Trying All of That (and then some) in a Small Town

[Jaunty Guitar Music]

Mike: Welcome everybody. This is Avoiding the Addiction Affliction brought to you by Westwords Consulting and the Kenosha County Substance Use Disorder Coalition. I'm Mike McGowan.

Mike: Substance use and misuse within a rural community presents a whole lot of problems. Services are not as available as in metro areas and patients who require treatment for substance use disorder usually have to travel long distances to access services.

Mike: So it's really important that existing health care facilities in a community play an important role in combating and addressing substance use and substance use disorder. Our guests today work for an organization that has a long history of providing services to that population. Rachel Stankowski is project manager for the Family Health Center and Danielle Luther, project manager senior, also for the Family Health Center of Marshfield, Wisconsin.

Mike: Welcome, ladies.

Rachel: Thank you.

Mike: Well, let's start. Let's just start out by this. Let's talk about Family Health Center for a second. What are you all?

Rachel: Yeah, so Family Health Center Marshfield is located across 19 counties in rural, central, northern, and western Wisconsin. So it's a little bigger than you might have expected.

Rachel: We have been a federally qualified health center, which you may also hear referred to as a community health center or CHC since 1974. So this year we're actually celebrating our 50th anniversary. One of the things that's unique kind of about community health centers in general is that we have to have a community majority board and that's federally required.

Rachel: So that means 51 percent of our board has to actually be comprised of patients who use our services. So we definitely represent the community we serve and it's the communities we serve that really tell us the direction that we need to go in to best meet their needs. So today we offer three primary clinical service lines that includes dental care, which is we have 10 dental centers across that service area, three substance use disorder treatment centers.

Rachel: So our FHC alcohol and drug recovery centers, as well as some new primary care initiatives. So our first site is here in Marshfield, Wisconsin where we offer primary care for all. So our big purpose really is to serve as a safety net clinic for individuals who might not be able to access care for reasons such as lack of income, lack of insurance coverage, or maybe just geographically, they have a hard time accessing care because of where they live.

Rachel: So if you're interested in more about community health centers and ours in particular, you can find that at familyhealthcenter.org. I will also actually ask Danielle if she could introduce quickly the HOPE Consortium, which is kind of where we do our community based substance use disorder work out of.

Danielle: Thanks, Rachel. So yeah, so another big piece of our work is our community collaborations, and we do that through our network called the HOPE Consortium, and that was formed in 2015, and it focuses really across the continuum of substance use care, so prevention, treatment, recovery, and harm reduction, and currently, right now, we have 71 different agencies.

Danielle: Throughout 12 counties and five tribal nations that participate in the HOPE Consortium through a wide variety of initiatives. So that is another big piece of how we get that feedback from our community members and really look at what we need to do as a federally qualified health center.

Mike: Well, you know, there's an old myth, right?

Mike: Oh, we moved here because, right? There's an old myth that we don't have these sorts of problems in rural communities. What are the realities?

Rachel: So exactly like you said, it's a myth. That's just not true. Substance use is everywhere. It doesn't discriminate by race, social economic class, or geography, and it's really prevalent in both urban and rural communities.

Rachel: You, however, might see some differences in the trends in the different areas, so rural and urban. One of the really great resources for rural health information is called the Rural Health Information Hub or RHI Hub. They actually just published a overview of substance use in rural areas in January of this year. So January 2024.

Rachel: And some of the trends that they point out are that rural adults, amongst rural adults. So those compared to living in more metropolitan areas have higher rates of tobacco and methamphetamine use. And but with respect to the opioid use crisis that we hear all over the news all the time, there's absolutely no difference between urban and rural environments.

Rachel: Amongst adolescents and youth they report that there is a higher rate of alcohol use amongst those that live in rural areas, which if you've ever been to a rural area and you've seen all the bars on every corner, that probably doesn't surprise you. And that those youth are also much more likely to engage in high risk behaviors like binge drinking and driving under the influence than those that reside in urban areas.

Rachel: So the problems may be different, but the level of concern related to substance use really is not any different in rural areas than it is an urban environment.

Mike: You know, Danielle, I travel a lot, right? I speak all over the place and whenever I go into a community, if I have a chance to talk to law enforcement, I always ask them, what are you dealing with?

Mike: And I used to get, oh, we're dealing with speed, cocaine, crack, meth, and that would be one answer. Then a little bit later I would get, oh, we're dealing with heroin and opiates and fentanyl. Well, last five years, what I've heard from law enforcement is, yeah, everything, everything! And that means the youth are exposed to everything as well, right?

