Webinar Resources

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Maysoun Freij: Good afternoon, everyone.

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Maysoun Freij: or Good morning, or good evening, depending on where you are.

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Maysoun Freij: Welcome to our webinar disparities in opioid deaths.

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Maysoun Freij: Let’s look at the system and not the individual from community science.

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Maysoun Freij: I’m Maisoon Frage. I’m 1 of your hosts today, and before we get started we would like to let you know that if you have technical issues to please, go ahead and put them in the Q. And A. Box, we’ll have time to answer questions at the end of our presentation portion. So if questions come to mind as we go through the content, feel free to add those to the Q&A as well.

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Maysoun Freij: Andrea Epstein will be monitoring the questions, and will also be able to help you with any technical issues

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Maysoun Freij: just to answer a common question right away. All of you who registered for this webinar will receive a copy of the presentation.

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Maysoun Freij: So in terms of

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Maysoun Freij: key takeaways, we hope that you’ll take away from the presentation today. Lessons on the role of racism in opioid use, disorder reasons, measures of intake and retention are not enough

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Maysoun Freij: how to use data to improve systems.

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Maysoun Freij: recommendations for promoting anti-racism in addiction treatment organizations.

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Maysoun Freij: And we are with community science and community science is a research and development organization that works with governments, foundations, and nonprofit organizations on solutions to social problems through community and other systems, changes, fostering learning and improved capacity for social change.

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Maysoun Freij: As I said, my name is Mysoun Freij. I’m a Senior Associate community science, and I’m really happy to introduce my colleague, Anna Ghosh, who will be leading this webinar. We both come from a background in public health and evaluation, with a focus on health equity.
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Maysoun Freij: Anna is a managing associate community science. She has more than 15 years experience as a public health researcher, evaluator, strategic planner for a range of programs that focus on substance use disorder, HIV and chronic diseases.

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Maysoun Freij: Anna’s work contributes to systems transformation that bring progress toward health equity.

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Maysoun Freij: She has conducted evaluations with states and individual organizations and provided technical assistance to increase

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Maysoun Freij: coordinated care for behavioral health developed discussion guides for health departments to use to identify where stigmatizing language for health conditions of substance use disorder, and HIV can be addressed

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Maysoun Freij: and develop rubrics to identify pathways and progress in implementing best practices related to the treatment of opioid use disorder.

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Maysoun Freij: She recently wrote about factors that evaluators can consider when engaging people with lived experience in the health area.

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Maysoun Freij: If you have.

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Maysoun Freij: if you’d like to find it, it’s on our website.

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Maysoun Freij: and I will help those who want to use evaluation to develop health, equity and substance, use treatment to identify strategies that focus on changing the system so that it can better support people who need treatment.

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Maysoun Freij: I’ll pass it now to Anna to lead the webinar.

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Annapurna Ghosh: Thank you, Myson. Excited. Thank you for everyone. Who’s joining here today. I’m excited to talk about this topic and excited to know that there’s others out here who are interested in this topic as well. So our agenda today. I’m going to set the stage for talking about health, equity and opioid. Use disorder by talking about each of them first, st

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Annapurna Ghosh: and then go into a discussion around systems thinking, and then go into

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Annapurna Ghosh: a mode of thinking about how to develop strategies, to promote health equity for Oud.

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Annapurna Ghosh: So this question, how do we identify how to achieve health equity for people with opioid use disorder. This is the driver for the content of the webinar today, and I’m going to focus how to direct our attention to the system rather than the individual. When we think about this.

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Annapurna Ghosh: And I just want to point out our webinar today is not really enough time to review all the various systems that impact people with Oud and to investigate all the forms of structural discrimination.

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Annapurna Ghosh: So I’m just hoping to set a landscape to get us thinking not trying to provide a blueprint. But there’s a lot to to build on here, and I hope it gives us something to reflect on and respond to, and I look forward to the discussion at the end of the presentation. So please do put your questions in the chat, and any thoughts you have.

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Annapurna Ghosh: So to get us started, I want to talk about what is equity, because it’s a term that’s getting used a lot. And here’s the definition that community science is using.

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Annapurna Ghosh: And you can see from this illustration, in order for equity to be present, people need to have fair access to resources, to opportunities to reach their full potential, their own full potential.

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Annapurna Ghosh: And they not only need access, but also the rights to those resources and opportunities that make that possible.

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Annapurna Ghosh: And furthermore, the conditions need to be present for people to be able to actually take advantage and use them.

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Annapurna Ghosh: And then, finally, while doing so, people need to be free of discrimination to obtain the resources and opportunities.

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Annapurna Ghosh: and those are granted in institutions and the law.

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Annapurna Ghosh: So when we talk about equity, we also acknowledge the role of power in being able to realize all of these things, because those who have power can have influence over all of these factors that are leading to achieving equity.

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Annapurna Ghosh: So in terms of

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Annapurna Ghosh: what causes

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Annapurna Ghosh: health, inequity? To begin with.

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Annapurna Ghosh: structural racism is so important for addressing health, equity.

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Annapurna Ghosh: structural racism, as you know, uses tools of laws, public policies, practices, and the way they are crafted through structural racism results in the fact that some benefit from structural racism

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Annapurna Ghosh: in other ways. In other words, it gives advantages to some racial groups and disadvantages to other racial groups.

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Annapurna Ghosh: and those who benefit end up with better places to live. They get better education, they get better jobs, they have

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Annapurna Ghosh: safer and cleaner environments, they get better healthcare, and those who do not benefit. They experience more harms in their neighborhoods. They don’t have access to quality, healthcare, education, jobs. They have a lack of space to enjoy life.

