Social Impact LIVE: Aimee Campbell on Columbia’s NYS-Wide Opioid Study
Richard Hara is joined by guest Dr. Aimee Campbell, who provides an update on Columbia’s HEALing Communities Study in New York State.
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Richard Hara: Hello, I’m Richard Hara, and this is Social Impact LIVE. I’m pleased to welcome today to the program Dr. Aimee Campbell. Dr. Aimee Campbell is an assistant professor of Clinical Psychiatric Social Work at Columbia University Irving Medical Center Department of Psychiatry and a research scientist at New York State Psychiatric Institute in the division on substance use disorders. Her research focuses on the development and testing of individual and program level interventions for substance use disorders, co-occurring mental health disorders, and HIV prevention and treatment, with the objective of increasing adoption and implementation of evidence-based treatments. Dr. Campbell’s experience includes both clinical effectiveness and implementation research studies, as well as delivery of implementation technical assistance, especially the integration of treatments for opioid use disorder in health care settings. For the last 10 years, she has collaborated with diverse partners to identify and study substance use disorder treatment best practices for tribal communities. Dr. Campbell is currently a co-investigator on the HEALing Communities Study, which aims to reduce opioid-related deaths by 40% in 16 of New York State’s most affected counties over the next three years. We’ll be hearing very shortly from Dr. Campbell about how the study is proceeding and her role in helping manage the logistics of such an ambitious public health project. Dr. Campbell, welcome to Social Impact LIVE.
Aimee Campbell: Thank you, Richard. It’s really great to be here.
Richard Hara: I was reading your bio and I understand that you did your master’s here at the Columbia School of Social Work and went on to do your PhD. So, I’m wondering, when did you first become interested in this field of substance use disorder treatment?
Aimee Campbell: So, it was actually quite a while ago, I won’t say exactly what year, but it was after my undergraduate work at the University of Washington, where I focused on a bachelor’s degree in sociology, really interested in that kind of group work perspective, kind of a larger perspective on, on social processes. And after my — after I graduated, I took a position as a research assistant and then a research coordinator at the School of Social Work at the University of Washington, working with Dr. Roger Rothman on a series of studies looking at brief interventions for folks with problems with cannabis use. And so, I did that for, for about five years before I, I went on and did my graduate work in social work, but that was really my entree into social work, into the values and ethics of the social work profession and I kind of fell in love with it then, both social work and addiction.
Richard Hara: Okay. So, so, as a result of your PhD level studies, you started looking at the efficacy of particular interventions and substance use disorders, what kind of work were you, were you doing at the time?
Aimee Campbell: So, at the time of my doctoral work, I was working on, on several large multi-site national effectiveness trials of interventions specifically, actually for, for women. I was working with two really great lead investigators, Denise Hien and Susan Tross. Denise Hien’s study, it was in the National Institute on Drug Abuse’s clinical trials network and I was one of the project directors, and we were looking at an integrated intervention for women who had substance use disorders and post traumatic stress disorder.
Richard Hara: Okay.
Aimee Campbell: The other study was an HIV risk reduction intervention for women in outpatient addiction treatment. And, and so, with those two studies, as a project director, I really was exposed to effectiveness trials as opposed to efficacy trials. So, effectiveness trials are really looking at the impact of the intervention in real world settings.
Richard Hara: As opposed to efficacy being —
Aimee Campbell: In much more controlled settings. So, oftentimes in, in research settings and research clinics, where you’re really trying to understand if the components of the intervention itself is effective, as opposed to focusing on external validity, where you’re looking at, well, can this be effective when you take into the context, what happens in the community?
Richard Hara: Okay. So, you started looking at just whether or not these kinds of treatments were effective and — within a particular — different settings and so on. At what point did you start to look at implementation, because now it seems like that takes it to a whole different level?
Aimee Campbell: That’s right. So, it’s kind of the next step in the translational continuum of moving evidence-based practices into communities and making them accessible to the folks that need them. So, implementation is really looking at is a kind of the systematic examination of the barriers and facilitators of integrating evidence-based practices into community settings. So, how is it actually done? So, once we know the intervention is effective, how do we actually get it into the community, with the clinicians that are working in the community to get it to the most people?
Richard Hara: Okay.
Aimee Campbell: And so, it’s kind of a natural progression to then think about, while we have all these interventions, right, we’ve developed — we’ve done a good job of developing some evidence-based practices for addiction treatment, but a lot of them are still not being used in the community.
Richard Hara: Okay.
Aimee Campbell: So, I kind of switched my focus to really thinking about, well, let me not develop more interventions. Let me work on the interventions that are already there, and how do we actually get them into the hands of the folks that need them?
