Presenters Dr. Ernie Fletcher Founder and Chief Medical Officer - RCORP-TA ...
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Presenters Dr. Ernie Fletcher Dave Johnson, MSW, ACSW Founder and Chief Medical Officer Chief Executive Officer
Recovery Housing, MOUD &
Emerging Issues
• Overview of RCOE
• Recovery Housing and Recovery Ecosystem,
Continuum of Care
• Social Recovery and Medical Model
• Recovery Housing & Corrections
• State-of-Affairs – Impact of COVID-19
• Recovery Housing in Rural Communities
• Funding – How do you do it?
Who Are
We?
The Fletcher Group Rural Center Of Excellence is supported by a HRSA
grant to promote evidence-based recovery housing and services.
Our Focus EVIDENCE - BASED TA
Field-proven tools and expertise to maximize your
effectiveness.
NATIONAL REACH
Rural communities in Idaho, Montana, Washington, Oregon,
Kentucky, Georgia, West Virginia, Ohio, Tennessee.
Mississippi and other rural communities as requested.
RECOVERY HOUSING CAPACITY AND
QUALITY
Emphasis on the homeless and those with SUDs involved in
the criminal justice system.
RCOE Target States — 24 Staff
Washington
Montana
Oregon
Idaho
Ohio
West Virginia
Kentucky
Tennessee
Mississippi Georgia
Recovery Housing & Emerging Issues
• Overview of RCOE
• Recovery Housing and Recovery Ecosystem,
Continuum of Care
• Social Recovery and Medical Model
• Recovery Housing & Corrections
• State-of-Affairs – Impact of COVID-19
• Recovery Housing in Rural Communities
• Funding – How do you do it?
What is a “Recovery Ecosystem?”
Community Collaboration
Holistic Support Services Clinical Care Alone is only 10% of the impact. https://www.orpca.org/initiatives/social -determinants-of-health
Understanding
Pathways to Recovery
Referral
Sources Case Management
Employment
Criminal Peer Support
Support
Justice
Treatment
Providers Stable Housing
Life Skills
Counselors Development
Community
Support Employment
Groups Behavioral Health Transportation
Education
Self-directed Housing
Support
Social Support
Recovery, Hope, Opportunity and Resiliency
• Next Generation
RHOAR • Evidenced Based Practices –
MOUD
• IOP
• Personalized Recovery Pathways
• Community Work Groups
• Recovery Kentucky combined
with EBP
• Meaningful EmploymentRecovery Ecosystem brings the Community Together Local and State Officials BH Service Organizations Providers Criminal justice Healthcare Faith-based communities Housing Public safety Human services Transportation Educational Institutions
NARR Levels of Support RECOVERY RESIDENCES IN THE CONTINUUM OF RECOVERY
Our Recovery Ecosystem Experience
18 Recovery Kentucky residences
Multi-agency teamwork—housing,
corrections, cabinet of Family and
Health Services, with a willingness to
think outside the box
“Community As Method” approach
promotes active participation in
peer-based group living
Remarkably effective in transitioning
individuals into the communityRecovery Housing & Emerging Issues
• Overview of RCOE
• Recovery Housing and Recovery Ecosystem,
Continuum of Care
• Social Recovery and Medical Model
• Recovery Housing & Corrections
• State-of-Affairs – Impact of COVID-19
• Recovery Housing in Rural Communities
• Funding – How do you do it?Many Modalities/Core Components
Harm Reduction Recovery
Syringe Exchange Clinical Management including
Medication Assisted Recovery
Controlled Drinking
Social Recovery and
Naloxone Distribution Therapeutic Communities
Fentanyl Testing StripsRecovery/Treatment Components Evaluation for physical and mental health conditions Medication Assisted Treatment (MAT) Individual Counseling—Motivational Enhancement Counseling, Cognitive Behavioral Therapy Group (Dialectical Behavioral Therapy) Peer Support Specialists Education and Self-help; 12-Step Curriculums Urine Analysis and Labs Recovery Capital—housing, employment, personal and community supports
ASAM Levels of Care
Silos and Mixed Messages “’No matter where you turn in this epidemic,’ East Tennessee State University public health professor Robert Pack told me, ‘there are systems in place to address the problems, but none of them are working together.’ The biggest barrier to collaboration is the fact that everyone involved views the problem too rigidly— through the lens of how they get paid….” Dopesick: Dealers, Doctors, and the Drub Company that Addicted America, Beth Macy, 2018
