By: Introduction- Preetika Banerjee (1); Case Study- Diana Gibbs (2), Jennifer Goulet (3)
“Health for justice, justice for health” – these ideals outline the connection between health, human rights, and social justice. This is also the message the United Nations aims to promote through the International Day Against Drug Abuse and Illicit Trafficking, 26th June 2019.
The opioid epidemic has progressed drastically in the United States since the 1990s. Drug addiction affects over 2 million Americans; there were an estimated 72,000 overdose-related deaths in the US in 2017, amounting to almost 200 deaths a day, nearly two thirds of which were attributable to opioids alone. The disease has a lasting impact on communities and individuals affected. While opioid use disorder is a medical condition, a range of contributors – poverty, education, isolation, and unemployment – may lead to the development of addiction. Community Health Workers (CHWs) play an integral role in addressing these social determinants of health along with ensuring access to care to those most in need.
Although CHWs play a pivotal role in disease management, there is a dearth of published literature on their contributions, activities, and influence in supporting patients with substance use disorder and drug addiction. The lack of published literature does not reflect a lack of community health worker programs supporting substance use in the US. For instance, a program carried out by Indiana University was successful in integrating CHWs into outreach programs directed at supporting opioid-dependent mothers and newborns. The recent CHW Central feature: Using the ECHO model to support CHWs also highlighted the Opioid Addiction Treatment teleECHO program, which expands access to information for healthcare providers on how best to treat and support patients with substance use disorders. Importantly, the use of CHWs in supporting patients with substance use disorders is also economical. A study conducted by the Washington State Institute of Public Policy, found that peer-delivered substance use programs (often CHW-driven) offer return on investment of $1.25 on every $1 spent.
To further highlight the critical role CHWs are playing in addressing this epidemic in the US, our friends at the North Country Health Consortium in New Hampshire share a case summary of their program. Like we did, we hope you’ll read, learn, and get inspired.
Addressing Opioid Addiction in Rural New Hampshire: CHWs as Addiction Recovery Coaches
The opioid epidemic has swept across the United States, leading to a record 72,000 deaths in 2017. New Hampshire ranks second in the country for overdose deaths, for which opioids are the main driver. Although one of the smallest states in the nation, with a population of only 1.3 million, NH is among the three states with the highest opioid-related death rates (39.0 per 100,000), contributing to more than 488 deaths in 2018. From 2016 to 2017, opioid-related emergency department (ED) visits increased by almost 10 percent in New Hampshire. Coos County had 51 visits per 10,000 population and ranked fourth in number of ED visits per county in New Hampshire- a 17 percent increase over 2016. In the same period, Narcan administration in Coos County increased by 11 percent. Despite the increase in overdoses, admissions to opioid treatment facilities declined in Coos County between 2016 and 2017 as a result of limited bed availability and lack of referrals made by emergency department staff.
“Rural residents face an even greater disparity as rural states are more likely to have higher rates of overdose deaths, specifically from prescription opiate overdoses.” Conditions found in the local population increase risk for substance use/opioid use disorder (SUD/OUD):
- High percent of white residents
- Low health literacy
- Low educational attainment
- High rates of uninsured and unemployed
- High rates of diabetes, arthritis, heart disease and disability
- Aging population
The depth of the opioid epidemic in the state has stimulated a political and social response, leading to an influx in federal and state support to address the public health crisis. To reduce morbidity and mortality related to SUD/OUD, North Country Health Consortium (NCHC), a rural public health network serving Northern New Hampshire, developed the “Wellness And Recovery Model Program” (WARM Program). To address treatment and recovery access barriers, NCHC’s WARM Program developed a recovery support workforce by hiring, training, and deploying community health workers (CHWs) to serve as recovery coaches (RCs). Given the extent of workforce shortages in the region- identified by the Federal Health Resources and Services Administration as a Health Professional Shortage Area (HPSA) across primary care, mental health, and dental health disciplines – this trained workforce provides needed capacity to bridge service gaps.
The WARM Program began in 2018 and is supported by two grants from the Federal Office of Rural Health Policy: the Rural Health Care Services Outreach Program and Rural Health Opioid Response Program. WARM approaches the crisis using two major strategies: 1) reducing stigma, increasing understanding of SUD/OUD, and increasing knowledge of treatment and recovery support services by providing community and family education, as well as professional training and development; and 2) providing direct client services for individuals who are referred to the program via self-referral, implementation of a Warm hand-off model in emergency departments, and other community-based referrals, such as Drug Treatment Court (DTC).
CHW/RCs are trained through NCHC’s CHW hybrid training curriculum that follows the national core competencies provided by the Community Health Worker Core Consensus (C3) Project. In addition, this curriculum focuses on: understanding the social determinants of health, CHW specialty professions, locating and navigating resources, motivational interviewing, and providing effective support in direct client services. WARM Program CHWs are also trained in the Connecticut Community for Addiction Recovery (CCAR) Recovery Coach Academy, HIV/AIDS, and Suicide Prevention to gain a better understanding of providing direct services to this high-risk, high-need population. NCHC has also developed staff and regional capacity for trained trainers to deliver the 4-day Recovery Coach Academy, as well as Ethical Considerations. Using this trainer capacity, NCHC is developing a Recovery Coach Network to provide volunteer services in the evening and on weekends when WARM services are not available. Finally, this newly trained CHW/RC workforce is supported through continuing education, team supervision, and one-on-one supervision.
The WARM Program provides direct services to clients 18 and older who reside in Coos or Northern Grafton Counties in rural New Hampshire who are seeking recovery support. To be eligible for services, individuals must meet one of the following criteria: fulfill the criteria for SUD/OUD; have experienced an overdose; are actively using substances; or are in recovery or have experienced a relapse. Services include ongoing recovery support for multiple pathways of recovery, treatment access, resource navigation, recovery wellness planning, advocacy, education, and accountability. The WARM Program CHW/RCs are compliant with confidentiality requirements related to substance use disorders and protected health information. The program uses proper consents when navigating resources, including, but not limited to, the criminal justice system, child protective services, treatment services, and many other community-based services. Working alongside clients, CHW/RCs provide connection support and ensure follow through.
The North Country Health Consortium (NCHC) is a non-profit public health organization based in Littleton, NH that collaborates with health and Human services providers serving northern New Hampshire. For more information about the Wellness And Recovery Model (WARM) and other NCHC programs supporting substance misuse prevention and substance use disorders, visit NCHCNH.org.
 The other states are West Virginia (52.0 per 100,000) and Ohio (39.1 per 100,000) (Centers for Disease Control and Prevention, 2017).
 Narcan (naloxone) is a drug used for the complete or partial reversal of opioid overdose.
 New Hampshire Information & Analysis Center, 2018
 New Hampshire Information & Analysis Center, 2018
 Rural Health Care Services Outreach Program, Notice of Funding Opportunity, 10/17, page 3.
 HRSA Data Warehouse: https://data.hrsa.gov/tools/shortage-area/hpsa-find