Putting Down the Bottle

Paul Gilbert is studying how problem drinkers quit without help from rehabilitation programs.

When alcohol consumption causes so many problems that a person decides to quit drinking, some will turn to clinical rehabilitation for help, but others will just put down the bottle and never pick it up again.

Paul Gilbert is interested in those who go cold turkey and how their experiences can provide insight into alcoholism in general. Gilbert, assistant professor of community and behavioral health in the University of Iowa College of Public Health, is studying people in eastern Iowa whose drinking was causing so many problems in their lives that they quit, but did so without entering a clinical treatment program.

EXPLORING PATHS TO RECOVERY

An expert on adult alcoholism who has conducted numerous studies about problem drinking, Gilbert plans to talk to 30 Iowans about their success quitting drinking. Using interviews and surveys, he’ll ask about their life history, their drinking patterns, what prompted them to quit drinking, and how they did it.

Gilbert is conducting this study as preparation for his next major research project, which will explore different paths to recovery. He will recruit a national sample of 600 former problem drinkers and assess how they define recovery, the degree of “recovery capital” available to them, and the various strategies they used to resolve their problems without treatment. Recovery capital refers to the quantity and quality of internal and external resources that a person has to initiate and sustain recovery from addiction.

Gilbert’s goal is to determine whether there are differences in successful strategies for recovery between men and women or by race/ethnicity. The initial Iowa study will provide preliminary information.

He also hopes the lessons learned ultimately will lead to more ways to minimize the harms from drinking even without clinical treatment.

A VARIETY OF STRATEGIES

Gilbert says the number of problem drinkers who use clinical rehabilitation programs after they make the decision to quit drinking is smaller than people might expect, only about 10 to 15 percent. Many of the rest use some sort of support program, such as a 12-step program. Many others use no program at all and just quit drinking.

Ultimately, Gilbert’s goal is to find out how some people can quit without clinical assistance and how their experience might help others who need help. For instance, the data might show that certain types of people benefit from earlier intervention or a different model of intervention. Some could benefit simply from guidance about moderation rather than complete abstinence.

Gilbert already has interviewed a dozen respondents, and though it’s too soon to draw conclusions, he found people use a variety of strategies to quit drinking. Some attend a 12-step program and continue to use it; others started by attending a program, then leaving when their drinking was controlled; yet others just said they were going to stop drinking or reduce the frequency of their drinking and did so with no assistance.

WHY PEOPLE QUIT

In all of his research, Gilbert says he’s found one important consistency in the reason the people wanted to quit in the first place.

“A family crisis or the role of a relationship,” he says. “Sometimes they quit because of a health crisis or a work crisis too, but most often the abrupt change is the result of a relationship. Maybe the person they were in a relationship with threatened to leave them; maybe they’d lose custody of their kids. But losing a relationship often prompts people to make a change.”

He hopes to answer one important question: Do people who quit on their own see quitting differently than people who go through rehab?

“It seems a lot of people who don’t get treatment have a more flexible view of recovery,” he says. “Maybe it doesn’t involve abstinence, so they allow them-selves to keep drinking as long as it’s at low level, or they drink only during special events.”

This story originally appeared in the fall 2017 issue of InSight.

Culture, Connection, and Recovery

Native American powwow dancer

Tribal communities are pushing back against substance abuse with culturally relevant approaches.

In 2012, Brooks Big John spoke to tribal, state, and federal leaders about the devastation the misuse and abuse of prescription painkillers was causing his community. Big John, at the time the tribal chairman of the Lac du Flambeau tribe in Wisconsin, described  the growing toll of overdose deaths, including  that of a lifelong friend: “He ended up sucking  out morphine patches, to the point where he  eventually overdosed and died.”

He went on to illustrate the desperate measures people took to obtain drugs. “We had a guy who was sleeping in the ceiling of the tribal center building where the clinic was, six or seven hours until everything closed, so he could break into our clinic and steal these pills.”

