Appalachian Opioid Community Response -- Tools and Resources Appalachian Deaths of Despair

▪ Update to study conducted in 2017 using 2015 data ▪ Analysis of 2018 mortality data1 among individuals ages 15 to 64 for the following causes of death (“ of despair”): ▪ Overdose (Alcohol poisonings and overdoses of prescription and illegal drugs – accidental and intent-underdetermined deaths) ▪ ▪ Alcoholic liver /cirrhosis

1CDC National Center for Health Statistics (NCHS)’s National Vital Statistics System (NVSS), accessed at http://wonder.cdc.gov/mcd- icd10.html Comparisons Between 2015 and 2018

2015 2018 Appalachian Deaths of Despair

Diseases of despair mortality rates for males, Diseases of despair mortality rates for females, ages 15–64, by age and region (2018)‡* ages 15–64, by age and region (2018)‡*

‡ Rates are presented as deaths per 100,000 population. Rates are crude mortality ‡ Rates are presented as deaths per 100,000 population. Rates are age adjusted. rates for each age group. * For both genders, Appalachian rate is significantly different from the non-Appalachian * For all age groups, Appalachian rate is significantly different from the non-Appalachian U.S. rate, p ≤ 0.05. U.S. rate, p ≤ 0.05. Source: Mortality Rates and Standard Errors provided by Centers for Disease Control Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html. Accessed at http://wonder.cdc.gov/mcd-icd10.html. Appalachian Deaths of Despair

Diseases of despair mortality rates, ages 15–64, by state^ and disease (2018)‡

^ For states within , only the for the Appalachian counties is shown. ‡ Rates are presented as deaths per 100,000 population. Rates are age adjusted. Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html. Appalachian Deaths of Despair - Overdose Mortality

Overdose mortality rates for males, ages 15–64, Overdose mortality rates for females, ages 15– by age group and region (2018)‡ 64, by age group and region (2018)‡*

‡ Rates are presented as deaths per 100,000 population. Rates are crude mortality rates ‡Rates are presented as deaths per 100,000 population. Rates are crude mortality for each age group. rates for each age group. * Appalachian rate is significantly different from the non-Appalachian U.S. rate, p ≤ 0.05. * For all age groups, Appalachian rate is significantly different from the non- Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Appalachian U.S. rate, p ≤ 0.05. Prevention, National Center for Health Statistics. Source: Mortality Rates and Standard Errors provided by Centers for Disease Control Accessed at http://wonder.cdc.gov/mcd-icd10.html. and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html. Appalachian Deaths of Despair - Overdose Mortality

Overdose mortality rates, ages 15–64, by state^ and type of overdose (2018)‡

▪ In 2018, in Appalachia, 70% or 4,548 of the overdose deaths were caused by opioids.

^ For states within Appalachia, only the mortality rates for the Appalachian counties are shown. ‡ Rates are presented as deaths per 100,000 population. Rates are age adjusted. † Due to small number of deaths, opioid mortality rate is unreliable and not age adjusted. Source: Mortality Rates and Standard Errors provided by Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed at http://wonder.cdc.gov/mcd-icd10.html. Appalachian Overdose Mapping Tool Appalachian Overdose Mapping Tool Appalachian Overdose Mapping Tool Appalachian Overdose Mapping Tool Appalachian Overdose Mapping Tool Opioid Misuse Community Assessment Tool Prosperity Index

RISK RESILIENCE

Poverty Rate Self-employment Rate Number of Industry Dependencies Business Establishments per 100 workers Net Migration per 100 people Number of Hospital Beds per 10,000 ECONOMIC population Labor Force Participation Rate Median Household Income Prosperity Index

Digital Distress 501 c3 and c4 per 10,000 population High School Drop Out Rate Educational Attainment (Bachelor’s Degree or SOCIAL more) Teen Birth Rate per 1,000 population Primary Care Providers per 10,000 population All-cause Mortality Rate per 1,000 population Voter Participation Rate Map of Prosperity Index Scores

Overall Prosperity Index Opioid Misuse Community Assessment Tool Prosperity Index vs. Persistent Poverty

Prosperity Index Prosperity Index vs.

