I think we can go ahead. Good afternoon, everyone. Thank you so much for joining us today. I sincerely apologize for starting a few minutes later than scheduled, but we will go ahead and kick right off. So welcome to today's webinar is how to opioid use disorder in rural America, hosted by the providers clinical support system, and partnership with the National Council for mental well being. Thank you so much for joining us today. Next slide please. So before we begin, I'd like to cover a few housekeeping notes on today's webinar is being recorded and all participants will be kept in listen only mode. The recording and slides will be made available on the PCSS website within two weeks. There will also be an opportunity to ask questions at the end of the webinar. So we encourage you to submit your questions through the q amp a box located at the bottom of your screen. So today's presenter. Yes, slide please. Next slide. Okay. One more. So today's presenter is Dr. Aaron when Stanley on Dr. When Stanley is an associate professor at West Virginia University, Department of Behavioral Medicine and Psychiatry, Dr. When Stanley received her doctoral degree from the john hopkins Bloomberg School of Public Health. She's, she has post postdoctoral training and behavioral pharmacology pharmacology, and she has over 20 years of experience as a behavioral health services researcher, Dr. When Stanley's current research is focused on reducing the morbidity and mortality associated with the overdose epidemic, as well as the use of technology to improve access and quality of behavioral health services. More specifically, Dr. When Stanley is investigating cognitive impairments and brain abnormalities that result from opioid related overdose and problems initiated buprenorphine treatment among individuals using fentanyl. And Dr. When Stanley has no disclosures. The overarching goal of PCSS is to train healthcare professionals and evidence based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications as well as for the prevention and treatment of substance use disorders. Next slide please. At this time, I'd like to turn it over to Dr. When Stanley who will review the educational objectives and begin the presentation. Thank you so much for that introduction and I'm thankful for everybody that's hung in there with our technical difficulties. So, the educational objectives for the webinar today is to define morality and its impact on the overdose epidemic in rural communities. I'm going to be describing how the social determinants of health in rural areas has increased the risk of drug use and overdose deaths will be discussing barriers to delivering evidence based prevention and treatment services for individuals with opioid use disorder in rural areas and finally we'll be talking about how the COVID-19 pandemic has exacerbated overdose deaths and created new opportunities for service delivery in rural areas. So I want to start by defining morality and throughout the presentation I've integrated some pictures that I've taken this is a grand view it's in the New River Gorge National Park. It's really beautiful part of the country. So, um, when we're defining morality. There are a lot of definitions that are available, and I think what's important to think about is really that place matters. And this is the social the build the natural environment in which we live really shapes our health behaviors and defines our exposure, not just the pathogens but also our ability to access health services, but reality has really been described as not an urban area. So today, internationally globally they're about 45% of individuals reside in rural areas. And you can see that that's much smaller in the United States or a smaller proportion only about 19% of individuals in the United States reside in rural areas. About half of the people in the United States that live in a rural area actually live in the south and rural areas. We know that agriculture and extractive industries are there are usually the primary industries, employing individuals. There are several different definitions that are actually used to define morality and so this really matters in terms of defining resources that are available to rural areas and that might be through the HRSA and other organizations. Some of the different definitions that are used are those put forth through the US Census Bureau, the US Office of Management and Budget, and the Economic Services Research Service. We usually talk about at the county level definitions that are defined by a area, having a population of 50,000 or more. And then there are more complicated these urban rural commuting areas known as RUCAs that are more specific information about the size of that geographic unit. In addition to work commuting and other factors that go into that. So just to give you some orientation here I'm presenting today from West Virginia University I'm located in Morgantown. And so Morgantown, when the students aren't here I think we have about 30,000 individuals that reside in the city. So, according to the OMB definition we actually would be considered a micro size so our city size is less than 50,000. Morgantown is located in Montegalia County. And Montegalia County does not meet HRSA's definition of rural, but it is interesting to note that despite that, the outlying areas of Montegalia County do not actually have ambulance service. So, while we're not considered rural, it's hard to imagine that people in my county don't have access to an ambulance. So that's something to keep in mind. We know that the population the proportion of people residing in rural areas has been continuously over time decreasing globally and in the United States. So it is anticipated you can see projected out through 2050 to continue this decline. And the majority of people who live in rural areas do often cluster outside of large urban areas. This is a rural density map that you can see the greater Atlanta region. And again you can see the darker areas of this orange or rust color indicates higher density of individuals residing just outside of the city of