E8: Community Engagement

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

As we’ve explored on OnePath, the doctors, nurses, pharmacists, and other medical professionals on the scene at MetroHealth play an integral role in addressing the needs of those with substance use disorders-- But without the social workers, patient advocates, and peer supporters available to those in the community seeking help with their recovery, MetroHealth would not be fully serving their patient population.

One of the people at Metro making a huge positive impact on the lives of those in recovery is Lisa Fair, who serves as the External Forensic Coordinator for the ExAM-- standing for Expanding Access to Medication Assisted Treatment-- Program out of the Office of Opioid Safety. The ExAM Program is carried out within the Cuyahoga County Corrections Center in Downtown Cleveland.

LISA: Our major function is to identify people who have opioid use disorders that's currently serving time in the Cuyahoga County Jail. Once we do an assessment for that person and determine that they do have an opioid addiction and they will be a good candidate for our program, we then have another person come in and do another assessment. We have an internal forensic coordinator as well that talks to that person. And then we have a nurse practitioner who comes in and does a medical assessment to determine if the person would respond better to Vivitrol or Suboxone.

My job is to make sure that people are connected with a medical provider to maintain and continue their medication once they get out of jail, and also to help them get enrolled in any intensive outpatient treatment, other concerns that they may have. Connect them to any other ancillary services just to help them maintain their sobriety while they're out of jail. I keep track of those people for six months, helping them in any way that they need as far as medical attention, anything that involves their addiction.

Upon a client’s release, Lisa’s first priority is to ensure that they have an appointment booked with a medical provider as soon as possible.

LISA: Most times they have a prescription, abridged prescription when they get out for seven days. That gives me enough time to make sure they have a subsequent appointment. Make sure that they're on the road to participating in some type of intensive outpatient treatment, a group of some sort. We suggest that they go to at least three AA meetings a week. I help them find a convenient AA meeting. [inaudible 00:05:16] Always call me when they get finished with any appointment just to follow up to make sure everything went smoothly.

MetroHealth’s partnership with Lyft is both logistically convenient and emotionally impactful for patients, ensuring that they actually get to the appointments that have been booked for them… and that they feel good about it.

LISA: I mean, that gives them a sense of they're really kind of in control over what's going on with them. They feel good that a car is coming to get them. They don't have to walk through the neighborhood to get the bus. They don't have to be on the bus with people who may be offering them drugs. So, we make sure they get a ride there and a ride back.

It's amazing how many clients I have that's never used the Lyft or an Uber. That gives them a sense of some importance. I deserve to be in this car. I'm being driven to my appointment and it makes them feel good about themselves. I like that.

Lisa gets to know her clients before they’re released from jail. To her, developing a good rapport with a client is essential to ensuring that they feel comfortable with her, and ultimately, utilize her as a resource. Once a client has been released, Lisa is on call to assist and support them nearly around-the-clock.

LISA: They may call me for any number of things, but by the time they get out, they know our whole staff. We basically turn our clients over from one to another, so they know everyone. I'm the last person that they encounter before they get out. But once they get out, I'm the first person that they should call. So, that means sometimes people are really anxious to talk to me, so my phone may start to ring at 7:00 AM.

I have people that call me sometimes on a daily basis when they first get out because they feel like I'm just a strong support system. They feel like they can trust me telling me things that maybe they wouldn't tell anyone else. So, it's an odd day. I get calls all day on my work phone. I enjoy my work immensely. So, I don't have a time that I stopped working necessarily.So I do a lot of different things during the course of a day. I talk to PO officers a lot, try to advocate for the patients, because of course, we understand that when someone has an addiction, it's not always easy sailing. Someone may have a little slip or something. So, I'm always trying to advocate for my clients in that way.

Lisa is, without a doubt, an excellent advocate for her clients. A big part of her philosophy centers around giving folks as many chances as they need to achieve sobriety. There are former clients of hers that had to start up with the ExAM program two or three times, following multiple jail sentences, before they were able to sustain a sober lifestyle-- but the important thing is, they finally reached that goal.