Big John delivered his comments at the “Tribal Prescription Drug Abuse Summit:  Moving from Information Sharing to Action Plan” held in Bloomington, Minnesota. The need for such a gathering was identified by tribal leaders, who had expressed concerns about an increase in the use and abuse of prescription drugs in American Indian communities. The summit was convened by the Substance Abuse Mental Health Services Administration (SAMHSA) in collaboration with the National American Indian & Alaska Native Addiction Technology Transfer Center (AI & AN ATTC), the Great Lakes ATTC, and other federal, state, and tribal health agencies.

CULTURALLY RELEVANT APPROACHES

National surveys show that substance abuse rates are consistently higher among American Indian/Alaska Natives than other racial groups. The 2013 National Survey on Drug Use and Health shows that 12.3 percent of American Indians were current users of illicit drugs, compared with 9.5 percent of whites, 8.8 percent of Hispanics, and 10.5 percent of African Americans.

Anne Helene Skinstad, program director of the National AI & AN ATTC in the CPH Department of Community and Behavioral Health, says that the rates are likely much higher, noting that data are underreported or not reported at all by tribes due to mistrust of federal agencies.

There is also a hesitancy among tribes to engage in evidence-based treatment practices, Skinstad adds. “Psychosocial treatment and medication are Western methods and not culturally informed,” she says. “They are met with reluctance and concerns.”

To make treatment practices culturally relevant, the center spends time with tribal communities and translates the essence of evidence-based practices, Skinstad explains. “We want to respect tribal sovereignty, and we let the tribes decide how they want to implement the practice in a culturally informed way.”

CONNECTING TO CULTURE

In 2013, Lac du Flambeau tribal leaders, including Big John, declared a state of emergency and a “War on Drugs” in the community. Working with law enforcement, courts, schools, elders and spiritual leaders, and others, the community wrote a three-year strategic plan to address the substance abuse crisis, pool local resources, and secure funding.

Although Big John no longer serves on the tribal council, he remains an active community leader. According to Big John, the tribe has addressed the selling of illicit drugs, reduced gang involvement and violence, and strengthened tribal statutes to allow law enforcement to increase safety efforts. The tribe also received support from SAMHSA and the Robert Wood Johnson Foundation to build their own treatment center, allowing tribal members to receive treatment sooner, remain in their community, and connect to their culture. These steps create a sense of belonging, a protective factor for substance misuse.

Culture played a key role in the “State of Recovery,” Big John’s term for progress made over the last few years. The community, already grounded in prayers, gatherings, songs, and Big Drum ceremonies, engaged traditional leaders to support recovery efforts, revitalize language programs, and hold “Wellbriety” pow-wows to widen the “Healing Circle.”

Youth participate in collecting wild rice and making reed mats to connect with their culture. The community also held a youth gathering to offer opportunities for their voices to be heard.

“We need our youth to heal from the oppression they’ve experienced and never forget who they are. Cultural identity is key for our prevention efforts,” Big John explains.

However, numerous barriers remain in tribal communities. “If you’re driving two hours for methadone maintenance treatment every day, how can you hold a job?” Skinstad asks. “Many communities still don’t have access to naloxone (an opioid overdose-reversal drug), so there are fatal overdoses that could be prevented.”

A VISION FOR CHANGE

Many tribal communities are developing action plans to address the opiate problem. Some of the initiatives include distribution of emergency overdose kits, providing secure drop-off sites for unused prescription drugs, and establishing hotlines for those wishing to quit drugs or report traffickers.

“What came out of the summit was a model for the country,” Skinstad notes. “Following the symposium, we held conference call meetings for tribal leaders who wanted to implement a plan in their communities. They are still active. We gave communities tools, they discussed them with their elders, then they implemented them successfully.”

