment around supporting this diversity of folks who need help is something that I think rural communities are good at doing in large part because yes, we do know the people who are affected by these conditions. And again, I think it's something that goes against kind of the mainstream media of, you know, you bringing in homeless people from Seattle to, you know, clog the streets of Kennewick. No, that's not actually happening. These are people who've grown up in Kennewick who now have lost their housing because of their fentanyl use. So, you know, in trying to, you know, in trying to look at like who needs support, being able to say, these are our kids and our partners and our co-workers has helped bring a lot of people who are doing like one particular thing into a room with people who were doing other things so that we can all start to talk to each other and combine our efforts. That's my take on, you know, when we're thinking about models. There's not a model of care that's excluded from rural areas but it's hard to find one place that's doing multiple things. So it becomes about having a commitment to having joint conversations with other providers. And so, everybody might have to extend or bridge or flex a little bit in order to try and support more people. A community drug court is a good place for some of these things happen or community court rather. LEAD is one of those programs that does it because it is a community organized, you know, intervention that brings in people from different sectors and occupations to, you know, support the recruitment of individuals into the program so that they can be case managed. >> Everett, I'm wondering if I could possibly speak for some in the audience who want to be having conversations with partners throughout their communities and for many reasons have a hard time doing so. Thoughts about those engaging conversations? >> Yeah. We have a couple of times now put together a, you know, basically a summit. We talk with public health. Do you want to run this? You know, do you want to take ownership of this and will attend? Or do you want Heart to Heart to, you know, kind of spearhead this? Or, you know, we certainly have people in the BHASO who are doing very particular kinds of activities. They're usually good to have at the table. Crisis responders, if you've got like a community paramedic program, we have one of those in Walla Walla or if you have -- for a while, West Richland had a Leave Behind Naloxone program that their EMS firefighters were doing. So when they are concerned someone else is going to overdose at a particular location, they'll leave Narcan there with people so that they have it on hand. You know, you can kind of look around your community and see, you know, who's doing interesting stuff? Can we get them in a room together? So there's, you know, Southeast Washington Health Alliance that Jac, who's probably listening right now. What is her last name? It'll come to me in a minute. But they have monthly meetings and they talk about, you know, behavioral health among community health topics as well. So I think, you know, kind of feeling out people who you know are in, you know, organizations that are doing good work and asking them, could we sit down? Could we, you know, hash out maybe like, you know, agenda for what we want to try and accomplish this year or this quarter? I think that's -- you know who your friends and champions are and if you've got an LD representative, you know, in the Senate, State Senate or House side that you know has a particular interest in some of these topics, invite their LA or them to come and join. But I've seen all kinds of people, you know, agree to -- yes, Martha, Jac Davies and Martha, exactly. Thank you so much. I got about five hours of sleep last night, so the brain is not quite lubed up. You know, I've seen a lot of people willing to come together and sometimes it means saying like, "I know you disagree with my organization's work in X, but I think we might have some overlap over this thing. Can we sit and talk about that?" It's a little bit like when I was running for State House in 2018 and I knocked on this guy's door and he was like, "You know, well, I only care about if you're going to take my guns or not." And I said, "Well, sir, you're going to be happy to know that the state constitution of Washington gives you an individual right to own a firearm. And I'm really here to talk about universal healthcare. Can we talk about that?" And he was like, "Yeah." And at the end of the conversation, he said, "You got my vote." So it's really about like finding where that overlap is with people and if they're engaged in law enforcement, or they're engaged in the courts, or they're engaged in social services, I think we're all really looking at the same kinds of folks because the crisis has really spread to all of these places where people are showing up. Hospitals are overloaded. I'm extremely concerned about healthcare in rural areas right now. You know, it's one thing to say Rite Aid is, you know, going bankrupt but it's another to like lose one of five pharmacies in your town, right, or one of three pharmacies in your town. So, you know, I think a lot of people are willing to talk these days who were maybe not ready to sit down at the table three or five years ago. So do reach out and talk to folks and say, "Let's just have, you know, let's just get coffee and see is there anything we think is synergistic here." OK. I'm not going to go into all of our current programs but I wanted them in the slide deck because if you want the slides after this, I'm happy to have Cassandra or Michelle or whomever share them out. But just so you know, these are the kinds of things that we're doing. And each one of these programs has a, you know, contract type, a contract associated with it. A lot of our work is cost reimbursable but some of it is milestones based. Very little of it is like a flat fee where we just get a payment every quarter, but we get a little bit of NASTAD funding like that. So we're doing work around HIV case management, testing and STI prevention, and increasingly treatment. These are all the things we do at the syringe programs. It's a lot. as you can see. It has grown organically over the years as, again as we were identifying gaps and needs and like can we fill in that need? I have a whole rubric for, if it makes sense for my agency to do it or for me to lobby another agency to do it, or to go back to my legislators or state partners and say, "Gosh, you know, I don't suppose you could come up with any funding for this particular activity." So this is really a list of things that -- you know, what we tried to do initially, I think I have a picture in here somewhere of one of our SSP shelves, but it's basically make more like a bodega or grocery store. You know, you're really standing in a medical closet. We wanted it to not feel like the doctor's office. We wanted it to feel like how you would pick out potato chips. You know, I like this kind and not that kind, right? Just to kind of give people a new, like a reset on their expectations or what they're going to get from us to help, you know, again, support that trust relationship with them. So when they're coming in -- you know, when overdoses started really skyrocketing, we started offering naloxone. When people started getting really scared about reproductive rights and access to care, you know, Plan B came along. When there was funding for nicotine cessation kits, there were some requirements from federal providers to offer nicotine cessation as part of some other interventions then those kits came along and you get a lozenge or a gum or a patch or whatever you want. So we have started doing things that, you know, whatever is going to be