Last August, The Boston Globe published an opinion piece titled, “A moon shot for the opioid crisis,” written by Jeffrey Samet, MD, MA, MPH, Boston Medical Center’s chief of general internal medicine. In it, Samet wrote about how BMC had been selected to receive a historic $89 million grant from the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration. The award was enlisting BMC in the groundbreaking HEALing Communities Study to help achieve its goal of reducing opioid overdose deaths by 40 percent over three years in 67 communities across four states. BMC would be leading the Massachusetts-specific study, focusing on 16 communities in the state that have been hard-hit by the opioid epidemic. Samet remarked they would “pull out all the stops,” but stressed moving the needle hinged on teamwork at the community level.
“We will only succeed because of these collaborations within these communities,” he wrote. “In partnership, we will work to assess the needs of each community, and tailor how the best practices can be implemented.”
Samet’s concluding remarks drove home the study’s vital position in turning the tide on the opioid epidemic. To that end, he called upon the media—and, by way of it, the public—to “keep the pressure on and hold us accountable.” This was much more than an invitation to keep tabs on their progress. It was about staking a claim to change the trajectory of the opioid epidemic. Since April 2019, the study’s goal has been a “moon shot” Samet and his team, including Project Director Carly Bridden, MA, MPH, have been working toward achieving.
About the MA HEALing Communities Study
The current landscape of the opioid epidemic brings to light that despite there being effective ways to decrease opioid overdose deaths, thousands of people are still dying from opioid overdose in the United States. This reality has been the impetus for the MA HEALing Communities study.
“The recognition was, ‘How does one get communities, where the deaths are occurring, to take on interventions that are known to decrease deaths?’” explains Samet. “The study was created to do just that. And we are doing so in a way where we can learn from the process and the best way for adoption of key evidence-based practices while being cognizant that each community will be different in how they receive and implement them.”
The evidence-based practices Samet speaks of fall into three buckets: medication for opioid use disorder; naloxone (an overdose-reversing agent); and safer opioid prescribing. Samet notes the latter has certainly improved in recent years—mainly, physicians are prescribing immediate-release opioids (instead of extended release ones) in lower doses and smaller quantities and are also closely monitoring patients for signs of misuse. “However, the other two lag behind in terms of adoption rates,” Samet says.
With a three-year timeline, the study hypothesizes opioid overdose deaths will be reduced by community-based clinical interventions and programs centered on prevention, treatment and recovery. The study emphasizes “shared decision-making and ownership in local communities,” and therefore, works closely with them to address unmet needs and deploy tailored, innovative models of treatment that have been shown to support long-term recovery.
The approach of operating in partnership with communities is rooted in trying to overcome the discrepancy between effective interventions and low adoption rates.
“We can’t keep telling them to use these [evidence-based practices],” Samet explains. “Instead, with a community-engaged approach, we’re asking, ‘What are your needs? Let’s understand where your gaps are.’ That’s where you really see and understand differences. A rural community might be saying transportation is a barrier, and an urban community might be saying the high cost of housing is an issue. Some have a hard time with harm reduction, others embrace it. Some appreciate learning about new approaches and it’s less so for others.”
The study operates in two staggered waves. Wave One lasts three years—two years of study support and one year without it—and consists of eight rural and urban communities. Wave Two will be an abbreviated version. The setup allows the team to measure the difference between the number of opioid overdose deaths when supports are in place and when they are not. Wave One, currently underway, focuses on Bourne and Sandwich; Brockton; Gloucester; Holyoke; Lowell; Plymouth; Salem; and Shirley and Townsend. Wave Two, set to begin January 2022, covers Berkeley, Dighton and Freetown; Athol, Greenfield, Montague and Orange; Belchertown and Ware, Lawrence, North Adams, Pittsfield, Springfield and Weymouth.
The Journey So Far
Right now, the study is in the process of transitioning from a planning and infrastructure-building phase to an implementation phase for Wave One.
One of the first courses of action for the study team was to establish relationships with existing substance use coalitions and work with them to become more comprehensive.
“We realized they didn’t represent the entirety of stakeholders that could be part of this initiative. We wanted broad representation from different sectors, like criminal justice, mental health and behavioral health,” Bridden says. “We spent a lot of time over a few months on this, bringing together individuals working in the community on these issues. Our community facilitators spoke with several people, leaving no stone unturned.”
With HEALing Communities Study-specific coalitions in place, the study team was ready to begin its work in the targeted communities. Because the study emphasizes the importance of community partnerships, the team set up ways to make it easier for existing local stakeholders to collaborate and strengthen the effect of their efforts.
“This has been an opportunity to bring different stakeholders and sectors to the table that previously may have been working in silos,” Bridden says. “There’s a lot of existing work being done by smaller task forces and local agencies. We’ve been setting up an infrastructure and some resources to bring more folks together around this specific issue.”
In addition to establishing and growing relationships, the team has been laying the groundwork and building plans for intervention. “On the research side, it’s been about developing protocols and making sure the four states are moving in a uniform direction,” Bridden notes. On the community side, the team has been conducting landscape analyses, creating community profiles and devising community action plans—all of which work hand in hand.
“The landscape analysis centers on questions like, ‘What resources does the community already have? What does the community look like? How many overdoses are happening?’” explains Bridden. “We even have a group that’s doing geospatial analysis [looking at data with a geographical component] to give us granular-level information on where deaths are happening, and whether they’re inside or outside the community, at home or in a hospital.”
Following the assessment of the current landscape, the team spoke with community members to compile key insights into community profiles. This background work culminates in the creation of community action plans—blueprints for actioning tailored prevention, treatment and recovery interventions. These also take into account unique variations that bear an impact on effective calls to action—for example, the team found that in some communities more than 30 percent of residents speak languages other than English at home, meriting the need for specific tools and resources that might not be applicable in an area with majority English speakers.
Challenges along the Way
Of course, the journey has not been without its trials. For one, the study team has had to adjust their expectations from the regimented environment of clinical trials that afford the ability to strictly adhere to timeline and protocol.
“Because this is community-based participatory research, things take more time—communities are moving at all different speeds,” Bridden says. “There’s this tension between a timeline and a protocol and letting communities guide the process and being flexible around that.”
Additionally, the COVID-19 pandemic rattled communities. When the virus started making a significant impact in March, the team’s first line of thinking was to suspend their involvement so communities could have some breathing room and focus their attention on relief efforts. And while some conceded, a great majority had the opposite request: they wanted continued support.
“The opioid epidemic was not going away during COVID-19—in fact, it was probably going to get worse. People were staying home. They weren’t coming in for harm reduction services. Those living alone were at increased risk for overdose,” Bridden explains. “It was an interesting realization that while we were trying not to be pushy, the communities actually wanted us there. They understood our support could help.”
As the fall rolls in, so will a new phase of the study: the implementation of evidence-based practices into Wave One communities. “We hope what we are testing and building will be sustainable within the four states and also become something we can disseminate nationally,” Bridden concludes. “We are potentially having an immediate and direct impact on the lives of real people.”