Atlanta. So I think it's a little bit different than what we normally typically think of so I normally think of rural areas you're thinking of the frontier or the plains area where as far as you can see, you are, do not see buildings or individuals perhaps just farm animals. So, that's really sort of not the case. I really enjoyed this article that recently appeared, and it's entitled the harmful popular misconceptions about rural America. I found that these are really entrenched in our belief systems on the stereotypes and ideas. We really think about, and I was guilty of this as myself as someone who grew up in Connecticut and largely spent the first half of my life living on the east coast, the northeast coast I should say that we really think of rural being the heartland or We think of rurality is this homogeneous unidimensional concept. And it's really entrenched with the culture of poverty. And we often don't think of the more positive aspects of rural America, and thinking about how important trust is really thinking about sustained commitment patients and partnerships. I grew up the first half of my life residing in urban areas like Baltimore and Cincinnati and Chicago and Boston, and in 2016 I moved to West Virginia, and I'll say personally I still probably struggle a little bit with the patients. But I really do learn quickly that when you don't have quick access to, I mean, and not just quick gas access but you know access 24 seven to resources and services that you really need to change your lifestyle and definitely plan more and have tremendous amount of patients. Rurality is multi dimensional so again it's not just the heartland we know that there are different regions of the country, and that have different natural environments different economies social cultures, history, weather and other factors that could influence and how people live in those communities. Some of the major areas might include the Great Plains the frontier region, Appalachia where I live, live and reside right now. And also thinking about tribal lands that encompass both rural and urban areas. And while we definitely see more homogeneity in as far as racial and ethnic homogeneity in rural areas that seems to recently be changing. So only 20% of individuals in rural areas identify as non Hispanic white. I'm sorry, guys not not that are not white, but that seems to be in some areas we're seeing increasing changes and increasing diversity, it's variable across these different world regions. Early during the opioid overdose epidemic we saw that from about, about 2005 to about 2015 2016 that overdose deaths were disproportionately occurring in rural areas this is very well been documented and known widely for across the United States. This uptick recently, as recent as 2016 at least in our national data, we're seeing increases in overdose deaths occurring in urban areas, but there's even been the most recent data that literally was just recently released from the National Center for Health Statistics that highlights some important differences in rural and urban areas in terms of overdose deaths. So we now from the latest data that they just published this year in 2002 2020 rather that there actually is a higher overdose death rate in urban counties again at We can see that males on and black individuals residing in urban areas have higher overdose death rates in urban areas compared to rural areas. And we've also started to see some differences in the deaths, the drugs that are involved in overdose deaths we're seeing more synthetic opioid deaths involved in overdose deaths in urban areas and that's drugs like fentanyl compared to rural areas where we're seeing higher rates of overdose deaths involving psycho stimulants like methamphetamines. But in general, you can see that there's really some nuance to how overdose deaths are occurring in these urban and rural areas. And despite some of these differences unfortunately West Virginia has had the highest rate of overdose deaths for 20 consecutive years. It's hard to imagine what that impact has had on communities in West Virginia. We do know that there's this higher potency of synthetic opiates might suppress some of the community efforts to prevent overdose deaths and really we see this long standing lack of or limited, I should say, public health infrastructure and resources in rural areas that are really problematic in responding to the overdose epidemic in terms of also setting up systems like surveillance systems. But it's really important to remember that when we try to make generalizations or understand the overdose epidemic and making these urban rural comparisons using overdose fatality data that these overdose deaths are really just the tip of the iceberg right and in fact we know that there are significantly more deaths. The director of the National Office of Drug Control Policy, Dr. Gupta, recently published in JAMA a commentary on the need for surveillance of non fatal overdose deaths. And the reason is in the article he presents data suggesting that approximately for every overdose death, there are 14 non fatal overdoses and this is based on data from Maine. So you can see that if we extrapolate that to the national data that that would mean that in 2021 there were over 1.5 million non fatal overdoses. And I think it's really difficult to track non fatal overdoses, because not everyone seeks services so unless they have a point of interaction with the system. How do we know that that occurred and how do we count that. So this is a picture of Babcock State Park and I really think it really epitomizes the West Virginia area where you're used to seeing these pictures right of the Appalachian Mountains, and also sort of this smoke that settles in between the mountain ridges which is truly spectacular. There are a lot of social determinants of health that actually contribute to the increased risk of drug use and overdose death in rural areas. And that begins with things like lower rates of education, higher rates of poverty and unemployment in rural areas. The autonomy that often is prioritized in rural areas is