Danielle: Yeah, and I think, like, in Wisconsin, it's important to know that alcohol use still remains number one in terms of use and sometimes, you know, you'll hear alcohol and other drugs, but, you know, alcohol is a drug. We know that methamphetamine is extremely prevalent. But opioids are in everything.

Danielle: Unless the person is just using alcohol alone, people are at risk of an opioid overdose regardless of what they're using. Because we've heard stories, like someone says, I'm just using marijuana. But then it's laced with opioids. Or we've conducted several focus groups through the work that we do, and we had one focus group participant in Marshfield say that methamphetamine was their substance of choice, and they ended up in the emergency room due to an opioid overdose, and they didn't understand.

Danielle: You know, they thought they were just using methamphetamine. And so they were not only concerned for themselves, but also had supplied meth to others, and they were afraid of potentially causing other overdoses. So we know that if people think I'm just using this drug that it's mixed, you know, there's not a lot of just singular use of a drug.

Danielle: We're also seeing like more availability with approval now of fentanyl test strips in Wisconsin. But the trends are there all substances and, and they come and go, you know, throughout different communities. But I would say a wide variety of substances being used.

Mike: Well, you know, it's funny what you just said, because I do a lot of school age presentations.

Mike: And if I ask a high school, what are the top three drugs in your community, they'll come up with everything except alcohol and some, eventually some kid will say, well, do you consider alcohol a drug? For those of you listening to other parts of the country, Wisconsin is the only state that I get asked that question in. So we have a different perception here, I could see in the Midwest and now as marijuana becomes legalized, are you also finding that your clients are not considering marijuana a drug?

Danielle: Yeah, I mean, I would say there's a lot of mixed messages about marijuana whether or not it's just marijuana alone or like hemp derivatives of marijuana and what's legal and not legal. And there's just a lot of confusion because you're right. Every state is different. You know, some have legalized recreational versus medical and Wisconsin has neither yet. There's been talks, but then it does create that confusion because even, you know, you look at different hemp derivatives and they might think because they're not monitored that it's under the 3 percent legal limit and then it's not.

Danielle: You know, so just, I think it's creating confusion across all of the lines and the borders of states.

Mike: Rachel, I work in places where you have to travel or somebody would have to travel a long way simply to get an assessment. How do you address that? Well, I think you addressed that in your opening, but how does Family Health Center address that?

Rachel: Yeah. So our three alcohol and drug recovery centers were placed as strategically as possible. Obviously we can't, we'd love to have a clinic in every community, but it's just not feasible. So we tried to be strategic about where we placed our three alcohol and drug recovery centers. We have one in Marshfield, which is in central Wisconsin.

Rachel: One in Minocqua in northern Wisconsin and one in Lady Smith in western Wisconsin. All of them are approximately 200 miles apart as the crow flies. So we know that obviously that doesn't account for the travel realities and like winter months in Wisconsin, for example it can take, you know, a bit of time to travel between the centers, but we tried to be strategic about that in terms of where our patients tell us that there's a need where community members are ready for that, you know, need to be addressed and also to serve kind of a gap.

Rachel: In where there just isn't anything. You may recall if you've been in Wisconsin for a while back in, I think it was 2015 or maybe even a little earlier, the Marshfield, the hospital in Marshfield closed its inpatient substance use disorder treatment unit. And that left a huge gaping hole in northern Wisconsin in general.

Rachel: I mean, we're not really even that far north in Marshfield. We're kind of in the middle of the state, but that's where everybody from the northern half of the state would send their individuals that needed inpatient services to. So it left a gaping hole and we were able to kind of plug that the best we could.

Rachel: It's not, you know, a perfect fix. But these three centers do offer a lot of services in these communities. The other thing that's really neat about the Hope Consortium is that when we came together initially, it was because no one felt they could do it alone. And that's that's true. Nobody can do this alone.

Rachel: And so all these partners in the Hope Consortium are really able to play off each other's strengths. And we work really hard to get people the care that they need the closest to home and as quickly as possible. So there is not a lot of competition between these agencies. Obviously, some of us are working for competing systems overall, but we know we don't have to compete.

Rachel: There's plenty of patients to go around. So there's a really big focus on working together and who can provide medication for this individual, who can provide the counseling, who can provide social support services, and we work together to make sure that that person has what they need to succeed.

