IU Rural Conference Highlight: Grand Challenge panel discussion probes intersection of addiction, stigma

FRENCH LICK, Ind.—Many of us know the statistics: for the first time in history, Americans are more likely to die of an opioid overdose than a car crash. Last year alone, it’s estimated that more than 1,600 Hoosiers died of drug overdoses.

But four panelists who spoke at the IU Rural Conference on May 13 believe we can better approach this crisis by studying the socioeconomic fabrics that overlay addiction. 

The discussion at the French Lick Resort before an audience of more than 160 rural community leaders grew out of Indiana University’s Grand Challenges program, a joint partnership between IU, Gov. Eric Holcomb, IU Health, and dozens of community organizations working on the frontlines of the state’s opioid epidemic.

 The shifting frontlines of addiction in Indiana have made it a true “grand challenge,” said Dr. Faith Hawkins, Associate Vice President for Research at IU.

“We’re not entirely sure the direction we’ll be going in a year or two, and that’s because when we see the crisis on the ground changing, we respond,“ Hawkins said. “If we had one isolated county that was in trouble, we’d need to work with that differently than if we have a region in trouble.”

More often than not, addiction does not observe county lines. Hawkins doesn’t believe data generated by the Grand Challenges initiative should, either.

“If our research stays on campus, not much is going to happen there. But if our research [on addiction] is going out into these communities and is in turn being informed by these communities, then we have the opportunity to do some good,” Hawkins said.

According to Nicolas Terry, fellow Grand Challenges researcher and a professor at IU’s McKinney School of Law, trends in addiction data should be approached with caution. Just because overdose numbers fell around 8% in Indiana this year, he said, does not mean we’re on solid ground yet.

 “While these numbers have decreased, they are death numbers—that means naloxone is probably showing itself in statistics, and we’re getting better at essentially finding people just before they die,” Terry said. “That doesn’t mean that we’ve made much of a dent in the addictions crisis. We still have huge numbers visiting emergency rooms, and we’ve seen the [methamphetamine overdose rate] come up quite strongly.”

Viewing Indiana’s drop in overdoses as cause to celebrate is worrisome to Terry. He said a serious consequence of the “problem solved” mentality is the potential for federal and state budgets previously allocated to the crisis to start “drying up.” 

“We’re a long way from flattening this crisis,” he said. “We’re so far from putting in the kind of healthcare structures, social work structures, and resilient structures that we need to handle not just opioid overdose deaths, but all types of addiction.”

The Toll

Hawkins says the overall financial toll that addiction has taken on Indiana since 2017 is roughly $4 billion in lost revenue.

Factored into this figure are the skyrocketing costs of treating neonatal abstinence syndrome (NAS) in infants, who on average require a stay of around 12.9 days in the hospital as opposed to 2-3 days, according to Franciscan Health Indianapolis, and also require opiate therapy to wean off substances.

“Infants with NAS have had a steady stream of opioids for the entire time they’ve been gestating, so once they’re born they’re no longer consuming this stream and you see extreme withdrawal symptoms like seizures,” said Angela Campbell, who is currently tracking the long-term outcomes of children born with NAS at the IU School of Medicine.

“As a researcher, it’s very difficult to separate the infant from the mother, because women’s health is really infant health,” Campbell said. “Frequently in our health system, we don’t become interested in women until they become mothers or get pregnant, but so much of what happens before pregnancy impacts the child’s outcome.”

A holistic approach where women are asked non-judgmentally about their mental and sexual health, as well as substance use, can go further than many people realize, she said.

For example, some women who are not addicted to opioids but take them as prescribed may not realize they are pregnant and inadvertently harm their baby—“it’s been found that even taking an opioid during pregnancy can be associated with developmental delays,” Campbell said. 

For a longtime opiate user who is pregnant, medication-assisted treatment, or “MAT,” is the best bet to minimize harm to the baby. 

“It’s actually agreed upon by the medical community that the best treatment is not for her to go cold turkey and stop taking the opioids, but instead transition to a different opioid like methadone to help ease the cravings,” Campbell said

Stigma: A Physician Perspective

Dr. Yolanda Yoder, a family medicine specialist based out of Paoli, Indiana, has had a front-seat look at the opioid epidemic for years. Around 27 percent of her pregnant patients tested positive for drugs this year, about the same percentage from 2015.

But Yoder is seeing pockets of success.

“What I can say is that we are now talking about [the opiate crisis] openly, whereas in the past we would see people in the clinic and wouldn’t ask whether they were using,” Yoder said. “We say it’s safe to talk about it, so it’s moving into the light. There are a lot of reasons to have hope.”