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Annapurna Ghosh: So all of those things are the things that make up what we call the social determinants of health, which I’m sure many of you are familiar with.

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Annapurna Ghosh: which are the conditions in the environments where people are born, they live, they learn, they work, they play, they worship, they age and that all affects health functioning as well as outcomes and risks.

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Annapurna Ghosh: And so what I want to point out is that structural racism is the thing that can negatively impact social determinants of health.

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Annapurna Ghosh: and those determinants are not in themselves positive or negative.

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Annapurna Ghosh: But when there are differences in those social determinants of health, it means that not everyone has access, capacity and rights. So to go back to that health equity, what is health, equity?

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Annapurna Ghosh: So when we see that difference or disparity in health status. We know that there’s inequity

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Annapurna Ghosh: and structural racism is the one of the most powerful, maybe most pervasive form of structural discrimination.

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Annapurna Ghosh: because it is about having access conditions and rights.

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Annapurna Ghosh: And it works through those laws, policies and practices.

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Annapurna Ghosh: And it cooperates through multiple systems. That work that are based in in race. And it basically takes away freedom from discrimination.

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Annapurna Ghosh: So I just want to know when you’re talking about structural racism, you’re applying a systems lens.

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Annapurna Ghosh: Now, I’m going to go into a framework that we use in terms of describing health equity.

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Annapurna Ghosh: And this is at the systems level. So for looking at this bit from left to right, moving left to right.

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Annapurna Ghosh: What I want you to notice is that we’re not talking about in any individual change. We’re not looking at individual change in knowledge or behaviors. We’re talking about the system. So we’re using resources, expertise partnerships, other supports. You have

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Annapurna Ghosh: to design strategies or initiatives in order to disrupt structural racism for the populations that have been historically disadvantaged. And we do that by transforming public policies, institutional practices.

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Annapurna Ghosh: norms. And it can involve multiple systems that

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Annapurna Ghosh: add up or cumulatively deny or limit access to opportunities and resources.

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Annapurna Ghosh: And

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Annapurna Ghosh: we also, on the other hand, strengthen the capacity of communities affected by disparities to frame issues and drive solutions.

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Annapurna Ghosh: If that’s in place, we’re making progress towards racial equity, and that improves the social determinants of health. So those are again, those conditions where people are.

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Annapurna Ghosh: If those social determinants of health improve, we can see reductions in disparities and improvements in health, equity.

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Annapurna Ghosh: And so this, again is using that systems lens to just unpack and understand and account for the influence of structural racism. That’s the starting point

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Annapurna Ghosh: in our evaluation efforts aimed at improving health equity.

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Annapurna Ghosh: And it is imperative to get

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Annapurna Ghosh: to this. Systems approach to make a change for population level in health equity.

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Annapurna Ghosh: And and I know that many people, including myself, have started at the point of social determinant of health, to try to direct strategies there. But I wanted to encourage us to go back to structural racism as the starting point, even though it might seem

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Annapurna Ghosh: pretty large and daunting.

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Annapurna Ghosh: And we’ll start talking about that in the context of opioid use disorder.

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Annapurna Ghosh: So I want to start talking about the context of racism

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Annapurna Ghosh: in terms of opioids and opioid use disorder. So racism has been a player for centuries. When we’re talking about opioids

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Annapurna Ghosh: in the mid 19th century, the British opium wars started when they when the British grew opium poppies in Indian lands that they colonized

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Annapurna Ghosh: and intentionally marketed the opium opium in China

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Annapurna Ghosh: to foster addiction so that they could leverage trade.

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Annapurna Ghosh: and then given the highly addictive step substance. It wasn’t surprising that many Chinese people ended up with opioid use disorder.

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Annapurna Ghosh: Then we fast forward to the war on drugs in the seventies initiated by President Nixon.

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Annapurna Ghosh: which was marked by criminalizing use and distribution of drugs rather than seeing substance use disorder as a medical issue. It legitimized, incarcerating large numbers of black and brown people for use as well as distribution.

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Annapurna Ghosh: We come closer to our present day with the rise in pharmaceutical use of opioids for pain that started around in the 19 nineties to to rise much more

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Annapurna Ghosh: so there was increased prescribing without key to the propensity for these opioids, these pharmaceutical opioids to become addictive.

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Annapurna Ghosh: And that’s a large factor in why patients and people with access to their prescriptions, developed opioid use disorder

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Annapurna Ghosh: and resulted in

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Annapurna Ghosh: overdose deaths.

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Annapurna Ghosh: And I just want to remind us that this started with a high concern for white patients. They who were experiencing pain.

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Annapurna Ghosh: pharmaceutical grade opioids were being prescribed in high doses to alleviate their pain, while black patients, pain was not well attended to, and they were less exposed to the pharmaceutical form of opioids

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Annapurna Ghosh: which led ironically to overdose death rates proportionally lower in black people than among white people. At the start of this recent rise of opioid use disorder and overdose deaths.

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Annapurna Ghosh: So just to give some more recent historical context.

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Annapurna Ghosh: In terms of this progression. And I know many people are familiar with this data

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Annapurna Ghosh: it. This is a visual that comes from the Cdc and describes the 3 waves of opioid overdose deaths. In recent decades. So in the 1st wave we see deaths from commonly prescribed opioids starting in the nineties, as I said.