a motivator for people then is something that's in our list as a service that we can give out to people. Low barrier buprenorphine, this started in 2019. It's been, as far as I'm concerned, wildly successful. Did we get the best outcome for every single person? No, but we know that people who are successful on Suboxone, you know, a lot of them started by using it in, you know, just from the street and, you know, a friend gave them a dose or two or five or whatever. We certainly have seen a lot of people who felt like they could not go elsewhere or their doctor was not amenable to it or nervous about prescribing it, even though now the X-waiver has been dropped. We were happy to sign on to that lobbying effort with Congress. You know, I think having it available, even if people aren't going to be successful this time, I've certainly seen people come back in the years since we started in 2019 and then be successful the second time or the third time and be really well controlled with cravings for years. So we're really, really happy to always -- you know, I've got a lot of folks that come in and they're managing their jobs and they bring their kids in, and they just have their consult and then they leave, you know. And I can never tell who's going to do well and not do well. There's just no pattern I can find. I really wish there was some secret sauce in there, but I think we just have as many opportunities for people to get on top of their lives as we can. And if something sticks then we just start running with that. So it does require quite, you know, financial commitment to run this program because the clinical staff are expensive and, you know, a lot of people in their hearts would rather be, you know, working with us than working in a clinic but they really like the pay of the clinic. And so we are competing with a very small, in rural areas especially, a very small workforce. And if you're going to have somebody, it means they're not working somewhere else in your area. So, you know, I think the hardest part of this program is you've got to find those people who are champions for the program. You've got to pay them as much as you possibly can so that you can make it make sense to them. Because think about their, they have a lot of loans from all those years. And it's cool but we've got some people who are really like true believers in what they're doing and I'm extremely grateful to them. I see a couple of questions. What proportion of your client base identifies as LGBTQ? Am I plugged into -- yeah. I feel like I'm plugged into community partners who provide support. Madeline, it's a really hard question to answer. I'm sure I have a lot of people who are LGBTQ plus identified. They don't always tell us. Sometimes they do. I think people know in general that, you know, I'm really supportive of that community. I'm part of that community. But there certainly is a lot of stigma in some of our places. We have a, you know, we have a public health district that hasn't been allowed the last three years to post anything during Pride Month on their website because a commissioner for their county won't allow it. So, you know, that's the kind of -- is that actionable? You know, possibly. But I think, you know, we know where some other providers are but there's no like Pride, but there's no community, I don't know, a community center out here in Southeast Washington. There are some organizations that like will run a Pride event or something like that. But it is kind of a lower, down low thing which for someone who spent 11 years in Washington, DC, it's really hard for me to see. But yeah, we support people as we can and we support everyone that comes out. OK. We've got a couple different diversion programs. That was our Law Enforcement Assisted Recovery or I think Let Everyone Advance with Dignity is the new moniker for LEAD. Those folks often have behavioral health, you know, challenges, including substance use and so they're perfectly eligible to use the other programs at our disposal as well as being in LEAD. And as I said, we have a jail program. So, we've been doing a long-acting Sublocade started here in Walla Walla County before any other county jail in Washington State. And I think the funding for that is over right now but we still are using Sublocade in our low barrier program outside the jail. It's working very well for some people who really just want to kind of like forget about dosing themselves throughout the month. And I'm glad that we have it as an option for people. We have a Drug User Health Equity Program that's mostly NASTAD funded, although DOH did have a contract called Strategy 3. They were both engagements around vaccinating people for COVID-19 who were using substances and I had to write a whole report for NASTAD about it. So if anybody wants to read that, how did we get 60% of people we approached to take COVID vaccine? It was really interesting. I could talk about that project for a whole hour just on its own. But what we found, like the takeaways for a discussion about rural health is being really consistent with where your mobile clinic is going and why it's servicing people is, you know, step number one. Doing as many things for as many people as possible is also really important because if people thought that the only thing our mobile clinic was there for was, you know, drug-use related, they didn't want to come near us because they didn't want everyone else in town to see them utilizing us. So we made ourselves available in Pomeroy, like to the farmer who stepped on a rusty nail, OK, we'll give you a tetanus shot. You know, now everyone knows, well, they'll do tetanus and singles and RSV for older people. Are they our target population? No. But are we going to serve the people in front of us? Yes, right. And in doing that then we can also serve the folks that are in our, you know, our target population. OK, let's see. Is your program involved in any health promotion or chronic disease prevention work with public health? Well, we certainly were part of the AVP, adult vaccine program with our public health partners. We also have been doing chronic hepatitis C treatment, testing and treatment, and I think we have like 10 people cured at this point of hepatitis C who were using substances and not, you know, going to talking to folks, you know, in their, in primary care land. We've also had a bridge program before with the ED in Walla Walla. So, if someone came in over the weekend and they wanted to prescribe Suboxone to them, they could do that. And then first thing Monday, they come back to us so they prescribe a couple days for them, and then we would finish the induction. I think there's all kinds of opportunities out there, as I said, to like, you know, see where you can work with another collaborator. If you don't have a -- you know, I think at one point we were talking to Shane McGuire at Dayton Community Hospital. He had really great providers to be able to do Suboxone but he didn't have, this is before COVID, he didn't have case managers. And I was like, "Well, I could send a case manager out here. You need a case manager for the people on Suboxone? Oh, sure. Let's make it happen. I've got funding for this. You can do your piece. I'll do my piece." I think rural areas are great for that kind of collaboration. I don't have any trouble really getting into jails in Walla Walla. We are the medical mental health provider in Walla Walla. I'm happy to spend time talking with you, Rebecca, about, you know, the work at the jail. We did certainly have to spend some time talking with, you know, the corrections officers and the jail commander.	Description not needed: The visuals in this video only support what is spoken; the visuals do not provide additional information.