LISA: It may take longer, some people may take longer, but we shouldn't count anyone out.

A significant challenge was tasked to Lisa and her team at the beginning of the Covid-19 pandemic when hundreds of inmates were abruptly released from prison to prevent overcrowding. 200 of those inmates were potential clients.

LISA: So, me and my counterpart, had a lot of work on our hands at that point, because people were calling us. Even if they didn't call us, we tried to locate those people to try to filter them into the correct treatment that they needed. A lot of people needed inpatient treatment, but we didn't have a chance to do an assessment to determine that. So, we found that a lot of people got out and just didn't want to talk to us at all and a lot of people started using. So, when we were trying to locate them to help them, a lot of them had a capias, which means that they have a warrant for their arrest. They thought that we were the enemy, because they didn't know who we were.

So, I had to start off conversations sometimes saying, "This is Lisa from the ExAM Program," then they would talk to me, but if I didn't lead with that, they would hang up. So, that was one of the things and then not being able to see them and not being able to maybe meet them at an appointment or certain things that I would do before a call, but I couldn't do it. So, that was a lot. That was a lot. I was really busy. When everybody was on quarantine, I was really busy. I work from home for a while. I had full days every day.

A lot of people don’t understand how violently ill a person can become while in withdrawal from opioids: sometimes, this leads Lisa to refer clients to the ED.

LISA: We always use every MetroHealth facility that's available to us. So, we make a lot of referrals to Parma and to the Broadway on location. Those two locations help us a lot with maintaining people's medical system treatment and they have IOP groups at both locations.

We also have intensive outpatient at the main hospital. So, we're always making referrals within our hospital system if we can. If not, we have community relationships with many other treatment facilities. We also use St. Vincent Charity Hospital sometimes for detox. We have multiple inpatient treatment facilities that we use for men and women. I know a lot of community agencies and people that run those agencies to help with jobs, education, shelter, food. So, we're interested in a person holistically. We try to help them in every way that we can. So, the more community partners we have, the better. I'm always looking for people that I can connect with to help our clients and offer them ancillary services, anything that they need.

Lisa and her team aren’t just advocating for their clients through one-on-one interactions with them and providing interpersonal support, but also by playing a role in Cuyahoga County recovery court and drug court.

LISA: We work very closely with both of those judges, which is Judge Matia and Judge Synenberg. Judge Matia is drug court. Judge Synenberg is recovery court. They have both invited us to sit in their debriefings and talk about clients individually, because most of the clients that participate in drug court or recovery court, the newer ones, we've dealt with them. It's good for both of us. It adds to the relationship that everyone has with the client because we can share information.

A lot of the judges look for advice or recommendations on what we think should happen with people who have addictions like inpatient treatment versus outpatient treatment, or going to prison versus maybe going to community-based treatment facility like CBCF or something like that. So, we're able to speak to a lot of those issues. I find that a lot of the judges and different people in the court system really rely on us now.

When we go and sit in on their meetings and they update every week about what's going on with clients, we can speak to maybe we know something. Maybe they've stopped going to the IOP groups or whatever. That can help us understand why a client may have some different issues that they didn't have prior to. We also get a chance to go and speak on behalf of the clients in the courtroom, which is very interesting. The judges asked us to come up and specifically talk about the interactions we've had with the clients and what we suggest.

Of course, the team’s main objective is to help the client. Generally, they don’t recommend sentencing anyone to prison, especially if that person hasn’t had the opportunity to go into a long-term treatment program or inpatient treatment facility. Lisa and her team believe in a rehabilitative approach to helping folks get clean, not a punitive one.

LISA: They use jail as a punishment. That's not rehabilitative to me at all. That's just sweeping things under the carpet. Had so many people tell me that they've learned really bad habits and have used more drugs in prison than out of prison. So, we have to consider. I don't think that jail is necessary the answer to addiction issues.