Rachel: So another big thing that's really important is our focus on access to basic needs. That's something that comes up over and over again amongst those in the consortium. Yes, substance use disorder treatment, clinical care, mental health treatment is really important. But if people don't have housing, if they don't have transportation, particularly in rural areas, where there just is no public transportation, then all those treatment services are not going to be effective.

Rachel: They're not going to be helpful because this person is too focused on where am I going to sleep tonight? How am I going to feed my family to be able to effectively engage in those services? So it's a combination. I wouldn't say that we've fixed the problem (finger quotes) or really addressed the problem, but that's the work that we do to try to make it better for the people that live in these rural communities.

Mike: Danielle, are those some of the other challenges you get from working with rural population? Housing, economics?

Danielle: Yeah, yeah, definitely. We know and even in some of our communities, like in Northern Wisconsin, we know that rental units are limited and that's because of the tourist communities.

Danielle: They're being bought up because they are, you know, VRBO or Virbo or Airbnb destinations. And so the lack of housing, even defined when, you know, when you find somebody for employment, but then they can't find somewhere to live. That's a challenge. And then we have folks that, you know, maybe have a felony or something on their background, a past eviction.

Danielle: And so they're looking for housing and they can't get housing because of their past. So just trying to support not only our professionals in this service area, but then trying to help people that are in treatment services with finding stable housing. Because like Rachel said, we know that if they're constantly worrying about basic needs, food, housing, they're not thinking about their treatment.

Danielle: You know, when they're worried about what are they going to eat next and where are they going to live.

Mike: Yeah, Rachel, you kind of addressed this already, but you know, when you work with a certain population, the study, and I went to the website you were talking about, suggests that not only is there a higher usage, but the adults are more tolerant in rural communities of youth drinking, vaping, tobacco.

Mike: And of course, we're talking about the backend with treatment, but you also do prevention. How do you educate the public about the risks of vaping, smoking, alcohol usage, the other drugs, and how important is prevention?

Rachel: Yeah, it's really interesting, the word tolerant, because I'm not sure that I would personally call it tolerance.

Rachel: I think a lot of what you see is kind of generational use or this theory that if I take the keys and the kids are drinking, they can do it safely here because they can use this stuff, I've got the keys, they're not going to drive anywhere. So there's this, yes, it's tolerance, but it's also something that's like a modeled behavior.

Rachel: So I saw my parents do it. I see my parents do this all the time. This is part of being in my family growing up. All of our kind of social events revolve around alcohol. That's just, It's very common here. So yes, tolerance, but also it's really something that's a modeled behavior. So we know that education is a first step, but education alone does not change behavior.

Rachel: So it's really important for us when we're talking to adults and those that are kind of responsible for keeping kids safe, for them to know that they need to create a safe environment if they're going to prevent the youth from using. So that means encouraging relationships with trusted adults.

Rachel: Maybe it's not just parents, maybe it's family friends, maybe it's teachers, maybe it's coaches, whoever that is in the community that can be a safe and trusted adult. One thing that's really difficult for people here is support for out of school time supervision. We know that this is the highest time of youth use is that those after school hours and it's expensive.

Rachel: It can be hard to find, even if you do have the money to afford it. Especially for kids that are in those really high risk years, like middle school and high school, where, you know, you'd really like them to be supervised, but there just isn't any kind of care out there for them. We also need to address the access to substances.

Rachel: So we have drinking at youth sporting events. You know, I know when I moved to Wisconsin, I was very surprised to go to 1 4th of July fireworks. You know, display at a high school and people were drinking. I'm like, you can't drink on a high school campus.

Mike: Oh yes you can!

Rachel: Yeah. And then we also need to think about the sale of hemp derivatives to minors.

Rachel: That's become really common. And like Danielle said, you know, you don't necessarily know what you're getting in some of these hemp derivatives and what the percentage of THC really is. And some of the packaging that we've seen, you know, with things that are sprayed with these hemp derivative oils.

Rachel: You know, it's candy, it's marketed to kids. Serving size is not a consideration. If you're eating a Nerd's rope, for example, you know you're not gonna eat an inch of it and then call it a day. That's just not the way that these things are consumed. So that sale of hemp derivatives to minors has been a really big challenge in our communities.

Rachel: We also need to emphasize that this is not your mother's marijuana, so to speak. There's a really difference in potency now than there was even 10 years ago. And so that's something that, that we're very concerned about. And also like Danielle mentioned earlier when she was talking about not knowing what you're getting, things are cut with everything and you don't know what that is.