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Annapurna Ghosh: and then, as prescription opioids became more difficult to get. Heroin flooded the market

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Annapurna Ghosh: with being a cheaper alternative. And you see deaths attributable to heroin rising. And that’s the second wave.

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Annapurna Ghosh: And then the 3rd wave became synthetic opioids. That came onto the scene, and that was Fentanyl Carfentanil and others. And you see a steep increase in deaths from those starting in 2,013 because their potency was was so high.

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Annapurna Ghosh: so in terms of the 1st wave of the opioid crisis with what it’s called with prescription opioids.

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Annapurna Ghosh: There was a high concern for deaths in white communities in the subsequent waves, with heroin and synthetic opioids, death spread beyond white communities.

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Annapurna Ghosh: and now

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Annapurna Ghosh: data from the Cdc shows that the highest rate of drug overdose deaths is seen among black men. And this data is from 2,020.

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Annapurna Ghosh: So what you can see is the blue line on the left side

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Annapurna Ghosh: points to the the rise among black men.

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Annapurna Ghosh: So with large numbers, initially of white people dying from opioids. It came to be seen as a medical problem.

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Annapurna Ghosh: different from prior decades of

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Annapurna Ghosh: of drug use.

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Annapurna Ghosh: And this spurred research and changes in clinical practice.

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Annapurna Ghosh: So what we now know is that treatment, initiation and retention in treatment with one of 3 FDA. Approved medications is the best best approach to prevent death

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Annapurna Ghosh: and mortality, and other outcomes as well are are improved for people while engaged in medication treatment in combination with behavioral therapy, to control cravings, withdrawal symptoms, and ultimately death. And these are Methadone, buprenorphine and Naltrexone.

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Annapurna Ghosh: I’m not going to get into the specifics of each medication today or the efficacy. But I just wanted to make the point that medications themselves are known to be effective to prevent the health outcome. We’re talking about to prevent overdose deaths.

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Annapurna Ghosh: So now I’m going to bring in the evaluation piece of this of this puzzle. So

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Annapurna Ghosh: I’m going to start with a basic type of logic model. Many of us are familiar with to describe what we’re talking about. So

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Annapurna Ghosh: what we can say that is, if people with Oed are encouraged to enter into treatment with medication for their health condition, and they follow the treatment plans, and then they furthermore stay engaged and retained in treatment.

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Annapurna Ghosh: Then deaths or other related negative outcomes will decrease. That’s the that’s the thinking right

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Annapurna Ghosh: And then strategies to help make that happen would be to provide education to support people, to understand what’s available in terms of treatment and availability

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Annapurna Ghosh: and then support people when they become clients in treatment programs so that they stay in treatment so that might mean helping with transportation or sending reminders, conducting motivational interviewing to find out what’s working

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Annapurna Ghosh: for the for the clients. But the hope generally is that the clients behavior is such that they stay in treatment so that we can avoid this long term outcome of death.

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Annapurna Ghosh: And then, in order to measure whether these efforts to address this public health issue have been working common metrics, would be to look at the number of those

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Annapurna Ghosh: people who are entering treatment and being retained in treatment according to this logic of thinking.

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Annapurna Ghosh: So someone who’s interested in health equity might be looking for disparities. They may go on to look at the outcome data by client characteristics such as race, which really makes sense, because, as we saw, there’s a higher incidence of death from opioid use among black men right now. So you’d want to look for that

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Annapurna Ghosh: and in order to understand if treatments being delivered to those currently with the highest burden black men. The data is analyzed to understand if the outcomes per this logic model lead to the long term outcome of interest?

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Annapurna Ghosh: Yeah. And in other words, are there disparities in treatment, initiation, and retention by race.

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Annapurna Ghosh: So one study, accordingly, the data on retention shows that there are differences in length of treatment, state by race. So there’s conclusions, often written in terms that basically lead to the talking point that black patients drop out of treatment at higher rates than white patients, as you can see from this journal article title, and this is just an example of how it might be framed

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Annapurna Ghosh: And the statement suggests that for us to understand retention, differences by race.

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Annapurna Ghosh: one might look more at characteristics of those black patients. Why are they not complying with the best practices or their treatment plans, as was designed by the strategy?

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Annapurna Ghosh: And then, when thinking about strategies to decrease this disparity. One might be led to think about how to focus on the black clients

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Annapurna Ghosh: and just pile on more education, pile on more support, to encourage them to stay in treatment.

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Annapurna Ghosh: It may not be untrue what these authors are stating, but the title and measurement indicates. There’s a responsibility and capacity of the person of that individual

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Annapurna Ghosh: and we’re recognizing that substances impair decision making. But we really under appreciate the power of systems to control freedom of action. When we’re focusing on this individual action.

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Annapurna Ghosh: So going back to our original logic model, what if the line of inquiry were adjusted?

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Annapurna Ghosh: What if we looked at the health system?

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Annapurna Ghosh: Are there enough providers of substance use treatment in communities where black people live? What if we looked more closely at the type of treatment?

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Annapurna Ghosh: Are black patients more likely to have access to the type of treatment for which there are more barriers to access. So Methadone is more onerous treatment, and it’s more likely to be found in communities where black people live compared to buprenorphine which is available where white people live?

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Annapurna Ghosh: Do black people need to make more difficult choices between getting to work or to treatment

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Annapurna Ghosh: is treatment delivered in a way that black patients can trust.

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Annapurna Ghosh: And then what if we looked at treatment providers? Are they aware of and practice in a way that’s respectful and culturally relevant to black patients?

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Annapurna Ghosh: Have they received appropriate training?

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Annapurna Ghosh: What if we looked at the location of the services?

