In this month’s installment of the Innovation of the Month series, we explore Guilford County’s Solution to the Opioid Problem, which aims to address opioid overdoses and opioid-related deaths through intervention and social programs.
MetroLab’s Ben Levine and Stefania Di Mauro-Nava spoke with Terri Shelton, vice chancellor for research and engagement at the University of North Carolina, Greensboro (UNCG); Jim Albright, director of Emergency Services for Guilford County; Stephen Sills, professor and director at the Center for Housing and Community Studies at UNCG; Chase Holleman, program navigator for GCSTOP and co-founder of CURE Triad; Guillermo Tremols, syringe exchange coordinator at GCSTOP; Melissa Floyd-Pickard, department chair at UNCG's Department of Social Work; and Ken Gruber, senior research scientist at the UNCG Center for Youth, Family and Community Partnerships, to learn more.
Ben Levine: Could you please describe what the Guilford County’s Solution to the Opioid Problem is? Who is involved in this effort?
Terri Shelton: The Guilford County Solution to the Opioid Problem (GCSTOP) serves residents of Guilford County, N.C. The program was initiated through funding provided from the State General Assembly to Guilford County’s Emergency Services for the purpose of addressing the county’s increasing incidence of opioid overdoses and opioid-related deaths. The funding was used to support the development and initial implementation of a Rapid Response Team intervention which is designed to prevent repeat overdose and to counsel persistent users to enter treatment or adopt evidence-based harm-reduction practices.
The program serves some of our community’s most vulnerable populations: people who have overdosed and others who are at high risk for opioid-related mortality. The program engages these individuals in harm-reduction practices, distributes and trains community members and high-risk populations on the use of naloxone, conducts community health education, coordinates community resources with other community partners (such as CURE Triad), operates mobile and fixed-site syringe exchange programs, and builds relationships focused on ending opioid overdose. The program is administered by UNCG'S Department of Social Work. It leverages ties to many academic units at UNCG that provide technical expertise, medical advice, social and human services capacity, and social science research.
There are a number of partners in the community working together on this effort, including: CURE Triad, Guilford County Emergency Services, Guilford County Health Department, other Guilford County offices, UNCG, Cone Health System, the faith community, treatment providers, law enforcement, Guilford County Commissioners and the North Carolina state legislature.
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Chase Holleman, GCSTOP program navigator coordinator, and Guillermo Tremols, Syringe Exchange Program coordinator, during outreach. Courtesy of Martin W. Kane, UNC Greensboro
Levine: Can you describe the challenges related to opioids in Guilford County?
Stephen Sills: Like many communities, Guilford County was struggling with the growing opioid epidemic. There were over 700 overdoses and 180 deaths from opioids in Guilford County in 2017. Around the same time, the North Carolina General Assembly was preparing to allocate funds to communities to battle the opioid crisis. Jim Albright, director of Guilford County’s Emergency Services, was contacted by a representative from the state legislature to see if Guilford County had a need for such funding. This call aligned with local conversations among county agencies, UNCG and CURE Triad regarding this growing epidemic.
Jim Albright: I remember the uptick in overdoses and deaths in 2014 and 2015. In the last weekend of April 2014, we had 24 overdoses, of which five were deaths, in a 24-hour period. Paramedics were running out of naloxone supplies because so many patients were in need and we needed to find a more effective approach. As the death toll continued to climb, it became apparent that we had to have a paradigm shift in the way we were treating folks. Simply responding to the call and reversing the overdose and then trying to provide some street-side counseling just was not enough.
CURE Triad, I and others had already been meeting to create a more unified approach to address addiction in the county. Based on those community conversations, I proposed to use bipartisan funding from the state Legislature to provide overdose survivors with harm reduction, addiction treatment and other services using a Rapid Response Team modeled after a similar program in Colerain, Ohio, and I reached out to UNCG. To me, this seemed like an absolutely perfect fit. There is capability within the university community that we felt like we could leverage.
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Ken Gruber, evaluator; Melissa Floyd-Pickard, chair of the Department of Social Work; and Jay Poole, UNCG SW, coordinator of Congregational Social Work Program — at College Park Baptist Church GCSTOP Clinic. Courtesy of Martin W. Kane, UNC Greensboro.
Shelton: As a Carnegie Foundation-designated research and community-engaged university, UNCG is actively engaged in the region addressing issues of community significance, such as the growing opioid epidemic. Part of that commitment was working directly with Albright. Initially, UNCG’s efforts were coordinated by Dr. Stephen Sills, director of UNCG’s Center for Housing and Community Studies. Stephen, a Guilford County native, had seen the social media posts about old friends who have died of drug overdoses and wanted to find ways to make a difference.
Chase Holleman: I’d also been working to find a better way to address substance use. Some folks we contact really would like to go to treatment, they've just been waiting for an opportunity. They have no idea how to get to treatment. I co-founded CURE Triad to find a way to reduce the stigma and fear that comes with being an addict. The first visit and first contact is all about building rapport, establishing trust and a relationship with that person and ensuring their safety.
Shelton: In response to the need and the strong community partners, and with the funding from the legislature, GCSTOP began in 2018. At the same time, UNCG was exploring with the county the possibility of applying to be part of MetroLab Network, with GCSTOP being one of the three projects to be launched as part of that effort.
Stefania Di Mauro-Nava: What have been some of your initial findings and how have they shaped the project?