Rachel: And the purity of drugs in general, there's some campaigns coming DOJ, things like one pill can kill because it looks like a pressed pill. It looks like a pharmaceutical. You think this has been through the FDA. It's safe. I know what I'm getting. You don't. There's pill presses in some of these more sophisticated labs and these pills come through and you really don't know what's in them.

Rachel: And so truly one pill could kill. You might be thinking that you're taking some party drug and then it's got fentanyl in it. And now you're overdosing. So there's a lot we need to do there. Obviously, we get really hot about this topic because there's so much information out there that needs to be shared.

Rachel: But I mean, you get on any little highway around here, even a county highway, and you start seeing signs 117 [inaudible] the border, you know, and so I mean, it's, it's marketed everywhere. And it's really hard to keep up with that messaging to the youth, especially in a scenario where parents think as long as I take the kids away, or they do it at my house, it's okay.

Mike: Well, I saw a statistic yesterday that a third of the marijuana sold in Michigan is to Wisconsin residents. So it's not as though it's not here. It's just coming across, soon to be near you. Well, I think that's great. The first time I attended an event where it was a fundraiser for a high school athletic team, and it was a wine tasting, beer tasting.

Mike: I nearly lost my mind, but I feel like I'm a lone voice in the wilderness. Danielle, so speaking about that, is it almost paradoxical that there's, it said everybody knows everything in a small town, right? So is there stigma associated with not using because everybody uses, or is there stigma associated with getting help for mental health?

Danielle: I mean, yeah, I mean, I think sure. I mean, I don't know if it's stigma about like lack of awareness. But it's like much more about socializing around those drugs, you know, you see, in particular, like it's a generational thing, you know, you drink at a sporting event or you drink here. But yeah, I mean, I think there's stigma for both mental health and substance use, you know, goes both ways.

Danielle: It's even stigma from the person themselves in recovery, you know, and then also having to deal with stigma of others, you know, looking at them when they seek care.

Mike: Yeah. When I looked at your website ladies, I was struck by the Hope Consortium. It's just such a terrific thing. Talk more about that.

Danielle: Sure. So the Hope Consortium, like I said earlier, has been around since 2015 and you know, we've grown over our time focusing across that entire continuum of prevention, treatment, recovery and harm reduction. And so just to kind of mention some of the projects and things that we're working on through those 71 partner agencies is a lot of our work is guided, of course, around our three alcohol and drug recovery centers.

Danielle: But we also pride ourselves on providing an annual training and technical assistance survey to all of our partners and that really helps us look at what types of professional development and training opportunities do folks need that we can support them in and so things that we put on our monthly webinars, we put that on in the spring then we have an annual Hope Consortium conference that we host in August each year. Other trainings, we've done the wrap around care coordination training, we've posted a couple week long doula trainings, and so all of those trainings really are guided by top needs, emerging trends maybe looking at positions that are hard to fill in the substance use treatment world. Then we also have a focus on specific populations. So we have a couple of projects where we work with our local jails on a medication assisted treatment program. That's comprehensive. So we're partnering with recovery coaches providing that medication prior to discharge.

Danielle: And then upon discharge, someone can meet up at one of our Family Health Center Alcohol and Drug Recovery Centers. So it's really been a good partnership of that connection to care immediately. We have helped one of our communities create a jail discharge planner position. Really looking at those basic needs and, you know, what happens if today you are released?

Danielle: Where would you live? Do you have a job? You know, what are your goals with your children? We also focus on those really young, so those impacted by neonatal abstinence syndrome. You know, if you're thinking about becoming pregnant or are pregnant and you have a substance use disorder, how can we help those young families?

Danielle: And then really continuing as we're learning to keep that connection with peer support. Through, you know, something that's rather new called Recovery Community Organizations or RCOs. So we have a Recovery Community Organization right here in Central Wisconsin called Three Bridges Recovery. That's new, that was formed in 2018 and we see more Recovery Community Organizations popping up.

Danielle: But it really is that peer to peer support, whether that's for substance use or harm reduction, and then also supporting basic needs like that, transportation, housing so lots of different projects and all of those have come from feedback from the Hope Consortium.

Mike: I love it. You can tell you're a 50 year old organization when you refer to something six years is new. I think that's great. And talk, you have a conference coming up Rachel, it's August...

Rachel: August 1st and 2nd this year.

Mike: Now, is it in person, virtual, both?

Rachel: It's virtual this year. So we started out in person in Lac du Flambeau every year. And then the pandemic hit and Danielle and I scrambled to put together a virtual conference real quick.