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Annapurna Ghosh: Are they in an area that’s accessible and safe for black patients to go to?

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Annapurna Ghosh: Is it even safe for them to disclose their substance use.

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Annapurna Ghosh: because we know that they’re more likely to be reported to child and family services or to their employers. To police.

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Annapurna Ghosh: So the main point I’m trying to make here is to ask why? So? To look at beyond the individual data and look at the system.

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Annapurna Ghosh: And that original logic model of how to reach better outcomes doesn’t help us interrogate the system it really boxes us in

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Annapurna Ghosh: to only think about the individuals and their outcomes.

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Annapurna Ghosh: and we need to stop measuring individuals. If we’re going to get to the system level change and our health equity framework will help us look for those outcomes directly related to structural racism.

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Annapurna Ghosh: So let’s go back to that.

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Annapurna Ghosh: The framework I described in the beginning.

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Annapurna Ghosh: So if we use this framing, we can stop focusing at

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Annapurna Ghosh: what we can do to change individuals. We can start focusing on strategies that change policies that change

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Annapurna Ghosh: community level factors.

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Annapurna Ghosh: So we we might be looking in terms of disrupting structural racism we could look at.

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Annapurna Ghosh: Where is there bias and discrimination?

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Annapurna Ghosh: What about factors of criminalization?

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Annapurna Ghosh: What about methadone policies and accessibility to treatment.

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Annapurna Ghosh: Provide our training.

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Annapurna Ghosh: And we can also look at at the social determinants of health in terms of what are workplaces like? What are the policies in those workplaces?

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Annapurna Ghosh: What is the availability of treatment in the places where people are working and living?

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Annapurna Ghosh: Is it easy and safe access to treatment.

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Annapurna Ghosh: And so this is getting more at the system level. Both the current systems as well as the the historical past

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Annapurna Ghosh: systems that are creating barriers to equitable access to treatment.

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Annapurna Ghosh: It also addresses those mental models that.

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Annapurna Ghosh: that providers hold that communities hold that people hold for themselves

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Annapurna Ghosh: and and with those mental models. There’s a lot of assumptions that are made and

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Annapurna Ghosh: much of it is based on. If someone did something wrong.

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Annapurna Ghosh: that maybe they didn’t take care of themselves in terms of their substance use which led to a substance, use disorder.

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Annapurna Ghosh: and that is really trying to be interrogated here in terms of changing those mental models which can then change systems

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Annapurna Ghosh: I also want to talk about. So I named a few things in the social determinants of health arena here. But as we know, structural racism affects many of these factors, employment, education, etc. So all of that needs to be addressed, because

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Annapurna Ghosh: in order to have good treatment outcomes and health outcomes.

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Annapurna Ghosh: we need to have, we need to have all the things that

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Annapurna Ghosh: improve social determinants of health, because otherwise they, any negative social determinants of health, will undermine any efforts for treatment outcomes.

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Annapurna Ghosh: They work together

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Annapurna Ghosh: and just as an as a parallel example, many people bring up diabetes.

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Annapurna Ghosh: So people with diabetes, we know that insulin is not the full solution. It is the treatment. But if people with diabetes didn’t have access to foods that support or manage their diabetes. Then the medication on its own wouldn’t be fully effective and sustainable. Similarly, here, there’s more to it than just having the medication. I don’t want to give the impression that that’s it.

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Annapurna Ghosh: So in terms of systems thinking. So, this is what where I’m I’m getting us to. So by changing the focus of the narrative

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Annapurna Ghosh: of retention from those who drop out of treatment.

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Annapurna Ghosh: So those outcomes when we’re looking, not looking at structural factors

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Annapurna Ghosh: to the factors within the system that don’t facilitate or support retention. Then we start applying the systems approach to designing strategies

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Annapurna Ghosh: which will reach better health outcomes.

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Annapurna Ghosh: And we can say that an anti-racist approach necessitates a systems approach.

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Annapurna Ghosh: And ultimately we could see conclusions. If we’re using this approach instead of that headline that I showed you before the journal title, we might see something different. And and have something like this. Number of providers deliver care that black patients can trust.

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Annapurna Ghosh: and that’s different. And and when you’re thinking about the strategy, you might think if you’re not reaching the percentage that

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Annapurna Ghosh: is appropriate for you to reach the better health outcome. The strategy here needs to change in terms of how can

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Annapurna Ghosh: trust be improved.

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Annapurna Ghosh: So with this type of data in hand. We can then go on to examine who stays in treatment, but not before, not before we examine the systems factors.

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Annapurna Ghosh: so that we are addressing health, equity. And again, that’s fair access to resources and opportunities, rights to those resources and opportunities, conditions that need to be present, and

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Annapurna Ghosh: whether people are free of discrimination.

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Annapurna Ghosh: and the systems level thinking leads us to understand that opioid use. Disorder is not only a disorder of the person, it’s a disorder of the systems that led us there.

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Annapurna Ghosh: And it’s those systems that we need to focus our attention on changing and measuring.

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Annapurna Ghosh: So you might be wondering so what parts of the system should we change? And and I want to encourage us to think in this way, so we can identify some of those systems changes.

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Annapurna Ghosh: But I also want to draw attention to this. This, this great study done by the Graykin Center for addiction at Boston Medical center, and they understood that there was not enough information to inform an anti-racist approach to substance, use disorder treatment.

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Annapurna Ghosh: and they launched a study focused on learning how to make addiction treatment more appealing, effective, and equitable for black patients.

