Transforming Opioid Addictions Care in New Mexico: Combining Medication Treatment with Patient Autonomy, Civic Engagement and Integrative Healing

Abstract

Opioid addiction is a complex issue. New Mexico has historically experienced some of the highest rates of deaths from opioid overdose, and opioid addictions have affected generations of New Mexicans -- starting many years before the more recent national crisis. Treatment approaches to opioid and other addictions are fraught with paternalism, stigma, surveillance, criminalization, shaming, racism, discrimination, and issues with access to care. Current treatment paradigms fail to take into account the social and economic factors of people, community, and context. New paradigms embracing a broader, more-just contextualization of addictions, along with evidence-based treatment approaches are needed to transform medicine’s historic role in the “war on drugs”. The Strong Roots/Raices Fuertes program was developed by two community clinics, Casa de Salud and Centro Sávila, in Albuquerque, New Mexico. The program evolved from a desire to to acknowledge and right historical harms that the medical-industrial complex has caused; to provide rapid access to dignified, life-saving, evidence-based holistic treatment for opioid addictions in a community setting; and to build a model of care that transforms the biomedical model into one of solidarity with community and collective care. Five key concepts underpin the program design: 1) Harm Reduction, Autonomy, and Agency; 2) Healing-Centered Engagement; 3) Language and Cultural Humility; 4) Transforming Health Systems Design; 5) Workforce Diversity and Pipeline Training. The program’s core components include conventional approaches such as low-barrier access buprenorphine (suboxone®) to medication treatment, primary care, case management, syringe exchange, and counseling/therapy in addition to more community-rooted and integrative healing modalities such as healing circles, acupuncture, massage, reiki, ear acudetox, and civic engagement. In sharing the values, lessons learned, and tools from our work in the Strong Roots/Raices Fuertes program, we hope to inspire and encourage others wishing to develop new systems of care for people dealing with addiction issues.

1. Introduction

This chapter shares how two community-based clinics in Albuquerque, New Mexico, USA, are working together to reframe treatment for opioid addictions. Program aims are to: 1) undo harms that the medical-industrial complex, structural inequities, and racism have created, and 2) reframe approaches to treatment. Our mix of evidence-based medicine, relational care, integrative healing modalities, trust-building with community, and a look beyond the biomedical model into structural issues aims to support individuals and our community in addressing root causes of pain and dealing with opioid addictions. The five-person team participating in the Clinical Scholars Program consisted of a Family Physician (AT), a Clinical Social Worker and Medical Anthropologist (WW), a Physician Assistant, a Family Nurse Practitioner and Curandera, and a Doctor of Oriental Medicine. We hope our experiences will guide others wishing to develop alternative systems of care for those dealing with addiction issues and support a broader responsibility of healthcare organizations in their communities.

1.1 A legacy of contradictions

The history of opioid pain pill and heroin use in the United States is fraught with contradictions, politics, moralizing, profit, stigma, and racism [1, 2, 3]. Use of these drugs has surged in recent years, triggering public health calls for responses to the epidemic, which in New Mexico has been fueled by political, social, and economic processes operating at the local level for decades, and in many cases, centuries. Acknowledging social suffering as a root cause of the epidemic shifts etiological explanations of the problem from historical, individual, moralistic, and medical frameworks to ones that take into consideration the roles of power, discrimination, and injustice in creating and maintaining racial health disparities.

Overwhelming evidence points to the pharmaceutical industry and the medical prescribing community as having key roles in manufacturing the current epidemic [4, 5]. However, the stigma associated with drug addiction is perpetuated by community perceptions rooted in racist, classist, and moralistic beliefs, and ignores the deep psychological, economic, social, and political forces that lead people to use drugs. Existing care systems erect barriers that include shortages of healthcare providers and clinics in the very communities needing them most—communities with high overdose death rates. The War on Drugs disproportionately targets and criminalizes minority communities and perpetuates the social exclusion, racism, disenfranchisement, and poverty that contribute to drug use [6, 7, 8, 9, 10, 11]. The dominant treatment culture individualizes, judges, shames, fears, and blames people caught in cycles of use, abstinence, and relapse [9, 10].

1.2 New Mexico’s colonial past: laying the groundwork for generational traumas

New Mexico’s colonial and settler legacy frames the local context that has contributed to drug addiction in Albuquerque’s South Valley. The South Valley has endured historic waves of invasion, displacement, dispossession, and campaigns to exterminate, subjugate, and assimilate the people. Colonial and settler structures that assigned racial identities and corresponding rights and privileges contributed to the erasure of the majority native and mestizo inhabitants from Albuquerque’s social, political, and economic landscape. These structures remain in place today, albeit contested, adding to the belief held by many Strong Roots/Raices Fuertes patients that existing civic institutions and structures are not intended for them.

The South Valley was built along the Turquoise Trail, a route that weaves along the Rio Grande Valley between Mexico City and Santa Fe and was traveled for millennia by the region’s first indigenous inhabitants [12]. After Spanish settlement it became known as the Camino Real [12]. The Spanish colonial administration created castas (castes) that reinforced racial hierarchies privileging European whiteness [12, 13]. Shortly after the signing of the Treaty of Guadalupe Hidalgo in 1848 that ended the Mexican American War, the Gadsden Purchase annexed the greater part of the Southwest and California as a US territory [14, 15]. The federal government denied statehood until there were more English-speaking white inhabitants [14, 15]. More than 60 years passed before New Mexico was recognized as a state in 1912 [14, 15]. Economic and political pressure to ascribe to whiteness forced many to cover up their indigenous and mestizo roots [16]. The promised benefits of assimilation never materialized for most and fueled racial tensions still present today [13, 14, 15, 16].

