The fentanyl crisis has taken a toll on communities all across Oregon. It has also shined a light on the challenges frontline responders face when trying to get people help for substance use disorder, especially in rural areas and jails or prisons where treatment can be hard to obtain.
But a training program in addiction medicine offered by OHSU is providing help by sharing resources, best practices and collaborative problem solving on complex cases. While most of the people who enroll in the course, which is taught remotely, work in healthcare, it is attracting growing interest among law enforcement. Enrollment overall in the training program has grown by nearly two-thirds in the past two years.
Dan Hoover, an assistant professor of medicine and the director of the Extension for Community Health Outcomes addiction medicine program at Oregon Health and Science University, joins us for more details.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. The fentanyl crisis, the latest wave in the ongoing opioid epidemic, has taken a huge toll on communities all across Oregon. It’s also demanding new sets of skills from a wide variety of people: doctors and nurses, police officers, corrections officials. A training program created by OHSU aims to help. The Addiction Medicine ECHO Program offers participants shared resources, best practices and collaborative problem solving on complex cases. Participation has grown by nearly two-thirds in just the last two years. Most of the people who enroll in the course are healthcare professionals, but it’s also attracting growing interest among people who work in law enforcement.
Dan Hoover is the director of the program. He’s also an assistant professor of medicine at OHSU, and he joins me now in the studio. It’s great to have you here.
Dan Hoover: Yeah, thanks for having me, Dave.
Miller: What’s the big idea behind this program?
Hoover: So the Addiction Medicine ECHO Program is really about getting specialty knowledge in addiction medicine out there to everybody in healthcare, and then increasingly to law enforcement folks as well. We know that this information is so helpful for anyone who’s gonna encounter a patient that has a substance use disorder, that has an addiction.
Miller: Let’s just first focus on what I think is the bread and butter of this for people who work in healthcare. How common do you think it is that somebody facing some kind of substance use disorder goes to their nurse practitioner, their primary care physician, and says “this is what I’m dealing with,” and that healthcare provider doesn’t really know how or what to do? How likely is that?
Hoover: Unfortunately, it’s pretty common. There can be a couple of reasons for it. One is that the healthcare provider might not have received any training during their medical education. Another could be that they have a stigma against people who are using drugs, people with addictions. So they’re setting their clinic up as a place where “we don’t want that kind of person, we don’t want that kind of patient here.” They’re shutting down those conversations before it can even happen, that could be going on. The patient may be using drugs and not want to be honest, not want to talk about that, even though it’s causing them health problems.
Miller: So that’s one thing, that they get the sense that there isn’t an openness on the part of their provider. Are you saying that there are times when a patient will say, “I’m dealing with meth addiction, opioid addiction, alcoholism,” and the healthcare provider, themselves, after hearing that kind of call for help, that they do nothing?
Hoover: Yeah. They might not know how to respond. They might say, “I’m gonna refer you to some place, here’s a resource. I’m gonna have you talk to a social worker at my clinic to refer you.” And actually, those links don’t happen all the time. We might assume that people follow through on those referrals. But if I’m the primary care doctor and you’ve trusted me to share with me that you’re using fentanyl, you want to get help, I have an opportunity right there to start you on a medication to treat your fentanyl use disorder and help you stop using. And that opportunity may just go away if I say I’m gonna send you 10 blocks over, or I’m gonna send you actually 20 miles to some other clinic. Patients are gonna face trouble accessing that, or just lose that moment that they wanted to make that change.
Miller: So you mentioned two things there. One is the stigma or the beliefs on the part of some healthcare providers, “I don’t want this kind of problem here.” But also just knowledge. You’re trained specifically in addiction medicine, board certified in that. But for people who went into other specialties or are internists who didn’t get that specialized training, how likely is it that they got any training in the most current evidence-based versions of addiction medicine?
Hoover: I think it’s not super likely, given the size of our existing health care professional workforce. It’s just now coming into best practices for the governing committees for education for health professionals to put addiction curriculum in there. But that’s a relatively recent addition. You have that large healthcare workforce out there that doesn’t know enough about addiction care.