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>> I'm fixing that. One moment, please.

>> Good morning or -- yeah, still good morning. And I have all these slides but -- >> All right, good afternoon and thank you for attending our monthly webinar series for the Rural Opioid Technical Assistance Collaborative. My name is Michelle Peavy and we are so excited to have Everett Maroon speak with us today. And let me just do a little introduction of Everett. So Everett Maroon, recent recipient of his master's degree in public health, is executive director of Blue Mountain Heart to Heart, a 501(c)(3) nonprofit based in Walla Walla, Washington. It's focused on HIV care and prevention and care and recovery for people with substance use disorders. He's engaged in regional and statewide efforts to increase pathways for recovery in rural areas and for stigmatized patient populations.

Everett coauthored the Greater Columbia Accountable Community of Health's opioid demonstration project called the Opioid Resource Network and continues to be engaged in Medicaid transformation efforts in his region. He manages a regional site for naloxone distribution on a multi-year SAMHSA contract, is a co-manager of the first LEAD Diversion Program, LEAD meaning Law Enforcement Assisted Diversion. That's the first LEAD Diversion Program in Washington State, east of the Cascades, so the more rural area, of course, in our state, and manages the Medical and Opioid Medication Program at the Walla Walla County Jail. Blue Mountain Heart to Heart operates three fixed site syringe service programs and one mobile site, and two clinics offering low barrier buprenorphine prescribing across five locations in southeast Washington State. Everett is the 2021 NASW Washington Public Citizen of the Year and he also serves as co-chair for Washington State's LGBTQ Commission. So, so many qualities and experiences and knowledge that you bring, Everett, incredible that you're able to present for us today and I will turn it over to you.

>> That's very kind of you. Thank you, Michelle. And I'm glad to see everyone can spend a little time with us today. I appreciate your time very much. Michelle and I talked a little bit before this. I'm going to have a hard time seeing questions as they come into the chat, but Michelle's going to keep an eye out. And so we'll do our best to answer questions during, but we're also going to have some time toward the end.

So if there's a question you want to hang on to and then we can do a little Q&A at the end, that's fine too. So this is about rural responses to opioid use. We are going to talk a little bit about psychostimulant use and contingency management as an intervention for that, which I know is near and dear to Michelle's heart. But hopefully if there are any things left on the field that we need to get to by the end, you're going to ask me a question about it. So I'm going to try hard not to dwell on any one thing too long so we can do a real good overview. So that's me. That's the name of the agency and then this is a presentation to you.

So here is, Michelle's going to talk for a couple of slides, a little bit about this technical assistance program.