both a positive and negative. Our communities are also quite close knit. There's definitely lack in the physical or built environment we see fewer services and prevention and treatment services for individuals who use drugs. They have to often travel greater distances and there's a lack of public transportation systems. This equates to less access to health care and of course it's becoming more acute, that we have rural areas have overall problems in, in the proportion of individuals that have access to health care providers and less mobility and lower rates of health insurance that are undoubtedly probably linked to the economy and jobs. People residing in rural areas often have higher rates of poverty individuals residing at the at or below the federal poverty level. So you can see the number of people living at the poverty level or below and metro areas at about 12%, and that's a little in rural areas. We can also see that the median annual incomes on average are lower in rural areas. And there's also likely fewer jobs available so one of the challenges that we encounter here in West Virginia is actually we also see lower rates of labor and workforce participation. We have an aging population we have a shrinking population size, and a lot of other factors that may be contributing to that, and similar and other areas. The National Appalachian Regional Commission has, in addition to having individuals residing in poverty we also see there are counties that are either designated as economically distressed or at risk of being economically distressed. When you start to see these clusters and in the map, these are the counties that are in red. You can imagine how much farther you're going to have to travel for jobs or access to resources, given these challenges in these counties. We also see lower rates of education attainment in rural areas. So in rural areas in 2019, about 21% of individuals had at least a bachelor's degree, and that's compared to almost 34% in urban areas. And then you can see how this and also actually the rates of poverty really exacerbates racial and ethnic inequities in rural areas. And that will become more clear as I go through the presentation. So there's so many risk factors in urban and rural communities that can be challenging, right? So in urban areas, we see things like, or at least we used to see when I was living in Baltimore, you know, crack houses and some of these images or television shows like The Wire, which was filmed in Baltimore, and other images in rural areas, which is coal mining. This is an actual picture from a tavern in West Virginia called Hart Times Tavern. I really feel like it's sort of a motto for the situation here. I have not been there. And then we have some pictures that are actually taken from the Portsmouth, Ohio area, which is also in Appalachia. There really was a paint, a, this has now been removed, but there really was a sign just outside the Portsmouth city limits that said unique pain clinic, legitimate pain care. So you sort of know that that's a problem. And of course, for those of you that have seen the Wild and Wonderful Lights of West Virginia, that's available on Netflix, it's really addressing the intergenerational aspects of substance use disorders, which occur both in actually urban and rural areas. And then the risk factors that are associated with fatal prescription opiate overdose deaths really show a manifestation of these social determinants of health that we've talked about, where you're seeing that early on, this is again, the earlier phase of the epidemic, where we saw people living in non-metro areas, much more likely to experience a prescription opioid overdose death. And this was really tied into them. A vast majority of them had a history of chronic pain and that they had a valid prescription for a prescription opioid. And again, looking at some of the industries that folks are working in rural areas that are extractive, whether that be mine or forestry or other industries where they have high rates of potential injury, workplace-related injuries, it's not surprising potentially that they had higher rates of pain in those communities. One thing that's been, I think, really stark most recently during the COVID pandemic, and I think been a complete concern for rural communities and perhaps even suburban communities is our vulnerable population and what's happened in terms of really seeing heightened rates of loneliness and isolation, how we're treating our unhoused populations and our ability to provide shelter and treat folks appropriately. So I want to talk now about some of the service delivery or delivery barriers. This is a picture of the New River Gorge Bridge in Fayetteville. It's a pretty spectacular part of the country. And if you are adventurous, I hear that you can bungee jump off of that bridge. So just to quickly summarize some of the barriers that I'll talk about and really think about them in three different areas. In terms of the built environment, there's really an incredible insufficient access to addiction treatment service capacity. There's been a significant amount of federal dollars that have been invested through different agencies to address these, the lack of services in these communities. And I think that is rapidly changing. There is a lack of integrated services. Transportation is a persistent problem. And now we are worrying with these higher gas prices, a simple ask of a patient to drive 60 minutes to a addiction treatment facility can be an incredible burden. If you're thinking about that 60 miles, 120 miles round trip, potentially depending on where you live and at gas hovering between $4 and $5 a gallon, that can be really, unfortunately, financially not feasible, not to mention the time out of your day that it takes to travel. We see delays in naloxone administration. And unfortunately, as we've seen expansion of telepsychiatry that continues to be problematic in areas that have limited broadband infrastructure, despite continuous changes in these areas to address that. We also have a lot of social and political potential