Richard Hara: Okay, great. Can you give me an example of an evidence-based intervention that for some reason is not being utilized, I guess, or getting the, the, the kind of support in the community that it could?
Aimee Campbell: Well, we — I mean, we’re going to be talking about the, the HEALing Communities Study, and so, one of the main evidence-based interventions that we’ll be trying to increase the adoption and rollout of are medications for opioid use disorder. So, those are certainly not interventions that I worked on to develop. They’re, they’re pharmacological interventions. But there, currently there’s only probably a third of the people that, that are currently on medications who have opioid use disorders now. And so, the idea is, what are some of the barriers and facilitators to getting medications into more healthcare settings, so that people have access to them.
Richard Hara: Okay.
Aimee Campbell: And that’s one of the main things that we’ll be looking at in the HEALing Communities Study. So, we have this pretty efficacious intervention for opioid use disorder medications, and there’s three FDA-approved medications for opioid use disorder — methadone, buprenorphine, and naltrexone — but they’re not being used to scale in the community —
Richard Hara: Okay.
Aimee Campbell: — for a number of different reasons.
Richard Hara: Yeah. And figuring out those reasons is part of the kind of studies that you do, or — am I correct?
Aimee Campbell: That’s — yeah, so that’s exactly what implementation science research would want to look at. So, so, here’s this intervention, here’s a particular community setting or a healthcare setting, a healthcare organization. What would be — what, what’s, what’s keeping those healthcare providers from utilizing this treatment for their patients that might have opioid use disorder?
Richard Hara: And now you’re looking at the broader, I guess, context, right, of how care is delivered, how people are screened, and things like that?
Aimee Campbell: Sure, so from, you know, kind of from beginning to end, you can think about where along those delivery pathways might be we running into barriers, and then, how can we provide support, technical assistance to alleviate some of those barriers and help to facilitate medications for opioid use disorder, in this particular case, from being adopted and implemented.
Richard Hara: And this provides a wonderful background to your current work, right, in the HEALing Communities Study. I just want to remind our viewers that we save the last 10 minutes of the program for question-and-answers. So, if you have a question, please write them in. Our manager will get them up on the screen for us, and we’ll have a chance to, to ask Dr. Campbell at the last part of the program. So, thanks a lot. To — yeah, to pick up our conversation, so, implementation research and as you’ve described it, it sort of looks at what are the barriers to having evidence-based treatments actually being utilized out in the communities in real life, right?
Aimee Campbell: Right.
Richard Hara: So, looking at the current opioid crisis, I mean, do we have that kind of information available to us? Or is the HEALing Communities Studies now going to sort of go out there into, what, 16 different counties here in New York State and, and, and, and start to get that information? I mean, what, what’s, what’s the plan?
Aimee Campbell: Yeah, well, that, that’s the question. So, we, we do know some of the things that are getting in the way of making medications more accessible to folks that need them. Some of that research has been done, and I would expect that on the HEALing Communities Study, given the scope, that we will learn a lot more about those things, and then, also how to help address those things. But for example, some of the things that we currently know is at least for a medication like buprenorphine, which requires a provider to have a specific training and get a waiver to provide that medication, that in and of itself could be one barrier.
But we also know that there are a lot of barriers even after a prescriber gets their waiver training in terms of feeling comfortable prescribing, maybe they haven’t had the training in substance use disorder treatment, especially folks that are general medical providers, maybe there hasn’t been a lot of extensive training in medical school or in residencies for providers around addiction treatment. That’s starting to change, but, but that’s a particular barrier. So people may not feel comfortable that they can manage patients that come in with opioid use disorder, so that’s another area that we can help facilitate and provide technical assistance. Additional barriers is that sometimes people feel like they need to have adjunctive behavioral health, either on site or with a direct referral. That sometimes isn’t something that they’ve had a lot of experience with. So, we can help folks around that if that is something that they want to also integrate with the medication.
So, there are a few — there are a number of things that we know and there are a number of solutions that we, that we know can work, including technical assistance around how do you create a team in a healthcare setting that can help the prescriber to support the work that they’re doing with, with patients that have opioid use disorder? So it doesn’t just fall on one person, but you can work in a, you know, an integrated or, or coordinated care framework.