>> Right. So this comes to you via the Rural Opioid Technical Assistance Collaborative. It's a SAMHSA-funded effort for our region, Region 10, Washington, Idaho, Oregon, and Alaska. And we are funded by SAMHSA federal funds. And there's the disclaimer that the presentation is the responsibility of the authors and does not necessarily represent the official views of SAMHSA.

>> Never represent the official views of SAMHSA, necessarily. OK. Very briefly, the history of Blue Mountain Heart to Heart is that it was founded in 1985 and then incorporated as a nonprofit, federal nonprofit in 1991. We began with 16 people who lived in Walla Walla who wanted to support folks who were dying of AIDS at the height of the crisis. And so this is really like glimpse number one of the counter-narrative to mainstream representations of what rural America is like. But it's not this backwards, you know, place where nobody supports anybody else and we're all beholden to some sort of ideology of not caring for each other. This is the height of the HIV crisis and these are people coming together to support loved ones.

In fact, we saw a lot of people come down from the Tri-Cities back in the mid-80s and early 90s because people were afraid to talk to their family doctor about what was happening to their loved one. And so they knew they could come to Walla Walla about an hour away and get support here. So as part of our response to the HIV crisis and epidemic, we took on Syringe Exchange back in 1998 as an HIV prevention intervention. And I ran across the original intervention design description when we were like moving from one office to another some years ago. I think it had an estimate of exchanging like 3,500 syringes that year. Before COVID hit we had 577,000 syringes exchanged between our three SSPs. And this year, I think we're down to about 420,000, yeah, 422,000.

It's definitely dropped off due to COVID. That's a switch to fentanyl where people aren't injecting or smoking. But we've been engaged in harm reduction for a very long time. And how harm reduction looks to us has evolved over time. So a running theme in my talk today is going to be when you are careful in analyzing gaps and needs, you wind up, you know, having really good ideas and conversations about programs to respond to those gaps and needs. And you can do that in an urban area but you can certainly also do it in a rural area. So in 2013, we held a board retreat.

We were looking at this increase in substance use and people who were our clients coming into or participants coming into our SSPs, our syringe service program sites. And we couldn't really do anything for them. If they had HIV, we could give them all kinds of support. But if they didn't have HIV, maybe they had chronic hepatitis C. Oops, sorry, there's nothing we can do for you other than these limited services. So we wanted to turn that around. Again, we were seeing gaps in service and to us that was something that we could take on as an organization.

So when I look at funding priorities for harm reduction programs, what I see kind of demonstrated in this logic model is we've got a pretty sturdy treatment silo or structure, infrastructure set up. It's about treatment and recovery. And then we've got a lot of prevention programs, a lot of them geared to youth, some of them geared to families, some of them geared to adults, some of them geared to veterans, you know, other kinds of identity communities or occupational communities where we know there's a higher risk of substance use in that occupation. But they're trying to prevent the thing from happening. But if you're in the middle, if you're kind of under that waterline and you're in use or you're in misuse or you're in use disorder, there's not a lot of program emphasis. But what's happening, it's not just like people are lost there, they are in a process of contemplation. If we think about the trans-theoretical model and moving them from pre-contemplation to contemplation to action, Blue Mountain Heart to Heart decided it wanted to be operating in that space.

Again, it was a gap in service with a need that wasn't being met. So we have tried to look at, you know, what can we do to either support people through that trans-theoretical model? What can we do to help limit harm to them using principles of harm reduction and, you know, trauma-informed care, culturally competent communications and, you know, other kinds of social service or social work empowerment model interventions and supports that we can give to people? And then see, can we move them, you know, to a more stable place whether it involves recovery or not. Because there certainly are public health goals that we're invested in as an agency and as a staff and board that may or may not involve recovery. Even helping people, you know, move to a different modality of substance use may decrease, you know, incidence of some of the sequelae associated with injecting drugs, you know, if we're moving and they're smoking, if they're smoking 10 times a day and we move them to five times a day, what are we doing to increase stability and wellness for them? And as you all know, in public health, if we're decreasing incidence of disease to a component of the community, we're lowering the viral load for the whole community through that.

So, those are some of our goals. But when we look at funding priorities, you know, what we were initially seeing was kind of, you know, funding on these polls and not really people who were kind of in the middle. So, we had an affirmative approach to try to change that and bring more money into that, more investment into that space. Our organization is set up to reflect this multi-layered and what you're going to see later, like a no-wrong-door service delivery to people. So again, this is a rural inclusive approach to how our staff are organized because as you'll see, they're organized around contracts. We may or, you know, I call them programs because one program may have one or more contracts supporting it. And to make, you know, rural organizations need to make sure that they're sustainable financially.