Pushing back against the opioid epidemic is long and hard work, but Big John encourages communities to be patient. “We didn’t get here overnight and the changes we want to make won’t happen overnight, but we are saving lives,” he says. “Good things come when people have the same vision.”

This article contains material written by Connie O’Marra, MSW, of the Training and Technical Assistance Center, that originally appeared in the September 2016 issue of the National AI & AN ATTC newsletter. O’Marra is a close collaborator with the National AI & AN ATTC and a trainer for the center.

This story originally appeared in the fall 2017 issue of InSight.

Reversing the Tide

illustration of breaking opioid addictionResearchers and advocates outline priorities for responding to the opioid epidemic in Iowa.

States and communities across the nation are grappling with how best to respond to the surging opioid crisis. In April 2017, the UI Injury Prevention Research Center (IPRC) sponsored a meeting in Des Moines to identify priorities for addressing the opioid epidemic in Iowa. The meeting was part of a larger national project funded by the Centers for Disease Control and Prevention, with the UI IPRC being one of four injury centers in the country participating in the grant.

Carri Casteel, IPRC associate director, led the meeting to discuss recommendations developed by the John Hopkins Center for Injury Research for reducing the opioid epidemic in several areas, including prescription monitoring programs, prescribing guidelines, overdose education, and community-based prevention. One goal of the meeting was to review these evidenced-based strategies and compare them to what is happening in Iowa.

“It was an opportunity for those working in fields affected by opioids to take an inventory of our successes and to identify gaps specific to Iowa that need to be addressed to move forward on this issue,” Casteel says.

Stakeholders at the meeting represented law enforcement, psychiatry, emergency medicine, public health, nursing, non-profit/advocacy, poison control, substance abuse treatment, pharmacy, insurance, drug control policy, elected officials, and others.

IDENTIFYING IOWA’S PRIORITIES

Among the barriers stakeholders identified were lack of training for health care providers on opioid addiction and treatment, lack of timely state data on opioid supply and overdose, and limited and unequally distributed addiction treatment services in Iowa.

The top five priorities for Iowa that stakeholders identified were:

  1. Provide physicians with evidence-based training in pain management and opioid prescribing.
  2. Educate physicians, nurses, pharmacists, and other practitioners to recognize patients at high risk for opioid abuse and addiction.
  3. Make the Iowa Prescription Monitoring Program a more accurate and effective tool.
  4. Strengthen opioid overdose surveillance and prescription opioid monitoring among multiple organizations and agencies.
  5. Improve health coverage for medical-assisted treatment and evidence-based behavioral interventions.

IPRC published the report “The Prescription Opioid Crisis: Policy and Program Recommendations to Reduce Opioid Overdose and Deaths in Iowa” that contains details about  the five priorities, county-level statistics on opioid overdose death rates and prescribing practices in Iowa, along with highlights of initiatives in Iowa communities that have had some success in slowing the epidemic. The report is available online at cph.uiowa.edu/iprc.

The report was sent to Iowa policy makers and other state leaders, and the proposals were discussed with a legislative interim study committee tasked with evaluating Iowa’s response to the opioid epidemic. This committee submitted a report with its findings and recommendations to Iowa Gov. Kim Reynolds and the general assembly to inform possible action during the next legislative session.

REDUCING HARM AND STIGMA

Community-based prevention efforts that focus on education, advocacy, and harm reduction strategies are also garnering attention. The national organization Harm Reduction Coalition defines harm reduction as “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. … Harm reduction incorporates

a spectrum of strategies from safer use, to managed use, to abstinence, to meet drug users ‘where they’re at,’ addressing conditions of use along with the use itself.”

Kim Brown of Quad Cities Harm Reduction
Kim Brown

“Much like substance use, harm reduction has a long but stigmatized history,” says Paul Gilbert, CPH assistant professor of community and behavioral health. “People often thought it was too permissive or even encouraged drug use. But high-quality, rigorous evaluations have shown that harm reduction strategies are associated with substantial benefits, such as fewer wounds and abscesses, reduced hepatitis and HIV infections, and lower risk of overdose and death. Given the scientific evidence that’s accumulated, it belongs in our repertoire of public health responses to substance use.”

