Waking Up Dreamland
Master of Public Health Program graduate Michael Dulitz, Opiate Response Project Coordinator for the Grand Forks Public Health Department, talks opioid response in the Red River Valley.
Thanks for your time, Michael. You graduated from the SMHS Master of Public Health Program’s Health Management and Policy track in May 2017. I know you do naloxone training from seeing you in action at the Grand Forks Public Library, but give us a sense of the work you’ve been doing more broadly since graduating.
I’m 100 percent dedicated to addressing the opioid crisis in the Grand Forks area, which took four lives in 2017 and one already this year. This is a new position for Grand Forks Public Health as of November 2017. The work is funded by the state through a federal program connected to the 21st Century Cures Act [enacted in Dec. 2016]. We’re one of five communities and three American Indian tribes in North Dakota that received the grant. I’m doing a lot of critical thinking about what would fit for the community.
Thinking and organizing, I imagine—
In Grand Forks we’ve been focusing on building infrastructure for prevention and treatment in so far as we’ve seen a steady increase of overdoses since about 2013, so it’s time to broaden our work. The prevention side is what gets all the press; that’s what you’d see me out in the community doing—the naloxone training. But, a majority of my work is building evidence-based treatment infrastructure in the community, eliminating barriers, and promoting wellness. We’re working on building this treatment continuum and supporting persons in the region to get access to these services too. Our mantra is “empowering the individual, protecting the community, enabling recovery.”
Are you finding that the training you received in UND’s MPH Program has served you well in this position so far?
I’ve used something from every class I took in the MPH program for this job. The most beneficial part of the program is that it gave me that cross section of public health training—the whole spectrum—and I’m now able to speak to businesspeople in their language, health care administrators in their language, treatment providers, community members, politicians. I was a sociology major as an undergraduate at Augustana [Sioux Falls, S.D.] before going on to paramedic school. So, I knew I had skills for this sort of position, and I’ve been putting them all to good use, especially those I developed at UND.
I assume this work is at least a little less intense than being a paramedic. Is that part of what attracted you to public health as a profession?
I was interested in being part of the solution at a higher level. You work in the clinical world—or as a paramedic—it’s easy to see the problems for individuals on the ground. And it’s easy to get jaded by the problems at that level. So, I was looking to think about these problems differently, from the standpoint of policy and other structures. In Grand Forks, we take an active role in supporting health policies in the community and when necessary, providing services where there are gaps, for example our social detox. It’s beyond what the average person thinks about when they think “public health,” and I like that.
There are likely many obstacles making your work more difficult than it should be. Where do those obstacles tend to be located—is it the level of policy and bureaucracy, or elsewhere?
There are two main challenges. The first is regulatory. The federal government has instituted a number of regulations on addiction treatment programs to prevent things like diversion [selling, sharing, or using medication for something other than the intended use], but some of those had the unintended consequence of stigmatizing addiction treatment. Why? Your average medical provider cannot prescribe most of these medications that are part of medication assisted treatment [MAT] programs. We’ve had physicians interested in becoming prescribers of MAT, but they need extra training. Then, they need to convince the members of their medical group that they should get trained as well—that it’s good for the group. Then, for those providers, having to deal with the institutional stigma that comes with addiction is hard in so far as you go to your manager and say “we should do this” only to run into even more hurdles. And that’s the other hump we need to get over—the stigma of what a use disorder is and getting people to come together to be part of the solution has been a huge challenge for me. So, while addressing the stigma in the community about what substance use disorder is and who the persons affected by it are has been tough, the regulatory hurdle is the biggest obstacle toward taking action to address the issue.
What sort of feedback have you received from community when you try to broach that issue of stigma?
To be honest, the community perceptions have changed a lot over the past few years. We’ve been chipping away at changing the conversation regarding how we perceive addiction. We’ve been trying to get the idea into the community that there are solutions to this through town halls and other community events. Fortunately, I’ve been met with many open doors in the community. My job has been relatively easy in that regard—people seem to want to be part of the solution on this. Even for those not on the frontlines, the willingness to reexamine their beliefs and change the way one talks about addiction helps to reduce stigma in the community.
Have you read the Sam Quinones book on all of this—Dreamland?
I haven’t had a chance to read it yet, but I come across his work all the time.
He covers it all, from prescription opioids and “big pharma” to heroin to the challenges of treatment.
There are a lot of barriers to getting treatment in this region still. When I started there were no medication-assisted treatment providers in town, which is one of the more important components of evidence-based recovery, and few peer recovery resources. We had counseling providers, but finding those providers who accept all types of insurance can be a challenge. So, we’ve been working on building that three-legged stool of evidence-based recovery—the legs being peer support, medication, and counseling programs. One of the evolving ideas about opioid use disorder treatment is that it can happen on an outpatient basis. It used it be that the model was you’d send someone away to an in-patient facility for 28 days so they could go through this detox process before sending them home without having the support to deal with the triggers in the community that brought them to the facility in the first place.
On that note, North Dakota recently joined a class action lawsuit that includes several states suing Purdue Pharma, the maker of OxyContin, for the company’s alleged role in contributing to the national opioid crisis.
The opioid epidemic has placed an incredible burden on governments, healthcare systems, families, businesses, and non-profits across the country. With the tactics used by pharmaceutical companies to increase opioid prescribing, the question of liability is important to answer, not just to offset the costs of this epidemic, but to ensure that organizations are held accountable for their actions as a way to prevent future epidemics.
And you recently returned from a national conference on opioids, right? What was the mood like there—the morale—among all these folks from around the country focused on this problem?
I think people feel like we’re sort of stuck in the trenches right now, but there is hope. We keep chipping away at the problem and we’re getting there. There’s more public knowledge of the problem and that helps to drive policy. And that policy drives interventions and resources, allowing us to focus on this. We don’t want to hang our hat on naloxone as the sole solution to the crisis but, it does help people stay alive until they can get into treatment. We’re seeing more resources being devoted to this problem in states across the country and we’re seeing many creative solutions tailored to the community’s needs. I had a chance to hear from one community in the region, Little Falls, Minn., which has successfully built a full care continuum for opioid use disorder. They started with a program to reduce opioid prescribing among their medical group and have evolved into a full MAT program as their community’s need dictated the solutions. They have been great about sharing their experiences with other communities and we hope to bring representatives of that community to Grand Forks in the future.