And so, having many legs to your stool holding you up means that one thing can go away or be delayed, you know, or time out, but you have other supports under there so that you can keep the work going. So that is a big, you know, part of my strategy for being able to do work in the long term because what our stigmatized patient populations that we serve in HIV and in substance use disorder, what they really need are stable providers, right? It's really, it's so difficult when I hear from a client, "Well, I bared my soul to this counselor, you know, and I thought we're getting along great. But by the third appointment, she was gone and I had a new person and he wanted to know my whole life story again. And I just can't keep going through that. So I'm not going back." You know, once we lose trust with a client, it's really, really difficult to reclaim it. So, our goal is to have stability of the staff and stability of the programs so that as people are on a trajectory of increasing stabilization and wellness that, you know, they always have a staff to, that they know they can count on.

So, one of the things that we do here is we set this organization up so that if someone's in jail with us and they start Suboxone and they're working with Amanda, the nurse, and Nadine, the physician assistant, and then they come out of jail, they can now be in our low barrier buprenorphine program. We're not saying, "Oh, well, too bad, you got to find another doctor." Or if they are, if they did walk in through our SSP to get onto Suboxone with us, you know, at one of our SSP sites and then they're arrested in a jail, it's still our medical staff that support them and continue that prescription while they're in Walla Walla County Jail. They can also be in LEAD and in another program. They can be in the Ryan White program for people with HIV and be in our low barrier MOUD program. If they're in our low barrier program and they say, "I also want to stop using meth," it is, you know, two doors away in the office to meet with our MSW who will get them onto the contingency management program. So I'll show you in a little bit, you know, kind of how that looks. But this is the program and staffing level and how we, you know, how we have kind of organized around what those potential individual needs are.

How are we doing on questions? OK.

>> We're good. We're all just in awe at what you've set up. So, thank you.

>> OK, lovely. So if I look at -- so one of the things that I see happening, not just in rural areas but certainly in rural areas, stigma comes in to make people afraid to ask for help, even when they're dealing with the negative consequences of their opioid or stimulant use. And so many of our programs start off by being not just confidential but also anonymous. We don't need to know your name in order to give you a safer smoking kit. We don't need to know your name to give you a hygiene kit or Plan B or anything like that. We don't even really need to know who you are to do basic wound care with you, although we do start to get to -- as you can see, like it becomes kind of a higher engagement in care. Then I got this little gold line here for, you know, there's some things that we provide to you where we really now need to know information about you.

So if we're going to provide a vaccine to you, we've got to report back to the state that we did it for that particular individual with that particular lot number and all of that. But what we've been working on is a trust relationship with people, right? So, they're moving on a path with us. All care is temporal, right? So all care happens over a span of time. And when you're building trust with people then, you know, you can earn their confidence that you're not going to, you know, traumatize them because they've shared something that made them vulnerable, like their name or where they live or whose family they're from. And that can be a really big barrier in rural areas where people are routinely subjected to healthcare providers who know a lot about their family history and their own individual history.

They may have a partner that had them as a student in kindergarten. You know, I mean, that thing happens here all the time. There's no real anonymity in some of these areas. Now, so when we get into contingency management and prescribing medications for them then we're in a full-fledged, you know, case management and medical management, you know, enrolled status with people. I see a question. I know federal funding can be difficult for harm reduction that goes beyond syringes. How do you find your safer smoking kits?

Well, we have a great partnership with the State Department of Health and we have also found ways with some public-private partnerships like NASTAD, the National Alliance of States and Territorial AIDS Directors. I always have to look up in the top left corner to remember that name. You know, AIDS United, some other, you know, foundations will support the costs of things like glassware and foils that we would give out in safer smoking kits. We certainly don't ever use federal funds against a restriction in those funds. And so, you know, I think safer smoking kits are particularly hard to fund because politically they're controversial. People yell crack pipe at folks and, you know, the Biden administration ran away from that when they came out with funding that did allow that a year and a half or so ago. But I think -- you know, and they're costly, like it's more expensive to get a glass pipe than it is to get a pack of syringes.

But I think there is some loosening up of funding for some of those things because I can show that we had a huge rebound in transactions at our SSP sites when we started distributing safer smoking kits in the summer of '22. We were very low on our transaction levels and our, as I said earlier, our syringe volume has really fallen off since fentanyl took over, you know, the underground drug market during COVID. If you're not motivating people to come in to your program, you can't deliver any service to them. So if you want to see engagement, you've got to provide things that they need. And, you know, anybody could come in who needs a sleeping bag or a tent. They may not actually need your other services. But if you're doing something that you know your target population needs really badly then you could help encourage the engagement.

