NC Technical Assistance Center: Supporting Programs for People at Risk of Incarceration and Overdose
Evan Ashkin, MD; Asheley Skinner, PhD
In 2023, the HRRC collaborated with the UNC Formerly Incarcerated Transitions (FIT) Program and NC Harm Reduction Coalition (NCHRC) to form the NC Technical Assistance Center (NC-TAC). This collaboration began in 2021 as the “Justice TA Center,” providing support to grantees across North Carolina who had received funding from the NC DHHS Division of Mental Health/ Developmental Disabilities/ Substance Abuse Services under two mechanisms to address the needs of people with substance use disorder involved with the legal system. The NC-TAC formed to begin offering support to any program working with people who use drugs who are impacted by the legal system. Supported programs represent many sectors including local health departments, law enforcement, treatment providers, supportive housing, and other community organizations. In August 2024, the TA team transitioned from Duke to the North Carolina Association of County Commissioners, where they will function as part of the Opioid Settlement Technical Assistance Team.
As a TA team, we hold monthly webinars, provide tailored support, produce training materials, and facilitate virtual community spaces for programs to learn from each other. The HRRC leads project management and provides TA around evaluation to build the capacity of organizations to develop and conduct their own program evaluations.
Program areas include:
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Pre-arrest and/or pre-trial diversion programs
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Comprehensive re-entry planning and navigation
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Jail-based overdose prevention education and naloxone distribution upon release programs
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Comprehensive jail-based medication-assisted treatment (MAT) program
The Justice TA Center and NC-TAC were funded by a series of awards from the NC DHHS Division of Mental Health/ Developmental Disabilities/ Substance Abuse Services.
HEAL Connections
Christoph Hornik, MD PhD MPH; Rachel Greenberg, MD MHS; Asheley Skinner, PhD
Research results need to benefit people living with pain, substance use disorder, and other co-occurring conditions but too often get stuck in journal articles and conference presentations. HEAL Connections was a center jointly run by the Duke Clinical Research Institute and George Mason University’s Center for Advancing Correctional Excellence and funded by the National Institutes of Health (NIH) through the Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative. HEAL Connections was aimed at supporting widespread dissemination and implementation of HEAL-funded research. The center’s goals were to create pathways to further build and sustain community partnerships, and to support HEAL researchers in meaningfully sharing results with communities and stakeholders that will benefit most from research findings. The Duke HRRC provided subject-matter expertise and supported content development for the HEAL Connections team. We also led a qualitative landscape analysis, interviewing HEAL researchers and program officers with the goal of better tailoring the services HEAL Connections provides.
HEAL Connections was funded by the NIH HEAL Initiative under OTA numbers: 1OT20D034479 and 1OT2OD034481.
Project MAPS Evaluation
Asheley Skinner, PhD; Logan Adams, MD
Project Mobile Addiction Prevention Services (MAPS) is an initiative to deliver patient-centered, low-barrier care to marginalized populations in Durham, NC, via a mobile medical outreach van. This initiative is led by an interdisciplinary team including the Durham Tech Community Health Lab, Duke Outpatient Clinic (DOC), and North Carolina Harm Reduction Coalition (NCHRC). The HRRC conducted a process and outcome evaluation of Project MAPS to guide improvement, support future expansion of services, and provide preliminary data for future research proposals on the effectiveness of a van-based outreach strategy in improving health outcomes for this at-risk population.
This evaluation was funded by a supplement from the Department of Population Health Sciences.
Understanding and Addressing Opioid and Benzodiazepine Co-prescribing among Older Adults with Cancer
Opioids continue to be the mainstay of cancer-related pain management, and benzodiazepines are frequently prescribed to help patients manage other common symptoms of cancer and its treatment. When prescribed in combination, opioids and benzodiazepines can have the unintended consequence of compromising patient safety and well-being – particularly for older patients. The aim of this study is the build the knowledge base necessary to (1) reduce avoidable co-prescribing of opioids and benzodiazepines after a cancer diagnosis and (2) prevent harms among those who are exposed to this drug combination after a cancer diagnosis.