Richard Hara: Yeah, so, so, again, to sort of go back to the beginning, we’ve — we know what kind of treatments work. We understand that there are certain barriers and, and that there are ways to work with that, right? It could be education for healthcare providers, it could be changing certain regulations regarding things like that. The needs of people to get adjunctive behavioral support and so on, and things like that. So, yeah, it sounds like a complex endeavor, obviously requiring a multi-disciplinary approach, working with — and I think this is something that Professor El-Bassel talked about, multiple stakeholders. It’s, it’s, it’s people and government, it’s, it’s clinicians, it’s researchers, and so on. So, and right at — right in the middle of this is, is the sort of implementation technical assistance piece that I think maybe you’re involved with?
Aimee Campbell: Yeah, so, I think that is kind of the centralized piece, but you’re exactly right, that this — so, you know, the, the overdose epidemic is, is a, is a big public health issue that obviously has a lot of different causes. And, and so, we need to come at this in a way that can tap into and leverage multi-systems, right? One particular system is not going to solve this problem, and that’s why the HEALing Communities Study was, I think, such an innovative and, you know, really novel collaboration between the National Institutes of Health, National Institute on Drug Abuse, and SAMHSA of coming together and saying, like, let’s really try to address this in a large kind of novel way. So, I appreciate that kind of emphasis.
But yes, so, so, it is multi-disciplinary, it’s multi-systemic. So, the intervention for the HEALing Communities Study has the backbone of really starting with the county. So, we’re — that’s our kind of unit of working with. It starts with a county. We’ll have a coalition within each county that will really drive, like, some of the decisions around what’s going to work in this county. As we know in research, the communities that we work with, they know what they need, right? They’re the experts on what’s happening on the ground in their community. And so, that’s why we’re starting with a, with a county coalition to really drive some of those initial decisions around which evidence-based practices are going to work here, how should those be rolled out? And then down the line, as they make those decisions, and they select some of those evidence-based practices that they want to see implemented within their county, then we will come in and help support and provide technical assistance for the different organizations and sectors that are going to be implementing those.
Richard Hara: Yeah, so it’s, it’s a fascinating model you’re — that you’re describing here, which I think sounds a lot like traditional social work, right? —
Aimee Campbell: Right.
Richard Hara: — We start where the client is, and in this case, it’s not the individual, but rather a sort of county-level population that you’re, you’re, you’re sort of targeting so to speak —
Aimee Campbell: That’s right.
Richard Hara: — creating coalitions engaging, right? Getting a sense of what are the needs — the stated needs and maybe the not so well articulated needs —
Aimee Campbell: Right.
Richard Hara: — by doing some kind of assessment and analysis, and then taking your technical expertise to help bring in the necessary resources, whether it’s training, whether it’s financial support and other programming, et cetera.
Aimee Campbell: Right.
Richard Hara: — to, to really affect solutions in a crisis? So, yeah.
Aimee Campbell: Yeah, that was a spot-on description. I couldn’t have said it better myself, Richard. Thank you.
Richard Hara: And coming, yeah —
Aimee Campbell: I think you mentioned, you mentioned social work being kind of a key discipline, because it does sound like what we learned as — in our master’s program and in my doctoral program. And I think social work is kind of uniquely positioned to really do a lot of implementation work. So, we come from a perspective of multi-systems that, that impact the individual, the family, the community, and, and the larger kind of macro level kind of structural things that, that impact us, whether that’s an ecological perspective or multi-systems. Come from your own framework. And we’re also trained really well to listen, listen till we understand what the issue is, listen to the people that have the expertise on what’s going on, and also bringing together diverse groups of people and generating consensus on, on what we can do to, to address a problem. So, I think all those things fit really well with social work. And I think, you know, in — I’m coming from the Department of Psychiatry, that’s where I’m working now, and I think that kind of collaboration between those two disciplines is really where a lot of the exciting work can be done, where you can bring in these different perspectives, and really work to generate kind of unique novel solutions to problems.
Richard Hara: Yeah, I like that in your title social work is there. And I just wonder what it’s like for you as someone who’s trained in social work to see our profession kind of right at this and, really a leader in this kind of venture? I mean, usually, yes, we work in a multidisciplinary team, but I don’t know that social work always has pride of place —
Aimee Campbell: Sure, that’s something we’ve been working on.
Richard Hara: — something that we’ve been working on. So, so what, I mean, what sort of skills do you need to bring to that kind of leadership position?
Aimee Campbell: I think for me, it’s really bringing the, the unique perspectives that social workers bring. And I think, I think more and more other disciplines are starting to see how important that is. So we’ve seen arise the emergence of implementation science, for example, in the last two decades as really, this kind of emerging science base. And as I said, social work is kind of uniquely positioned to really be leaders in that field. And so, I think that there’s just a greater awareness in some of the other disciplines that, that bringing in this perspective can really elevate their own work and can increase the effectiveness of the work that they do. So, I know with my addiction psychiatry partners uptown at Columbia Medical Center, are very appreciative of the perspective that I bring on “Well, let’s think about medications for opioid use disorder.” And it’s not just up to one prescriber to make sure that this gets implemented and rolled out. It takes a team. And so I can contribute in that way to those discussions. And so I think that there’s a growing recognition of just the, the importance of that in our research and in our clinical practice.