I've worked with people who are living with AIDS and HIV. I've also worked with, like I said, people who have addiction issues. I've done a lot of community work around prevention in both areas. I think that a lot of people don't understand that people who have mental health issues sometimes self-medicate, because they don't know any other way to deal with things like everyday problems or everyday struggles that they've had.

When people start to use illicit substances to treat mental health issues, especially if they're young, that's all they know. And then that causes other problems, of course, with maybe stealing to get the drugs, not being able to work consistently, not following rules and laws. So, that that brings in a whole another component.

I think we've had a system that is very... It doesn't tolerate any type of missteps or whatever. Most people who have substance use disorder and mental health disorders have suffered a lot of trauma. A lot of people don't get a chance to really discuss that. A lot of people are operating in a world and they don't even know why they respond to things the way they do. The only way to bring that out is to have some therapy, to have someone that is willing to spend time with you and put the puzzle together.

It’s hard for Lisa to ignore the ingrained inequalities she encounters in her work, specifically when it comes to the treatment of Black Americans caught up in the criminal justice system and the systemic issues that contribute to their incarceration in the first place.

LISA: African Americans suffer disproportionately in this country. They suffer in so many different ways. I mean, it's a known fact that the jails are full of African American people who maybe shouldn't be there, but most of the time, they haven't really had a chance in life. So, there's a lot of things that I think we need to look at as far as incarcerating people.

I do understand that Black people suffer in this country, but I also understand why people also suffer in this country. So, if I'm put in a position where someone needs my help, I'm going to help that person. That's my responsibility in life as one human being to another. That's one thing. There's a lot of different conversations that can come from everything that's going on in the world now and I'm very happy that we're having them or starting to have them at least.

When I work in drug and recovery court, the participants are 98% Caucasian. I don't see Black people. A lot of people don't understand that 98% of the people that have opioid addictions in this country now is Caucasian. A lot of people don't know that, nor do they think that's true. Reason being that in the past, a lot of people were given prescription drugs, which then turned into an opioid addiction. Of course, on the street, heroin is much cheaper than pills. So, there are ways and means for us to help these people who have opiate addictions.

I've lived through the crack epidemic, the AIDS epidemic. I've lived through a lot of epidemics that affected Black people in the communities. I didn't see all of these things take place as far as help for addiction issues. Saying that, I think that blaming and talking about it isn't going to help anything. I think a lot of things need to happen now, since we are being made aware of a lot of issues that need to be fixed. As I said, I don't have an issue with the people that I serve in drug court or recovery court, but I do notice it's just a big difference. I think there's something wrong with that.

Another pocket of community engagement for those living with opioid use disorder exists within the system of Thrive Peer supporters available to patients both in the Emergency Department of Metro and in the county jail.

LISA: Every person that we interact with in the ExAM Program has a Thrive peer supporter for the most part. The inmates really look forward to Thrive coming and talking to them. One of the stipulations to being a Thrive peer supporter is you would have had to have an addiction issue yourself. So, this offers a lot of continuity with the inmates as far as understanding the Thrive peer supporter. They offer them all kind of support.

They take them to meetings, maybe able to take them to doctor's appointments. I like to talk about that too. That's something that I missed out, but just basically there to help them through the tough times. We have a really good rapport with their Thrive supporters for the men and women for the women, which I think is good. That helps me a lot once an inmate is released from jail, because we then have meetings and talk to their peer supporters and compare notes. So, we'll know if someone's lacking in the area, if they need help in an area that maybe is more my wheelhouse and I can really help. The Thrive peer supporter can see where they can help more. They pick that up.

Avril Chuppa has been a Thrive Peer supporter since 2017 and takes great pride in her work.

AVRIL: By definition peer support is sharing a lived experience in order to provide that care and compassion between two individuals to help one another succeed. So sharing that lived experience and then the peer supporter having the know how and the resources to help the individual going through a difficult time….