Medication Assisted Recovery
Acamprosate
Treatment/Medications Disulfiram
For Alcohol AUD Naltrexone
Topiramate
Gabapentin
Buprenorphine - multiple
delivery modalities
For Opioids OUD Methadone
ER - Injectable NTX
Naltrexone - Injectable
Kivlahan, D. (2017) Evidence-Based Clinical Practice Guidelines for the
Management of Persons with Substance Use Disorders. American
Psychological Association. https://www.apa.org/career-
development/evidence-based-guidelines.pdfEmerging Treatment for Stimulant
Use
Recent Study of Medication for Methamphetamine Use Disorder
• New England Journal of Medicine – NIDA Funded Study *
• Using naltrexone and bupropion
• 403 participants, multisite, double-blind, placebo controlled
• 13.6% (11.1% with placebo controlled) responseMedication Assisted Recovery
Pharmacologic intervention as part of a comprehensive substance use
treatment*
A meta-analysis documented significant improvements in mortality
rates with both methadone and buprenorphine.
“Despite an exhaustive and systematic search, the small number of
studies that report on outcomes of interest and the weaknesses in
the body of evidence prevent any strong conclusions about the
effects of MAT on functional outcomes or differences in effects
among medication types, route of administration, treatment
modality, or length of treatment.”
No overall benefit to adding drug counseling to buprenorphine-
naloxone and weekly medical management” in some populations.
*References at end of presentationHealth Affairs PDMP Analysis - Adherence Survey of Prescription Drug Management Program Prescriptions – actual data of Rx and Purchase of SUD medications Analysis based upon standard 180-day treatment standard Looked at adherence – how many individuals continued to purchase medications for 180-day treatment period Buprenorphine Treatment By Primary Care Providers, Psychiatrists, Addiction Specialists, And Others; Olfson, Health Affairs June 2020 39:6;
PDMP Analysis – Adherence for 180-day Average Primary Care Physicians--23.7% to 30.3% (2010 compared to 2017) Addiction Medicine Specialist from 24.5% to 26.7%, Other prescriber groups--22.4% to 26.7% Taken together, less than 1/3 of patients started on buprenorphine continued treatment for 180 + days Adherence is a major challenge for all chronic diseases
Emerging Treatment for Stimulant
Use
Recent Study of Medication for Methamphetamine Use Disorder
• New England Journal of Medicine – NIDA Funded Study *
• Using naltrexone and bupropion
• 403 participants, multisite, double-blind, placebo controlled
• 13.6% (11.1% with placebo controlled) responseCombination MAT and Social
Support Services
• Improve adherence
• Reduce drop-out rates – Hazelden Betty Ford, COR-12
• Potential synergyOxford House
Social Recovery with Housing Supports
Overview Evidence
• Democratically run, self-supporting and • Oxford House has been evaluated in a two-
drug free home. The number of year randomized, clinical trial which reported a
residents in a House may range from significant reduction in substance use,
six to fifteen; there are houses for men, increases in “self-control,” increases in
houses for women, and houses which employment, and reduced criminal justice
accept women with children. involvement.
http://www.oxfordhouse.org/userfiles/file/purpose_and_structure.php
SAMHSA NREPP, “Intervention Summary: Oxford House Model,”
https://nrepp.samhsa.gov/Legacy/ViewIntervention.aspx?id=223Recovery Kentucky
Social Recovery with Housing Supports
• Social Recovery model combines supportive housing with structured
education and focused reliance on a mutual-help 12-step program.
• Programs are overseen by professional staff, this mutual-help recovery
model utilizes peer mentors and peer role models.
• Program curriculum includes community meetings among the participants
of the facility, and a structured educational program.