Richard Hara: Okay. So, talking about the work in the abstract, but concretely, where are we with the HEALing Communities Study? At what point are we in that, you know, process?
Aimee Campbell: Yeah. So, we’ve been working very hard over the last six months to organize and develop how the study was going to roll out. The counties, I’ll speak for New York, but there are four states that are involved in the study, and so that’s Kentucky, Ohio, Massachusetts, and New York. We randomized our counties a couple of weeks ago. So, we have two waves, Wave 1 and Wave 2 counties. Wave 1 counties will start with this intervention that we’ve put together called Communities That Heal. And then, we’re just starting some of the orientation meetings now with counties starting to develop those coalitions. So, we’re really on the, the, the front end, just starting to, to really edge into that intervention work with Wave 1 counties. So, it’s a, it’s an exciting and very busy time.
Richard Hara: I can imagine, I can imagine. Let’s see, I think it’s time for us to turn to some questions. Probably got quite a few from the audience. How much of an issue is transportation for people who are not accessing care? I mean, it seems like a very basic question.
Aimee Campbell: Yeah.
Richard Hara: Yeah.
Aimee Campbell: It — yes, and some of the barriers that we encounter are pretty basically that way: insurance, transportation, childcare. Some of those can be very big barriers to people actually getting to their appointments and getting their care. So, for example, 30% of the counties that we’re working in in New York State are rural counties. So, in rural counties, transportation becomes a major issue. So, we’re going to be looking at some of the solutions around that. That could include getting medications and other sorts of substance use disorder treatments available in maybe smaller office-based settings. So, you don’t necessarily need to find a specialty addiction treatment program, you might be able to go to your primary care physician. We’ll also be exploring telemedicine, telehealth. So, once you maybe access a medication or a behavioral treatment, then maybe you can utilize telemedicine so that you don’t have to travel great distances multiple times a month, et cetera. So, things like that. But huge issues and, and require kind of multi-system thinking and how we could address those, because we can address them at the individual level, but there’s also policies and things like that they can also facilitate.
Richard Hara: Right, right. Next question. I believe New York State has already tried a lot of interventions to get these meds out to those affected by opioid use disorder. Why have their efforts failed and what precisely will the HEALing Studies do that hasn’t already been attempted by other groups? So yeah —
Aimee Campbell: Yeah, great question, right?
Richard Hara: Sure.
Aimee Campbell: Yeah. And I would say that efforts by New York State to increase access to medications haven’t failed. I think that there’s been a lot of progress. Certainly, New York City — New York City and New York State Department of Health have been very involved in increasing accessibility to medications for opioid use disorder, training prescribers, and providing technical assistance. I think how the HEALing Communities will address this in a unique way is really a coordinated effort at a county level and involving all of the critical stakeholders to make these medications and other treatments more available. So, I think it’s really that coordinated effort. I think it’s understanding what the barriers are — the unique barriers are within each of these geographic settings that’s going to help us to understand how we can best intervene. And I would say that the other thing is, is just bringing in a diverse group of stakeholders, so not just targeting the healthcare setting, or the specialty addiction treatment setting, but also bringing in the criminal justice system and law enforcement, bringing in emergency departments, bringing in office-based primary care, interfacing with first responders, interfacing with drug users themselves, people with lived experience, families that might have lost somebody. So, I think coordinated efforts in — with, with diverse stakeholders to really kind of push this forward to the next level.
Richard Hara: Well, that’s a pretty broad mandate, right, in terms of who you’re going to be… I’m just curious, what’s the buy-in like? Is everybody on board at, at this county level of social service organizations, county officials things? I mean, maybe you’re in the process of, of, of, of sort of forming that kind of coalition right now. But what’s it like, going into the process?
Aimee Campbell: Yeah, well, I think — yeah, to be honest, it’s, it’s, it varies, right? So, I think as social workers, we all know, you go, you go into a new setting, it’s, it’s not everybody’s in the same place, right?
Richard Hara: Yeah.
