Caring for the most stigmatized population - North Carolina Health News
By Melba Newsome
Despite having lived in Asheville for several years, Ashley had no idea what the Mountain Area Health and Education Center did before she got pregnant in 2019. The 37-year-old who asked we not use her name had been in recovery, using medication-assisted treatment to manage her 14-year-long heroin addiction. Her first thought was finding an OB-GYN practice to provide prenatal treatment for someone like her.
She started Googling and MAHEC popped up.
After her first appointment, the midwife referred Ashley to Project CARA (Care that Advocates for Respect, Resilience and Recovery for All), a perinatal substance-use treatment program designed to reduce barriers to treatment and quality obstetrical care.
She experienced near-universal judgment and derision a decade earlier when she got pregnant while still using heroin. She expected the same at Project CARA.
Instead she found understanding and access to resources she never knew were available.
“It was the most respected I’ve ever felt by a doctor,” says Ashley. “I was able to be honest about what I was feeling without getting really stressed out and still feel supported.”
Filling a critical need
Project CARA is both a clinic and a network of resources and the only OB safety net provider for the western region. Providers with the program see about 200 patients each year who are, on average, white, 26 years old, and in their second or third pregnancy. In addition to routine OB-GYN care, the women receive access to services such as Hepatitis C screening, counseling, peer support programs and even legal services.
There is a shortage of primary care doctors in western N.C. Seven of the 16 counties have no practicing OB-GYNs and six hospital labor and delivery units have closed in fewer than five years.
The mountains are also ground zero for the state’s opioid epidemic.
Project CARA medical director, Melinda Ramage says a routine OB-GYN visit may be the first time a woman is willing to confess her substance use. The program’s job is to ensure that patients feel safe enough to confide in them so they can help them have a healthy pregnancy and birth.
Providers at Project CARA begin with the assumption that every patient has a history of trauma. In recent years, a growing understanding of people’s history of trauma and adverse childhood experiences informs the need for “trauma-informed care” to overcome the wounds that often undergird substance use.
The CDC reports that one in four women has experienced domestic violence and one in five has been raped at some point in their lives. Medical services themselves can be traumatizing because they often involve asking sensitive questions and intimate physical exams.
“Trauma-informed care means making sure we treat them with respect and try to normalize these forms of addiction as disorders,” says Dr. Susan McDowell, hepatitis C program lead. “Addiction is a chronic disease, just like diabetes, or hypertension. It’s a part of who they are, not who they are.”
Because pregnant women with a history of addiction are at greater risk for relapse, more than 80 percent of Project CARA’s patients receive medication-assisted treatment (MAT) to improve their chances of succeeding in recovery. Patients receive Suboxone, a FDA-approved medication that has been shown to reduce the risk of pregnancy complications that accompany continued opioid use or sudden opioid withdrawal such as fetal distress, preterm births and underweight babies.
Unfortunately, many people, including those who use it, see MAT as a crutch that must ultimately be discarded in order to achieve real recovery.
“One of the first questions I get when we start folks on medication-assisted therapy is ‘how long will I be on it?’,” said McDowell. “If you have diabetes and you’re on insulin or Metformin, no one would ask when you’re going to stop taking that.”
Part of Project CARA’s success is its practice model of wraparound care that connects patients with the services they need. Tammy Cody, lead care coordinator, oversees complex care for patients involved with multiple agencies and systems like detention and homelessness. While roughly half of their patients come to Project CARA for help own their own, many are referred by community agencies.
“If someone shows up pregnant in the jail, and they’re using substances, they will call me for a referral into Project CARA for obstetrical care and substance abuse treatment and whatever else she might need,” said Cody. “Our collaboration strengthens obstetrical and gynecological care, and helps us make a plan for safe care for moms and babies.”
If a Project CARA patient needs detox or is struggling with a relapse, they are referred to an adult residential and detox/crisis stabilization treatment facility where they spend five to seven days in detox and two to three weeks in inpatient treatment. Patients who don’t require inpatient care but who are deemed too high risk for a Suboxone prescription are referred to an opioid treatment facility to receive their daily dosage of medication.
Expanding the health care model
Given the scale and scope of North Carolina’s opioid problem, too few providers have completed the training that allows them to prescribe opioid replacement medication, particularly in the sparsely populated western region. A 2019 study in the Journal of the American Medical Association classified 41 of North Carolina’s 100 counties as “opioid high-risk.” About 50 percent of the patients treated at the Asheville clinic come from outside Buncombe County.
Almost since its inception, Ramage and her team have pondered how they can build capacity and infrastructure to best serve patients where they live. The hub and spokes model of healthcare emerged as the best option.
So far, Project CARA has expanded to include Polk and McDowell counties where staff provide training and care management support for providers in community health centers and local health department clinics. A combined $1 million grant from the Foundation for Opioid Response Efforts (FORE) and the Dogwood Health Trust will help expand access to treatment and medication to other western counties.
“This is a model that, in its basic construct, is evidence-based and has the same goals but can be adapted to what best serves the community where it’s being done,” said Ramage.
When a Project CARA mom arrives at Mission Hospital for delivery, the labor and delivery team has already received their prenatal records and a heads-up. Project CARA has coordinated everything from the length of hospital stays for moms and babies to urine drug screens to maternal-fetal medicine referral and counseling.
Mission has developed a standardized treatment protocol to ensure that every mom, regardless of her history, receives the same care.
“We want to make sure that our own biases don’t play into the care,” says Mary Cascio, director of nursing for Mother Baby, Labor and Delivery. “We know that they’re scared so we ask ourselves how we best care for them and provide them with all the information and support they need to take a baby home that’s going to have more needs than a normal newborn.”
Data from 2017 shows that Project CARA patients were 36.5 percent less likely to test positive for illicit drugs at delivery. As a result, many Project CARA moms don’t lose custody and leave the hospital with their babies.
Ashley has four-and-a-half years of recovery and just earned her bachelor’s degree. But she has been in a similar place before and still lost her way. So, she can’t stop worrying.
Success for her means shutting down the toxic thoughts that can derail her recovery.
“When things get stressful, there’s always this voice that’s louder than the other voices saying ‘How long can you really do this? How long before you mess all this up?’” she said. “That continues to be my big challenge.”