Generations of South Valley families relied on military service as a pathway to greater economic stability. Soldiers wounded in the line of duty and treated with morphine found heroin a more accessible and affordable way to manage physical and psychological pain on their return home [17]. Many of the patients in the Strong Roots/Raices Fuertes program are children and grandchildren of veterans from the Korean and Vietnam Wars who grew up watching their role models struggle with finding a way to cope with their pain.

1.3 New Mexico today

New Mexico suffers high rates of opioid overdose deaths. For almost two decades, New Mexico ranked #1 or #2 for per-capita overdose death rates from heroin or opioid pain pill use [18]. The drop in recent years is in part due to the escalation of rates in other states experiencing the effects of the nationwide opioid crisis. In Bernalillo County, opioid overdose death rates are 22.2 per 100,000 people – nearly double the national rates (13.3 per 100,000 people) [19]. From 2010 to 2014, overdose death rates in the South Valley of Albuquerque ranged from 37.1 to 41.1 per 100,000 [20].

Because of the high overdose death rates, New Mexico has pioneered innovative harm reduction and treatment work. The state was the first to train first responders on naloxone administration for opioid overdoses, the first to pass a Good Samaritan 911 law, and one of the first states with an opioid addiction treatment program within a county jail, providing methadone to inmates. The state’s Department of Health has a robust program supporting and funding syringe exchange sites and naloxone distribution for opioid overdose prevention.

A toxic mix of concentration of poverty with a greater concentration of industry and environmental exposures leaves the South Valley of Albuquerque experiencing huge disparities in access to primary care and behavioral health, and in health outcomes [21]. Some parts of the South Valley have a 15-year decrease in life expectancy compared to other parts of Bernalillo County [22]. However, the South Valley also boasts a high rate of home ownership, a mix of families present for generations and recent immigrants from Mexico and Central America, and a farming culture given its semi rural landscape.

1.4 Adverse childhood effects and opioid addictions

The Adverse Childhood Effects (ACES) study looks at kinds of childhood exposure to various factors including but not limited to physical, psychological, or sexual abuse; growing up in a household with one or more parent who uses drugs; mental illness; domestic violence; and having an incarcerated household member [23]. Exposure to multiple types of trauma in childhood builds up “toxic stress” and has shown to have lifelong impacts for children, including addictions in adulthood [24].

Nationally, 34 million children have had at least one adverse childhood experience (ACE), but in New Mexico, nearly 30% of children have two or more, the fourth highest in the country [25]. An individual with five or more ACEs is ten times more likely to use IV drugs as someone with no adverse childhood effects [26]. Children with four or more ACES have 32.6 times greater likelihood to have learning or behavioral issues [27]. A direct link between exposure to adverse childhood effects and juvenile delinquency has been demonstrated. Among all teens held in juvenile detention in 2011 in New Mexico, 100% of the girls and 96% of the boys had two or more ACEs [28].

1.5 From biomedical model to greater responsibility

The National Institutes on Drug Abuse and leading physicians and scientists refer to opioid dependence as a “chronic, progressive, relapsing, brain disorder” that requires treatment instead of criminalization [29]. However, this approach individualizes and medicalizes an issue that has roots beyond chemical changes in the brain. It also places individuals into a “cage” of sorts -- someone labeled as having a relapsing progressive disorder may feel trapped, as if they can never improve, and others may treat them as such, reinforcing the perception. As neuroscientist and author Dr. Carl Hart states, “…if the problem is a person’s neurobiological state after exposure to a drug, then either the drug must be eradicated from society through law enforcement or an individual’s brain must be treated. In such a myopic approach, the socioeconomic and societal factors that contribute to drug addiction are considered a footnote in research, clinical practices, and policy, despite their apparent importance [30].” More recently, the opioid epidemic has been framed as a public health issue, but few public health solutions have arisen from this paradigm.

1.6 Two community clinics team up

Casa de Salud and Centro Sávila are two organizations in the South Valley of Albuquerque, New Mexico. Both clinics emerged from a recognition of significant gaps in New Mexico’s public health safety net that leave thousands of community members without access to dignified healthcare.

Casa de Salud was founded in 2004 by medical practitioners, volunteers, and the Kalpulli Izkalli traditional healing collective. The clinic serves primarily uninsured New Mexicans and people with Medicaid. Services include safe, accessible, holistic, and culturally humble primary care; a wide variety of integrative healing options; transgender care; a syringe exchange; addictions care; medical debt support, and community organizing/advocacy. The clinic offers a unique, immersive health apprentice program as a pipeline health workforce opportunity primarily for students of color.

Centro Sávila opened its doors in 2011 to address the need for culturally and linguistically appropriate behavioral health services in New Mexico. Clinic staff work to decrease racial health disparities in Bernalillo County by providing outpatient mental health services; case management; health insurance enrollment assistance; food security support; drug and alcohol counseling and recovery support; and supervision, training, and research opportunities for students and health professionals. Central to this effort is the need for New Mexico’s behavioral health provider workforce to reflect the same diversity of the state.

Support from the Robert Wood Johnson Foundation Clinical Scholars program in 2016 allowed staff from the two clinics to participate in the first cohort of the Clinical Scholars Program, deepen their existing partnership, and expand both the scope and depth of their efforts to combat opioid pain pill and heroin addiction and its underlying causes. Naming the Wicked Problem Impact Project “Strong Roots/Raices Fuertes” reflects the team’s desire to lift up the community’s strong culture and resiliency, while looking to address root causes of addictions in New Mexico. The raison d’être of the Strong Roots/Raices Fuertes program is a drive toward recognizing the contradictions inherent in providing health care to address problems with social, economic, and political roots. The program’s health care providers recognized the wicked problem of addiction is fueled by social injustice and trauma.