Kim Brown of Davenport, Iowa, is president and co-founder of Quad Cities Harm Reduction (QCHR). She helped form the nonprofit organization after losing her 33-year-old son Andy to an unintentional heroin overdose in May 2011.

“All of these overdose deaths are preventable,” says Brown, who is a registered nurse. “Addiction is a medical disorder. It should be firmly entrenched in public health. As long as we criminalize a medical condition, we have shame and stigma. We need true, realistic drug education.”

Andy’s death was shrouded in stigma, Brown recalls. “Nobody would talk to me about what happened to my son. But I wanted to do something to bring awareness to the community and legislators and law enforcement.”

INCREASING NALOXONE ACCESS

Brown has been advocating since 2012 for increased naloxone access in Iowa. Naloxone is a medication administered as a nasal spray or injection to reverse the effects of an opioid overdose.

In late 2016, a new Iowa law coupled with a standing order issued by Dr. Patricia Quinlisk, Iowa Department of Public Health Medical Director, allows naloxone to be purchased at a pharmacy without a prescription. Pharmacists are authorized to dispense naloxone to individuals at risk of opioid overdose, a family member or friend in a position to assist an at-risk person, and first responders.

More recently, University of Iowa emergency medicine physician and CPH alumnus Chris Buresh (12MPH) provided a standing order that allows QCHR and the Iowa Harm Reduction Coalition in Iowa City to dispense naloxone without prescription to Iowans at little to no cost. The standing order went into effect June 1, 2017.

But Brown would like to see even more done. “The state needs a standing distribution order to community and harm reduction organizations. We need a syringe exchange program to prevent people from getting HIV or hepatitis C and to keep used needles out of public bathrooms and off the ground.

“We need to get naloxone to the folks who really need it,” she continues. “Overdoses are often reversed by friends and family. I can’t have my son back, but I can help others keep their children alive.”

Related stories:

The Growing Opioid Crisis
Iowa’s Opioid Epidemic

This story originally appeared in the fall 2017 issue of InSight.

Iowa’s Opioid Epidemic

needle and opioid pillsThe college is tackling Iowa’s increasingly deadly opioid crisis with a multidisciplinary response.

Despite its relatively small population, Iowa is not immune from the opioid epidemic. While prescription drug overdose deaths and rates of opioid prescribing are low in Iowa compared to other states, rates of prescription opioid deaths since 1999 have quadrupled in Iowa, making it only one of four states with such a dramatic increase. Reflecting national trends, the state is also seeing rising rates of heroin deaths.

“Heroin overdose death rates in Iowa have increased more than nine-fold in the past 15 years,” says CPH Associate Professor Carri Casteel, associate director of the UI Injury Prevention Research Center (IPRC). “The rapid growth of heroin death rates in Iowa is two to three times higher than the national average.”

A SECOND CHANCE

Laura McCaughey of Davenport, Iowa, was almost one of those overdose death statistics. McCaughey was introduced to heroin at age 16 by a boyfriend and was soon hooked. “Drug dependency gets out from under your feet before you know it,” she says.

She barely graduated from high school and dropped out of college after one semester. She job-hopped and acquired a criminal record, finding herself stuck in the same cycle for four years even though she sought treatment several times. “Nothing would stick,” McCaughey says.

Heroin addiction nearly took her life. “I OD’ed five times,” she says, recalling how she’d wake up in hospitals throughout eastern Iowa. “Every time my record got worse because I was found with drug paraphernalia.”

In October 2012, at the age of 20, McCaughey was jailed for possession of heroin and drug paraphernalia after being pulled over by Davenport police. “My parents wouldn’t bail me out because they knew I was safe there,” McCaughey says. “I had no stability, I didn’t have anything. I was just defeated.”