So, you know, I'm happy to talk about exactly where the funding comes from but I think DOH is moving more toward supporting some of those purchases of those supplies. This is that no-wrong-door approach. So we've got a client and what we try to do as staff is identify what their needs are. They're very good at telling us, you know, some of what their needs are. And sometimes by probing and having, you know, a trauma-informed and helpful discussion, you can identify other things that they need too. So when we look at our -- you know, the blue, the bright blue pieces are really the programs and the strategies and then the light blue are all of those activities and services and resources we can bring to bear. So no matter what it is somebody needs, you know, we can come with, you know, a variety of things that wind up feeling kind of customized to the individual.

Help us stay an agile organization at the same time and, you know, help us really get to that relationship building with them so that they say, "OK, well, I'm not ready for, you know, contingency management today but I'd really love support with housing and getting re-housed. I'd really love to talk to your care coordinator to deal with some of these medical bills that I have. For the last time, I tried recovery and now I owe, you know, thousands of dollars to some for-profit provider," or something like that. So, you know, in us doing any kind of work on behalf of that client and helping show them that like they deserve to have a better and more stable life, and they're capable of doing these things, by using a shared decision-making process with them and using direct, supportive, empowering communication with them, you know, they wind up identifying a whole host of things that they really want to work on with us. So that no-wrong-door approach has really helped us get to some pretty good outcomes for some of our clients. OK. In general, when I think of models of care that are available in rural areas for stigmatized populations, it doesn't look very different than what list I might put together in an urban center, right?

We still have, you know, a whole host of different kinds of care that we can bring in. Where it starts to look different is, for rural communities, is in who's doing what. It's not as common out here. Even if you're thinking about like an FQHC that does a lot of things under one roof, they might not have a board that says, "Yeah, we're going to go for it and have a harm reduction, you know, SSP." And, you know, maybe they'll do naloxone distribution but they don't want to do syringes or safer smoking kits. But you do have somebody that can do that. Maybe you've got someone else that is doing peer-based recovery and they've got a couple of groups going and maybe have a smart recovery group and maybe there's, you know, a housing program, supported housing or something that has a good counselor available. What it looks like in rural areas is you're putting pieces together from multiple organizations.

So people coming in and, you know, aligning around a goal is something that I see happening in rural areas that really is to the benefit of the whole community because we're helping people who are otherwise delaying care, avoiding care, and then things are getting worse for them as they do that. And again, I think prevention models are pretty robust in many places but they're not necessarily linked in to people who are already facing, you know, overusing their medications or who have begun to turn to street drugs or illicit manufacturers for things. And there are other programs where like maybe someone is doing behavioral therapy, but if they think that you have started using again and it's like the third or fourth time, you know, they cut you off. So, trying to get people into alignment around supporting this diversity of folks who need help is something that I think rural communities are good at doing in large part because yes, we do know the people who are affected by these conditions. And again, I think it's something that goes against kind of the mainstream media of, you know, you bringing in homeless people from Seattle to, you know, clog the streets of Kennewick. No, that's not actually happening. These are people who've grown up in Kennewick who now have lost their housing because of their fentanyl use.

So, you know, in trying to, you know, in trying to look at like who needs support, being able to say, these are our kids and our partners and our co-workers has helped bring a lot of people who are doing like one particular thing into a room with people who were doing other things so that we can all start to talk to each other and combine our efforts. That's my take on, you know, when we're thinking about models. There's not a model of care that's excluded from rural areas but it's hard to find one place that's doing multiple things. So it becomes about having a commitment to having joint conversations with other providers. And so, everybody might have to extend or bridge or flex a little bit in order to try and support more people. A community drug court is a good place for some of these things happen or community court rather. LEAD is one of those programs that does it because it is a community organized, you know, intervention that brings in people from different sectors and occupations to, you know, support the recruitment of individuals into the program so that they can be case managed.

>> Everett, I'm wondering if I could possibly speak for some in the audience who want to be having conversations with partners throughout their communities and for many reasons have a hard time doing so. Thoughts about those engaging conversations?

>> Yeah. We have a couple of times now put together a, you know, basically a summit. We talk with public health. Do you want to run this? You know, do you want to take ownership of this and will attend? Or do you want Heart to Heart to, you know, kind of spearhead this? Or, you know, we certainly have people in the BHASO who are doing very particular kinds of activities.

They're usually good to have at the table. Crisis responders, if you've got like a community paramedic program, we have one of those in Walla Walla or if you have -- for a while, West Richland had a Leave Behind Naloxone program that their EMS firefighters were doing. So when they are concerned someone else is going to overdose at a particular location, they'll leave Narcan there with people so that they have it on hand. You know, you can kind of look around your community and see, you know, who's doing interesting stuff? Can we get them in a room together? So there's, you know, Southeast Washington Health Alliance that Jac, who's probably listening right now. What is her last name?