Cardiovascular Disease Mortality

Prosperity Index

Source: CDC Interactive Atlas of Heart Disease and Stroke. Prosperity Index vs. Diabetes

Diabetes Prevalence

Prosperity Index

Source: CDC Diabetes Atlas. Prosperity Index vs. Overdose Mortality

Rural Counties – Prosperity Index Score vs. Mortality Rate

Outlier threshold: 61.2 deaths per 100,000

Rural Strengths and Assets Data and Information Sources Data Collection Scope Literature Synthesis • Boolean search strategy, over 320 articles National Discussion Forum • n=27 Key Informant Interviews • n=24 Regional Community Forums • U.S. Mexico Border: n=34 • Delta: n=48 • Northeast: n=58 • Upper Midwest: n=43 Vetting Sessions • All State Offices of Rural Health and partners • Appalachia regional vetting session: n=80+ Formal Non-Health Sector • NACO Rural Action Caucus convening: n=40+ Engagement • NADO Focus group: n=6 National Conferences • Feedback sessions at 9 conferences Number of Sectors Represented 36

Total Participants & Reviewers n=400+* *Does not include all participants at national conference feedback sessions

Cultural Assets

• Core values, including: • Close-knit sense of community • Support systems and neighborly social ties • Religious affiliation and faith • Pride in self, family, and place • Self-reliance and independence • Justice, loyalty, and patriotism • Strong work ethic • Social cohesion • “Culture of collaboration” • Collective efficacy • “Community spirit” • Shared history • Innovation and creativity Leveraging Assets to Improve Health

Leveraging Strengths & Assets: A Real-World Example

Leveraging Strengths & Assets: A Real-World Example Leveraging Strengths & Assets: A Real-World Example

• Since we did this work this trend has made it’s way into West Virginia – using 2015 to 2019 data, WV now has 1 county in the top 10, and 3 in the top 20.

Drug Overdose Mortality County Rate (2015-2019) Decline Wyoming 103.7 per 100,000 -52 per 100,000 Monroe 40.3 per 100,000* -33.7 per 100,000 Boone 98.1 per 100,000 -29.9 per 100,000 Leveraging Strengths & Assets: A Real-World Example

• Themes for why drug overdose mortality is declining in Eastern Kentucky • Bipartisan, sustained support • Increased access to treatment • Medicaid expansion and Kentucky’s enhanced substance use treatment benefits • Recovery community and initiatives (i.e., recovery housing, second chance employment) • Changing approach of the criminal justice system • Harm reduction • Reduced stigma • Partnerships, community coalitions, and longstanding commitment to addressing substance use • Primary prevention and education • Shifts in drug use patterns (i.e., increasing use of methamphetamine)

BUT, ground is being lost due to COVID-19 Rural Evidence Based Toolkits

1. Identify 2. Study 3. Disseminate evidence-based and experiences of lessons learned promising these programs through Evidence- community health including Based Toolkits programs in rural facilitators of communities their success

Rural Health Information Hub: https://www.ruralhealthinfo.org/ Rural Evidence Based Toolkits

• Rural community health • HIV/AIDS prevention and • Access to care for people with treatment disabilities • Mental health • Aging in place • Oral health • Care coordination • prevention • Community health workers • Philanthropy • Diabetes prevention and management • Prevention and treatment of • Food access substance use disorders • Health networks and coalitions • Services integration • Health promotion and disease • Tobacco control and prevention prevention • Transportation Rural Evidence Based Toolkits Rural Evidence Based Toolkits

Module 1: Introduction to Topic Area

Module 7: Module 2: Program Program Models Clearinghouse

Module 6: Module 3: Dissemination Implementation of Best Practices Considerations

Module 5: Module 4: Evaluation Sustainability Considerations Strategies Opioid Research Consortium of Central Appalachia

ORCCA-Patient Centered Outcomes Research Institute (PCORI) Engagement Award #460243;Directors–Kim Horn & Rob Pack

Rural Evidence Based Toolkits

For more information --

• Appalachian Diseases of Despair Report - Appalachian Diseases of Despair, October 2020 (PDF:1 MB) (arc.gov)

• Appalachian Overdose Mapping Tool – http://overdosemappingtool.norc.org

• Opioid Misuse Community Assessment Tool – http://opioidmisusetool.norc.org

• Prevention and Treatment of Substance Use Disorders Toolkit - Rural Prevention and Treatment of Substance Use Disorder Toolkit - RHIhub (ruralhealthinfo.org) Connect with Us

Michael Meit, MA MPH Director of Research and Programs ETSU Center for Rural Health Research [email protected] 240-273-2751

Center Web Site - https://www.etsu.edu/cph/rural-health-research/

Twitter - @etsucrhr