barriers, lack of understanding of addiction as a chronic relapsing medical illness. We do see higher rates of stigma associated with addiction and lack of community buy-in for empirically demonstrated services. And economically, there are constraints. They have limited financial resources. They have challenges. It's very, very difficult to recruit healthcare professionals to work in rural areas. There's challenges in having funding to support real-time surveillance and actually scaling up services in rural areas require money and personnel that can be challenging in rural areas. In rural areas, we know that this is not particular to substance use disorder prevention and treatment services. Overall, they actually have less access to healthcare. It was heartbreaking for those of us residing in rural areas to see that during the peak of the COVID-19 pandemic, that we saw hospital closures continuing to occur. We see fewer hospital beds, in particular ICU beds, and ongoing closures in rural areas. We see fewer addiction treatment programs. It has been documented that there are fewer syringe exchange programs. Rural residents may be less likely to engage in use of preventative services. Because of stigma, it's difficult to have any anonymity in a rural area. It's pretty easy in an urban area, particularly our largest cities, but in rural areas where people know you or they know your family, and you do something as simple as go to the community pharmacy to fill a buprenorphine prescription, in that process, people will know you and know your family. It's also problematic in terms of individuals that are trying to seek mutual support groups. Again, the same idea, people saw you go into that building, everyone knows in the community what happens in that building from five to six o'clock at night, that it is a mutual support group for people with substance use disorders. COVID-19 has caused a lot of reductions or cessation in treatment services that likely were problematic and contributed to what we now know is the increase of overdose deaths. There's also a lack of resources. I took this picture, and we don't have a Costco in West Virginia. I was up in the Pittsburgh area, of course, like everyone at the very beginning of the pandemic, on the hunt for paper towels and toilet paper and cleaning supplies. I thought this was one of the few times that probably people residing in urban areas could see and feel what it's like to not easily get what they need and get what they need in terms of basic services. It's really funny when you think about how the pandemic maybe leveled the playing field, or maybe for those of you residing in urban areas, gave you a feeling of what it's like to not have access to some of these services or quick access like we normally think of. I wanted to share that picture with you. We know from work done by Dr. Chris Jones that there is a really significant treatment capacity gap in the United States that we simply do not have with our current infrastructure capacity. Even if all of our methadone, buprenorphine treatment programs were at full capacity, they would still be unable to reach the number of people that we estimate have an opiate use disorder. Of course, this work that has really been pretty telling here that demonstrates, even as this updated data from the 2019 publication, we can see here that about more than a third of rural counties in the United States do not have a clinician who's wavered to prescribe buprenorphine. That's indicated here by the white boxes. You can see this whole areas that do not have a single provider. I have done work in North Dakota, and it is incredibly challenging to find access to resources. Despite some of these areas may have fewer individuals residing in them, but opiate use disorder is ubiquitous and has affected all of our communities. Some of the things that we've done in our part of the country here in West Virginia to expand access to medications for opiate use disorder is using a similar model that we saw come out of Vermont, the Hob and Spoke model, where we were able to use SOAR and SAMHSA funding to actually use a modified Hob and Spoke model, where our Chestnut Ridge outpatient buprenorphine clinic, which serves an average 450 patients, became a Hob, trained Hobs in different parts of the state, the different areas, and they actually became satellite programs. At the time that I moved to West Virginia in 2016, there were approximately more than 400 people on our buprenorphine treatment waiting list, which was unbelievably overwhelming. I can say now that our treatment program waiting list is actually quite short, if existent at all. There might be a little bit of delays. We don't necessarily have same-day treatment, but we certainly don't have dozens and dozens or hundreds of people on a waiting list anymore, and this is pretty outstanding. We do have consistent problems, though, that are occurring. We just published data that we have. We did a survey of our patients in our buprenorphine treatment clinic. We found that, again, about a third of them had problems filling their buprenorphine prescription in the past year. This is really problematic. Again, there might not be a lot of different pharmacies that patients in rural areas can go to, so if their local pharmacy refuses to stock it, refuses to fill their prescription, or the different types of problems they encounter, then, again, they have to go to another pharmacy and hope for the best. We recently heard a report in the southern part of the state from a treatment program that tried to call eight pharmacies in the southern part of the state, none of which would fill a legitimate buprenorphine prescription for a patient enrolled in an addiction treatment program, and this is just completely unacceptable, so I think doing some more work to see how we might be able to work on that is going to be critical. Also, we know that one of the challenges, and I think this is through urban and rural areas, is the impact of stigma, so this is really problematic and, I would argue, more exacerbated in rural areas, and this is really linked to