It'll come to me in a minute. But they have monthly meetings and they talk about, you know, behavioral health among community health topics as well. So I think, you know, kind of feeling out people who you know are in, you know, organizations that are doing good work and asking them, could we sit down? Could we, you know, hash out maybe like, you know, agenda for what we want to try and accomplish this year or this quarter? I think that's -- you know who your friends and champions are and if you've got an LD representative, you know, in the Senate, State Senate or House side that you know has a particular interest in some of these topics, invite their LA or them to come and join. But I've seen all kinds of people, you know, agree to -- yes, Martha, Jac Davies and Martha, exactly. Thank you so much.

I got about five hours of sleep last night, so the brain is not quite lubed up. You know, I've seen a lot of people willing to come together and sometimes it means saying like, "I know you disagree with my organization's work in X, but I think we might have some overlap over this thing. Can we sit and talk about that?" It's a little bit like when I was running for State House in 2018 and I knocked on this guy's door and he was like, "You know, well, I only care about if you're going to take my guns or not." And I said, "Well, sir, you're going to be happy to know that the state constitution of Washington gives you an individual right to own a firearm. And I'm really here to talk about universal healthcare. Can we talk about that?" And he was like, "Yeah." And at the end of the conversation, he said, "You got my vote." So it's really about like finding where that overlap is with people and if they're engaged in law enforcement, or they're engaged in the courts, or they're engaged in social services, I think we're all really looking at the same kinds of folks because the crisis has really spread to all of these places where people are showing up. Hospitals are overloaded. I'm extremely concerned about healthcare in rural areas right now.

You know, it's one thing to say Rite Aid is, you know, going bankrupt but it's another to like lose one of five pharmacies in your town, right, or one of three pharmacies in your town. So, you know, I think a lot of people are willing to talk these days who were maybe not ready to sit down at the table three or five years ago. So do reach out and talk to folks and say, "Let's just have, you know, let's just get coffee and see is there anything we think is synergistic here." OK. I'm not going to go into all of our current programs but I wanted them in the slide deck because if you want the slides after this, I'm happy to have Cassandra or Michelle or whomever share them out. But just so you know, these are the kinds of things that we're doing. And each one of these programs has a, you know, contract type, a contract associated with it. A lot of our work is cost reimbursable but some of it is milestones based.

Very little of it is like a flat fee where we just get a payment every quarter, but we get a little bit of NASTAD funding like that. So we're doing work around HIV case management, testing and STI prevention, and increasingly treatment. These are all the things we do at the syringe programs. It's a lot. as you can see. It has grown organically over the years as, again as we were identifying gaps and needs and like can we fill in that need? I have a whole rubric for, if it makes sense for my agency to do it or for me to lobby another agency to do it, or to go back to my legislators or state partners and say, "Gosh, you know, I don't suppose you could come up with any funding for this particular activity." So this is really a list of things that -- you know, what we tried to do initially, I think I have a picture in here somewhere of one of our SSP shelves, but it's basically make more like a bodega or grocery store. You know, you're really standing in a medical closet.

We wanted it to not feel like the doctor's office. We wanted it to feel like how you would pick out potato chips. You know, I like this kind and not that kind, right? Just to kind of give people a new, like a reset on their expectations or what they're going to get from us to help, you know, again, support that trust relationship with them. So when they're coming in -- you know, when overdoses started really skyrocketing, we started offering naloxone. When people started getting really scared about reproductive rights and access to care, you know, Plan B came along. When there was funding for nicotine cessation kits, there were some requirements from federal providers to offer nicotine cessation as part of some other interventions then those kits came along and you get a lozenge or a gum or a patch or whatever you want.

So we have started doing things that, you know, whatever is going to be a motivator for people then is something that's in our list as a service that we can give out to people. Low barrier buprenorphine, this started in 2019. It's been, as far as I'm concerned, wildly successful. Did we get the best outcome for every single person? No, but we know that people who are successful on Suboxone, you know, a lot of them started by using it in, you know, just from the street and, you know, a friend gave them a dose or two or five or whatever. We certainly have seen a lot of people who felt like they could not go elsewhere or their doctor was not amenable to it or nervous about prescribing it, even though now the X-waiver has been dropped. We were happy to sign on to that lobbying effort with Congress.

You know, I think having it available, even if people aren't going to be successful this time, I've certainly seen people come back in the years since we started in 2019 and then be successful the second time or the third time and be really well controlled with cravings for years. So we're really, really happy to always -- you know, I've got a lot of folks that come in and they're managing their jobs and they bring their kids in, and they just have their consult and then they leave, you know. And I can never tell who's going to do well and not do well. There's just no pattern I can find. I really wish there was some secret sauce in there, but I think we just have as many opportunities for people to get on top of their lives as we can. And if something sticks then we just start running with that. So it does require quite, you know, financial commitment to run this program because the clinical staff are expensive and, you know, a lot of people in their hearts would rather be, you know, working with us than working in a clinic but they really like the pay of the clinic.