2. Methods

The five clinicians of the Clinical Scholars Strong Roots/Raices Fuertes team were motivated by a drive to promote social justice and health equity in developing and implementing the Strong Roots/Raices Fuertes program. Aims of the program are to 1) provide rapid access to dignified evidence-based holistic treatment for opioid addictions in a community-based setting, and 2) develop a model to focus on mind/body/soul as well as collective care, going beyond the biomedical model. The team wanted to build tools to transform the medical-industrial complex that historically medicalizes, shames, and exploits communities. Underlying this aim was a desire to work in solidarity with the community to empower them to create change at the individual and systems levels instead of maintaining a power differential that silences people who use drugs.

2.1 Key concepts

The approach of the Strong Roots/Raices Fuertes program focuses on addressing individual healing as well as the underlying causes of addiction. Five key concepts underpinning the program design and thinking are 1) harm reduction, autonomy, and agency 2) healing-centered engagement for mind/body/soul 3) language and cultural humility, 4) transforming health systems design, and 5) workforce diversity and pipeline training.

2.1.1 Harm reduction, autonomy, and agency

Harm reduction, autonomy, and agency as concepts comprise a set of interconnected practical strategies to reduce the negative effects of health behaviors without necessarily stopping the behaviors completely. Harm reduction is based in values of humanism, pragmatism, individualism, incrementalism, and accountability without termination [31]. Guiding principles are to:

• meet people where they are

• accept that drug use is part of our world

• center on the person seeking treatment

• support individuals in their decision-making and recovery choices instead of replicating patterns of shame, blame, or trauma

• affirm the individual as his or her primary agent of change, a critical element for success, recovery, trust, and sense of purpose

2.1.2 Healing-centered engagement for mind/body/soul

Trauma-informed care reframes “What is wrong with this person?” to “What has happened to this person?” The latter frame is important but can lead care providers to prioritize individual traumas over collective traumas or community-based needs. Healing-centered engagement goes beyond trauma-informed care and is culturally rooted, reflective, and incorporates spirituality, civic action, and collective healing. The cultural rootedness strengthens trust from participants to support healing. A key innovation of Strong Roots/Raices Fuertes is opt-in access to multiple integrative healing services (Table 1) to restore the connection with mind/body/soul healing, and to lift up approaches to care that are culturally safe, hands-on, and relevant. Patients are also accepted as leaders with strength and agency, working together on structural and community level change.

Frontline Advocacy/Case Management

Factors not directly related to health (e.g., lack of housing, food insecurity, transportation challenges, and access to ID / documentation) impact peoples’ success in the program and in their lives beyond treatment. Case workers actively support patients with specific needs and coordinate care with services outside the program (e.g., referrals to specialist physicians, communicating with parole or probation officers). Community health workers, peer support networks, and navigators/promotoras assist patients in getting other basic needs met.

Emotional and Psychological Support with Behavioral Intervention

Culturally humble, licensed clinicians provide individual and group counseling and psychotherapy. Empathic, non-judgmental, and patient-driven meetings help identify emotional, thought, and behavior patterns that trigger substance use. Clinicians create a safe and confidential setting to help build trust, increase patients’ insight into the ways substance use has affected their lives, and practice alternative and healthier behaviors that more effectively regulate and manage psychological and physical suffering.

Table 1.

Supportive and behavioral care components.

2.1.3 Language and cultural humility

The role of language is critical in addiction treatment. Finding appropriate ways to discuss addictions without falling into the trap of focusing on personal character flaws or poor choices requires a macro frame that guides intervention on the individual and family levels. Cultural humility reflects a need to be humble about our understanding of our patients’ values and beliefs, be aware of our own assumptions and prejudices, understand and shift the power inherent in the clinician-patient relationship to a co-learning relationship, and hold ourselves and our institutions accountable to this practice. Cultural humility requires dedication, organizational buy-in, and regular practice among all staff and team members [32].

2.1.4 Transforming health systems design

Health system transformation requires the desire and investment in resources to reflect on user experience, patient care flow, and barriers to care, and to iterate on positive changes using direct feedback from patients and community members. Transformation helps systems move away from common barriers, such as distant locations that feel intimidating, (e.g. large hospitals, or clinic designs that treat patients in an assembly-line fashion by curt and overworked employees). Fee-for-service pay structures can oblige providers to filter access to healthcare services based on patients’ ability to pay and language barriers can leave patients confused over what they are paying for.

2.1.5 Workforce diversity and pipeline training

Racial health disparities are exacerbated by disparities in the healthcare workforce. The demographic diversity of New Mexico’s healthcare provider workforce does not look like the racial diversity of the general population. This gap reflects financial, geographic, and racial barriers that have historically limited access to pathways for professional development. Health care institutions play a critical leadership role in recruiting, training and hiring people that want to work in the communities they are from. Research shows that trust and patient satisfaction are directly related to concordance of patient and clinician racial/ethnic background. Medical schools across the country have increased diversity in general in the last twenty years, but the number of underrepresented minorities in medical school classes around the country -- Black, Latinx, or Native American medical students -- have actually decreased per 100,000 US population [33]. There is also a critical lack of social workers and therapists of color in New Mexico, a state with an almost 50% Latinx/Hispanic population. Internships and apprenticeships are powerful opportunities for students to serve their communities, in ways that are culturally humble, sensitive, skilled, and that understand the reality of patients from impacted communities.