the idea that an opiate use disorder is a moral weakness and it's a poor choice or failing. Rather than understanding it as a chronic medical illness, we see that health professionals can be failing to use person-first, medically accurate language, and there has been published research that has found that when health care professionals use stigmatizing language, that it results in lower quality of care, and individuals in rural areas often have a lot of concerns about confidentiality or their anonymity when they're seeking services, so really trying to think about that. I think most importantly is that there's a lot of self-stigma that occurs, and I think it's particularly difficult to overcome that, let alone when our patients or individuals that use drugs experience it from community or service providers, so in thinking about the impact of the COVID-19 pandemic and some of the challenges that it's encountered but also new opportunities, so this is a picture, and I'm the second person back there. You can see we're actually doing some whitewater rafting on the Savage River. This was my first whitewater rafting trip, and what I didn't realize, luckily this is the time that I took it with my family, but when you get in that boat, you don't realize that you're putting your life in the hands of everyone else in your boat, and it really shows that it's a community or a group effort to actually navigate these challenging or these difficult rapids. I alone can't make it through these rapids, and that we really need each other, and of course what's interesting too for those of you that haven't done whitewater rafting, it's not just our boat and the people in our boat, but also the boats that are traveling together, they hover together because if someone falls out of one boat, then another boat is in a position to help rescue that person, and so it's critical to actually work together. So as I mentioned earlier, the exacerbation of racial and ethnic inequities in rural areas, we also have seen that unfortunately get significantly worse during the COVID-19 pandemic, so we know that patients were much more likely during the pandemic to use drugs to become infected with COVID-19 and also experience much more likely to experience morbidity and mortality associated with COVID-19, and that was even grossly higher among African Americans with substance use disorders. And thinking about the impact of stigma, I think we also have to think about what I've coined overdose-related compassion fatigue. I really love this sculpture entitled Melancholy by Albert Giorgi, and you can see he's kind of looking down and looking at a hole that's in the center of him, so when we're thinking about folks, healthcare professionals, first responders, anyone working on the front lines of the overdose epidemic in a rural community, when someone dies, these people, we know these people. They're our friends, they're our family members, they're our co-workers' children, they're people that we knew through our church and other civic organizations, and it actually overdoses our traumatic events, whether they're directly witnessed or indirectly learned of, and you can imagine all children in particular, too, that are witnessing their parents or other people in their family overdose, so this is traumatic, and it causes a lot of, it may cause an erosion and may cause compassion fatigue and create challenges in the community that has a high emotional impact on these individuals and may erode compassion, right, so because they're frustrated that they keep trying to save people and their efforts appear to them to not be working. If you saw the Netflix documentary called Harrowing with an E at the end, you'll see it was filmed in southern West Virginia and cleverly the director asks one of the first responders that works at the fire department there how do you cope with you know finding these people overdosed and the young man responds by saying that he goes home and he drinks. And again during the COVID-19 pandemic you can think we've all sort of experienced I'm speaking for myself probably you know that our rural behavioral health care workforce is I think beyond burnt out in areas that were already saw very high rates of not just overdose deaths but obviously many rural areas have high rates of death by suicide they have health care shortages and that this is a really persistent and only became worse during the COVID-19 pandemic and even as we hopefully are slowly moving towards a better times there are still some people that are languishing right now. I want to talk just briefly about some of the things we're doing here in our department of psychiatry and what we've done in response to this compassion fatigue and our concerns about our rural behavioral health care wellness and we formed a healthy healers committee and it's ongoing we conducted a needs assessment to really understand what do our behavioral health care workers need and what are the key issues we work to try to create a culture of wellness. We've actually implemented good news and gratitude I think it's a been really positive we have weekly communications because transparency and good communication has proven to be incredibly important to the morale of our workforce and looking at novel ways of addressing and continuing to support our work staff. We had just had a publication under review where we analyzed the needs assessment results I think it was pretty startling you know I think some health care organizations may say oh well we offer an employee assistance program or a faculty and staff assistance program and that should be enough to sort of help individuals and what we found is very few people you know less than five four ten percent have actually accessed those services and what we found importantly was that individuals our health care workforce wanted to have autonomy in choosing how to take care of themselves and reset and take time. We also really saw that was interesting when we used a multivariable model that we saw that in terms of in reducing compassion fatigue that social support was important it's not just when