MSPH/MPAP(s)

Our presentation to the Harnett County Sheriff’s Office concluded our work as Team OVERDOSE. I am honored to work inter-professionally with a group devoted to law enforcement. One would not think there would be many crossings of professional lines when thinking of the roles of a Sheriff’s Office and public health. However, they do intersect in the duty of serving the people in the community in which they work and live and protection. Although our focus of protection differs, with public health focusing on protecting health and law enforcement protecting from harm and maintaining safety, we both aim to influence social determinants of health in a positive manner. We had to make some changes to our first advocacy ideas, which suggested the use of medication-assisted treatment (MAT) for those who are in jail or prison in Harnett County. Lt. Christensen informed us of the difficulties with implementing this program: most justice-involved persons are not in Harnett County Detention Center for long periods of time, they cannot start MAT here and discontinue it upon arrival at another location, and the diversion of medications could pose a threat. We had to switch direction, even though jail-based MAT is recommended by the National Sheriff’s Association and continues to be the gold-standard for opioid use disorder treatment. We wanted to incorporate something which was gaining traction around the country, using a network of services to lead people to treatment following an overdose.

Our advocacy program fed off of the Angel Program. This program links addicts to treatment by allowing law enforcement to lead people directly to treatment with the help of a person in recovery, or Angel. It utilizes resources in the community to help those who seek treatment and does not punish addicts for having illicit substances on them. It is voluntary and can be seen as an alternative to arrest or the public health approach to getting people treatment who need it.

In many cases, law enforcement will aim to arrest the way out of a problem that can be solved with treatment and therapeutic interventions. The punitive nature of jails and prisons are not necessarily helping addicts. In fact, our data showed an instance where an addict did overdose directly after leaving jail. This is a common occurrence, as addicts think they have the same tolerance and try to use the same amount, which leads to an overdose because their tolerance has decreased while remaining abstinent in lock up. If Harnett County Sheriff’s Office were to adopt a form of the Angel Program, it would require addressing access to care barriers and health care challenges. There simply are not the treatment options required to make this happen; there is no detoxification facility in Harnett County, and if addicts could detox successfully at home, they would not be addicts. Of course, resources do exist to provide a referral to other areas, but those resources are already strained. The form that could be adopted would lead to linking people who overdose with those who are in recovery, using a peer recovery specialist to help this person who just almost lost their life. Developing this connection could lead to more stories being shared, conversations being started, and possible reduction in denial that plagues addicts.

We presented our advocacy ideas, which focused on this social issue, to the Sheriff’s Office with instant feedback. Lt. Christensen seemed to be receptive to the idea. There was no direct talk of starting this policy any time soon, but we did challenge the stigma of addiction as a moral failing. If it were simply a moral failing and someone could easily quit, there would not be reimbursement from insurance companies for substance use disorder, AA/NA would not exist, treatment centers would cease to operate, and the American Medical Association would have been wrong about calling alcoholism/addiction a disease for over 50 years now. We can only hope that starting the conversation is only the beginning of helping this community and leading more people to treatment and into recovery. This experience, I hope, allowed law enforcement to see this a public health issue and not something which punishment can solve. We hope to see an adoption of some form of the Angel Program or utilizing the social capital of persons in recovery to link addicts who are using and dying to treatment. This activity allowed us to successfully meet competency F14: Advocate for political, social or economic policies and programs that will improve health in diverse populations. Our diverse population includes addicts who have overdosed across Harnett County, which represented both sexes, multiple races, and community members just like you and me. This is an issue which we all must see as a family disease, now that drugs have reached suburban and rural areas, we have the chance to switch from arresting people to meeting them where they are and walking with them when they are ready for treatment.

The APHA annual conference gave me some much-needed motivation to push to the end of our group practicum as an abundance of research is being formulated on the opioid crisis.

Team OVERDOSE started meeting at Harnett County Sherriff’s Office in August 2019. Our first goal was to digest all the data we were given, which included data from 2016-2019. This task was no small one, as we are still interpreting data and creating more charts and graphs. One day as we were looking through piles of incident reports, an officer crossed the room to tell us he had another incident report of an overdose that he was submitting. So, the problem is apparent and ongoing. Our job has been to stay away from diving into the story of the incident, or as Lt. Christensen said, “it is sensitive information, try not to get caught up into the death investigations.” This is quite the task because some of this could be viewed from a qualitative perspective, even though we are not actually interviewing the victim, the data does tell a story. Some of the phenomena we encountered were: children in the next room of individuals who overdosed, some frequent drug users or repeat individuals, overdoses in the home (notably the bathroom), some overdoses in businesses, multiple substances, mental health issues, and some suicide attempts.

To compile all our data, we started with Google sheets, which allowed us to share the data within our team. Each team member had a year to input data or write the information onto a paper spreadsheet. This allowed code words for things mentioned above, to determine if any trends existed in the data. Once we went through all the paper incident reports, put that into useable form in Google sheets, and agreed on different variables to use, we put the data into Statistical Package for Social Sciences (SPSS). This program allows us to view the data, gain descriptive statistics, create graphs, and have a direction for our advocacy plan. The variables used for SPSS are case number, demographics (age, sex, and ethnicity), date, time, zip code, whether the incident took place at the residence of the victim or not, drugs involved (if mentioned), if naloxone was used (if mentioned), if the result was death, if the patient was transported to the hospital or refused treatment (if mentioned), and a section for other noteworthy information.