Aimee Campbell: And so part of what the intervention is, is, is, how can we bring people to consensus that come from very diverse settings with very diverse problems and think about the overdose epidemic in unique ways. And so part of this intervention is kind of bringing stakeholders to the table and having some of those discussions. And I think some of those discussions are challenging. Um, the other thing I would say in terms of the technical assistance, we encounter the same thing when you go in and provide technical assistance in an organization, right? You may have a champion within that organization that really wants to see something move forward, but you also need buy-in from leadership, you need buy-in from front desk staff, you need buy-in from other frontline providers. And so, the process is really, you know, how to understand and how to strategically and with evidence-based strategies bring people to the table.
Richard Hara: Okay.
Aimee Campbell: So not easy, not easy. That, that’s going to be a challenge. But I think that’s specifically what this intervention is, is designed to do.
Richard Hara: Well, at the end of the day, I mean, is some of this driven by Albany and, and sort of, you know, sort of state level, kind of, I don’t want to say pressure, but it’s sort of — yeah —
Aimee Campbell: There’s different sticks and carrots, right?
Richard Hara: Right, yeah.
Aimee Campbell: I would say that, that we’re very involved with government officials. They’ve been very excited about this study being brought into New York State and assisting them with the work that they’re already doing, collaborating with them. So, they’re, they’re a very key partner in the HEALing Communities Study. And I think they’re, you know, they’re going to need to help drive the solutions for the overdose epidemic.
Richard Hara: Top down, bottom up, right?
Aimee Campbell: That’s right.
Richard Hara: Okay. We have a question. What is the role of stigma in these treatments not reaching the communities where they’re needed?
Aimee Campbell: Yeah, I think that’s huge. I — we see it with a lot of the issues that we work with as social workers, but I think addiction is, is one of the top where there’s just a — there’s a lot of misperceptions, there’s a lot of misinformation about who a drug user is. And there’s also misperceptions in the medical community as well about how you treat people with substance use disorders. Can you do it? What is that going to look like? And then, there’s, you know, there’s different stigma in different sectors of the community. So it’s — so that’s a huge issue. I think education is key. I think exposure to folks… I mean, you know, people are around people with substance use disorders every single day. And so hearing from, from people with lived experience directly can be huge at reducing stigma, understanding what causes addiction and the different pathways that people enter into having a substance use disorder as well as all the different pathways to recovery. So we’ll be doing a number of things on the HEALing Communities Study to, to help address this that, that includes education, training, bringing in, you know, leaders within the community to really understand this, and then go out into the community and talk about it. We’ll also be having a communications campaign that will help to address some of the issues around stigma as well. So a multi-pronged front on that. It’s a, it’s a huge ongoing issue.
Richard Hara: Yeah. And not necessarily one that you would just sort of isolate, you know, as a separate component but rather interwoven, yeah, with all aspects of care.
Aimee Campbell: Yeah.
Richard Hara: Okay, great. The question came up at Monday’s meeting (and Monday’s meeting meaning we had a Town Hall, Hall here hosted to talk about the HEALing Communities Study) and, but how can RNs in emergency rooms be trained in harm reduction methods? Do they have the time and resources for learning and applying such methods?
Aimee Campbell: Yeah, you know, that’s, that’s a, that’s a very interesting question and very specific question. And, and there are a number of ways that we’ve been trying to integrate getting folks initiated on the medications for opioid use disorder in the emergency department. And RNs are a huge part of that. The nursing staff in the emergency departments are a huge part of that, because they really interface with, with the patient coming in to such a large degree. And so, in those kind of ED settings, there would be training for, for all of the staff. Time is always an issue. What helps with that is if we have leadership say this is a priority for this emergency department to do this work and to help to address this issue. So you need you need that leadership buy-in. But, but nursing staff absolutely can be trained to screen for opioid use disorder and work with a prescriber on staff to maybe initiate somebody onto buprenorphine and then help to get them to connect to treatment outside of the ED. Other folks in the ED that can be helpful, of course, are having social workers, other allied health professionals. We’ve also used peer navigators in EDs to help make that connection once somebody is discharged from the emergency department. But, but nurses are a key, key role.
Richard Hara: Right. Our last question or comment: Dr. Campbell, great work. If you were looking for an anesthesia provider for your team, I’m interested. So, yeah.
Aimee Campbell: That’s great.
Richard Hara: Always, always looking for people to, to participate and, and to sort of bring in their different perspectives, right?
Aimee Campbell: Absolutely. Yeah, everybody can play a role in, in addressing this issue. Yeah.
Richard Hara: Yeah, yeah, absolutely. So, again, thank you so much for joining us here today on our program. That concludes today’s episode. We’ll be joined next week by Dr. Mimi Abramovitz to discuss the role social workers can play in getting out the vote in the 2020 elections. So, until then, have a great week. Bye-bye.