Yoder pointed out the lack of confidentiality in rural areas as a significant hurdle that most urban patients simply don’t have to deal with.  

“Stigma is the idea that when you live in a small community and you want help – and you’re at the doctor’s office, and know half the people who work there – that there’s an extra measure of courage required to take that first step,” Yoder said. “That’s a definite difference for rural patients.”

In her office, Yoder has integrated a successful behavioral therapy service that allows a patient experiencing depression or anxiety to meet with a counselor that very same day. She’s also testing out ACE screening on her new moms, giving them the CDC-developed questionnaire on adverse childhood experiences ranging from divorce to sexual abuse.

About 31 percent of her patients receive an ACE number four or higher, a score reported by CDC research to increase a patient’s risk of addiction by 8 times.

“As we begin to figure out the complexity that goes into why someone begins to use a substance, we know that their ACE score does have an impact on that. It’s not their destiny, but it can have an impact,” Yoder said.

Ever since Yoder began performing ACE questionnaires last year, she said conversations that patients never expected to have but desperately needed to be having have cropped up.

“Invariably our days and visits are much longer now than they had been, just by making this one move, but it’s something that makes a big difference especially when dealing with addiction,” she said. “Paying attention to someone’s mental health seems to be one of the most impactful ways that you can address their needs.”

Recently, a group of individuals in Paoli opened up a safe haven recovery center as a resource for people facing addiction and stigma in the community. Many staff members, some in attendance on Monday, have been in recovery themselves.

“We know that relationships with people who understand, whether they be peer recovery coaches or simply people who have walked the walk, are effective,” Yoder said.

Structural Solutions

According to the National Institutes of Health, we’re currently facing the third and most deadly phase of the opioid crisis.

First came prescription opioids in the 2000s; then, a second wave of heroin overdoses in 2010. In 2013 a massive spike in the deaths attributed to fentanyl ushered in phase three.

However, phases one and two continue to play out across Indiana, Terry said, complicating the epidemic. “We have different addictions crises occurring in different timeframes in different places,” he said. “It’s just very hard.”

Despite very real issues phases one and two still cause, Terry said we must focus on the more pressing issue at hand: fentanyl. 

“Everyone wants to keep talking about prescription drug monitoring programs in Indiana, but why?” he asked.

“Our problem at the moment is fentanyl, which is quite hard to get a prescription for. But by putting all your efforts into slashing prescription drugs, you will not only undertreat people with pain who need opioids, but push people from prescription to street drugs.”

In short, if opioid overprescribing is the only problem we see, then prescription drug monitoring will be the only solution. But our current problems are far more complex, Terry stressed. 

For example, with this year’s new data on health outcomes on a county-by-county basis in Indiana, few conclusions can immediately be drawn.

“You might as well have asked a 4-year-old to color in different counties,” Terry said. “You could make some rough guesses, but there is no real pattern, whether urban, rural, suburb—it’s just different types of addiction unfolding in different phases.”

But if you look at a map of economic distress in rural Indiana and overlay dots marking opioid overdose deaths, he said, there’s a rough correlation. If you then layer another map on top of that with healthcare performance stats, it also looks roughly the same. 

“There is clearly an economic and social dislocation, particularly rural, that gives rise to what researchers call the ‘diseases of despair’ like addiction,” he said. “The statistics on correlation are very strong,”

Both Yoder and Terry agreed that without improving healthcare and legislative structures, the addictions crisis will retrogress.

It’s clear that we do not have a healthcare system that works for all and that the current system discriminates against women and people of color Terry said.

 “The availability of buprenorphine to persons of color barely moved over the last few years, while white people were 35 times more likely to gain access,” he said.

A combination of buprenorphine, methadone and counseling are often the first lines of defense against opioid addiction. Vermont’s “Hub and Spoke” model built to deal with substance use disorder should be a benchmark adopted by Indiana, Terry said.

In this model, “hubs,” or opioid treatment programs that provide daily medication and therapeutic support, are connected to “spokes”, or primary care practices for patients to continue their treatment.

For low-income Hoosiers on Medicaid, finding an addictions provider in-network is often a struggle.

“We have known since the Surgeon General’s report in 2016 that the single best approach in dealing with the opioid overdose crisis is expanding Medicaid,” Terry said.

Though Indiana has expanded its Medicaid eligibility, a new FSSA proposal has demanded new work requirements for its clients. 

“There is no data anywhere that suggests that making work a requirement for Medicaid will improve anything. It certainly doesn’t improve health. In fact the data goes the other way—if people’s health improves, they will find work,” Terry said.