McCaughey credits the judge who heard her case for giving her a second chance. “She told my parents, ‘She’s not a criminal, she needs help.’ The judge let me out on the condition that my dad immediately drive me six hours to a treatment facility in Sioux City.”

The treatment stuck, and in 2013 McCaughey returned to Davenport to restart her life. Now 25, McCaughey is working full-time, pursuing a degree in psychology, and raising her two-year-old daughter. “She’s the light of my life,” McCaughey says.

PARTNERING ON A RESPONSE

Laura McCaughey
Laura McCaughey

McCaughey’s story underscores the complexity of opioid abuse and the importance of involving many partners and resources in responding to the crisis.

In November 2015, IPRC co-sponsored the summit “Heroin and Opioids: A Community Crisis.” The event, hosted at the College of Public Health, brought together more than 200 experts to discuss the heroin and prescription opioid epidemic plaguing eastern Iowa.

IPRC also has conducted research on prescription opioid and heroin overdoses and overdose deaths in Iowa using state death certificate records (2002–2014) and insurance claims data (2003–2014). Among the key findings:

  • The rate of prescription opioid overdoses in Iowa increased from 2.1 /100,000 in 2003 to 8.8 /100,000 in 2009. This rate declined to 5.1/ 100,000 in 2014.
  • In Iowa, prescription opioid overdoses and overdose deaths are decreasing, while heroin overdoses and overdose deaths are increasing.
  • Those ages 25 to 49 make up the majority of all opioid-involved overdose deaths in Iowa.
  • Males make up the majority of deaths from both prescription opioids and heroin.

IPRC also met with key stakeholders in Iowa to identify priorities to address this growing crisis in the state (see page 6).

MULTIDISCIPLINARY APPROACHES

College of Public Health researchers are taking a multidisciplinary approach to addressing opioid use and addiction in Iowa.

“We’re doing work on risk factors for overdose and dependence, and thinking about patterns of use,” says Ryan Carnahan, CPH associate professor of epidemiology. Investigators are also looking at patterns of long-term prescription opioid use, especially in conditions unlikely to benefit from it. Future work may involve in-depth evaluations of prescribing patterns for different health conditions.

Natalie Langenfeld, a doctoral student in biostatistics, is conducting research that applies infectious disease modeling to study the path of opioid addiction in communities over time (monthly) and space (Iowa’s 99 counties). The model incorporates data on prescription rates, demographics, overdose death records, possession arrests, distribution and manufacturing arrests, and treatment data. Ultimately, the model can be used to evaluate interventions as new data are made available.

The Iowa Institute of Public Health Research and Policy (IIPHRP) and the CPH Research Office have convened a broad group of researchers from across the university, including public health, pharmacy, and medicine, to identify teams interested in opioid research.

“Bringing together multidisciplinary teams generates new ideas and initiatives that will inform practices and policies related to this important topic,” says Vickie Miene, IIPHRP interim director.

OPEN CONVERSATIONS

McCaughey encourages more open conversations about opioid use. “If five people are in a room, probably three know someone who is affected by addiction,” she says. “The more we talk about it, the quicker we’ll find solutions and save someone’s life.”

McCaughey is vice president of Quad Cities Harm Reduction, a nonprofit organization working to save the lives of those struggling with substance use disorders. She remains strongly motivated to help others caught in drug dependency.

“I want to be a source for people to come to if they’re ready to be clean, or whatever is going on with them. Addicts are so alone,” McCaughey says. “I didn’t die for a reason. I want my daughter to be proud of me. I want to have a good ending to my story.”

Related stories:

The Growing Opioid Crisis
Reversing the Tide

This story originally appeared in the fall 2017 issue of InSight.

The Growing Opioid Crisis

Both urban and rural areas are awash in opioids.