Logan, T., Miller,J., Cole, J., and Scrivner, A. (2018). Findings from the Recovery Center Outcome
Study 2018 Report. Lexington, KY: University of Kentucky, Center on Drug and Alcohol ResearchSAMHSA RECOGNIZED
Evidence Evidence-based model for Criminal
Based Justice System Treatment and
Recovery of Criminal Justice
involved individuals with SUD.Recovery Housing & Emerging Issues
• Overview of RCOE
• Recovery Housing and Recovery Ecosystem,
Continuum of Care
• Social Recovery and Medical Model
• Recovery Housing & Corrections
• State-of-Affairs – Impact of COVID-19
• Recovery Housing in Rural Communities
• Funding – How do you do it?Criminal Justice and Recovery
Our Greatest Challenge May Also Be Our Best Opportunity
• In 2018, 1,654,282 arrests occurred due to drug use
violations*
• 80% of the incarcerated have used illicit drugs**
• Only 20% receive treatment while incarcerated
*FBI - Uniform Crime Reporting (UCR) Program – drug arrests for 2018 (https://ucr.fbi.gov/crime-in-the-u.s/2018/crime-in-the-u.s.-
2018/tables/table-29/table-29.xls)
**Adam Chamberlain et al., "Illicit Substance Use after Release from Prison Among Formerly Incarcerated Primary Care Patients: A Cross-Sectional Study," Addiction
Science and Clinical Practice 14, no. 1, 2019)High Risk Upon Release Including fatal overdose among those who have lost tolerance while incarcerated.
The Revolving Door
“They don’t rehabilitate you in
prison, and they don’t make it
easy for you to get a job.”
“I truly believe they don’t make it easy because they want
you back, and they want you back because that’s the
new factory work in so many places now—the prison.”
(From the book, “Dopesick” by Beth Macy)The High Cost • $182 billion spent
Of Criminalizing Addiction
each year on
incarceration
• Up to 60% of inmates
diagnosed with SUD
• A 15% reduction in
incarceration - $27
billion in savings.
Mass Incarceration Costs $182 Billion Every Year, Without Adding Much to Public Safety
https://eji.org/news/mass-incarceration-costs-182-billion-
annually/#:~:text=According%20to%20the%20Bureau%20of,to%20support%20incarcerated%20loved%20onesALABAMA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
States Releasing Prisoner Early Due to COVID-19
FLORIDA
GEORGIA
HAWAII
ILLINOIS
IOWA
KANSAS
KENTUCKY
• 35 State have released prisoners from state and local
LOUISIANA
MAINE (jail) facilities in response to COVID-19\
MARYLAND
MASSACHUSETTS
• Most have face difficulty providing the reentry
MICHIGAN
MINNISOTA
supports
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
• Limited SUD supports
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
TENNESSEE https://www.prisonpolicy.org/virus/virusresponse.html
TEXAS
UTAH
VIRGINIA
WEST VIRGINIA
WISCONSINLocking people up doesn’t work. It only
What To Do? makes things worse for those with an SUD.
Our Proposal Think of the Criminal Justice System as an
“Entry Point for Treatment.”
Coordinate the efforts of primary care
How To Do It? providers, the criminal justice system,
recovery housing and providers, and
nonprofit organizations.
36Recovery Housing & Emerging Issues
• Overview of RCOE
• Recovery Housing and Recovery Ecosystem,
Continuum of Care
• Social Recovery and Medical Model
• Recovery Housing & Corrections
• State-of-Affairs – Impact of COVID-19
• Recovery Housing in Rural Communities
• Funding – How do you do it?What is the State of Affairs in SUD • Federal Efforts – Over $ 7.4 Billion* • Slight Decrease in Overdoses 2018 • Then…COVID-19 * 2018 for all branches of Federal Budget addressing opioid: https://bipartisanpolicy.org/wp- content/uploads/2019/03/Tracking-Federal-Funding-to-Combat-the-Opioid-Crisis.pdf
AMA Issue brief:
Reports of increases in opioid related overdose and
other concerns during COVID pandemic
More than 40 states have reported increases in opioid-related.
AMA Issue Brief, updated September 8,2020
Clearly, what we have lost with the pandemic is a loss of connection.