we go home the people we have to support us but also think about organizational support and creating that and we also saw that compassion satisfaction individuals that are had inherently higher resilience had also had higher compassion satisfaction so we know that that sort of compassion satisfaction helps us absorb sort of secondary or vicarious trauma that we might be help rural health care workers may be exposed to. I think some of the strength in rural communities during the epidemic COVID-19 pandemic sorry should also be taken into consideration so when we at the very beginning of vaccine distribution we saw that rural areas from Alaska to West Virginia and other parts of the country were actually leading vaccine deployment and I think that's because rural communities have the capacity to be creative to be adaptive we have personal connections that were able to leverage to rapidly bring out resources oftentimes and then part of the success in West Virginia is that we have were able to quickly roll out a decentralized approach to vaccine distribution and we used our community partners to actually make this happen quickly and so it sort of behooves us as and those of us working around the opiate epidemic is to think about how can we leverage what we saw in rural areas shine during vaccine distribution to actually roll out or improve access to prevention and treatment services for individuals who use opioids. We saw a wrap we were able to rapidly transition to the use of telepsychiatry during the COVID-19 pandemic. You can see in our published report honestly within seven days we were able to rapidly transition our clinic. We have you can see we have actually annually or during this time period over 10,000 visits and we were able to within seven days rapidly transition our entire population to telepsychiatry. I should let you should know that we were not doing telepsychiatry for anyone seen in person in our clinics. We were aware of this through HRSA funding and providing telepsychiatry services to our ruralist parts of the states and mostly southern West Virginia. Anyone who could not drive to services but because of that experience we were able to rapidly deploy this and this has been published and shown across many different areas that you can see during this time about 40% of our participants were not using videos. We do not have good access to broadband and internet so being able to maintain telepsychiatry or telemedicine visits that allow for phone-based therapy is going to be critical for the ruralist of our communities and ensuring that continued access. So in terms of strengthening rural communities we really absolutely have to address stigma and reduce regulatory barriers. I think it's exciting to see opportunities to look and expand access through low threshold settings of care delivery. We really need to think about what the long-term economic consequences of the pandemic could be worse in rural areas and cause in terms of higher rates of unemployment, fewer services, continuing exacerbation of shortages of behavioral health care workers and looking at the ability to consider these low threshold models of delivery care, care delivery and also how we can best integrate telehealth during these time periods. In terms of you know we're short a little bit short of time due to the late start but I've really started to put this together and how we can think about being creative and using low threshold services across a lot of different settings and thinking about who our community partners are. And you know in rural areas it's not just an individual responsibility or an organizational responsibility to improve resilience but really an opportunity to say how can we actually foster community resilience in rural areas. And so I love this Claudia LaBlanca is known for her graffiti art in Florida. I should look her up and so she painted on the side of the Jackson Memorial Hospital in Florida you know social worker as a as a heroine. And I think that building community support is going to be critical to this and it's something that a real strength these individual connections and willingness to help neighbors. We've been doing some work here to address stigma and trying to get our health professional students involved and really a campaign about starting to share awareness. I know there are a couple of ending slides and I do want to just try to keep a few minutes for discussion. So I have my contact information again some really great pictures of West Virginia and Emma I'm going to ask if we need to actually say anything about these concluding slides or if we're able to move to see if anyone has any questions. Yes I believe we're moving into questions now. Thank you Dr. Winstanley for such an informative presentation. I'm going to pass it over to Casey to see if you have any questions from the audience. Thank you Dr. Winstanley for your presentation and so many wonderful pictures of West Virginia as well. Around compassion fatigue what do you have do you have any like thoughts or recommendations around the role of workplace and workforce interventions in rural areas to help reduce compassion fatigue? Yeah I think that a couple of things that we learned from our own work and our and this is through our needs assessment that we did with our behavioral health care workforce here in West Virginia. What we found was I mean asking people what they need trying to understand how you can improve organizational support creating a culture a workforce culture that actually values wellness ensuring that people are aware of some of these opportunities to engage in EAP or other services that might be available. In addition I think talking about gratitude I have more information than I'd be happy to share in my publication because there are some evidence-based practices that do not work. I mean I'm sorry rather there are some things that folks are doing that are not working and clearly there are some things that work but I think most importantly acknowledging beginning to create an opportunity that we can talk about exposure. I mean our patients our patients