Especially me in the ED, and my team, we see people who have just overdosed or have just been through some terrible trauma, they're not going to always be pleasant. But because we have that experience and have been there in that situation, we're able to understand where they're coming from. We understand why they're angry or they're sick or they're exhausted or tired and we understand why they may not trust those people that are trying to help them.

Avril says that a lot of her role as a peer supporter consists of providing assistance with tasks and obstacles that can be particularly difficult or triggering for those early on in their recovery.

AVRIL: For example, anybody that's been to the DMV knows that's it's probably very stressful and nobody likes it. People without substance use disorder or mental health, people without those things and don't suffer from those things get stressed at the DMV, so a person who has substance use disorder or experience mental health they don't necessarily ... It's hard for us staying in line and to deal with the stress and the overwhelming nature of the DMV or filling to job applications or just putting one foot in front of the other, it can just be hard. So our peer supporters in the community, hold their hands throughout that time. Set the scene, let them know like, "Hey, we're going to be in the DMV for about two hours," or "We're going to drive around to a lot of places today and apply for jobs these things are going to be hard, but you're never going to have to do this alone. I'm with you," and that in itself is such a relief to our clients.

In Avril’s experience, early recovery was a challenging and confusing time: peer supporters now exist to make that less of a reality for those working towards sobriety.

AVRIL: I got lost a lot and overwhelmed and hopeless a lot, and so what's amazing to see is that when our clients are working with their peer supporter, it's not so overwhelming, and they don't feel lost and they don't give up. Whereas, before, you'd have like a counselor or say you got in trouble, and you're in the court system, and the courts say, "Okay, you have to go get an assessment," that's a very overwhelming process. Especially, if you go do a walk in at one of the outpatient facilities. You're in line, they're asking you questions like, an assessment, they ask questions of, "How much do you use a day and at what age did you first start using and what amount did you start off using," and those questions in themselves can be very frustrating.

A lot of people are like, "I don't know. I don't know," and so having that peer supporter by their side, letting them know like, "Do your best, answers the questions as best as you can." You know, Thrive Peer Support just helps bridge that gap that a lot of people tend to fall into and tend to become unmotivated to continue their recovery.

Thrive peer supporters are available at MetroHealth, in-person, 24 hours a day, seven days a week. Once a doctor obtains verbal consent from a client, the doctor can send for a Thrive Peer supporter to come down, receive a debriefing on the client’s situation, and then speak with that person face-to-face.

AVRIL: We always come down prepared with our contact information and some resources in case the client decides they don't want to speak with us, that way, they at least have somewhat of a connection. But more often than not, the people that we're referred to, they want help and so we go down and we give our spiel, if you will. Mine usually goes, I usually go in very kind and gentle, trying to practice that trauma informed care. That's one of the things that we learn about when we're getting our certifications is trauma informed care, motivational interviewing, the stages of change. And so I go in and I just gently introduce myself. I say, "Hi, my name is Avril. I work with Thrive Peer Support. I'm contracted here at Metro. Everybody I work with and work for, the majority of us all have a history of substance use disorder and we're here to help you. You don't have to be alone in this. Is this something you'd like to do?"

And that’s when a client will start sharing their story with Avril. She says that peer support is oftentimes just listening, hearing the needs of the client, and assessing barriers they’ve come across in their road to recovery.

AVRIL: And as a peer supporter, I'm validating their concerns. I'm validating their emotions and their feelings, because that's what I needed. And then I present the options to them and I let them know, "Hey, there's all these things that you have access to."

If somebody comes in and they don't have insurance and they meet eligibility for Medicaid, we're able to assist them in getting presumptive Medicaid so that we can connect them with a treatment facility or a lot of the times, the ADAMHS Board, if you're a Cuyahoga County resident, we can use the resources that the ADAMHS Board will cover, so that's like for insurance. If somebody doesn't have an ID, a lot of treatment facilities will accept any kind of photo ID, in some cases mug shots. We get pretty creative. A lot of people don't want to go somewhere because of clothes or because they have a pet at home, I mean any situation, we do our best to try to figure it out and just conquer all those barriers.