The quantitative phase of our study used SEER-Medicare data to (a) characterize patterns of opioid and benzodiazepine co-prescribing among older adults diagnosed with breast, colorectal, or lung cancer and (b) examine the risks of avoidable harms associated with opioid and benzodiazepine co-prescribing among members of this population. In the qualitative phase of the study, we conducted semi-structured interviews with providers to identify factors that influence their practices with respect to co-prescribing and mitigating associated risks among older adults with cancer.
This project was funded by National Institute on Aging (NIA) 1R21AG072688.
The following projects were funded with the generous support of The Duke Endowment.
Data Surveillance
DataMart: Opioid Surveillance and Linkages at Duke Health
Understanding the current state of opioid use and prescribing behavior within Duke’s Health System is fundamental to designing appropriate interventions. Built on electronic health records, Duke's data warehouse contains rich information about opioid prescriptions, opioid-related encounters and events, the context surrounding opioid use, and patient outcomes. Through this project, clinical data was curated and organized into meaningful and informative reports, models, and facts to construct a useful data model that answers questions regarding opioid management at Duke. These data are used to support several projects within the Duke Opioid Collaboratory.
Dental Prescribing Medicaid Analysis
Previous research has highlighted the role dentists play in opioid prescribing, however, little is known about how this impacts NC Medicaid enrollees. Using information derived from prescription and dental claims data, we described the dispensing of opioids associated with dental procedures—statewide and by dentist. This project was in collaboration with NC Medicaid, Division of Health Benefits at the NC Department of Health and Human Services.
Cancer Survivors & Opioids
Opioids are the mainstay of pain management during active cancer treatment. However, the extent to which cancer survivors continue to use opioids beyond active treatment is not well understood. Using unique data from the NC Cancer Registry linked with Medicare, Medicaid, and private insurance claims, we quantified and identified:
- Predictors of long-term opioid use in the 5 years following diagnosis with stage I-III cancer
- Predictors of potentially high-risk co-prescribing of opioids with other drugs (e.g., benzodiazepines) after stage I-III cancer diagnosis
In addition, we conducted interviews with cancer survivors and providers related to their experiences with and perspectives on long-term opioid therapy for chronic pain after cancer treatment. With the growing population of cancer survivors with chronic pain, efforts to improve the safety and effectiveness of pain management will become increasingly important. This project was in collaboration with the Cancer Information & Population Health Resource at the University of North Carolina’s Lineberger Comprehensive Cancer Center.
- Check DK, Bagett CD, Kim K, Roberts AW, Roberts MC, Robinson T, Oeffinger KC, Dinan MA. Predictors of Chronic Opioid Use: A Population-level Analysis of North Carolina Cancer Survivors Using Multi-Payer Claims. J Natl Cancer Inst, 2021 Apr 20;djab082. PMID: 33881543
Linking Homelessness Data to Death Data for Overdose Research, Surveillance, and Action in North Carolina
Mike Dolan Fliss, PhD, MPS, MSW
Housing is fundamental to health, and people experiencing homelessness have been shown to have increased risk of all-cause and overdose-specific mortality. This project piloted record-linkage between homelessness and health data in NC by:
- Joining homelessness data systems to build a statewide homelessness data set
- Joining homelessness data to death data
By piloting these linkages, we established feasibility and requirements for ongoing data linkage to death records and other key state datasets, enabling a stronger research to action framework and improved public health surveillance for overdose (and health in general) among people experiencing homelessness in NC.
- Fliss MD, Chung EO, Carey A, Alexander BK. People Experiencing Homelessness in NC have Increased Mortality, Including High Overdose, Violence, Injury, and Chronic Disease Death Rates. N C Med J. 2022 Sep-Oct;83(5):390-391. doi: 10.18043/ncm.83.5.390. PMID: 37158551.