The United States is struggling with a worsening opioid epidemic. Since 1999, the number of overdose deaths involving opioids (including prescription painkillers and heroin) quadrupled. Every day, 91 Americans die from an opioid overdose and more than 1,000 people are treated in emergency departments for misusing prescription opioids, the Centers for Disease Control and Prevention reports. The numbers continue to trend upward. In 2015, there were more than 52,000 drug overdose deaths in the United States. That number grew to an estimated 64,000 overdose deaths in 2016, according to provisional data compiled by the National Center for Health Statistics.

The current epidemic of drug overdoses began in the 1990s, driven by increasing deaths from prescription opioids that paralleled a dramatic increase in the prescribing of such drugs for chronic pain, according to a CDC report. In recent years, as health care providers have become more cautious in prescribing opioids, other illicit drugs—including heroin and synthetic opioids such as fentanyl—are driving sharp increases in overdoses and deaths.

“This issue affects all of Iowa,” emphasizes Carri Casteel, associate director of the University of Iowa Injury Prevention Research Center, which is taking part in a CDC-funded project on preventing overdoses. “Our research shows deaths from prescription opioid overdoses are concerns in both urban and rural counties in Iowa. We also found high doses of prescription opioids are dispensed in both rural and urban parts of the state. It crosses all borders.”

College of Public Health researchers from across disciplines are collaborating to provide data about the opioid crisis in Iowa and develop policy and program recommendations to prevent overdoses.

“There’s a lot of interest in Iowa around prescription opioids, heroin, and fentanyl,” says Casteel. “We have many stakeholders—law enforcement, physicians, and others— looking for better ways to communicate ongoing efforts and share data to address the crisis.”

Related stories:

Iowa’s Opioid Epidemic
Reversing the Tide

This story originally appeared in the fall 2017 issue of InSight.

 

Gilbert receives New Faculty Research Award

A portrait of Paul Gilbert, assistant professor of community and behavioral health at the University of Iowa College of Public Health.Paul Gilbert, assistant professor of community and behavioral health, has been selected to receive a College of Public Health New Faculty Research Award of $10,000. The grant funding will be used for a project titled “Natural Recovery from Alcohol Use Disorders in Southeast Iowa.” The project will be funded for the 2017 calendar year.

The purpose of the New Faculty Research Award is to assist CPH primary faculty in collecting preliminary data or pilot studies leading to larger projects.

Project Description

The majority of people in the United States with an alcohol use disorder (AUD) do not receive treatment, and some social groups, such as women and racial/ethnic minorities, are less likely to receive help than their male and White counterparts, respectively. Nevertheless, as many as three-quarters of those with AUD will achieve remission without treatment. This paradoxical phenomenon of unassisted self-change, known as natural recovery, has been long recognized by alcohol scholars but remains poorly understood.

Research over the past three decades has identified a number of factors associated with natural recovery, such as individual psychosocial characteristics, interpersonal networks, individual health status and health events, and environmental circumstances. In turn, these findings have been applied in a wide variety of intervention trials to promote natural recovery, often with only modest success in reducing problematic drinking. Such limited effectiveness may be due to incomplete understanding of the processes at work.

Further, there has been scant attention to variability of this phenomenon. Only one study to-date has examined effect modification by gender, finding differences in the psychosocial and interpersonal factors associated with natural recovery between men and women. To the researcher’s knowledge, there has been no reported investigation of differences between racial/ethnic groups, despite criticism that many early studies of natural recovery relied on overly homogeneous, predominantly White samples.

In response, this study will use qualitative methods to elaborate the processes of natural recovery among White, Black, and Latino men and women in southeast Iowa.

The specific aims of the project are:

  • To identify and characterize the process of natural recovery among adults who have not received treatment for alcohol misuse.
  • To determine the most productive recruitment strategies to reach adults who have experienced natural recovery.

The study’s preliminary data will be used in support of a larger, subsequent study to examine natural recovery.