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Annapurna Ghosh: So they held 6 focus groups with black people with lived experience of substance use disorder so that could be themselves

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Annapurna Ghosh: or having family members who had a substance, use disorder

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Annapurna Ghosh: and and findings from this research team identified 8 recommendations.

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Annapurna Ghosh: 4 ways treatment organizations can make an efforts to create treatment that’s more appealing, effective, and equitable for black patients. So I’m just going to go through these briefly. But you can see that requiring leadership, commitment and holding leaders, accountable, changing organizational operations to promote equity.

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Annapurna Ghosh: changing the way that staff are hired, trained, and supported.

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Annapurna Ghosh: empowering and supporting patients.

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Annapurna Ghosh: reshaping addiction treatment with a less punitive, more strength based approach.

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Annapurna Ghosh: addressing trauma

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Annapurna Ghosh: and removing barriers to the receipt of mental health care.

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Annapurna Ghosh: and then addressing the social or practical barriers to care.

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Annapurna Ghosh: And again, this helps guide us

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Annapurna Ghosh: as researchers and evaluators, to identify what to measure.

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Annapurna Ghosh: and whether there are changes in these aspects, because these are at the system level. That need to happen to get to health equity.

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Annapurna Ghosh: Some other recommendations I can think of is

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Annapurna Ghosh: you know, thinking about Methadone regulations, and we know that Methadone is more onerous. But it’s in the communities where black people are, so

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Annapurna Ghosh: can there be different

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Annapurna Ghosh: policies around? How onerous this type of treatment is.

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Annapurna Ghosh: and make it less burdensome, so that people can stay in treatment because that is the ultimate goal.

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Annapurna Ghosh: And then making sure that treatment is available, including buprenorphine not having treatment deserts as we talk about?

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Annapurna Ghosh: And how can we incentivize primary care providers to offer the buprenorphine.

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Annapurna Ghosh: and which is mostly in the white communities.

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Annapurna Ghosh: How can we offer incentives for them to also practice in the communities where opioid use disorder is rising in the black communities.

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Annapurna Ghosh: We know that insurance parity for behavioral health has long been an issue and still needs to be more completely addressed. We know for a long time there’s been deep

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Annapurna Ghosh: criminalization and policing of black people. So how can we change policies to lower decriminalization. See

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Annapurna Ghosh: substance use disorder as a health condition. And

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Annapurna Ghosh: interestingly, deaths of despair came around when

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Annapurna Ghosh: to explain why white people were

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Annapurna Ghosh: getting that opioid use disorder. But it wasn’t around when

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Annapurna Ghosh: when heroin was being seen in black communities for quite a few decades.

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Annapurna Ghosh: We can also look to employers. So

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Annapurna Ghosh: employment opportunities, we know, have long been affected by racism.

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Annapurna Ghosh: but if people had access to employment, it would support their recovery

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Annapurna Ghosh: as well as possibly not having to

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Annapurna Ghosh: to to sell drugs for a living.

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Annapurna Ghosh: Employers can also create environments where they’re not punitive about people having history, of using drugs, or they can become recovering friendly

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Annapurna Ghosh: where employees can take time. Employees can take time to go to treatment appointments in a way that’s not punitive to their employment status.

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Annapurna Ghosh: especially if that means for them. They need to go to a methadone clinic on a daily basis, so they don’t need to sacrifice getting to work versus getting to treatment.

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Annapurna Ghosh: and I’m sure there’s other recommendations we could discuss here, but those are just a few.

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Annapurna Ghosh: So what I’ve been framing in the context of improving outcomes for opioid use. Disorder is to conduct evaluation in service of equity. And this is based on work that community science has done with the Kellogg Foundation. You can find the Practice Guide Series on our website.

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Annapurna Ghosh: and I know that there’s many people who are doing great work to shine, a light on stigmatization, discrimination, racism related to substance use

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Annapurna Ghosh: on the one hand, and then there are evaluators and researchers who are measuring disparities in treatment and in depth. And what I’m suggesting is that the 2 could come together under this framework of evaluation and service of equity, where we redirect measures to the system, so that strategies are therefore also aimed at addressing the systems factors that are underlying the disparities in outcomes.

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Annapurna Ghosh: because if we do that.

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Annapurna Ghosh: we will also be able to gain a deeper understanding of the power shifts that need to happen.

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Annapurna Ghosh: and that will be the foundation for what many people want to achieve both newer and stronger partnerships and collaborations across sectors and across people who have been advantaged and disadvantaged.

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Annapurna Ghosh: These partnerships and collaborations are what are needed for increased advocacy to move the levers that lead to change

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Annapurna Ghosh: and change hopefully at the level of policies and practices that contribute

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Annapurna Ghosh: to help inequity.

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Annapurna Ghosh: Remember that this approach and being explicit in addressing structural racism identifies where changes are needed. So they’re needed at that level and policies, partnerships, the systems level.

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Annapurna Ghosh: So finally, I hope you all take away that equity is in a constant state of change. We need to focus on the systems level.

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Annapurna Ghosh: We need to focus on the drivers of health inequity being structural racism. We need to conduct evaluations that ask the questions and probe to find where improvements to strategies are needed to advance health equity.

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Annapurna Ghosh: And by doing so we can be the researchers and evaluators who use our methods of inquiry to put the focus on systems change.

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Annapurna Ghosh: Starting with the way we plan and design our evaluation

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Annapurna Ghosh: so that our measures are also focused on the outcomes that make a difference in health equity.