Health System Quality
Project COMET: Opioid Use Disorder Consult Line
Project COMET (Caring for Patients with Opioid Misuse through Evidence-Based Treatment) improves the quality of care for hospitalized patients with opioid use disorder by focusing on the initiation or continuation of medication for opioid use disorder (MOUD) and providing a safer and smoother transition to the community following discharge. We created a consult service line staffed by physicians and a social worker. The team sees inpatient consults for patients who may have opioid use disorder. The provider initiates MOUD (e.g., Suboxone or methadone) when appropriate. A social worker helps transition patients to community organizations for continued care. We evaluated program implementation during the first six months and built robust data management structures for ongoing quality improvement.
- Clifton D, Ivey N, Poley S, O'Regan A, Raman SR, Frascino N, Hamilton S, Setji N. Implementation of a comprehensive hospitalist-led initiative to improve care for patients with opioid use disorder. J Hosp Med. 2022 May10. PMID: 35535562.
Transitions for Patients Experiencing Homelessness
Donna J. Biederman, DrPH, MN, RN, CPH, FAAN
Durham Homeless Care Transitions (DHCT) supports homeless patients transitioning from Duke University Health System hospitals back to the community. DHCT provides case management and connections to housing for their clients. Many DHCT referrals and enrollees are on the opioid use disorder spectrum. We used program and medical record data to evaluate DHCT, characterizing the patient population and better understanding how the program works and impacts health, health care utilization, and self-efficacy.
- Biederman DJ, Sloane R, Gamble J, Sverchek C, Daaleman TP. Program Outcomes and Health Care Utilization of People Experiencing Homelessness and Substance Use Disorder after Transitional Care Program Engagement. JHCPU. 2022.
- Nohria R, Biederman DJ, Sloan R, Thibault A. Use of health care utilization as a metric of intervention success may perpetuate racial disparities: An outcome evaluation of a homeless transitional care program. Public Health Nursing. 2022.
- Smith CM, Feigal J, Sloane R, Biederman DJ. Differences in Clinical Outcomes of Adults Referred to a Homeless Transitional Care Program Based on Multimorbid Health Profiles: A Latent Class Analysis. Front Psychiatry. 2021.
Opioid Prescribing Process and Quality Improvements Project (OPPIP)
North Carolina enacted the Strengthen Opioid Misuse Prevention (STOP) Act, which addresses the opioid epidemic by enforcing safer opioid prescribing practices. Adhering to this law requires rapid clinic transformation and system changes, through focused education and local shifts in practice. Our team assessed, educated, and revamped the approach taken by providers and clinics to become compliant. We worked with Duke-based clinics on quality improvements for patient safety and decreasing high-risk opioid prescriptions to reduce harm.
Acupuncture in the Emergency Department
This project piloted an acupuncture program in the Emergency Department (ED) as an alternative strategy for pain management. We conducted a pragmatic randomized controlled trial (RCT) that evaluated the feasibility and acceptability of two types of acupuncture as adjuncts to usual care for ED patients with acute musculoskeletal pain. Participants were randomized to auricular (ear) acupuncture, peripheral acupuncture, or the control group receiving no acupuncture. Subjects assigned to an acupuncture group receive their first treatment in the ED as well as four weeks of twice-weekly follow-up treatments in an outpatient clinic. The overall goal was to reduce opioid use by improving acute pain, anxiety, and disability with non-pharmacologic treatment options at a critical entry point for patients into the healthcare system.
This pilot was initially funded under The Duke Endowment grant and was expanded under an award from the Substance Abuse and Mental Health Services Administration (SAMHSA).
Low-Barrier Medication for Opioid Use Disorder at Lincoln Community Health Center
Lincoln Community Health Center (LCHC) is a Federally Qualified Health Center offering patient-centered, comprehensive, and coordinated care primarily serving low-income and uninsured patients. To improve quality of care for patients with opioid use disorder, LCHC implemented a low-barrier approach to providing buprenorphine for opioid use disorder aimed at increasing treatment initiation rates and care retention. This model established new pathways for expedited and same-day treatment initiation by increasing provider availability, and offering group treatment sessions and supportive services including:
- Counseling and case management
- Naloxone distribution
- Hepatitis C treatment
- Integrated behavioral health services
- Access to full-spectrum primary care
The HRRC conducted an evaluation of this program to explore whether the low-barrier model expands access to buprenorphine treatment and improves patient outcomes. While differences in retention in care and patient outcomes were not significant, low-barrier MOUD engaged a higher risk population.
