Acacia Network, the leading Latino integrated care nonprofit in NY, began in 1969 to address the consequences of heroin in the South Bronx. Our founding leaders, Carlos Pagan, Julio Martinez, Gumersindo Martinez, Hector Diaz, Evalina Lopez Antonetty, and Lorraine Montengreo, among others, understood then that the social determinants of health and sparse attention dedicated to the Latino and other communities of color demanded a comprehensive health, community empowerment, and economic intervention. Their pioneering vision inspired our current integrated array of services across 38 programs, including primary care; outpatient and residential behavioral health services for substance abuse and/or mental illness; over 5,000 units transitional, supportive, and affordable housing; a skilled nursing facility for people with HIV; academic enrichment and supports; several wraparound support services; and eight senior centers providing meals, social and cultural activities.
The opioid epidemic has devastated communities. As a result of prescribing practices in the late 1990s, a shifting philosophy of pain management, followed by intense pharmaceutical industry lobbying the epidemic’s foundation was set. Over the last several years, Acacia Network identified three key strategies to successfully address the rising opioid epidemic—change the culture of treatment and clients’ treatment expectations, address stigma and fully engage the community in program design and implementation, and employ “no wrong door” and open access by integrating substance use assessment, MAT, and naloxone training and kits into every service access point.
Changing the Health Care Culture and Patients’ Treatment Expectations
Beginning in 2008, our substance use outpatient and residential treatment programs recognized that MAT was a critical option. Residential programs included people prescribed methadone, ensuring transportation to local clinics for their medication; and the client- peer support group engaged in understanding options to reduce stigma and improve recovery. This integration strengthened the recovery milieu in contrast with expectations.
In the Spring of 2014, the early onset of the current epidemic’s consequences resulted in four nonfatal overdoses in one program location. Instead of over focusing on increased security, a community engagement initiative was started. Staff, community members, and clients worked together to identify problems, gaps, and solutions. The action steps included employing peer ambassadors, training staff in naloxone, increasing client education on opioids, expediting integrated primary and behavioral health care, engaging and educating the community, and increasing partnerships with the local public safety professionals. This had an immediate impact and no further overdoses have occurred at that location.
In March 2016, the CDC’s Guideline for Prescribing Opioids for Chronic Pain report was published. Subsequently, Acacia aligned internal prescribing standards by quickly instituting a policy to limit all opioid prescriptions to seven days and require an in-house pain management referral for follow-up and continuing treatment. To effectively change the prescribing culture among medical staff, the new policy was widely disseminated and discussed in regularly-scheduled meetings and reinforced through written communications. In addition, medical assistants, nursing staff were trained to review toxicology reports to improve clinical decision making.
Shifting patient expectations proved equally as important. Building on the 2014 initiative, the Network began utilizing “iStop”, an internet-based prescription monitoring program to identify patients receiving medications from multiple sources. Medical staff engaged patients in more informed and effective treatment conversations, including treatment alternatives. All patients are issued “controlled medication contracts” outlining their responsibilities including self-management. Contracts are reviewed at each medical appointment to promote collaborative discussion regarding treatment modification. Additionally, medical provider and patient education on naloxone stepped up as an important harm reduction strategy, and has been implemented in transitional and supportive housing and mental health clinics. All staff are trained and most carry naloxone kits.
Addressing Stigma and Engaging the Community
In 2014, Acacia Network’s Hispanics United of Buffalo (HUB) opened its licensed outpatient substance use treatment program and methadone clinic. The agency’s experience in opening a treatment facility was not unlike other organizations’ in terms of drug user stigma and strong community resistance. HUB’s Executive Director, Geno Russi, implemented a four-pillar strategy to generate and maintain community acceptance and support: 1) seek to understand stigma and accept the community concern; 2) respond through continual education sharing community statistics, and trends; 3) promote respectful culture and train clients, family members, and staff; and 4) maintain high intensive community involvement.
Early in the planning process, HUB leadership spent time listening to the community’s concerns about opening a treatment facility and its impact on the community. Rather than ignore or dismiss these concerns, HUB staff regularly attended community meetings, actively participating in discussions and providing literature to counter misinformed beliefs. The ultimate goal was to put a face to the epidemic, and develop positive community partnerships to address related problems together. To advance community support, HUB implemented the “Good Neighbor Policy”, which trains clients to be productive community members, engage in volunteerism, maintains tobacco free and no loitering zones outside the clinic, uses facility perimeter cameras, and employs non-armed security guards trained in de-escalation to conduct foot and bicycle patrols. The Police Department’s Crime Analysis Unit completed a crime study covering the two-year period prior to and following the clinic’s opening and found crime had decreased by 40%.
Integration of Opioid Treatment Services
Opioid interventions must cast a wide net to truly address the epidemic. Acacia also focuses on prevention through its Strengthening Families Program (SFP), a highly structured, evidence-based family skills training. The program aims to delay substance use onset for children, teach skills to resist social pressure, increase family stability and well-being, enhance parent-child bonding, and teach appropriate consequences for behaviors.
In direct response to the community Acacia Network’s Buffalo methadone treatment program is open from 6:00 AM to 9:00 PM and Albany’s is open until 6:00 PM, with unlimited capacity. Buprenorphine and Vivitrol are available, and the clinics are pursuing integrated licensure for wrap around care.
Across all primary care and mental health clinics, Acacia Network incorporates the evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) intervention. Each primary health care site employs the evidence-based Nurse Care Manager model to treat and manage opioid addiction. (D. Alford, et al, Five Year Experience with Collaborative Care of Opioid Addicted Patients using Buprenorphine in Primary Care, 2011) Through this model, a nurse is responsible for all aspects of buprenorphine/naloxone and naltrexone treatment—intake assessment, induction, stabilization, maintenance, and relapse management—and leading integrated care plan meetings with a client’s care team. A mobile outreach team engages individuals living in the shelter system through patient education and on-site screening, and linkage to primary care and behavioral health services. Under a newly-awarded Substance Abuse & Mental Health Services Administration (SAMHSA) grant, Acacia Network is working with the NY State Office on Alcoholism and Substance Abuse Services (OASAS) and the National Center on Addiction and Substance Abuse on a demonstration project aimed at increasing access and better integrate care, and provide better care coordination between methadone treatment programs, FQHCs, and mental health clinics.
Recognizing that there is no single solution to the opioid epidemic and that the pharmaceutical companies and medical profession must take joint responsibility, there is hope. Acacia Network encourages the health and social service sectors to continuously expand a multi-faceted approach to increase access to and engagement in treatment. Towards that end, Acacia is spearheading the Bronx Collective Impact Project to leverage current resources, close care gaps and improve transitions, address stigma and social isolation, and ensure community members are integral voices and decision makers in all activities. The kick-off meeting included representation from City Government, Health Care, Substance Abuse Treatment, Harm Reduction, Criminal Justice, Managed Care, Foundations, Clinical Laboratory, Elected Officials, Research Organization, Pharmaceuticals, and community members. Through strong community partnerships and client relationships together we can identify ways to strengthen the approach.