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Annapurna Ghosh: So with that, I want to pause. I wanna

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Annapurna Ghosh: thank everyone for listening. And I wanna

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Annapurna Ghosh: see what questions are coming up. In terms of the content I’ve provided, but also I would love to hear. If this framing is useful to you, how would you use it? What else have you done to try to move towards strategies at the systems level for opioid use disorder, substance, use disorder more generally. How it might be leading to health equity.

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Annapurna Ghosh: I’ll pause to see if there’s questions coming up in the chat.

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Maysoun Freij: There, there is a long nice long question. Shall I read it out? And then you can answer, okay.

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Maysoun Freij: there’s some context to the question. It says, I. So I fully support this from Leslie Wood. Thank you so much. I fully support that all all that you said, and I know the problem is increasing for black folks and decreasing for white folks in my community as well. However, I have noticed in my own research that similar patterns of inequity follow with extremely poor unhoused folks of any race.

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Maysoun Freij: I also see that over time even those who do receive treatment lack the support they need post-treatment, and are often not able to sustain their recovery.

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Maysoun Freij: Any ideas on how we can extend appropriate equity and support through the through and post treatment.

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Maysoun Freij: Thank you so much for drawing your attention to these issues.

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Annapurna Ghosh: Yeah, thanks for this question, Leslie. I so much agree with you, because, all best intentions. And then post treatment, people are in the environments that they’re in are facing all the inequities in the in the world that they face.

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Annapurna Ghosh: My suggestion would be just to to go back to that initial framing the logic model and to extend it further out. So it doesn’t have to end with with treatment. So you’re saying, I think if I’m

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Annapurna Ghosh: I’m understanding you. So it doesn’t end with when they how long they’re in treatment. But it extends out in terms of other factors. So I think you could still frame it that way as

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Annapurna Ghosh: being part of the outcomes, and then interrogate again with questions of why, what are the systems level

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Annapurna Ghosh: factors at play that do or do not sustain recovery.

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Annapurna Ghosh: for for people in the communities where they are.

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Annapurna Ghosh: But again focusing on

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Annapurna Ghosh: on the systems, level factors interrogating those rather than

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Annapurna Ghosh: being about the people. That may or may not

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Annapurna Ghosh: be able to maintain their recovery.

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Maysoun Freij: Thank you. Another question comes from Elizabeth Loomis. Can you elaborate on what key partnerships look like, partner? With who? How can we evaluate these partnerships?

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Annapurna Ghosh: I think that partnerships can look very different, depending on what you’re doing and what your strategy is.

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Annapurna Ghosh: so, in terms of

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Annapurna Ghosh: partnering to improve

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Annapurna Ghosh: engagement with treatment. If I’m understanding so those partners might be with community organizations, they might be with healthcare providers.

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Annapurna Ghosh: They might be with

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Annapurna Ghosh: even

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Annapurna Ghosh: families, schools wherever people are found, so that we can understand what what people need in terms of trying to

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Annapurna Ghosh: engage them with systems level change. So thinking about, where are those mental models that we need to change? What are the biases in the community? So

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Annapurna Ghosh: we see that many communities don’t want substance, use disorder, treatment in their communities?

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Annapurna Ghosh: So what? What is driving that? What are, what are the biases? What are the fears? So those partners may be a little bit different in terms of trying to get at that. So I think it would just depend on where where you’re trying to focus.

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Annapurna Ghosh: But given.

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Annapurna Ghosh: And I always think that addressing substance use disorder, it’s almost any anyone in any aspect you can think of is touched.

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Annapurna Ghosh: but it’s a matter of where do you start? But I think that

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Annapurna Ghosh: partnership can look pretty broad.

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Annapurna Ghosh: And how do we evaluate these partnerships?

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Annapurna Ghosh: I guess I’m not sure what you mean about evaluating the partnerships. Maybe the quality of the partnerships, or how well

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Annapurna Ghosh: these partnerships are working out. You could definitely look at the strengths of the partnerships, whether there is trust, whether they’re

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Annapurna Ghosh: You know what the process is for building consensus across partners.

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Annapurna Ghosh: whether conversations are really getting at the real factors. Or you know we can, you know, with any health issue we can speak

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Annapurna Ghosh: in

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Annapurna Ghosh: in very positive terms. But we need to get at the real conversations in terms of what are the challenges and what are their real underlying factors

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Annapurna Ghosh: that are

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Annapurna Ghosh: that are not allowing systems, level changes. Are we really looking at the the elements of structural racism, structural discrimination at play here?

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Annapurna Ghosh: That answered your question.

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Maysoun Freij: You received a shout out from Lauren Link, saying, This is so helpful. We’re a local Health Department.

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Maysoun Freij: and have a chat going on the side about how we want to apply this framing to our overdose Fatality Review and Opioid Settlement Committee.

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Maysoun Freij: But you have some more questions.

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Maysoun Freij: And they said, Thank you. And then you have other questions. Rebecca Mccloskey. And this is helpful. Thank you. Most programs that approach us for assistance with evaluation already have individual level outcomes in mind.

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Maysoun Freij: Can you point to more examples of system level outcomes to measure and best practices of where you’ve seen this done? Well.

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Annapurna Ghosh: so I, I think that’s probably true for a lot of people. I’ve encountered that as well

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Annapurna Ghosh: and

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Annapurna Ghosh: and as as someone who’s worked in evaluation for a long time. We’re often handed those like outcomes that people want to know about death. And and how do we shift that conversation. How do we shift.