This pilot serves as a model for other clinics to expand access to buprenorphine treatment through community health centers and primary care settings
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Carter J, Li Z, Chen H, Greiner M, Bush C, Bhattacharya D, Poley S, Sachdeva N, Crowder JC, Feigal J. Low barrier medication for opioid use disorder at a federally qualified health center: a retrospective cohort study. Addict Sci Clin Pract. 2022 Nov 5;17(1):60. doi: 10.1186/s13722-022-00342-1. PMID: 36335381; PMCID: PMC9636799.
Integrated Pain Management Policy
To combat the opioid crisis, policymakers have employed prescription drug monitoring programs and prescribing guidelines. These efforts have resulted in lower prescription rates, but do not address the underlying problem of untreated pain that integrated pain management models (incorporating pharmacologic, psychological/behavioral, physical, and occupational therapies) can effectively address.
The goal of this project was to increase access to evidence-based integrated pain management that improves outcomes while reducing over-reliance on opioids. We are contributing to this effort by better understanding the development and implementation of integrated pain management models and making recommendations for better use.
- Lentz T, Gonzalez-Smith J, Huber K, Goertz C, Bleser WK, Saunders R. Overcoming Barriers to the Implementation of Integrated Musculoskeletal Pain Management Programs: A Multi-Stakeholder Qualitative Study. The Journal of Pain. 2023 May; 24(5). doi: https://doi.org/10.1016/j.jpain.2022.12.015.
- Integrated Pain Management: Lessons from North Carolina Health Systems and Beyond
- Exemplary Integrated Pain Management Programs Case Studies:
COVID-19 and the Opioid Epidemic: Health System Perspectives
The goal of this project was to better understand the impact of the COVID-19 pandemic on the ongoing opioid epidemic. We conducted individual semi-structured interviews with providers at Duke Health about the health system’s capacity to maintain its response to the opioid epidemic during COVID. This data was used to inform short-term decisions on how to sustain, adapt, and modify programs for patients most at risk of opioid-related harms.
Associations between Opioid-Related Issues and Alcohol Screening/Intervention in Veterans
This project investigated the co-occurrence of self-reported alcohol use and documented brief intervention by clinicians, and assessed opioid-related outcomes including opioid prescriptions, opioid use disorder diagnosis, and opioid-related hospitalizations in Veterans. We analyzed retrospective data from patients in the Veterans Health Administration to determine whether yearly alcohol use screenings and brief interventions have any association with impactful opioid-related outcomes.
- Blalock D, Berlin SA, Berkowitz T, Smith VA, Wright C, Bachrach RL, Grubber JM. Associations Between a Primary Care-Delivered Alcohol-Related Brief Intervention and Subsequent Opioid-Related Outcomes. American Journal of Psychiatry. 2024 May 6.
Implementation Strategies for Integrating Treatment for Opioid Use Disorder in HIV Care
This project assessed the benefits and potential drawbacks of integrating HIV and opioid use disorder (OUD) care for patients in Mecklenburg County, NC. The team conducted individual interviews with providers involved in HIV and OUD-related care.
This project was funded by a microgrant from the Duke Center for AIDS Research (CFAR)
- Knettel BA, Chen H, Wilson E, Agor D, McKellar MS, Reif S. Provider perspectives on screening and treatment for opioid use disorder and mental health in HIV Care: A qualitative study. PLOS One. 2024 June 24.