Dr Mike Brumage https://www.theguardian.com/us-news/2020/jul/09/coronavirus-pandemic-us-opioids-crisis
AMA Issue Brief, updated September 8,2020Predictions Prior to the Pandemic
The Opioid Crisis Is Expected To Worsen
The projections, under current circumstances, are:
– 82,000 opioid ove rdos e de a ths a nnua lly by 2025
– A tota l of 700,000 de a ths from 2016 to 2025
– Inte rve ntions will he lp lowe r the incide nce of
pre s cription opioid mis us e but only by 3 to 5.3 pe rce nt
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2723405‘Cries for help’: Drug overdoses are soaring during the
coronavirus pandemic…Washington Post
Alarming spikes in drug overdoses — a hidden epidemic within the coronavirus
pandemic.
Emerging evidence … isolation, economic devastation and disruptions to
the drug trade in recent months are fueling the surge.
But data obtained by The Washington Post from a real-time tracker of drug-
related emergency calls and interviews with coroners suggest that overdoses
have not just increased since the pandemic began but are accelerating as it
persists.
https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose
41A New Addiction Crisis: Treatment Centers Face Financial Collapse In April, the National Council for Behavioral Health surveyed its 3,400 members, most of whom are nonprofit community treatment centers. Nearly all — 92.6% of both residential and outpatient centers — had cut back their programs, forcing many to furlough employees or lay them off. A month into the pandemic, two-thirds of those centers said they had enough cash to last three months or less. https://www.npr.org/sections/health-shots/2020/06/15/865006675/a-new-addiction-crisis- treatment-centers-face-financial-collapse
Recovery Housing also Faces a Financial Crisis
Operators Surveyed - May to June 2020 FGI’s RCOE collaborated with the
NARR and Oxford.
1,419 responses analyzed
Data included increased costs and lost revenues due to COVID-19
Some operators documented decreased number of residents as high as
40% due to COVID-19 (individuals are losing access to services)
Most significantly, estimate 17,900 RH facilities nationwide face an
estimated $162 million in lost revenues and increased costsOur ability to respond to crisis within the pandemic! Increase SUD and Overdose during Pandemic Need to build more resilient Recovery Ecosystems
Now Is The Time Our Efforts Are Needed Most! Encouraging CJS and Recovery Housing collaborations to develop the recovery ecosystem may be
Connecting with Corrections State and Local Criminal Justice Systems • State Department of Corrections • Local Jails • Drug Courts and Judges • Parole • Probation
CJS and SSA Collaborations: Addressing the Issue Examples from Kentucky : Recovery Kentucky Our historical success… • 16 Years of experience working with Corrections • Diversion, Parole, Probation • Per diem – win—win
Recovery Housing & Emerging Issues
• Overview of RCOE
• Recovery Housing and Recovery Ecosystem,
Continuum of Care
• Social Recovery and Medical Model
• Recovery Housing & Corrections
• State-of-Affairs – Impact of COVID-19
• Recovery Housing in Rural Communities
• Funding – How do you do it?Rural Communities – How do you do it”
Start Small, but think Big
“Dream no small dreams for they have no
power to move the hearts of men (and
women)”
Johann Wolfgang von Goethe119 Counties
In 10 States Unique Rural Challenges
• Kentucky
• Ohio HIGHER RATES HIGHER COSTS
•West Virginia of SUD incidence, morbidity, Long-distance travel to
overdose occurrence and facilities adds significantly to
• Georgia mortality. already high costs.
• Mississippi
• Montana FEWER GREATER
• Idaho RESOURCES STIGMA
• Oregon Doctors diagnosing SUDs are Smaller rural communities
• Tennessee less likely to have the may experience less privacy
resources and training for and, as a result, more social
• Washington follow-up care. stigma.VULNERABLE DISTRUST
Unique
More Native Americans meet Of mainstream institutions
the diagnostic criteria exacerbated by treatment
for SUD than any other ethnic protocols that may be
or minority group. culturally insensitive. Cultural
Challenges
GEOGRAPHY COMPLEXITY
Widely dispersed facilities and Areas lacking social services
the technicalities of insurance and education are also more
can present additional likely to interact with the
problems. criminal justice system.S ta t e e ffo r t s Br in g d o w n s ilo s a n d
a n d s tra te g y in fo r m R H s t r a t e g ie s
Top Down
Versus Local
In t e g r a t e w it h
Bottom Up c o m m u n it y
e ffo r t s
e x is t in g e ffo r t s
“All politics are local.”