And so we are competing with a very small, in rural areas especially, a very small workforce. And if you're going to have somebody, it means they're not working somewhere else in your area. So, you know, I think the hardest part of this program is you've got to find those people who are champions for the program. You've got to pay them as much as you possibly can so that you can make it make sense to them. Because think about their, they have a lot of loans from all those years. And it's cool but we've got some people who are really like true believers in what they're doing and I'm extremely grateful to them. I see a couple of questions.

What proportion of your client base identifies as LGBTQ? Am I plugged into -- yeah. I feel like I'm plugged into community partners who provide support. Madeline, it's a really hard question to answer. I'm sure I have a lot of people who are LGBTQ plus identified. They don't always tell us. Sometimes they do.

I think people know in general that, you know, I'm really supportive of that community. I'm part of that community. But there certainly is a lot of stigma in some of our places. We have a, you know, we have a public health district that hasn't been allowed the last three years to post anything during Pride Month on their website because a commissioner for their county won't allow it. So, you know, that's the kind of -- is that actionable? You know, possibly. But I think, you know, we know where some other providers are but there's no like Pride, but there's no community, I don't know, a community center out here in Southeast Washington.

There are some organizations that like will run a Pride event or something like that. But it is kind of a lower, down low thing which for someone who spent 11 years in Washington, DC, it's really hard for me to see. But yeah, we support people as we can and we support everyone that comes out. OK. We've got a couple different diversion programs. That was our Law Enforcement Assisted Recovery or I think Let Everyone Advance with Dignity is the new moniker for LEAD. Those folks often have behavioral health, you know, challenges, including substance use and so they're perfectly eligible to use the other programs at our disposal as well as being in LEAD.

And as I said, we have a jail program. So, we've been doing a long-acting Sublocade started here in Walla Walla County before any other county jail in Washington State. And I think the funding for that is over right now but we still are using Sublocade in our low barrier program outside the jail. It's working very well for some people who really just want to kind of like forget about dosing themselves throughout the month. And I'm glad that we have it as an option for people. We have a Drug User Health Equity Program that's mostly NASTAD funded, although DOH did have a contract called Strategy 3. They were both engagements around vaccinating people for COVID-19 who were using substances and I had to write a whole report for NASTAD about it.

So if anybody wants to read that, how did we get 60% of people we approached to take COVID vaccine? It was really interesting. I could talk about that project for a whole hour just on its own. But what we found, like the takeaways for a discussion about rural health is being really consistent with where your mobile clinic is going and why it's servicing people is, you know, step number one. Doing as many things for as many people as possible is also really important because if people thought that the only thing our mobile clinic was there for was, you know, drug-use related, they didn't want to come near us because they didn't want everyone else in town to see them utilizing us. So we made ourselves available in Pomeroy, like to the farmer who stepped on a rusty nail, OK, we'll give you a tetanus shot. You know, now everyone knows, well, they'll do tetanus and singles and RSV for older people.

Are they our target population? No. But are we going to serve the people in front of us? Yes, right. And in doing that then we can also serve the folks that are in our, you know, our target population. OK, let's see. Is your program involved in any health promotion or chronic disease prevention work with public health?

Well, we certainly were part of the AVP, adult vaccine program with our public health partners. We also have been doing chronic hepatitis C treatment, testing and treatment, and I think we have like 10 people cured at this point of hepatitis C who were using substances and not, you know, going to talking to folks, you know, in their, in primary care land. We've also had a bridge program before with the ED in Walla Walla. So, if someone came in over the weekend and they wanted to prescribe Suboxone to them, they could do that. And then first thing Monday, they come back to us so they prescribe a couple days for them, and then we would finish the induction. I think there's all kinds of opportunities out there, as I said, to like, you know, see where you can work with another collaborator. If you don't have a -- you know, I think at one point we were talking to Shane McGuire at Dayton Community Hospital.

He had really great providers to be able to do Suboxone but he didn't have, this is before COVID, he didn't have case managers. And I was like, "Well, I could send a case manager out here. You need a case manager for the people on Suboxone? Oh, sure. Let's make it happen. I've got funding for this. You can do your piece.

I'll do my piece." I think rural areas are great for that kind of collaboration. I don't have any trouble really getting into jails in Walla Walla. We are the medical mental health provider in Walla Walla. I'm happy to spend time talking with you, Rebecca, about, you know, the work at the jail. We did certainly have to spend some time talking with, you know, the corrections officers and the jail commander.

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RURAL RESPONSES TO OPIOID USE from a non-profit perspective

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