Drug overdose is recognized as a leading cause of accidental death in the United States. In Milwaukee County between 2012 and 2015, drug overdose deaths related to opioids increased from 144 to 231 deaths per year. Heroin was the most common drug found in toxicology reports and the majority of overdose victims were white males with an average age of 43 years. Since 1999, prescription opioid sales have increased by 300% despite no change in the amount of pain reported by Americans. Higher prescription rates for opioid analgesics are associated with increased opioid use disorder (OUD), addiction, and diversion (defined as illicit transfer of opioids from the person to whom they were legally prescribed to someone else).
Wicked Problem Description:
Veteran drug poisoning deaths among those who receive services in Department of Veterans Affairs (VA) settings are twice the national average, with opioids reported as the agent in 51.4% of these events. Prevalence of opioid receipt by VA patients climbed from 18.9% in 2004 to 33.4% at the height of the VA prescribing crisis in 2012, a 76.7% relative increase. Since that time, the VA has initiated a number of system-wide efforts to reduce opioid addiction and deaths. Despite such ongoing efforts, overprescribing of opiates remains high because many veterans experience non-cancer related pain due to combat exposure and other factors.
A large retrospective cohort study by the VA examined returning veterans from Afghanistan and Iraq and found that 6.5% of veterans positive for pain (but without mental health diagnosis) were prescribed an opioid, compared to 17.8% of those with PTSD and 11.7% of those with other mental health problems. Veterans with PTSD were also more likely to receive higher doses, receive two or more opioids concurrently, and obtain early refills. Further, this study found that veterans with a combination of pain, PTSD, and opioid prescription were at increased risk for adverse clinical outcomes. Encouraging multi-layered community care for veterans suffering from opioid addiction is particularly fragmented as veterans and their families must navigate federal systems (VA), state and regional resources (e.g. each state’s Department of Veteran Affairs), and community service providers.
In the context of opioid misuse, strategies to control pain and strategies to treat trauma have developed within silos. Despite calls to incorporate trauma assessment and intervention into pain treatment, the two approaches have rarely, if ever, been combined as part of a comprehensive, community-based prevention and intervention effort. This lack of integration constitutes a missed opportunity to fully address the psychological, social and physical aspects of pain experienced by veterans.
Project Milwaukee PROMPT: Prevention of Opioid Misuse through Peer Training will address opioid misuse among veterans at Dryhootch, a community partner which provides peer mentoring services to veterans returning from combat and has witnessed the rise in opioid addiction. The Milwaukee PROMPT team aims to work across disciplines to forge innovative ways to address OUD among veterans. Our four Clinical Scholars are committed providers with diverse expertise and experience related to opioid misuse: a family physician with extensive experience in community engaged research (CEnR) and over 30 years of practice (Syed Ahmed, MD, MPH, DrPH); a clinical psychologist with expertise in the impact of trauma and trauma informed care (L. Kevin Hamberger, PhD); an anesthesiologist with expertise in the management of chronic pain (Robert Hurley, MD, PhD); and a clinical pharmacist with expertise in pharmacology of opioids and management of chronic pain (Kajua Lor, PharmD).
The PROMPT project focuses on prevention of OUD in a subset of the Milwaukee veteran population by seeking to change their knowledge, attitudes and behaviors related to opioid use through a peer-delivered curriculum. Using community engagement (CE) strategies, we aim to develop and implement a trauma-informed, peer mentoring approach to OUD prevention. The team plans to merge focus group input from veterans with clinicians’ expertise to collaboratively develop an OUD prevention curriculum. The curriculum—delivered by peer mentor specialists at Dryhootch—will consist of targeted modules and will incorporate Trauma-Informed Care (TIC) strategies. Mental Health America Wisconsin (MHA) will support the peer mentors working with veterans by providing supervision, consultation, training, and program and curriculum development.
The overall goal of this project is to prevent OUD and OUD-related deaths among veterans. Our project has several objectives that will help us progress towards the goal:
- Increase the number of veterans who request opioid-related treatment or prevention services with peer specialists at Dryhootch
- Increase the number of referrals of veterans to Dryhootch’s peer mentoring services from other veteran-serving organizations
- Positively impact veterans’ knowledge, attitudes and behavior related to opioid use
Development (1-12 months): The team will conduct focus groups with community partners and veterans; convene a Community Academic Advisory Board (CAAB) that will meet regularly; develop an opioid use disorder (OUD) prevention peer mentoring curriculum; develop a general opioid misuse prevention campaign; obtain baseline tracking data about the veteran population with whom we will work; establish an evaluation, sustainability, and dissemination plan; and prepare for program implementation.
Implementation (13-30 months): Dryhootch and MHA will collaborate to train and support five peer mentor specialists who will deliver the curriculum to 90 veterans seeking OUD prevention. A general awareness campaign will be rolled out for veterans, at Dryhootch and will be shared with other veteran-serving community organizations. Veteran input at focus groups will inform possible updates to the existing iPeer Quick Reaction Force app which provides peer specialists with the “temperature” of how a veteran is doing in between in-person meetings. We will collect data throughout the implementation phase to track the impact of the various program components.
Evaluation, Sustainability & Dissemination (31-36 months): The team will establish an evaluation, sustainability, and dissemination plan during the development phase; integrate the curriculum, education campaign, iPeer app, and tracking of veterans throughout regular programming; seek further funding from federal, private, and philanthropic sources; disseminate program successes and lessons learned; and evaluate the success of the program through a variety of qualitative and quantitative measures.
A team of partners from the Medical College of Wisconsin (MCW), Dryhootch, and Mental Health America of Wisconsin (MHA) have contributed to the development of this project. Dryhootch is a nonprofit organization founded in 2008 by a Vietnam veteran with a mission of “helping veterans and their families who survived the war, thrive in the peace.” Their coffee shop serves as a community rally point to provide a welcoming, drug and alcohol free environment for veterans, families, and community members. From 2010-2014, Dryhootch administered a SAMHSA-funded grant to provide peer-to-peer recovery support services and found that generally, the 658 veterans who participated experienced positive outcomes in substance use, mental health functioning, and social and economic well-being. Dryhootch recognizes that peer support empowers veterans to overcome issues such as PTSD, traumatic brain injury, depression, drug and alcohol addiction, family relationship issues, unemployment, and homelessness and has collaborated with MCW for about a decade on health-related efforts for veterans. MHA is an affiliate of the national non-profit dedicated to helping all Americans achieve wellness by living mentally healthier lives. They have experience running programs for populations affected by opioid addiction, were the first organization in Milwaukee to have peer mentors, and have observed that trauma is almost universal among the people they serve.
To determine if the objectives of the project were met, the team will work with Dryhootch and MHA to collect baseline data on the opioid status of the veterans who work with peer specialists on OUD issues; gather quantitative and qualitative data for the proposed activities; and conduct a final evaluation to assess the opioid status of veterans who complete the curriculum. Because of the complicated nature of this issue, we plan to focus on one community at a time, be informed by our efforts with that community, and subsequently adapt our approach as needed. Once we determine whether this intervention is a successful approach, MCW’s team can expand efforts and offer training in the use of the curriculum.