Tip O’Neill, Speaker, House of US Representatives, 1977-1987NOT IN MY
BACKYARD?
REMIND OBJECTORS WHO PEOPLE with SUD ARE —
YOUR NEIGHBORS, YOUR FRIENDS, YOUR FAMILY.Women's Addiction Recovery Center in Henderson
W.A.R.M. • 28,757 county residents
• The first recovery facility in the state of Kentucky
• Frequently accepts residents from TennesseeMISSION Provide hope to homeless women suffering
from alcoholism and drug addiction.Recovery Housing & Emerging
Issues
• Overview of RCOE
• Recovery Housing and Recovery Ecosystem,
Continuum of Care
• Social Recovery and Medical Model
• Recovery Housing & Corrections
• State-of-Affairs – Impact of COVID-19
• Recovery Housing in Rural Communities
• Funding – How do you do it?LIHTC
1 $5,000,000
(OVER 10 YEARS)
How Debt -Fre e
Cons truction Works
2 HOME FUNDS $250,000
How $5.9 million in
AFFORDABLE
construction costs were 3 $150,000
covered at the Regional HOUSING TRUST
Men's Recovery Center in
Owensboro, Kentucky
4 FEDERAL HOME
$500,000
BANK LOANDEPARTMENT OF
1 $550,000
CORRECTIONS
How Operational
Da y-To-Da y 2 HOUSING CHOICE
$200,000
S us ta ina bility Works VOUCHERS
COMMUNITY
How $1.3 million in annual 3 DEVELOPMENT $300,000
day -to -day operating costs BLOCK GRANTS
are covered at the Men's
Addiction Recovery Center
4 FOOD STAMPS
$150,000
in Bowling Green, Kentucky (SNAP)
5 LOCAL $100,000It’s All About People
“The program changed me and I’m now a peer
me ntor. I know a bout this dis e a s e be tte r a nd
ha ve the tools to s ta y s obe r.”
60
“The y truly, hone s tly ca re a bout me a nd wa nt
me to ha ve a fruitful a nd productive future .”Dedicated to expanding access to quality
Evidence-Based Recovery Housing for all
populations, particularly the most vulnerable.
ONE VOICE
We work hand-in-hand with NARR and
other partners to ensure a nationally
unified voice for Recovery Residences
supporting people in recovery.Medication Assisted Recovery References https://www.bmj.com/content/357/bmj.j1550 Maglione, M.A., et al Effects of Medication Assisted Treatment (MAT) for Opioid Use Disorder on Functional Outcomes: a Systematic Review. (2018) RAND National Defense Research Institute. https://www.rand.org/pubs/research_reports/RR2108.html Weiss, RD and Rao, V The Prescription Addiction Treatment Study: What have we learned. Drug and Alcohol Dependence 173” (2017) https://ac.els-cdn.com/S0376871617300029/1-s2.0- S0376871617300029-main.pdf?_tid=ae502d7a-ca19-11e7-804e- 00000aab0f27&acdnat=1510759911_69cedcc11b88b80cc78372fdc82eedef Accessed 11-15-17 See also, David A. Fiellin, M.D., V. Pantalon, Ph.D., Marek C. Chawarski, Ph.D., Brent A. Moore, Ph.D., Lynn E. Sullivan, M.D., Patrick G. O’Connor, M.D., M.P.H., and Richard S. Schottenfeld, M.D. Counseling plus Buprenorphine–Naloxone Maintenance Therapy for Opioid Dependence New England Journal of Medicine 355;4 www.nejm.org July 27, 2006 pp 365-374 http://www.nejm.org/doi/pdf/10.1056/NEJMoa055255 Accessed 11-15-17
Contact Information
Fle tche r Group, Inc.
601 Meyers Baker Rd #238
London, KY 40741
EMAIL ADDRESS
info@ fle tche rgroup.org
P H O N E N U MB E R
(606) 657-4662
This product was supported by the Federal Office of Rural Health Policy (FORHP), Health
Resources and Services Administration (HRSA), U.S. Department of Health and Human
Services (HHS). The information, conclusions and opinions expressed in this product are those
of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.You can also read