Albright: GCSTOP has had some initial success but it is clear that this has to be a long-term commitment to a different way of doing business and not just a time-limited grant or one-and-done project. This project reinforced an Emergency Medical Services view that in order to prevent overdoses and deaths, we need a community-based, integrated approach that blends evidence-based practice with practice-based evidence. We know that approaching people moments after their drug overdose has been reversed isn’t the right time. Instead, a more effective approach is for paramedics to ask patients if they’re willing to have someone reach out to them within 72 hours of an overdose. If they sign a release, then Chase and the GCSTOP reaches out.
Guillermo Tremols: Meeting a person where they are involves understanding their situation and respecting their perspective on their situation. It involves active listening and authentic engagement. It is not about trying to execute changes that we think they need. It’s about finding out what changes they want to make and assisting them in achieving those goals.
Melissa Floyd-Pickard: Another change was thinking about the long-term sustainability of UNCG’s efforts. We moved the coordination of UNCG’s efforts to our Department of Social Work to leverage the department’s expertise, to ensure a focus on the role of the complex social determinants of health issues, to leverage the resources of students and to address future workforce development needs.
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Jim Albright, director of emergency services, speaking with a community member. Courtesy of Martin W. Kane, UNC Greensboro.
Di Mauro-Nava: How are some of the initial findings being used and implemented?
Albright: The percent of suspected overdoses ending in death dropped from 18 percent in 2016 to 11 percent in 2018, with 2019 on track to be lower. However, the total number of overdoses in the county continues to increase. We hope that the new measures, like restrictions on how many pills doctors can prescribe and closed legal loopholes related to lab-brewed fentanyl analogues, will help, but we haven’t seen the impact yet.
The initial rapid response team has morphed into a Post Overdose Response Team that started with EMS referrals solely, and now has a syringe exchange and hepatitis C bridge counselor coordinating in-field blood draws by EMS personnel. Persons in active drug use see little opportunity for sobriety, and facilitated interactions with clients can lead to positive change. The program also works to bridge divides between people that use drugs and the public safety community by reducing stigmas toward people that use drugs and educating those people about public safety.
An analysis of successes and challenges also led to a change in methods, expansion of services and the addition of new partners. The initial focus was on mobile outreach but has shifted to safer “pop-up” clinics at businesses including a new site at College Park Baptist Church, staffed by a behavioral health nurse, GCSTOP staff and social work students, that provides health screenings and referrals as well as opioid-use focused services.
Ken Gruber: Part of the partnership is an ongoing evaluation and continuous quality improvement process, bringing together quantitative data, research on evidence-based practices such as harm reduction, along with the key stories and qualitative data from community partners, survivors and their families. This ongoing tracking is key to garnering and keeping funding and can help expand successful practices to other communities.
These data have guided the changes outlined above: methods (mobile to safer pop-up clinics); partners (outreach to treatment providers and churches); services (health services and not just addiction treatment and harm reduction); and funding (initial state funding augmented with county funding, foundation funding and federal grants).
In addressing workforce development needs, the Joint Master’s in Social Work program at UNC Greensboro and North Carolina A&T State University received a $1.1 million Health Resources and Services Administration opiate workforce expansion grant. Students in UNCG’s undergraduate and graduate social work programs are required to do internships to gain practical experience before they graduate. These internships allow GCSTOP to help more people.
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Social work graduate student Bryan Kendrick (left) conducts GCSTOP follow-up visits with Guilford County Sheriff’s deputy Harold Farlow. Courtesy of Martin W. Kane, UNC Greensboro.
Levine: What was the most surprising thing you learned during this process?
Albright: We have really started to learn the power of motivational interviewing and in the importance of celebrating incremental positive change in a client. This carries over to patients with other chronic diseases. The Syringe Exchange Program is also seeing a significant amount of use by clients that have not had an EMS encounter.
Floyd-Pickard: Most surprising thing to me personally is how different aspects of opiate addiction and recovery are from other addiction work I have done.
Holleman: The tragic surprise of GCSTOP has been the sheer magnitude of the problem. Having referred over 1,000 people within a year, we have hardly scratched the surface. There are many more folks in Guilford County who could utilize our services. The traditionally overserved population is who we are missing. We can find the folks who are homeless and transient. It is the people who are in the shadows we cannot find. Those who have careers, school and mortgages. They are better able to keep their use a secret.
Di Mauro-Nava: Where will this project go from here?
Albright: We would like to expand services to include a formalized and funded justice-involved component to work with clients that are incarcerated and at high risk of overdose on discharge (and others leaving residential conferment), as well as expand opportunities to treat post-overdose survivors with a “medication-assisted treatment” option.
Shelton: We hope to continue to learn from research, our data, our community partners, survivors and their families about what works and what doesn’t to keep reducing and eliminating deaths but also reduce and prevent overdoses. We also hope to add simultaneous services that are closer to the actual overdose like ER consults, low threshold medication assisted treatment and wrap services.
Holleman: I see GCSTOP growing into a program that serves people that use any drug, including alcohol. I anticipate this unique partnership allowing GCSTOP to provide life-saving medications to the people we serve right off the back of a decommissioned ambulance. I see a recovery community center in Guilford County's two major towns that provides full spectrum services that can address social determinants of health for our members in partnership with many other county nonprofits. A data dashboard will be created that can share information between law enforcement, the university, emergency services, the local hospital chain, treatment providers, the health department and the jails in real time. GCSTOP will ramp up community education on drug use and equip them all with information and skills to address substance use. GCSTOP will grow into an important county resource that becomes a line item in the budget facilitating proper growth and ceasing the growth limitations associated with grant funding.