Rachel: And we consider that one of the gifts of the pandemic, because honestly, it's made the conference much more accessible to all of our partners. And you know, we can afford really top notch speakers and things because. We're not paying for lodging, mileage, airfare, you know, those kinds of things. So it's been really exciting.

Rachel: This is actually our eighth annual conference this year. So for those that are listening and interested you don't have to live or work in Wisconsin to join. If you would like to attend, it's really inexpensive, only $25 and comes with CEUs for participating. So hopeconsortium.org is the website.

Rachel: There's a conference tab there. And this year, We'll have over 30 sessions. Just to name a couple of the different topics we'll have updates from our state, Wisconsin Department of Health Services, as well as federal partners at the Substance Abuse and Mental Health Services Administration. Lots of sessions on working with those who are pregnant or parenting and also impacted by substance use.

Rachel: Suicide and substance use and lots of great sessions on harm reduction efforts. Specifically how do we implement those in rural communities that may be a bit averse to providing some of those services. Working with indigenous populations which is really important in rural Wisconsin. [inaudible] are becoming more and more popular throughout the state and across the nation and we have a couple sessions on that. Trauma, which is often underpinning kind of substance use disorder. Some really kind of different and exciting ones. We have a session on the role of nutrition in substance use, as well as creating recovery ecosystems in rural environments.

Rachel: And I think one other thing that's also worth noting is that several of our conference presenters are currently practicing in rural Wisconsin. So we're resource limited, yes, but that can also drive a lot of innovation and creativity. So some presenters, for example, Jill Gammes, who's the director of Arbor Place, which is over in Menominee, Wisconsin, and they're establishing a new treatment center for women who are pregnant so that both the woman and her baby and or young children can be there and stay at that residential treatment facility while receiving treatment services.

Rachel: So lots of our partners are willing to lend their expertise. So I think it's really important that people have the expertise to sharing kind of what they have learned about doing this difficult work in a very difficult environment at our conference, so I think, valuable for anybody who lives and works in a rural area to hear how we've kind of operationalized some of these things in this environment that's not typically studied just because the population is lower.

Mike: And you already know if you're listening that we have at the end of the podcast, there are links to both consortium as well as family health center and the upcoming conference. And I love that it's rural based. So there's a lot of places in our country that don't have access as extensive as you guys.

Mike: There you have, Danielle, you also have you alluded to it before, a webinar series that is on your website. Is that also just, hey, here it is. I can upload it and go.

Danielle: Yeah, so for the last three years, we've hosted that spring webinar series, and if we've gotten permission from presenters, we've posted those links on our website, but also like this year, we've sent out Zoom recorded links to attendees.

Danielle: So if you're interested in a topic for this year, we'd have to email you the link instead of YouTube. But yeah, we have recorded ones up from the last couple of years and we continue to change those and update those as we do that survey each year.

Mike: Right. Well, I'll let you both go with this question.

Mike: I'll let you both answer it. While there's certainly challenges to work in a rural area, it's got to be beautiful. You got to enjoy it. What do you enjoy most?

Danielle: I think it's the partners that keep me energized in all of the work that we do. You know, everybody is passionate about working together to identify the gaps.

Danielle: And so to me, what keeps me energized is being creative and kind of solving issues that people say, Well, that's impossible, but it's not when you work together. You know, so

Mike: I love the word impossible.

Rachel: Yeah. I hate to say the same thing as Danielle, but our partners are just superhuman in small agencies.

Rachel: People wear a lot of hats. And so the wealth of knowledge that one person can hold is unbelievable. And when we have so many partners that are willing to give them their time and energy and just their brain power to solving these really difficult problems. And it's resulted in so many amazing programs over the years.

Rachel: And because we're small. We do get to be more relationship based and less transactional, which I think feels really good in the work that we do, because I would consider some of the people that I've worked with through the Hope Consortium since 2015, my very best friends. That's how I met Danielle, to be honest with. Writing the initial Hope Consortium grant.

Rachel: And now, you know, we've spent over a decade together sharing two halves of the same brain. And it's just it's a really great environment in which to kind of slow down and think hard together and, you know, get to be really creative.

Mike: I'm so glad you could talk about this today. I'm in these communities a ton over my professional career and you know, you hit it right on the head when you said, it's not tolerant it's multigenerational acceptance and the norm. And so turn that ship is not an easy thing to do, but so necessary.

Mike: For those of you listening, we hope you enjoyed this. We hope you listen in next time. Again, there are links to all of their resources at the bottom of the podcast. Until you can join us again, please stay safe and stay connected.