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Annapurna Ghosh: looking solely at these outcomes that were handed? And I would say, it’s not easy, but I would encourage you to use this thinking about. So for looking at health equity. And I’m assuming that the people you’re working with

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Annapurna Ghosh: want to address health inequity.

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Annapurna Ghosh: is to go back to your evaluation planning. And to start at that that logic model level. And that’s why I started there as well is to. That’s what’s boxing us in into thinking about individual level outcomes. And if we go back and reframe

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Annapurna Ghosh: the full logic model to include those deaths. But further down the line. But

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Annapurna Ghosh: what we’re looking at initially is not

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Annapurna Ghosh: not behavior change that’s leading to

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Annapurna Ghosh: decrease deaths. It’s looking at those systems level. So if we go back to the all those things that we could be looking at in terms of who has access, which providers are trained?

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Annapurna Ghosh: is there bias? Is there trust?

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Annapurna Ghosh: And we create a logic model or theory of change based on that. And that becomes the measurement framework for what you’re doing. It can help change that conversation.

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Annapurna Ghosh: And I agree, it’s not. It’s not easy, but

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Annapurna Ghosh: with the focus on health equity. I think we just need to keep reminding ourselves everyone around us that we can’t keep focusing

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Annapurna Ghosh: on individual level change because health equity is a system level change. So we need to start there.

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Maysoun Freij: I have a question that sort of relates to this and it. And my question is in terms of the context of planning and evaluation. Is it possible to have sort of a phased approach where you’re asked? Let’s say you start by asking more

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Maysoun Freij: why questions and system questions, and then maybe get to the the outcome questions of interest like, Is it a choice like, do you have to do one or the? Are you recommending one or the other? Or can you do both? And is it really more a matter of like

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Maysoun Freij: staging? Let’s say of like, when you’re asking

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Maysoun Freij: the

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Maysoun Freij: like the population level outcome questions like deaths or

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Maysoun Freij: retention and treatment, or things like that.

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Annapurna Ghosh: I mean, it’s it’s a a practical question. And I would say, probably staging is appropriate. But I’m also curious, and I want this to be a discussion here. What you all think and my, soon, even if you have a recommendation as an evaluator

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Annapurna Ghosh: in health for a long time open to

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Annapurna Ghosh: to your suggestion as well.

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Maysoun Freij: I was thinking more in the context of the question that was asked in the sense that, like people, come with these outcome indicators that they already know that they want. And what I’m hearing is you saying is that like, well, they’re not. The priority questions, let’s say, like the priority is really understanding the system.

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Maysoun Freij: But is it a do you have to make the choice? Or are you recommending people? Make a choice and only focus on the systems questions, or what place to do. These kind of like more traditional outcome measures play in the evaluation.

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Annapurna Ghosh: yeah, I suppose you don’t have to make a choice? I think, the

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Annapurna Ghosh: the pitfall, I guess or harm that could be done in not making the choice early is again getting locked into harmful narrative. When you’re

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Annapurna Ghosh: when you’re producing data that leads you to start thinking about strategy and improvement.

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Annapurna Ghosh: That’s again going back to a place that isn’t going to help you change the system.

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Annapurna Ghosh: so maybe a parallel process to ease people into it. But but I would focus more on getting people into

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Annapurna Ghosh: into a different way of thinking early, so that they’re

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Annapurna Ghosh: they’re not. They’re strategizing differently. And we all want to end up at the end of the day, making a difference in the actual

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Annapurna Ghosh: the actual programming and

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Annapurna Ghosh: and treatment offerings. So

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Annapurna Ghosh: so if we are able to do that in in a parallel way, I would say yes, but being cognizant of

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Annapurna Ghosh: where harmful narratives might lie as well.

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Maysoun Freij: Yeah, I I really appreciated your examples of alternate kind of measures of like

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Maysoun Freij: the black people trust their providers is like, is like a good measure of the success of a program as much as

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Maysoun Freij: you know.

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Maysoun Freij: Other things that may, like you said promote more of a false narrative of. Oh, they don’t come to treatment, or

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Maysoun Freij: Graham.

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Annapurna Ghosh: And you don’t see.

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Annapurna Ghosh: you know. Traditional evaluations met, you know, having trust as a real.

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Annapurna Ghosh: you know, central piece of measurement. But it, knowing that that

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Annapurna Ghosh: is a key element

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Annapurna Ghosh: of what’s driving people to

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Annapurna Ghosh: to engage or not engage in treatment.

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Annapurna Ghosh: We need to start there, too, to say.

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Annapurna Ghosh: what are the strategies to build this trust?

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Annapurna Ghosh: And is it working.

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Maysoun Freij: yeah, I realize we’re a little limited with the QA in terms of discussion. So but if people do have other comments or thoughts on this topic, please feel free to put them in the

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Maysoun Freij: QA. There was a question also about the role of advertising pharmaceutical drugs on TV. And you know whether this plays a role in

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Maysoun Freij: in, I think.

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Maysoun Freij: It’s not stated in the question, but in terms of substance use disorder.

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Maysoun Freij: This is coming from Chanel Payne. So thank you. And they and they say some other countries do not advertise drugs on television.

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Annapurna Ghosh: Yeah, I,

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Annapurna Ghosh: I don’t have a I don’t have anything to to back that up, but but it’s a good point in terms of

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Annapurna Ghosh: the rise in use of pharmaceutical opioids. It could be a factor.

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Maysoun Freij: right? I found it very interesting. How you said, you know the deaths of despair is not a concept that’s applied to communities of color.

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Maysoun Freij: So much in terms of an explanatory model for why the substance use is happening. In the 1st place.