Public Health
Law Enforcement Assisted Diversion (LEAD) Program Evaluation
North Carolina law enforcement leaders, in partnership with the North Carolina Harm Reduction Coalition, have implemented Law Enforcement Assisted Diversion (LEAD) programs for individuals who are at high risk of overdose and high risk of cycling in and out of the criminal justice system. LEAD programs connect individuals with opioid and other substance use disorders to treatment and community services as an alternative to arrest. The evaluation of the LEAD programs in North Carolina identified challenges and successes and assessed effectiveness in:
- Reducing recidivism
- Improving health and quality of life for LEAD participants
- Reducing criminal justice and public health costs
Evaluation of Naloxone Distribution from Jails
Lauren Brinkley-Rubenstein, PhD
In North Carolina, a recent study found that individuals newly released from incarceration are forty times more likely to die from an overdose than the general population. In response, four rural North Carolina counties implemented overdose prevention and naloxone education programs in county jails. This evaluation identified best practices and evaluated preliminary results to optimize program implementation and reduce rates of overdose upon community re-entry. This project was conducted in collaboration with the NC Harm Reduction Coalition and NC Division of Public Health’s Injury and Violence Prevention Branch
Evaluation of Medication-Assisted Treatment in Durham Jail
Lauren Brinkley-Rubenstein, PhD
The Durham County Detention Center committed to implementing a medication for opioid use disorder (MOUD) ) program that includes:
- Screening all individuals for opioid use disorder
- Continuing and initiating patients on MAT while incarcerated
- Offering Suboxone and naltrexone as MAT options (with plans to offer methadone at a later stage) as clinically appropriate
- Linking individuals to community MAT programs upon release
Evaluation of this program identified barriers and facilitators to optimize expansion and provide lessons learned to other carceral settings interested in implementing similar programming
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Medications for Opioid Use Disorder in a Criminal Legal Setting: Recommendations from Stakeholder Interviews
Evaluation of Local Health Departments Overdose Prevention Strategies
In late 2018, the NC Division of Public Health’s Injury and Violence Prevention Branch funded 22 local health departments to develop programs that address the opioid crisis in North Carolina. Programs included:
- Developing or expanding syringe services programs
- Connecting justice-involved persons to harm reduction, treatment, and recovery services
- Establishing post-overdose response teams led by peers or emergency medical services
We evaluated these programs at each local health department to provide evidence on barriers and facilitators and identify lessons learned. This evidence has been used to optimize programming and provide support to other counties interested in implementing similar initiatives
- Final Report: Qualitative Study of Local Health Department Programs to Prevent Opioid Overdose in North Carolina
- Key Recommendations One-Pager
- Overdose Prevention Case Studies:
- Granville and Vance Counties: multiple programs
- Pitt County: syringe services programs
- Wake County: post-overdose response teams
Providing a Resource: Telemedicine at Needle Exchanges to Reach Under-served Populations (PARTNER UP)
People who inject drugs (PWID) are at risk for a range of adverse health outcomes including opioid use disorder and HIV infection. However, this population often experiences stigma and discrimination in the health care system which can lead to distrust and reduced access to care including medication for opioid use disorder (MOUD) to address opioid dependence and pre-exposure prophylaxis (PrEP) to prevent HIV. To improve access to MOUD and PrEP, the Duke team partnered with local harm reduction organizations to offer care through trusted syringe services programs (SSPs), using telemedicine for follow up visits.
In the first phase of this project, the team partnered with the NC Harm Reduction Coalition and the Center for Prevention Services’ Queen City Harm Reduction to determine whether treatment with MOUD and PrEP through SSPs was acceptable and feasible when conducted via telemedicine. The team also conducted in-depth interviews with participants to evaluate the program.
In the second phase of this project, the team worked with North Carolina Survivors Union and Dr. Jennifer Carroll, following similar protocols, with the addition of hepatitis C treatment as an option for eligible participants. Hepatitis C treatment was identified in the first phase as a major need among participants of SSPs.
- The PARTNER UP Study: Providing Medication for Opioid Use Disorder and Pre-Exposure Prophylaxis for HIV Prevention through Syringe Services Programs in North Carolina
- McKellar MS, Des Marais A, Chen H, Choi Y, Lilly R, Ayers D, Bennett J, Kestner L, Perry B, Poley S, Corneli A, Meade CS, Sachdeva N. Providing medication for opioid use disorder and HIV pre-exposure prophylaxis at syringe services programs via telemedicine: a pilot study. Harm Reduction Journal. 2024 Mar 26.