are they die and that takes a toll and being able to really understand how can we formally support people and informally and think about the role of autonomy in that process you know what does the individual health care worker or first responder need to have an opportunity to reset and it may be different and allowing some flexibility in that and then also asking for support. Great thank you so much. How do you coordinate or do you incorporate traditional healing models when working with Native Americans and American Indians? Do you have any land-based models that help people to reconnect as we all know the opposite of addiction is connection? That is a great question. I do not have that available for you now but I know it's available. I'd be happy to if you were able to I can put my contact information I think it's on this hopefully everybody can see it my email is on the slide and I'd be happy to connect you with some resources because I know they are available and I think that's a really important point though is to keep in mind that what is helpful for one individual based on their culture their religion their race ethnicity might be different and being able to take into consideration those aspects. I can say you know one advantage of living in a rural area particularly during the COVID-19 pandemic is we do have the opportunity to get outside and get outside and connect with people in nature and engage in those sort of activities that we find are a help us to decompress and reconnect with our support system and reconnect to what's important to us in our lives. Thank you. I think we have time for maybe one more question. How do you integrate into service arrays services into a service array for patients who are affected by mental illness and suicidal ideation as well as substance use disorders? I think that's one of the challenges that I mentioned is for it can be particularly difficult to in rural areas to either co-locate mental health and substance use services and also to find health professionals that are qualified to work with dually diagnosed patient populations and then there's just a timing issue right the reality is when they present at crisis units it's really difficult to disentangle whether it is to do differential diagnosis and understand is this you know meth-induced psychosis is this an underlying psychiatric illness and of course the interaction between the two so being able to partner with community organizations and if you're not able to have them located and appreciate the challenges that patients encounter we are actually starting to do I think it's going to be really important I think it's through HRSA funding telepsychiatry in our emergency department so it's like a consult service so our psychiatrists located here in Morgantown are able to provide to tally into emergency departments in rural parts of the state to provide that sort of level of diagnostics expertise to provide assistance in those areas where they find challenges either in having integrated services or qualified personnel particularly during these crisis interventions. I think one thing that I've always wanted to do that I have no problem sharing with everybody is there's a really great intervention called caring notes that I think has demonstrated to improve outcomes for patients at risk of death by suicide and I think why can't we expand that to individuals with opiate use disorder or have recently overdosed I mean it's really and it's getting back to the previous point that someone made right it's connection it says I'm so glad you're here and I'm here for you right why don't we do follow up after we after people leave treatment why don't we send them a note that just says I'm so glad you came I'm so glad that you're okay and we're here if you need anything because that's a way that we as health care professionals can make a connection with people that's beyond the discrete treatment episode and even making this simple connection with it says I you know rather than the stigma and other things that they encounter to simply say I'm so glad you're alive so I think there's a lot of opportunities despite the challenges to address some of these issues I realize that we're out of time out of time so I'm not sure I love all these great questions in here and I'd certainly be willing if we're able to I could stay and answer some questions in the chat or I'm not sure what you'd like to do yeah yeah well that's all the time we have for questions so thank you again Dr. Winstanley for presenting today I really appreciate your willingness to share your knowledge and expertise with everyone as a gentle reminder the recording and slides will be posted on the PCSS website within two weeks from today before we leave I'd like to go over make you aware of two resources that are offered through PCSS that may be of interest to everyone versus the PCSS mentor program that is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions and you have the option of requesting a mentor from the mentor directory or PCSS can pair you with one so for more information please visit the PCSS website noted on this slide and secondly PCSS offers a discussion forum comprised of PCSS mentors and other experts in the field who can help provide prompt responses to clinical cases and questions there's a mentor on call each month who's available to address any submitted questions through the discussion forum you can also create a new login account by clicking the image on the slide to access the registration page and this slide lists the consortium of lead partner organizations that are part of the PCSS project and finally the PCSS website contact information and social media handles are listed here if you would like to find out more about the resources and trainings offered so once again thank you all for joining our webinar today and we hope you have a great rest of your day and week

Opioid Use Disorder

Rural America

Providers' Clinical Support System

Dr. Erin Winstanley

COVID-19 pandemic

Social determinants of health

Stigma and regulatory barriers

Compassion fatigue

Workforce wellness