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Assessing Community Needs to Combat the Opioid Epidemic in Washtenaw County, Michigan

Marquez, Juan Luis MD, MPH; Loveluck, Jimena MSW; Marshall, Jessie Kimbrough MD, MPH; Power, Laura MD, MPH

Author Information
Journal of Public Health Management and Practice: May/June 2021 - Volume 27 - Issue - p S174-S178
doi: 10.1097/PHH.0000000000001316

Abstract

There are multiple efforts to combat the opioid epidemic that has afflicted the United States over the past 30 years. Many of these are at the national and state levels but local jurisdictions also play a key role in combating opioid misuse among community members. Washtenaw County, a county in Southeast Michigan with a population of approximately 350 000, has seen an increase in opioid misuse with the number of opioid-related overdoses doubling from 3 every week in 2015 to 7 every week in 20171 and resulting in more than 2229 potential years of life lost in 2015,2 exceeding that of cardiovascular disease in the same time period.

In response to this increase, in 2013, a coalition of health care, community organizations, and community members in Washtenaw County formed the Washtenaw Health Initiative Opioid Project (WHI-OP). The efforts of this coalition were patterned after Project Lazarus3 (www.project lazarus.org), a program focused on community engagement and based on 2 overarching assumptions: (1) overdose deaths are preventable, and (2) communities are responsible for their own health. Project Lazarus is organized in a hub-and-spoke model with the hub being the core components (public awareness, coalition action, data and evaluation) and the spokes being the additional components (community education, provider education, hospital emergency department policies, diversion control, pain patient support, harm reduction, addiction treatment).4 Using this model, the WHI-OP formed multiple work groups that regularly met to address issues including addiction treatment, community education, and hospital policies among others.

Methodology

In 2018, after 5 years, the WHI-OP proposed a reevaluation of its efforts and community needs using both surveys and interviews of stakeholders. To support this, a Health Resources & Services Administration–funded preventive medicine resident (author J.L.M.) was deployed to work with the WHI-OP. The resident's work was incorporated into the full-time required block rotation at the Washtenaw County Health Department and extended into a continuity experience throughout the practicum year of the residency program. Preventive medicine physicians are trained to address complex public health problems, such as the opioid crisis, by applying a public health approach, implementing community-based prevention programs, and evaluating the success of such programs.5 Competencies acquired during residency include systems-based practices that align with assessing the needs of a population, including the use of epidemiologic methods to analyze data and improve program planning.6 In addition, a preventive medicine resident can provide workforce support to facilitate the needs assessment process, which can be very time intensive.

The preventive medicine resident created survey questionnaires in consultation with experts in the WHI-OP and modified the questions to ensure clarity and face validity. Stakeholders were chosen on the basis of past work with WHI-OP. The preventive medicine resident electronically distributed surveys (see the Table) to 2 groups of stakeholders: providers and community organizations. Providers in health care organizations were asked to describe challenges in providing care to patients with opioid misuse (including treatment of conditions not related to opioids, addiction treatment, and pain management). Community organizations were asked to describe the types of services provided and barriers they faced in providing these services to the community. The survey responses were compiled and analyzed for common themes by the preventive medicine resident using a manifest content analysis approach.