I started with the year 2017, which had 74 reports to go through. Of those, I encountered 21 deaths, 28.4% of those who overdosed and had Harnett County Sherriff’s Office dispatched passed away. We had to cross-compare the death stack to the number of deaths we found in our respective year. For deaths, we encountered 36 reports, which included autopsy and toxicology reports for most. This allowed us to take toxicology results and add that to the drugs consumed column. The total number of incident reports by year were: 27 in 2016, 74 in 2017, 110 in 2018, and 54 in 2019. Altogether, we went through 301 incident reports, with about 12% dying as a result of their overdose. For the year 2017 (using SPSS), I created graphs for zip codes (to demonstrate the areas where overdoses were most prevalent), a bar graph for age ranges, and bar graphs for ethnicity and gender. I also created an additional information graph, indicating different locations, history of drug use/ODs, mental illness/suicide, and children being present when the officer arrived. This information can be disseminated easier now that it is in graphical form. Katlyn ran a chi-square for sex and overdose and race, white vs. non-white, and overdose. There was a statistically significant association between being male and dying as the result of an overdose, according to our incident reports. Inputting the data into Google sheets then SPSS, followed by investigating the years to find trends, and creating graphs qualifies us to meet the competency (F3): analyze quantitative and qualitative data using biostatistics, informatics, computer-based programming and software, as appropriate. After presenting the data and seeing how members of the Sheriff’s Office were happy to see the “other notable factors slide,” I can see the benefit of utilizing statistical packages and data to inform those working close to the issue of actual points to consider.

I was able to see some interprofessional friends from Harnett County Sheriff’s Office, our precepting organization, in action at the Denim Days Parade. After completing the brochure, we are now prepared for Farmer’s Day on Saturday!

Team OVERDOSE began our work of combining public health efforts with law enforcement to examine overdoses in Harnett County, and respond collectively. We met Lt. Christensen and Intel Analyst Kimberly of the Narcotics Division of the Harnett County Sheriff’s Office. Our task is to collect the incident reports from overdoses since 2016 and organize this into useable data. We were briefed on some of the details within these incident reports, given a history of the opioid crisis, provided with data handling procedures, and provided with four stacks of incident reports, with some being quite substantial (years 2016-2019). Our first priority was to recognize barriers and challenges for the health of overdose victims and addicts in Harnett County.

Before diving into the incident reports, our group decided to research prevention and treatment programs for confronting the opioid/substance abuse issue in Harnett County. We encountered the following programs: naloxone access for most of the county, medication drop boxes, one pain clinic in Lillington, which provides medication-assisted treatment (MAT), and one MAT program in Dunn. Our research and discussions led us to understand some challenges addicts of Harnett County may face.

We discovered that the Harnett County Health Department website does offer a list of pharmacies which offer naloxone, for opioid overdose reversal. This allows more naloxone availability in the community. Access to care, like naloxone, is seen as controversial to some, but it does save lives. However, areas like Western Harnett County only have one location which distributes naloxone nearby, a Walmart in Cameron, NC. More sites are needed in this vulnerable area and knowledge of the availability is essential. The western corner of Harnett County is up to 20 minutes from first responders, who carry naloxone. If it is unavailable in a timely manner, either from first responders or lay-persons, an overdose victim does not stand a chance. Those who argue against naloxone access say it enables addicts to continue to use, despite overdosing multiple times. From a public health standpoint, it is not up to us to decide when someone decides to make positive changes in their lives, we can simply be there to meet them when they do. That fifth or sixth time receiving naloxone may give someone the wake-up call they need to start seeking help.

Once we began examining and entering data from overdose/death reports and tying some of it into our research, other access to care barriers and healthcare utilization challenges became apparent for parts of Harnett County. Some residents lacked access to treatment for their addiction and fell victim to becoming another statistic. With only one MAT clinic in Harnett County (Morse Clinic of Dunn), there may be an overwhelming wait to see the provider. There are other providers at a separate location, Neurology and Pain Management of Lillington. Outside of an actual clinic, MAT can be very costly for those without insurance. Another issue, which affects healthcare utilization, is the idea of stigma associated with MAT. I have waited in line at the methadone clinic and it is not a pleasant early morning activity, when even the staff stigmatizes you. In a rural county, individuals receiving treatment may not want to park their vehicles outside of the clinic because someone they know may recognize them.

There is a community-level intervention underway with Project Lazarus: Project Pill Drop and Healthy Harnett, which provide medication drop boxes at various locations, including the Sheriff’s Office. This prevention effort addresses the misuse and diversion of opioids, and other prescriptions, by getting rid of unused medications. There are three locations in Lillington, two in Dunn, and one in Coats. Speaking from personal experience, having unused opioids is a contributing factor to substance abuse. This prevention model looks to take these unused medications away from those who may abuse or sell them. Getting the word out about this intervention, or having a large community medication take-back event, could increase awareness and get unused potentially harmful prescriptions out of medicine cabinets.