That’s really a huge focus of our ECHO program because we have folks practicing all around Oregon. They’re very busy, they don’t have days and days to get an update on this important education. So with the ECHOs, we fit that into their busy clinic schedule or their hospital work with like a one-hour Zoom they can jump on, and start learning and start interacting with their peers. And they’re excited to join those.
Miller: What do these training sessions actually entail?
Hoover: Most of them are gonna be … half the session, so a half hour, will be a short presentation by an expert. It might be about stigma of addiction and how do we counter that? It might be about, how do we start a medication like buprenorphine, brand name Suboxone.
And then the second half is honestly the most fun part and what the participants all look forward to the most, I think, and that is a case discussion. So in medicine, we all get excited about bringing a case, and saying this is a patient that I was seeing, here’s the difficulty I was having with this patient, we’re really struggling with getting this medication started or helping them with this social problem that was contributing to their health. What do I do next? Who’s got advice for me?
Our team on the ECHO of educators, they’re gonna give advice from different perspectives, because we have often physicians, recovery peer support specialists and counselors that are all on there together to give advice. And then you’re also going to hear from your peers. So it could be someone from Wallowa County sharing with someone from Multnomah County about a good practice that they’re doing, or vice versa.
Miller: What’s an example of a kind of case that has been brought up in the past that you think illustrates how useful this is, and how information can be shared?
Hoover: Well, we have a lot of scattered systems or ones that don’t naturally connect in Oregon. I’ll bring up that we had a case on our adolescent addiction ECHO. And the faculty team on the ECHO is making some recommendations. The patient in this case was in custody, they’re a youth in custody. And they were transferring facilities, going somewhere that was saying “we can’t prescribe you your medication for addiction. We don’t have the prescribing team, we don’t know how to do that.” So they’re hitting an education barrier that’s common. But our team on the ECHO was able to say “here’s some telehealth prescribing resources for buprenorphine,” so that actually this patient could get the care they need. And it was basically connecting the dots here, connecting the systems that haven’t worked together previously for this patient case.
Miller: Nearly 30 members of law enforcement have participated in these programs in the last year. Where do they come from?
Hoover: Most of them are going to be law enforcement leaders. It could be ranking jail officers or jail commanders, and sometimes ranking police as well, like a police lieutenant. And they’re coming because of the impacts right now that we’re seeing from fentanyl and other drugs in Oregon, of course.
Miller: And this is completely voluntary? They’re choosing to sign up for this.
Hoover: Yes. They’re not coming for the medical education credits either.
Miller: What do you hear from them that’s driving them to take this class?
Hoover: Well, a lot of them have really had their eyes open to thinking of addiction in a new way. They’re coming to explore and coming to think about how we can collaboratively work our systems together better. So something common, if you’re a jail commander, and you’re seeing people come back time and time again to jail, and their addictions just continue, they’re not treated, they’re not improving, and they’re back to jail – one of the roots of the problem is probably that addiction itself. But how are you going to address that? And if you’re seeing that cycle, you start to think how can I break that cycle? How can I help that person to do better? How can I help them get on a road to recovery?
So we’re seeing a lot of motivation like that, getting more addiction care treatments into the jails. And then with deflection, it’s a similar conversation about police officers starting those conversations.
Miller: Have you seen an increase that you think is tied to the stepping up of deflection programs in Oregon over the last year?
Hoover: Yeah, absolutely. Consciously, as an ECHO program, the past couple of years have been really the first season that we started to dedicate training for a law enforcement audience. So we’re seeing the participation because we built the education curriculum for them to come. And the deflection ECHOs have been new for us starting in April 2024.
Miller: I’m imagining that if you’re talking to a police lieutenant or somebody who runs a county jail, these are not MDs or nurse practitioners, they’re not prescribers, right? I’m assuming you wouldn’t be getting into the nitty-gritty of, this is how and and when you prescribe Suboxone. So what are you telling them? Besides stressing the importance of making treatment available or breaking down stigma, what is the addiction medicine training for non-medical professionals actually entail?