TABLE - Survey Questions
Survey Questions—Providers
Question 1: What is your specialty?
Emergency medicine
Hospitalist
Primary care
Subspecialty (please specify)
Physical medicine rehabilitation
Surgery
Anesthesia
Dentistry
Other (please specify)
Question 2: Do you experience any challenges with providing care to patients due to opioid-related issues?
Yes
No
If yes, please explain
Question 3: Do you experience challenges with patient care in regard to pain management?
Yes
No
If yes:
Acute
Chronic
Both
Question 4: Do you experience challenges due to limited or lack of addiction treatment programs for patient referral?
Yes
No
If yes, please explain.
Question 5: Do you experience challenges due to limited or lack of pain management clinics/services for patient referral?
Yes
No
If yes, please explain.
Question 6: Do you experience challenges due to health insurance coverage restrictions for non–opioid-based pain?
Yes
No
If yes, please explain.
Question 7: Do you believe that providers have limited knowledge on the opioid epidemic?
Yes
No
If yes, please explain.
Question 8: Do you believe that providers have limited knowledge on the current opioid-prescribing guidelines?
Yes
No
If yes, please explain.
Question 9: What role should providers and the medical community have in addressing the opioid epidemic?
Policy advocacy
Obtaining continuing medical education (CME) on patient care related to opioids
Survey Questions—Community Organizations
Obtaining CME regarding pain management
Utilizing Michigan Automated Prescribing System
Obtaining additional training in addiction medicine and/or treatment for opioid addiction (ie, medication-assisted treatment, eg, Suboxone, Vivitrol, and methadone prescribing)
Participating in local opioid epidemic-focused coalitions
Patient education
Community education
Other (please describe)
Question 10: General comments
Question 1: What is the name of our organization/program that provides opioid-related services?
Question 2: What specific opioid services or activities are your organization/program engaged in? Please choose all that apply.
Addiction and treatment
Community education
Provider education
Provider prescription policy
Diversion control
Patient pain support
Harm reduction
Naloxone training and/or administration
Other (please specify)
Question 3: Which of the following age group(s) does your opioid-related organization/program target? Please choose all that apply.
Neonates
School-aged youth
Young adults
Adults
Seniors
Question 4: What geographic area do you serve in Washtenaw County? Please choose all that apply.
Urban
Suburban
Rural
Other (please specify)
Question 5: Please tell us about any other important details about the population that you serve?
Question 6: Do you evaluate the effectiveness of your opioid-related program/services?
Yes
No
Question 7: Which of the following are a focus of your evaluation? Please choose all that apply.
Process measures (eg, assessment of protocol adherence)
Outcome measures
Client/customer/patient satisfaction
Other (please specify)
Question 8: Which of the followings methods are you using for your evaluation? Please choose all that apply.
Focus groups
Key informant interviews
Surveys
Other
Question 9: Is there anything else you would like to tell us about the evaluation of your opioid-related program/services?
Question 10: How do you receive payment for services rendered to the individuals you serve? Please choose all that apply.
Health care insurance reimbursement
Third party (eg, community mental health, community mental health partnership of Southeast Michigan, or other prepaid inpatient health plan [PIHP, etc])
Sliding scale free
Donations
Grant funding
Other (please specify)
Question 11: What are the biggest barriers your organization/program faces in addressing the opioid epidemic? Please rank the following choices with 1 being the largest barrier and 5 being the smallest barrier.
Limited funding
Limited knowledge/awareness
Competing priorities
Lack of support from external organizations (eg, private agencies and/or public authorities/agencies)
Other (please specify)
Question 12: Are you a member of the WHI Opioid Project
Yes
No
Question 13: What type of activities do you believe that Washtenaw Health Initiative (WHI) Opioid Project should be engaged in?
Question 14: General comments

Face-to-face interviews were carried out by the preventive medicine resident with individual stakeholders who have been involved with WHI-OP efforts. This included large, multidisciplinary addiction treatment centers; addiction medicine clinicians; housing services; members of the faith community; local government; local schools; law enforcement; judicial system; the business community; and individuals in recovery. These interviews were modeled after the Maryland Behavioral Health Administration Opioid Misuse Prevention Program (OMPP)7 key informant interview templates. The OMPP is based on the Strategic Prevention Framework and provides a tool kit to conduct all aspects of the framework including the needs assessment.

In addition, although not part of the preventive medicine resident's project, individuals currently using opioid opioids, in treatment, or in recovery were surveyed separately by other members of the WHI-OP project to evaluate availability of treatment services and any barriers/stigma that they encountered related to their opioid use. These responses were also incorporated into the needs assessment and strategic plan.

Throughout the process, the preventive medicine resident received guidance and feedback from the local health department medical director and rotation preceptor (author J.K.M.) and the deputy health officer and cochair of the WHI-OP (author J.L.). Overall, the resident worked on this project for approximately 1 year, with developing and conducting the surveys and interviews and analyzing the findings.

Results

Provider surveys were completed by 154 providers. The major themes that emerged from the provider survey were (1) providers experiencing challenges caring for patients due to use of opioids, (2) difficulties with patient pain management and lack of addiction treatment programs, (3) lack of pain management services, and (4) confusion about the evolving opioid-prescribing guidelines released by the state of Michigan.

Community organizations were completed by 55 individuals from 32 distinct organizations. Themes that arose from the community organization survey were (1) multiple challenges in delivering services related to limited resources, (2) competing resources, and (3) limited awareness of their services. When asked about support that was needed from the WHI-OP, themes included increasing community awareness and education, advocacy, and increasing access to services.