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Maysoun Freij: would you want to talk any more on that? Or do you have any thoughts on that.

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Annapurna Ghosh: Yeah,

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Annapurna Ghosh: you know, just from a personal perspective, I’ve worked in substance, use prevention and treatment realms for a long time.

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Annapurna Ghosh: And

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Annapurna Ghosh: and Facebook are

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Annapurna Ghosh: a lot of statements that people would say in terms of

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Annapurna Ghosh: you know, what do people need to change in about themselves or about parenting or about

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Annapurna Ghosh: you know, motivation.

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Annapurna Ghosh: To stay healthy, and things like that which you know we all know all the moralizing around substance use.

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Annapurna Ghosh: And

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Annapurna Ghosh: and when there was the rise in opioid, use disorder among white people. And then this concept of deaths of despair came about to explain why were people dying? In white communities. Why were they using opioids? Why were they facing high numbers of overdose? It became despair. Because jobs were going away. Because they didn’t have hope and etc.

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Annapurna Ghosh: which is very sympathetic, and and

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Annapurna Ghosh: quite a good framing for people on why they might turn to might find themselves using drugs and might find it in their communities. But it just was not used until that time. And

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Annapurna Ghosh: and I think that if we are to say that there were deaths of despair, then deaths of despair should have existed

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Annapurna Ghosh: for a long time, so that could be the explanation

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Annapurna Ghosh: forever about substance. Use not just recent substance use. So I I would like to see it personally used, either more broadly to explain all substance, use, or

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Annapurna Ghosh: to acknowledge that it is

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Annapurna Ghosh: limited to certain types of substance use because empathy is only given for despair, for certain users of of drugs and

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Annapurna Ghosh: and time of use.

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Annapurna Ghosh: I welcome anyone to to say say something. That’s different, because I think it’s it’s been a a topic that’s been discussed quite a bit

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Annapurna Ghosh: has anyone commented in the chat about any suggestions they have for creating more health equity around around Wt. I would love to hear

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Annapurna Ghosh: anyone else has

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Annapurna Ghosh: done work in this, carry on.

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Maysoun Freij: No, we haven’t had any chats in a in a bit. But

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Maysoun Freij: I was going to ask also about

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Maysoun Freij: You mentioned sort of among the policy solutions. One that you touched on, that I wondered if you had, since we have a bit of time to elaborate on might be methadone policies saying that they’re very onerous, yet they are more available in black communities. So I wondered if you could sort of elaborate on that.

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Annapurna Ghosh: Oh, sure!

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Maysoun Freij: Examples of how they could be less onerous and

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Maysoun Freij: and would that really help fill gaps in access to treatment if they were more

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Maysoun Freij: less onerous.

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Annapurna Ghosh: so methadone has been around for a long time. And it is dispensed in federally regulated settings

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Annapurna Ghosh: and

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Annapurna Ghosh: administrated on a daily dose basis. So people have to come in

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Annapurna Ghosh: every day for their medication, and be monitored. And so there’s testing and all of that.

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Annapurna Ghosh: And when buprenorphine became available. That’s my primary care, providers, so that they can. People can go to their Pcp’s office and receive that. So that what we’ve seen happening, the research is showing now, pretty recently is that where you find methadone is in the places where black people can

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Annapurna Ghosh: access treatment, there is much more methadone availability there.

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Annapurna Ghosh: buprenorphine is less available there. But buprenorphine is ease of access is so much higher, and you don’t have to go for daily dosing

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Annapurna Ghosh: and so there are these 2 types of treatment. We’re looking at

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Annapurna Ghosh: engagement with treatment as it

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Annapurna Ghosh: primary driver for reducing deaths. But if some people have

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Annapurna Ghosh: have to do more to stay in treatment. It makes sense that their rates of death might be higher.

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Annapurna Ghosh: Because they’re facing more barriers to that treatment. So there, you know, during the pandemic there was some relaxation of rules around Methadone, and there’s still a lot of conversation we know happening around. Relaxing those those rules. But it’s not at the

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Annapurna Ghosh: at the level where buprenorphine is. And

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Annapurna Ghosh: and can it be

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Annapurna Ghosh: work, or do we, you know, strategize on just getting the Buprenorphine providers into these

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Annapurna Ghosh: communities where they haven’t been before.

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Maysoun Freij: Thank you.

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Maysoun Freij: Leslie has another comment. They say suggestion may have already been alluded to ask people who need help with substance use what they need, instead of determining it for them, because what works for suburban white folks does not always work for poor and or non-white folks meet them in the community and have discussions about what is missing and what they would like to see, or how we can support them.

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Annapurna Ghosh: That’s a great suggestion, Leslie. I wish everyone was doing that.

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Maysoun Freij: And I think very much in spirit with this talk.

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Annapurna Ghosh: Okay, okay.

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Annapurna Ghosh: with.

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Maysoun Freij: So we’re just about a time. Anything else you want to add, Anna, before we wrap up.

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Annapurna Ghosh: No, just thank you for attending, and I’m so glad there’s people who have been interested in the topic and engaged in the discussion. And please do follow up if you want to talk further.

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Annapurna Ghosh: Thank you for being here today, and everyone will receive a link to the recording today.

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Annapurna Ghosh: They’re interested in having it.

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Annapurna Ghosh: Thanks, Messine, for facilitating as well, and Andrea, for

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Annapurna Ghosh: monitoring all in the background.

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Annapurna Ghosh: Thanks. Everyone have a good day.

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Maysoun Freij: Bye, you too