- Corneli A, Perry B, Des Marais A, Choi Y, Chen H, Lilly R, Ayers D, Bennett J, Kestner L, Meade CS, Sachdeva N, McKellar MS. Participant perceptions on the acceptability and feasibility of a telemedicine-based HIV PrEP and buprenorphine/naloxone program embedded within syringe services program: a qualitative descriptive evaluation. Harm Reduction Journal. 2022 Dec 3.
Helping Assess Rural MOUD: Novel Office-Based Treatment (HARM NOT)
Since 2017, Granville-Vance Public Health has addressed opioid use disorder through a novel office-based opioid treatment (OBOT) program that offers medication for opioid use disorder (MOUD) and related health and counseling services. We evaluated this program using a mixed-methods approach to:
- Describe patient outcomes over time in the Granville-Vance OBOT program
- Describe patients’ goals for the OBOT program and how they envision and describe the program’s success in relation to their lives
- Identify and describe the challenges and successes in the program’s integration from both a patient and clinician/clinic staff perspective
- Provide guidance for other rural counties to expand access to MOUD in a patient-centered way
- Provide initial insight on patient-centric metrics that could be used to evaluate the success of MOUD programs from the patient perspective
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Advocacy Brief: Advocating for Office-based Opioid Treatment Programming in Your Community
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Coles T, Chen H, Des Marais A, Sachdeva, Buch C, Macon Harrison L, Guthrie S. Patient-Centered Outcomes Associated With a Novel Office-Based Opioid Treatment Program in a District Health Department: Mixed Methods Pilot Study. JMIR Form Res. 2023 May 24.
Faith-Based Responses to Reduce the Harms of Opioids
This project aimed to increase the capacity of faith communities to effectively support individuals with opioid use disorder. We conducted a needs assessment of Christian faith communities across NC to inform modification and planned dissemination of practical resources developed by the Duke Divinity School’s Theology, Medicine, and Culture (TMC) Initiative. These resources provide tailored guidance for faith communities to better understand and address the needs of persons with opioid use disorder in their communities.
Developing Data Infrastructure for Syringe Services Programs
Syringe services programs (SSPs) are an evidence-based intervention shown to reduce the potential harms of drug use and to serve the broader needs of people who use drugs. We worked collaboratively with SSPs in NC to develop the infrastructure to streamline data tracking systems and processes to improve services, reduce administrative burden, and improve organizational reporting. We designed these systems in consultation with Olive Branch Ministry, Guilford County Solution to the Opioid Problem (GC STOP), NC Harm Reduction Coalition, the NC Division of Public Health Injury and Violence Prevention Branch, and the NC Safer Syringe Initiative.
Workforce Development for Syringe Services Program Leaders
The objective of this project was to increase workforce capacity to improve, expand, and sustain syringe service programs. To this end, we:
- Conducted a leadership development and training needs assessment
- Provided and evaluated a customized nonprofit management training for syringe services program leaders
We are developed the training in collaboration with the national Harm Reduction Coalition, the NC Division of Public Health’s Injury and Violence Prevention Branch, and the NC Safer Syringe Initiative.
Telehealth Treatment and Mental Health Support for People who use Opioids (TeMPO)
The TeMPO project explored currently available services and gaps in care for individuals with opioid use disorder (OUD) in rural North Carolina. We partner with the Duke School of Nursing and Granville Vance Public Health to conduct listening sessions and individual interviews with local providers involved in care for individuals with OUD to inform potential interventions that bolster available services, especially involving mental health.
This project was funded by a grant from the Duke School of Nursing Center for Nursing Research Pilot Program.
1. Chen H, Knettel BA, Macon Harrison L, Des Marais A, Nelli A, Campbell HA, Muhirwa A, McKellar MS, Gulur P, Guthrie S. Leveraging Policy Changes Made in Response to COVID-19 to Advance Telehealth and Novel Treatment Approaches for People Who Use Opioids: Qualitative Perspectives From Two Rural North Carolina Counties. North Carolina Medical Journal. 2023 July 17.