2.2 Core components

Strong Roots/Raices Fuertes incorporates multiple core components that reflect both traditional medical approaches and integrative medicine. Core components are divided into four primary types: program orientation and primary care/medication treatment (Table 2), supportive care and behavioral care (Table 1), integrative healing modalities (Table 3) and purpose and leadership (Table 4). All fit the key concepts that guide program design, most already existed in the clinics with years of positive feedback about their value, and all offer the patients and community a wide array of options to choose from to meet their individual healing needs. Patients in the Strong Roots/Raices Fuertes program additionally have access to the New Mexico Department of Health’s robust syringe exchange services program -- as Casa de Salud runs the busiest syringe exchange and naloxone distribution program in the South Valley.

Description	Approach
Orientation to Program
A session in which clinicians; Share information about program format Explain values of harm reduction, autonomy, and agency Discuss philosophy of mind/body/soul healing with integrative care Describe what is available to patients at each of the two clinics	To help equalize power, patients sit in a circle with clinicians, passing around a talking stick.; Use language of patients as leaders Talk about why treatments are free, why care is made accessible, and how trauma may be stored in the body Patients who wish to, may receive hands-on healing engagement at orientation sessions
Primary Care
Patients in the Strong Roots/Raices Fuertes program may not be receiving primary care elsewhere, and many have untreated Hepatitis C. Patients receive primary care in the patient’s preferred language (English/Spanish) for the range of health concerns they may be experiencing.	A key evidence-informed dimension is the program’s emphasis on care for the ‘whole patient’. Many patients come with a history of negative experiences with conventional western medicine such as; Feeling stigmatized, or not comfortable discussing the range of issues with which they need support Having been asked to identify one ‘single problem’ to address in a visit Experiencing moralized judgments from clinicians, or systems with barriers to care
Medication Treatment
Buprenorphine (suboxone); Reduces overdose death risk by 50% Provides short-term and long-term success for opioid use disorder Increases quality of life Can easily be prescribed in outpatient treatment programs or primary care settings	Strong Roots (Raices Fuertes) program; Uses a harm reduction approach -- “come for the suboxone; stay for everything else we offer!” Has no mandatory requirements for additional services Does not cut patients cut off from suboxone for urine drug test results that could otherwise result in a therapeutic discussion Does not withhold medicine for arbitrary reasons.

Table 2.

Orientation and primary care/medication treatment.

Acupuncture

East Asian Medicine (EAM) is thousands of years old, and is a system of medicine that looks at the entire body as a whole and includes relationships of the body systems as well as relationships of people to the world. It takes into account how all systems affect health and longevity and employs many different tools including diet, exercise, meditation, herbal therapy, cupping, moxibustion, and acupuncture. Acupuncture uses fine needles to stimulate and enhance the body’s ability to heal itself, through channels or meridians -- and has been used to effectively approach issues of energy, digestion, stress, anxiety, emotional and physical pain, cravings, neurological issues, immune system issues, blood pressure, and more.

Massage

Massage therapists use the healing power of human touch to hold, press, rub or otherwise manipulate muscles and other soft tissues. Massage has proven effective in healing trauma, managing pain, and integrating emotional pain and somatic experience. Many patients’ addictions began when they needed relief from a physical or emotional trauma. By paying attention to the ways in which the body holds the variety of lived experiences ranging from stress, trauma and isolation, to love, joy and connectedness, massage therapists help patients to feel whole.

Reiki

Reiki is a Japanese healing technique shown to be effective in managing pain, calming the nervous system, and decreasing stress. It is based on the premise that a reiki practitioner can channel energy into a patient and assist him/her to activate natural healing processes to promote relaxation and balance, and restore emotional well-being. Reiki can also be practiced on oneself. A session can be hands-on, where a practitioner applies light touch during the session, or hands-off where they hold their hands slightly above a patient’s body.

Ear Acudetox

Ear acudetox is an evidence-based, standardized ear acupuncture protocol used for heroin, alcohol, and cocaine addictions treatment, as well as for sleep, anxiety reduction, and stress reduction [34]. Following the National Acupuncture Detoxification Association (NADA) protocol, five very small needles are placed in each ear. Ear acudetox has been used as supportive care for people struggling with addictions since it was developed in the 1970’s at Lincoln Hospital in Bronx, NYC, through community activism and a self-help model. It is currently practiced around the world.

Healing Circles

Healing circles are based on the Native American talking circle in which each participant is passed the sacred feather and given time to speak. The Strong Roots/Raices Fuertes program offers healing circles in which patients share their stories and support each other. Each three-hour session is co-facilitated by two healers: a nurse practitioner who is also a curandera or traditional Mexican healer, and a reiki master, both of whom are ear acudetox specialists. After the talking circle, participants are offered ear acudetox, reiki, and a limpia (cleansing ceremony), in a group setting, to provide healing, calmness, and closure to the talking circle.

Table 3.

Integrative healing modalities.

Civic Engagement

Civic engagement focuses its efforts at understanding root causes of addiction and building movement toward systems change. The Strong Roots/Raices Fuertes Program provides opportunities for patients to become engaged in civic leadership. Civic engagement efforts include advocating for changes to the criminal justice system, increased access to treatment, and opportunities to talk with elected officials and decision-makers. Patients receive training in storytelling for public speaking and peer-to-peer support around addictions. Popular Education workshops are delivered by patient leaders who train in facilitation, to help community members educate each other, toward action. A deeper understanding of the leadership capacity of and leadership development desires of community members also offers the two clinics opportunities to develop resources alongside patients and community members.

Table 4.

Purpose and leadership.