Twenty-five face-to-face interviews were completed (2—large, multidisciplinary addiction treatment centers; 3—addiction medicine clinicians; 2—housing services; 2—members of the faith community; 3—local government; 2—local schools; 4—law enforcement; 2—judicial system; 2—business community; and 3—individuals in recovery). Themes that arose from individual face-to-face interviews included the need for more resources overall and specifically the need for access to treatment services. In addition, a general overarching theme was the need, and request, for WHI-OP to help coordinate the existing programs and services to better serve the population.

Discussion

After the surveys and individual interview themes were analyzed, the WHI-OP leadership met several times to narrow down the most salient needs that were presented. These included (1) community education and primary prevention; (2) options for pain management; (3) better tools for providers to communicate with patients who are currently using or in recovery; (4) managing care for patients with opioid use disorder within Michigan-prescribing guidelines; and (5) increasing access to treatment. This needs assessment, as well as the underlying methodology, was presented to the larger WHI-OP group for approval. To ensure that these needs reflected the larger Washtenaw County community needs, the finalized draft was presented at the 2018 Washtenaw County Opioid Summit. This summit is held annually by WHI-OP. It is free of charge to the community members. During an interactive session, community members met in small groups to provide feedback on the needs assessment that was ultimately incorporated into the final assessment.

Development of strategic plan

Using the needs assessment as a foundation, the WHI-OP met over the course of several months to develop a strategic plan for the collaboration. One of the needs that was uncovered but not specifically addressed in the assessment was the need for better collaboration and coordination among the various providers, community organizations, and individuals. To address this, WHI-OP proposed not trying to provide all the services directly. Rather, the group would focus on supporting and monitoring efforts in the county, where appropriate, to help coordinate efforts. In addition, the WHI-OP would engage in the development and maintenance of a repository of community information that all organizations could access to improve this coordination. The strategic plan, “2019-2022 WHI Opioid Project Proposed Roles and Key Activities,” is included in the Supplemental Digital Content, available at https://links.lww.com/JPHMP/A753.

Implications for Policy & Practice
  • Addressing opioid misuse requires a coordinated effort from multiple stakeholders; the work is time intensive but is important for developing a meaningful community strategy.
  • Needs assessment should take into account both quantitative and qualitative data to provide a full understanding of the community priorities.
  • Frameworks and tool kits, such as the OMPP, are available to assist organizations and public health agencies in conducting a needs assessment.
  • Preventive medicine physicians have unique skill sets to support the mission of local health departments and other organizations, with competencies5 that include
    • engaging with community partnerships to address health problems;
    • conducting program and needs assessments and prioritizing actions;
    • identifying organizational stakeholders and processes;
    • communicating effectively with a broad range of audiences; and
    • developing policies and plans to support individual and community health efforts.

Conclusion

The process of gathering data through multiple channels from varied stakeholders including community organizations, providers, and key informants is time intensive. This is also true for analyzing the data in multiple iterations and presenting them to different stakeholders. The inclusion of all individuals and organizations in the planning process allows for a better understanding of the needs and ultimately a more successful implementation of the programs and services. With the additional support of the preventive medicine resident, the WHI-OP was able to conduct an in-depth needs assessment with input from key stakeholders and to determine the direction for future work in prevention of opioid misuse.

References

1. Waller A. Opioid Related Overdoses and Deaths of Washtenaw County Residents. Vol 4. Ypsilanti, MI: Washtenaw County Health Department; 2018. https://www.washtenaw.org/ArchiveCenter/ViewFile/Item/425. Accessed July 13, 2020.
2. Waller A. Opioid Related Overdoses and Deaths of Washtenaw County Residents. Vol 3. Ypsilanti, MI: Washtenaw County Health Department; 2017. https://www.washtenaw.org/ArchiveCenter/ViewFile/Item/422.
3. Albert S, Brason FW II, Sanford CK, Dasgupta N, Graham J, Lovette B. Project Lazarus: community-based overdose prevention in rural North Carolina. Pain Med. 2011;12(suppl 2):S77–S85.
4. Project Lazarus. https://www.projectlazarus.org/. Accessed September 12, 2020.
5. Jung P, Lushniak BD. Preventive medicine's identity crisis. Am J Prev Med. 2017;52(3):e85–e89.
6. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in preventive medicine. https://acgme.org/Portals/0/PFAssets/ProgramRequirements/380_PreventiveMedicine_2020.pdf?ver=2020-06-30-144631-400. Published July 1, 2020. Accessed January 15, 2021.
7. Opioid Misuse Prevention Program (OMPP). https://bha.health.maryland.gov/OMPP/Pages/Home.aspx. Accessed September 12, 2020.
Keywords:

needs assessment; opioid misuse; substance use disorder

Supplemental Digital Content

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