After a treatment plan is created for a client, they are encouraged to make their own decisions about their recovery, with significant support from Thrive and the team at Metro.

AVRIL: After that is completed, we then move onto the coordination phase and that's where we work very closely with the doctors and the nurses and the social workers. We all work out those barriers and the logistics.

And if they're going somewhere in Cuyahoga County, we order an uber and we go with them to the treatment facility in Cuyahoga County. We make sure that when they walk in, that they're supported and while they're waiting to be seen, we continue a conversation of hope and encouragement and we don't leave their side until we know they're saying. That they're safe, that they're comfortable, and that they're content. We don't leave their side, until that's the case. And also throughout that process, we're talking about our community program and a lot of our clients get very excited about that, knowing that, "All right, what you just experienced here isn't just going to stop here. We're going to be with you until you tell us that you don't want us anymore. We're going to go along with you through every step of this until you're walking on your own two feet again."

One of the primary goals of Thrive Peer Supporters is to make sure that their clients never feel alone in their recovery process-- as Avril said, clients will be supported until they’re 100% confident that they no longer need it. In the face of Covid-19, Thrive kept their work as consistent as ever.

I mean for our community peer supporters, they were able to use Telehealth and thrive. We have done everything that we could to make sure that our clients don't feel alone. As far as the ED, I mean, we never stopped going down to the ER. We've continued to meet with clients face to face, follow the correct PPE and everything like that, but we haven't stopped. Governor DeWine deemed us essential and so we haven't slowed down and fortunately a lot of the resources that we use didn't slow down either.

We've never really had the gap of not being able to help people. We were able to reach out and network and understand, okay, what facilities are not accepting clients anymore, what facilities are and we stayed up to date with that so that we didn't skip a beat and so that nobody could be turned away. I mean throughout COVID-19, I think we've just been able to just and continue and really attack that loneliness that's come with COVID-19.

We came at it with a force and encouraged our peer supporters to be mindful that this is a lonely stressful time. And so all of our peer supporters kept that in mind and made sure that our clients were taken care of.

Occasionally in her work as a peer supporter, Avril will come across a patient who resists fully committing to recovery. While this choice is, of course, up to the patient, Avril has a strategy she employs with those who aren’t so sure about what they should do next.

AVRIL: If somebody says, "You know what, I'm not ready to start my recovery today," especially like when we're in the ER, I remind them. I'm like, "Well, let's think about your today. You woke up, you shot up heroin, what you thought was heroin. You overdosed. The friends that you were using with stole everything that you had and you cracked your head on the floor from going out. You were revived, thank goodness, and now you're back in our ER, what do you think tomorrow's going to look like?" Is the question I ask somebody.

And "Are you looking forward to tomorrow? Do you think that you'll ever look forward to the next day? Is there something I can do to help you look forward to the next day?" And then I also share my, that's where I share my experience." I share how I thought everybody who was trying help me, I thought I could always get one over on them by telling what they wanted to hear and then doing another thing instead. So telling them I will go to treatment or I will go to treatment tomorrow or making up all these excuses and reasons and then not following through. I'd share my experience with that and how I always thought I was getting one over on that person trying to help me until I realized I was only fooling myself. And I bring up that point to our clients and that's the motivational interviewing in combination with sharing your experience that can really change somebody's mind, even if they thought it was very made up, so it's really cool.

Avril says that when you’re a peer supporter, transparency is of paramount importance.

AVRIL: ...Peer support is so unique is because we're able to professionally share our own experience. And I mean, a lot of the times, that's key and that's really what builds trust.

A lot of people that come to the hospital, especially if you haven't really lived life above board, so to speak, we all tend to get into some trouble and we're doing things that aren't always legal. So a lot of people that come to the hospital, they're afraid that they're going to get the police called on them, that their probation officer and parole officer are going to find out. I mean, they're very scared to say anything. I was. I commend a lot of the clients that I see in the ER, because when I would go to the ER, you couldn't pay me to tell you about my addiction.