2.3 Popular education workshops

The EleValle Collaborative is a collective of South Valley organizations that work together to improve the health and quality of life for residents and their families. The Strong Roots/Raices Fuertes program and the EleValle Collaborative supported development of two workshops, one two hours in length and the other six hours. A clinician from the Strong Roots/Raices Fuertes program trained six patient leaders in facilitation skills. Patient leaders helped develop and implement four two-hour workshops on various issues specifically for others in the community who care for people struggling with addictions or who were struggling with addictions themselves. Workshops included content on the history of the drug war, resiliency, storytelling, and trauma. A subsequent six-hour event for the community was created, composed of content from the two-hour workshops plus overdose prevention training. The goal of this process was to lift up those most impacted by addictions in our community and develop peer-to-peer education workshops that could be used locally and beyond.

2.4 Inherent leadership survey

The Strong Roots/Raices Fuertes program and the EleValle Collaborative also worked with a local evaluator to develop a ten-question leadership survey. The purpose was to gather a sense of inherent leadership and desires for leadership training, among individuals struggling with addictions. The survey was administered to 1) people who use drugs and who actively utilize the syringe exchange, and 2) patients in the Strong Roots/Raices Fuertes opioid addiction treatment program. Most had not attended the Popular Education workshops described above. Survey questions are shown in Table 5.

Leadership Survey Questions

1. Give an example of a time in your life when you showed leadership.

2. Currently, what are some ways that you show leadership with your friends, family, co-workers, or community?

3. Currently, do you feel like you are a leader in your community? [(Likert scale response from 1 (not at all) to 10 (very much)]

4. Are you interested in becoming more of a leader in your community? [(Likert scale response from 1 (not at all) to10 (very much)]

5. What are some of the most pressing issues facing your community that require more leadership?

6. If we (Casa de Salud, Centro Sávila, or ACCESS) offered regular opportunities to get together with others to build leadership skills and knowledge, are you likely to participate?

7. What are some skills that you are interested in building (for example, public speaking, writing, healing therapies)?

8. What types of activities would you be interested in (for example, a book club, a social club)?

9. What issues affecting your community do you want to learn more about (for example, the history of war on drugs, current policies regarding treatment of people who use drugs, etc.)?

10. When you think about building leadership skills and knowledge, what are some fears or barriers that you face?

Table 5.

Leadership survey questions.

3. Outcomes

3.1 Partnering to improve care

Casa de Salud and Centro Savila met weekly and for several day-long retreats, to develop and implement the Strong Roots/Raices Fuertes program. Regular meetings were key for iterating on processes, for ensuring alignment with values and goals and language of the program, and for troubleshooting issues. In addition, the team regularly met to discuss patients, and approached their care from a truly transdisciplinary process, learning from each other to best partner with our patients for care. The two clinics improved upon pre-existing modalities and services that the organizations offered, and built new joint services and projects together. Outcomes for patient care are detailed more in the Evaluation section.

3.2 Response to integrative healing services

A key innovation of Strong Roots/Raices Fuertes is opt-in access to a variety of integrative healing services to restore the connection with mind/body/soul healing described earlier. These low-cost, high-touch, non-pharmacological, relational therapies are key components in patients’ paths to recovery. One patient shared: “In other programs, nobody ever wanted to touch me. Here we experience healing touch, and that means everything to my confidence and my connection with society.” Others have shared the ways in which bodywork and energy work helped release trauma, or as ongoing tools for stress and anxiety reduction.

3.3 Popular education workshops

More than thirty participants attended each of the four two-hour workshops; most were active drug users or had immediate family members who were actively using drugs or were in treatment. The six-hour workshop that combined content from the two-hour sessions and added overdose prevention training had 80 attendees. Overall, more than 200 community members participated in workshops. Survey feedback from these events was overwhelmingly positive. A toolkit for broad use of these workshops was developed in this process. The response from the community and the leadership development of patient/client leaders who facilitated these workshops was very moving. Patient leaders built confidence while training in facilitation skills and through delivering workshops. They described the process as transformative and engaging. Two of the patient leaders (33%) subsequently pursued Certified Peer Support Worker (CPSW) certifications, with an interest in building careers in this area.

3.4 Inherent leadership survey

One hundred and one people completed the Leadership Survey. In response to the prompt, “give an example of a time in your life when you showed leadership”, resulting themes from patient stories included being leaders on their high school sports teams and current workplaces, and having roles as parents and caregivers.

Responses to the self-assessment of their leadership question ranged widely. Participants were asked to rate themselves on a scale of one (not at all) to ten (very much) as to whether they identified as leaders in their communities. More than a third of patients rated themselves as low on the leadership scale (three or lower), roughly half rated themselves in the middle range (four to seven), and almost 20% of patients self-identified as currently “very much” a leader in their communities (eight to ten). When asked if they were interested in becoming more of a leader in their community, more than 80% responded with positive interest. Some cited barriers to developing their leadership such as lack of time due to family and community responsibilities and fear of failure. Participants noted specific fears around leadership, including being labeled as a “junkie” if they spoke out about their recovery journey, or internal fears around their self-esteem or anxiety regarding public speaking. About 40% stated they were somewhat interested in developing their leadership and ∼ 40% responded they were “very much” interested.

In response to the question, “what are some of the most pressing issues facing your community that require more leadership?”, several clear themes emerged including homelessness, police, violent crime, loss of connection to cultural heritage, and public services. One syringe exchange participant wrote, “the police and homeless are issues we face. As a community we need to step up and try to get more help for the homeless population and especially the youth. The police are killing and shooting with no real reason, people are fearing and not trusting the police.” Another person shared, “homelessness, violent crime, non-violent offense charges being too drastic.” On the issue of loss of connection to cultural heritage another wrote, “my community needs leadership to keep our traditions and language alive.” These results were incredibly informative for next steps in leadership development work in partnership with our community.