Hoover: A lot of it is gonna be about changing the facility culture, or maybe cultivating a culture that is just positive towards these interventions, including the medication. Another part of it would be about operations. Because if you’re a jail and you start offering really incredible addiction treatment, it’s gonna change the way you operate, it’s gonna change the way your health department operates at the jail. So we get into all the nitty-gritty of that for the jail operations commander or manager when we’re on our jail ECHO.
Miller: Is there a county lockup in Oregon that is providing excellent addiction medicine right now?
Hoover: Yes, I absolutely agree with that. We have jails where their in-house medical team is doing that. We also have jails that are subcontracting a community addiction provider to do that. I’ve been involved in some of those partnerships, helping them get set up and coaching with best practices, and a lot of them join our ECHO group. I get to kind of brag on them and say, “Look how well you’re doing. Look at this fantastic addiction care work that you’re doing.”
Miller: Who stands out right now? What counties would you rise up as examples for the rest of the state?
Hoover: There’s a lot. We have Metro counties that are doing a lot. I will brag on a couple of rural counties because of course we know rural areas there’s less resources. Clatsop Jail – I’m really impressed with the partnership that they have, the peer services and the medications that they provide. I’m really impressed with Union County. They’re a jail that I provided some technical assistance to, and they took that and they ran with it. And they’re using injectable buprenorphine, which is a fantastic medication. And then some of the Metro jails that I’ve talked with, Multnomah of course, Clackamas, Jackson County.
We’re doing continuous quality improvement, so these jails are doing a lot, and we’re always like, “How can we take that a step up? How can we do even better?”
Miller: What do you see as you look around the state to be the most common barriers, within either county lockups or state prisons, in terms of getting effective treatment for people behind bars?
Hoover: It usually comes down to staffing and funding – those connected topics. And I am thankful that there’s some alleviation of pressure in that area, where we had the Oregon Criminal Justice Commission put forth a grant. We had 21 jails take advantage of this grant program this fall, and that’s funding those medications that treat opioid use disorder in jails. So I’m personally super excited about that. I’m on the grant review committee for that grant and saw tremendous applications come in from 21 of our Oregon jails.
Miller: Why did you personally seek out addiction medicine as your specialty?
Hoover: Oh, it’s such a good question. Two pieces to that. I am a follower of Jesus, and this is something I believe Jesus cares so much about, and wants to see lives changed through this process.
I think the second thing I’ll say is my desire as a doctor to see effective medications make an incredible difference. And in addiction medicine we’ve got these medicines like buprenorphine and methadone that are very much underused, hard to access. So we got so much work to do on our health systems to really change that. That gets me super excited. Those medications change lives. That’s one of the personal rewarding points is patients doing so much better. Now they’re getting reunited with their families, they’re back to gainful employment, stable housing, all that when they get the access to these medications. So we’ve got to make those changes and I get to be a huge part of it.
Miller: When you say I’m a follower of Jesus, and you see this is something that Jesus would do, what exactly do you mean?
Hoover: If I [can] just mention one passage from the Bible where Jesus says if there’s a homeless poor person and you’re giving them housing, or you’re visiting someone in prison, it’s like you’re visiting me. He actually says that. So I believe that the compassion we show to people, it’s part of what Jesus wants us to be doing.
And then to me, when I thought about how am I gonna make an impact as a doctor that’s meaningful in this world, it came down to underserved populations, people with addiction, homeless. Originally, I wanted to be a primary care doctor, actually. And through some incredible mentoring actually, with the Old Town Clinic and staff there, downtown in Portland, I saw excellent addiction care being provided and kind of took it in an addiction direction. I just saw such a potential for an impact there.
Miller: Dan Hoover, thanks very much.
Hoover: Thank you, Dave.
Miller: Dan Hoover is an assistant professor of medicine and the director of the Addiction Medicine ECHO Program through OHSU.
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