I make it clear like, "We're not here to make life more difficult for you. That's not why we're here," and we wouldn't do that.

Avril has had dozens of incredibly impactful conversations and interactions with those pursuing recovery through her work with Thrive, but there was one young woman whose situation has really stuck with her.

AVRIL: I get emotional even thinking about it. There was a girl who had been sleeping in the hospital and she was pregnant and she had been staying at the hospital because her significant other was staying there and she did what she thought was helping him by bringing in what they needed by bringing in heroin and trying to feed their habit. And she got caught by the Metro Health police and the Metro Health police ... called me and asked me to come down to, at first, it was just to kind of help them identify she had a lot on her.

So to kind of say what's what, but most importantly, he didn't have to, but he did. He asked her if she wanted to help ... The Metro Health police officers see us all the time running around the hospital and they know what we do and they keep us safe but they also help us do our job a lot of the time and so he asked me to come talk to her and I went down and I spoke with her and I told her who I was. And, her and I, she shared her story and I shared mine and we related a lot. She was afraid of leaving the guy that she was with. She was very scared and I was telling her about how I was like, "We can go inside right now and we can start your life over now."

We just sat outside of Metro Health on a bench for about two hours and I walked her inside. She was so afraid of being sick. She was so afraid of how her relationship would be like, and what it would be like with being on her own and she felt like she couldn't go to her parents. I just held her hand and we went up to labor and delivery…

She got a sonogram and there's just this little baby in her, just swimming all around. I mean this baby was going nuts and she was debating on what choice she was going to have to make. And I told her that you have our support that you're not alone with this. So she got admitted and a lot of the times for expecting moms… the first night is the hardest because I don't think that they can give you as much as one would like. So the first night's the hardest, so the team and I just surrounded her in support and I would go and visit her every day and she would look better every day and she wanted to go to further treatment.

And I worked so hard to make sure she could find somewhere where they would take her being expecting and take her having Subutex. Just we talked every day and I was so proud of her, because she didn't leave after that first night. A lot of times mothers leave because it's so hard and she stayed and I was able to get some clothing donations for her and then she was so happy because she could go take a shower and she was doing her makeup. And she agreed, she went to treatment.

This woman moved to a new city, relatively far away, but…

AVRIL: I checked in on her not that long ago and she's still doing great and she decided to keep the baby and she's happy. And so when I think about that, her parents got her back. That baby is healthy and happy and all of that happened and it all started in a jail cell in the hospital. So it's ...I don't know what would've happened if Metro Health police didn't ask her if ... I don't know what would've happened if Thrive Peer Support wasn't there or somebody like us wasn't there. I don't know if she would've ever felt comfortable enough to share what she shared with me.

Avril has learned A LOT through being a peer supporter: new skills, but also, new things about herself and her own power to impact change.

AVRIL: I've learned how to kind of be a social worker. I've learned how to be a financial counselor. I've learned how to be just everything, a food bank, a clothing store. I mean, I've learned how to do all these things. I've learned how to talk to pharmacies and advocate and I mean, just the education I've received is… It's so cool.

When I have that conversation of hope and encouragement and I come across somebody in the ER that I'm referred to, and they've come in from the worst situation, and I'm able to get them clothes, get them set up to go to a wonderful treatment facility, and help them get a start at a brand new life, I mean as soon as they get in that van or whatever means of transportation, it's a whole new experience for me. It's the most exciting thing, I get so excited thinking about what their life is going to be like and how it's not just the one person we're helping in that situation. That person has loved ones in their lives that have tried everything that they could to help that individual, and now they're also relieved.

...I never thought what I already was doing in my personal life, helping others, I never thought that I could have a career in that and the blessing that that's been, when I come to work, I never thought I would have a job where I could be so passionate about I do, and believe so wholeheartedly in what we do. It's just the biggest blessing.

Next time on One Path…

We check in with the Office of Opioid Safety’s education team.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.