3.5 Practicing leadership

Strong Roots/Raices Fuertes staff and patients together presented to state legislators and public health officials as well as government leaders and community health care providers. These presentations helped raise awareness about opioid addictions and harm reduction, the need for community focused approaches, and also focused on structural issues, such as the disproportionate effect of criminal justice efforts on communities of color and the harmful effects of the war on drugs. Our organizations have a voice at the Bernalillo County Addiction Treatment Advisory Board, at the county’s Criminal Justice Coordinating Committee, and with the City of Albuquerque, which is exploring a new Department of Community Safety as an alternative to police, and is looking to us, among other organizations, to build infrastructure to improve support services for a community approach to addictions.

4. Evaluation

4.1 Framework and process

The Strong Roots/Raices Fuertes team aimed to build and analyze data that was meaningful to our clinics and to our patients. This was a topic of great discussion among team members of both clinics during regular team meetings. The values and key concepts of the program, including harm reduction and autonomy, meant that conventional indicators such as how many “relapses” patients experienced; length of stay in the program; positive urine drug screens for illicit substances; were not of primary interest.

Instead, the team aimed to learn about what barriers to care existed (from program design or external factors), and how transforming system design could improve patient care and engagement; what recovery journeys patients would choose within an opt-in program that valued autonomy and choice over prescriptive structured programming; how we could avail patients of naloxone and other tools more systematically; and how we could re-engage patients who stopped interacting with care.

With the help of an independent evaluator, we developed an Engagement and Registry system, populated using code that pulls data from Casa de Salud’s electronic medical record (EMR), OpenEMR, an open source system with powerful and flexible reporting abilities. We also developed an external data process that captured information on anybody who expressed interest in the program -- interest by phone, through the syringe exchange, through case management -- who were not yet patients in the electronic medical record.

4.2 Data

Initial data show that over the course of two years after the program redesign, 68% of people who expressed any interest at all in the program -- initial interest by phone, through primary care, or through the syringe exchange -- followed through to starting buprenorphine medication, orientation, and engagement in optional healing modalities. Before the program components were redesigned to decrease the number of mandatory steps present in the first few weeks -- despite the profound healing nature of the mandatory modalities -- less than 40% of people who expressed interest in treatment and healing successfully completed orientations, healing circles and achieved medication treatment.

Data on days from interest in the program to starting medication treatment, before the program was redesigned, is limited and variable, given time cycles of mandatory components (orientation and healing circles) before start of medication treatment. However, from the limited prior data, it appears program redesign reduced average wait times to start medication from two weeks down to one week or less, in an already accessible program.

In addition, with a fully opt-in program for many components and services, 45% of patients engaged in opt-in components of the program, including acupuncture, massage, reiki, healing circles, counseling, coaching, case management, and more. Many patients engaged in multiple components of the program.

Each month, former patients also returned to the program after dropping off in communication and treatment -- and they were welcomed back without judgment or hurdles to jump through. Over time, the clinics also proactively reached out to patients who dropped off, with the help of coding within the EMR that flagged staff when two to three months had lapsed since last communication with a patient.

Trainings on naloxone (Narcan®) as an overdose prevention tool were systematically incorporated into the program. At orientations, patients shared stories of saving others’ lives with Narcan®, or receiving life saving treatment from others -- and through story sharing they were lifted up as leaders. Patients encouraged friends in their peer networks to utilize the syringe exchange in order to use drugs more safely, if they were not ready to quit. Of the Narcan® units that Casa de Salud distributed to community members (within and outside of the treatment program), fully one-third of units were reported to be used to save community members’ lives outside of any healthcare setting. And initial data collected by Casa de Salud a few months into the COVID-19 pandemic showed that more than 50% of units of Narcan® distributed were reported to be used on others in the community, which correlates to national data around an uptick of opioid overdoses in the U.S. during the initial few months of the pandemic [35].

The dynamic iterative model of changes in the program made the measurement of some outcomes challenging, and the opt-in model that meant that any single patient could engage in a unique set and frequency of programming available to them. However, an overwhelming number of patients reflect that healing touch improved their self-confidence and accelerated their healing process; that the program allowed them to connect mind–body-soul and reconnect to their bodies in new ways; that skilled counseling/therapy done at their own pace instead of starting from day one, allowed them to move through healing in their body first until they were ready to talk, and allowed for necessary trust building. Lastly, the ability to navigate warm handoffs and treatment among interdisciplinary providers allowed for interruptions in patients’ triggers that curbed relapse risk (see link at the end of this chapter for a video of acupuncturist at Casa de Salud speaking to the power of a warm handoff and transdisciplinary care in a specific patient situation). We are building “practice-based evidence” alongside evidence-based practice.

The multiplier effect of the health apprentices program at Casa de Salud -- future clinicians and healthcare leaders -- and the social work interns at Centro Sávila -- future therapists and advocates -- is palpable as students enter institutions of higher education with community based practice knowledge gained in either institution, and then go on to practice healthcare, impact patients and communities, and mentor other future healthcare leaders.

Casa de Salud developed a unique immersive health apprenticeship program that provides more than 500 hours of immersive experience, primarily to students of color interested in healthcare careers and who want to work, live, and invest in their communities. Apprentices learn medical assistant skills such as phlebotomy, greet patients, support clinicians with procedures, staff the syringe exchange, and understand the administration of nonprofit integrative care. The apprentice program trains a future workforce that is culturally humble, bilingual, sensitive, skilled, and that understands the realities of patients from impacted communities. Apprentices deepen their understanding of how to provide care with dignity to communities, help close provider-client demographic gaps, and demonstrate what culturally-rooted and responsive care looks like. Apprentices at Casa de Salud share stories of transformation in their own attitudes in working with active drug users and people seeking treatment, and their impact on shifting attitudes among family members and friends. The effects of humanization, compassion, and passion for supporting drug users and people in recovery will be multiplied many times during the careers of these future clinicians and healthcare leaders.

