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Opioids Strain Health Workforce

BHW's Division of Nursing and Public Health hosted a conference earlier this month that posed a stark warning on the effects of the opioid crisis on local health providers.“It is imperative that we have an adequate health care workforce prepared and well placed to address this crisis,” said CAPT Sophia Russell, director.
The HRSA Bureau of Health Workforce Division of Nursing and Public Health hosted a conference earlier this month that posed a stark warning on the effects of the opioid crisis on local health providers.“It is imperative that we have an adequate health care workforce prepared and well placed to address this crisis,” said CAPT Sophia Russell, director.
 

In the mountainous region of Coal Country, long known as ground zero in the opioid epidemic, West Virginia for many years has led the nation in the ill effects of narcotic drugs – from spiraling death rates to fetal addiction.

Now comes a new concern: Much of West Virginia's health workforce is exhausted, said Angela Gray, Director of Public Health Nursing in Berkeley County, west of Harper's Ferry.

Years of health care shortages and a rapidly aging population – together with the sheer volume and pace of overdose emergency calls, ER admissions and hospitalizations – have coarsened many first responders, police and whole communities, she said in a National Public Health Week presentation at HRSA headquarters.

Hospitals and clinics are facing a widely reported crisis in nursing so severe that "we're importing them from out of state" on short-term contracts, Gray said. Exacerbating the shortage, local nurses frequently burn out in treatment facilities and leave for less stressful and better-paying healthcare jobs.

"Everyone sees the numbers.
On the ground level,
I see the faces."

 Angela Gray

HRSA has invested more than $400 million in the state since 2015 – including some $9.4 million in health workforce training and development awards last year alone. West Virginia grantees also received $8.2 million in opioid response funding in 2018.

"Of course (many people) are getting cynical," Gray said of her friends, neighbors and colleagues. "All they've seen, day in and day out, (is) going into homes where children are performing CPR on their parents." Multiple emergency calls from the same addresses on the same day or week are not uncommon, she added.

Paul Sacco, Associate Dean for Research at the University of Maryland School of Social Work, who trains young students in addiction counseling under a HRSA workforce grant, said what's happening in West Virginia is emblematic of hard-hit counties, cities and towns nationwide.

  Overburdened: Even in states like Maryland, which has a relatively advanced opioid strategy, demand for rehab services often exceeds local workforce capacity and facilities, said researcher Paul Sacco.
Overburdened: Even in states like Maryland, which has a relatively advanced opioid strategy, demand for rehab services often exceeds local workforce capacity and facilities, said researcher Paul Sacco.

 

In Baltimore, which accounts for about a third of all opioid deaths in the state, for example, the local population of people misusing the drugs is estimated at some 25,000 city residents. But there is no treatment available for about a third of them, despite the presence of world-class hospitals and advanced HRSA-supported  health centers, Sacco said.

The problem is especially brutal across swaths of rural America, he added.

Last December, the CDC reported that West Virginia's death rate from overdoses involving prescription and synthetic opioids was the highest in the country, at 17.2 deaths per 100,000 – far exceeding the next two highest states: Maryland (11.5), and Utah (10.8).

"The problem got so big, so fast, because we weren't talking about it," observed Gray. "There are a lot of people who still are scared to share their story," and purposefully avoiding contact with health providers for unrelated services like flu shots and check-ups – for fear of their addiction being discovered.

Figures revised last month by the National Institute on Drug Abuse suggest no easy path forward:  By 2017, the opioid overdose death rate in West Virginia had doubled since 2010.

Behind the numbers: West Virginia communities are strained by multiple public health crises, said public health nurse Angela Gray: high poverty and unemployment; degraded housing stocks; high rates of smoking and respiratory diseases, obesity, diabetes and premature births.
Behind the numbers: West Virginia communities are strained by multiple public health crises, said public health nurse Angela Gray: high poverty and unemployment; degraded housing stocks; high rates of smoking and respiratory diseases, obesity, diabetes and premature births.

 

The region also is among the nation's most vulnerable to hepatitis and HIV outbreaks, even among the very young, due largely to needle-sharing among those with opioid misuse disorder. The CDC has warned that some 250 U.S. counties fit a similar profile.

Perhaps most striking, little more than half the state's population is employed, and here too drugs are a contributing factor. In the state's southern counties, where more jobs exist, otherwise able-bodied candidates are often unable to pass pre-employment criminal background checks and drug screens.

First responders should realize that most of the people they rescue from overdose eventually become productive members of society, Gray said. But frustration over their inability to effectively link people to nearby treatment can lead to "compassion fatigue."

Because of a lack of substance abuse options and resources, many West Virginia communities are not "recovery-ready," she said. 

Notwithstanding policy changes -- ranging from legislation enabling more widespread use of the overdose-reversal medication naloxone, to the advent of Medication-Assisted Treatment and formal action by the State Board of Pharmacy to reduce the number of opioid prescriptions – the epidemic continues.

"When the decrease (in prescription opioids) happened," Gray observed, "is when our overdoses shot through the roof, (as) people went to the streets and started getting heroin," which quickly led to an upshot in fentanyl use. The now-ubiquitous synthetic narcotic is similar to morphine, but up to 100 times stronger.

Gray's descriptions of the epidemic's complexity in small, isolated towns where basic medical care itself is often scarce are a case study in unforeseen consequences to public health – and perhaps an early indicator of what could happen in similar rural jurisdictions.

"Cold spots": Despite widespread coverage from HRSA-supported health centers (locations in red), West Virginia is pocked with what officials call "cold spots" -- isolated areas of the mountainous region that are many miles from the nearest health care facility where those suffering from opioid misuse disorder might get Medication-Assisted Treatment (MAT). As in most geographically isolated rural regions of the nation, "time and distance to care" has been a chronic problem in the state for decades.
"Cold spots": Despite widespread coverage from HRSA-supported health centers (locations in red), West Virginia is pocked with what officials call "cold spots" -- isolated areas of the mountainous region that are many miles from the nearest health care facility where those suffering from opioid misuse disorder might get Medication-Assisted Treatment (MAT). As in most geographically isolated rural regions of the nation, "time and distance to care" has been a chronic problem in the state for decades. 

 

"We have mothers who are using with their sons, and sons that are using with their grandparents, and dads that are using with daughters," Gray said. "Everyone sees the numbers. On the ground level, I see the faces."

Overdoses are so common – "part of our daily life," she said – that they are changing social norms; neighbors who pride themselves on "taking care of our own" turn hostile or ambivalent; stigma sets in; those suffering from opioid misuse disorder become more secretive, setting the stage for contagious disease outbreaks.

The trend is particularly harsh in an era when children as young as 12 are turning to the drugs, Gray said.

Date Last Reviewed:  April 2019