In a survey of health apprentices conducted during the Clinical Scholars fellowship time period, 94% reported increased awareness of issues in the community during their apprenticeship, and 84% reported improved clinical skills. A total of 87% of apprentices were between the ages of 16 and 24 years of age and 84% of the apprentice team during this time period identified as women, and over 90% of apprentices identified as Latinx or Hispanic. About 60% of apprentices reported the highest parental level of education of either parent as a high school diploma or below. Each year, 20–30 students complete rigorous immersive apprenticeships at Casa de Salud. Over the course of the health apprenticeship program’s history, upwards of 40% of former apprentices who Casa de Salud is in touch with are enrolled in or have completed health professional schooling, public health school, allied health fields, and other areas of education, and are working as clinicians and other professionals.

By investing in the human capital of apprentices and interns, Centro Sávila and Casa de Salud have begun to train a new generation whose commitment to local community will ease the recruitment and retention in healthcare provider shortage areas.

5. Discussion

“So the opposite of addiction is not sobriety. It is human connection… You can build a system that is designed to help drug addicts to reconnect with the world — and so leave behind their addictions.”

• Johann Hari, author of Chasing the Scream.

The Strong Roots/Raices Fuertes program has made important contributions to the South Valley community, residents of Bernalillo County, and the State of New Mexico. Through a three-year process that engaged staff and patients, the program evolved greatly. Access to low-cost, life-saving naloxone and buprenorphine has saved many lives - buprenorphine has been shown to reduce all cause mortality by a staggering 50%, and naloxone delivered by community members is estimated to have saved around 27,000 lives over an 18 year time period [36, 37]. The program’s array of holistic services to support the recovery process is unique in that it prioritizes culturally-rooted practices and recognizes cultural, social, and historical factors that contribute to the opioid epidemic. The program earned the trust and respect of local community members and succeeded in recruiting and retaining patients. During one orientation, a patient shared she had learned about the program from her drug dealer, who respected her desire for treatment instead of drugs.

By far, the most popular service in the program was the low-to-no-cost medication treatment with buprenorphine. The importance of supporting patients with lifesaving evidence-based medicine, in the window of time they are ready, with dignity and without barriers or shame, is critical. Apprentices and staff sometimes “ghost call” other clinics, as patients, to explore barriers in the community such as wait times and hurdles to starting treatment. Often there are wait times of several weeks to several months, or many mandatory requirements in order to start medication treatment -- which many programs do not even offer. Same-day or next-day buprenorphine start for people seeking treatment, is a goal for the Strong Roots/Raices Fuertes program.

Patients often reflect on their ability and power to choose their path and programming for their own recovery goals. Many of our patients have experienced overbearing surveillance from the criminal justice system and from the medical-industrial complex of clinics and for-profit treatment programs. Healthcare systems would benefit greatly from reworking treatment and recovery options to provide less surveillance and more autonomy.

Low-cost, relational, high-touch, healing modalities should be incorporated into treatment programs. Many of our patients reflected greater calm, decreased pain (previously a trigger for relapse), fewer withdrawal symptoms, more grounded nervous systems, improved sleep, and decreased anger and reactivity after receiving massage, reiki, acupuncture, ear acudetox, or participating in healing circles. Specific benefits from healing circles included building community, letting go of shame, connecting with others, not feeling alone, and reconnecting with their spirituality. Numerous patients reflected that high-touch healing modalities allowed them to connect to their bodies and feel human and cared for. Two patient leaders in the program were so transformed by massage, acupuncture, and reiki, that they pursued and completed Reiki certification courses, with Casa de Salud’s reiki master. They utilized this training to practice reiki on themselves, for stress reduction and calming their nerves, and plan to continue certifications in this practice.

Healthcare must become anti-racist. A recent study showed that Black patients who tested positive for illicit drugs were discharged from treatment at a significantly higher rate than white patients [38]. Neighborhoods in need of healthcare and drug treatment options have systematically been denied appropriate treatment in part based on their racial and socioeconomic makeup. White Americans are almost 35 times more likely to have access to suboxone than Black Americans [39, 40].

Developing a unified approach to care and a common language requires time to iterate on the program and hold each other accountable. Clinicians and staff from both clinics meet regularly, for introspection, reflection, and improvement. Clinicians together shifted away from language of “addicts” and “clean vs dirty” urine samples, among other things. Feedback from patients provides valuable insights into ways to improve. The majority of our clinicians at both clinics, and all health apprentices/medical assistants are fully bilingual (English and Spanish) to support our community of patients, many of whom are monolingual Spanish speakers.

Casa de Salud and Centro Sávila are intentionally small clinics, in walking distance of each other, and rooted centrally in the South Valley community. The clinics are approachable, have a neighborhood appeal, are colorful and welcoming, and are non-clinical in feel. Many aspects of our clinical environments are designed to reflect our core principles, evident in the ‘community’ feel of clinical rooms, an inclusive front door setup shared by all patients and syringe exchange clients, and our reconceptualization of the ‘front desk’ as a space that welcomes rather than alienates or shames. Casa de Salud runs a syringe exchange program and has built trust with the drug using community through thousands of exchanges over the last 15 years.

In teaming up to improve support for patients seeking treatment and recovery for opioid addictions, we tried to put ourselves in our patients’ shoes - patients who may be rejected by systems when seeking care, have internalized shame around barriers to care, and are finally ready to seek treatment and have a small window in which supporting them could go a long way. Significant introspection helped us identify barriers we were inadvertently creating with our orientation process or with prior mandatory requirements to start on treatment. Healthcare systems can incorporate shifts, small or large, to improve patient experience, flow, design, and accessibility to care. Clinicians in communities should engage with each other to reflect on their systems’ inadvertent barriers to care and discuss ways to shift these in practice, on the ground level.

Both clinics recognize the critical financial barriers to care inherent in our healthcare system and magnified in the world of addictions treatment. Despite Medicaid expansion and the Affordable Care Act, more than 10% of the state’s population is still uninsured, and undocumented patients have no meaningful way to access affordable health insurance. Many Strong Roots/Raices Fuertes patients are recently out of jail or prison and may not have Medicaid reinstated when starting treatment. The two weeks post-release from jail or prison have a several times elevation in overdose death risk for people struggling with opioid addiction [41, 42, 43, 44]. Our clinics work hard to ensure patients had access to Medicaid or insurance on the health exchange, and for those who remained uninsured, we provide global care (as many visits for treatment, therapy, primary care, acupuncture, massage, reiki, and other services as patients needed), at a small monthly fee, which is subsidized or waived when financial barriers existed. Financial barriers cause avoidance of care or create a firm barrier to care; this is very apparent in treatment of addictions. We encourage clinicians to better understand their institutions’ fees for care (especially for uninsured patients), collections policies, and any sliding scale options possible, and to advocate for positive change.

Fostering civic engagement that acknowledges the structural and systemic factors contributing to addiction engages new leaders to become the change they want to see in their communities. In the Strong Roots/Raices Fuertes program, we specifically include avenues for civic engagement for our patient population. We shift the language we use with patients; when they start in the program, we refer to them as leaders. We thank them for making this step in their recovery. We work on multiple approaches (e.g., patients co-designing and delivering community workshops, developing leadership skills) to support patients who were interested in doing something bigger than themselves, and/or speaking out for themselves and others.

One central aspect of the Strong Roots/Raices Fuertes Program is that our two organizations are small, community-rooted, non-profit startups that emerged out of a need to address gaps in New Mexico’s public health safety net. The experience of “making the road by walking it” provided our program with a unique appreciation of the importance of community engagement and advocacy to address both the individual and systems levels of human suffering. In this time of the COVID-19 pandemic, clinicians around the country have united more than ever before, and discussions about healthcare workers organizing are inspiring, for greater long-term impact on systems change. Solidarity and partnerships with patients and our communities can result in sustainable building of power, with potential for immense policy change locally and nationally.

6. Toolkit

The Toolkit for our Wicked Problem Impact Project for Clinical Scholars can be found at www.ClinicalScholarsNLI.org/community-impact. Our Popular Education Workshop materials can be found in Appendix A (Spanish) and Appendix B (English). At the following link you can find a video of an acupuncturist talking about integrating our care for Strong Roots/Raices Fuertes patients (https://drive.google.com/file/d/1op5A_p_qGzJGFiVRTCkiP8NJsfFZLdGs/view).

Acknowledgments

We are grateful to the Robert Wood Johnson Foundation Clinical Scholars Program, and its program staff, for believing in the ideas of, and investing in the leadership development of and financial resources for, our Clinical Scholars team. We grew so much alongside our incredible national cohort of Clinical Scholars fellows from around the country. We dreamed and struggled and implemented together with our local Clinical Scholars team - thank you to Lorraine Cordova FNP, Dominic Villanueva DOM, and Kate Porterfield PA-C - in addition to numerous staff members at both Casa de Salud and Centro Savila, to build the Strong Roots/Raices Fuertes program. These staff members include clinicians and healers (Paula Terrero Reiki Master, Sarah Sidelko LMT, Alejandra Casarrubias RN, Leah Jo Carnine PA-C, Dina Bello DOM, Justin Remer-Thamert LMT, Laura Rifka Stern MD, Carlos Flores LMSW, Irini Georges LPCC, Carolina Verdezoto LCSW, Moriah Mahoney NP), Operations and Intake team staff (Elizabeth Boyce, Fizz Perkal, Sarah Sidelko), data/evaluation expertise (Judy Bartlett PhD), clinic flow coordinators (Phoenix León, Oscar Munoz, Tegan Whitney, Kenya Quiñonez, Denise Ornelas, Joe McDonald, and others), peer support/program staff (Robert Hoberg, Kristin Muniz LMSW), and all of our health apprentices. Every single patient leader we worked with in the Strong Roots/Raices Fuertes program humbles us and teaches us, and many contributed to the program’s development. We stand by our patients as community leaders every day. We are also grateful to the EleValle South Valley Healthy Communities Collaborative for collaborative work in developing popular education workshops, and to artist Gabriela Hernandez/Joteria Undocumented for the design of the workshop materials. We thank the City of Albuquerque, especially Director of Equity and Inclusion Michelle Melendez; Bernalillo County; and the New Mexico Department of Health’s Harm Reduction Division, for supporting our work.

In writing this chapter, we thank Dr. Nadine Ijaz PhD, for her coaching on the chapter development. We greatly thank the editorial team of Carol Lorenz, Edith Amponsah, and Lia Garman, and the Clinical Scholars Directors, for their generosity, patience, inspiration, and feedback on the writing.

A.1 Popular Education Workshop Materials (Spanish)

• Causas fundamentales de la addicion

• Resilencia

• Guera contra las drogas

• Historias

A.2 Popular Education Workshop Materials (English)

• Root causes of addictions

• Resilience

• The war on drugs

• Storytelling for social justice