Why Local Coalitions Matter

Host:I’m here with Christina Clark and Alex Windings. Thank you guys for being here.

Christina: Thank you for having us.

Alex: Yes, sounds good.

Host: Absolutely. I always like to start each interview to talking about each guest and their own journey. How they got here? Why do they do what they do? Could you guys start with that, maybe start with Christina?

Christina: Yes, of course. I started my career actually in domestic violence and really working as an advocate in the court system for women and families that are being afflicted by violence. A lot of times that include drugs and alcohol at home. That was during when I was in college and then right after I graduated, I knew I wanted to be in the field and wanted to work in prevention and nonprofit work in general.

I was lucky enough to become the executive director of an anti-drug coalition in Coffee County, Tennessee, Manchester, and Tullahoma. Worked with them for 10 years building infrastructure and a plan for prevention of substances within that county and that led me to working in Tennessee and across the nation training and working with communities on developing plans for substance use prevention.

Host: Yes, and Alex?

Alex: Mine, I guess when I was in a– Gosh, it goes back to even third grade, I was always interested in nonprofit work. I went to a really a small school and started a food drive when I was still in third grade.

Host: It got to start somewhere.

Alex: I really did it. It started from there and ever since then I was involved with nonprofits back home volunteering and when I went to college, I just took off in that direction and interned at different small nonprofits in the area back home. Then when I got out and moved here, I too come from a coalition background and so I was in Williamson County, just a little south of here and gosh, we’re in Brentwood, aren’t we? I keep thinking we’re in Nashville.

Host: Yes, technically.

Alex: I don’t mind, here in Williamson County where we are.

Host: South of Nashville.

Alex: South of Nashville. I was here for almost four years doing prevention work and I too love training. Christina and I met with the coalition, but then they took me on to do some training and then she stole me full time and now I’m here.

It even goes back a little a little bit further, a little personal note, my cousin, when I was in the later years of high school about to go off to college, he struggled with misusing prescription pills. I lived about half a mile from my grandparents who he was living with at the time after he had gotten out of being in and out of jail. I got to see firsthand how that affected my family especially my grandparents and my parents and just seeing just how that all went together. It’s interesting I never really thought I would be doing what I’m doing, but thinking back, it’s interesting to see we all have a personal connection, we just may not even realize it.

Host: Yes, just to see the real-life effect. I’m just curious you say you both come from the coalition world. Could you describe that for somebody who is not familiar with not working in nonprofit? What does it mean to you when you say that?

Christina: For us, the best way I’ve known to explain it is we’re the mortar in the brick walls. There’s a lot of people working on substance use issues in a community. We have law enforcement, health departments, and educators and our job as coalition leaders is to bring those people to the table and come up with a solid plan so that we’re all in the same page that we’re not duplicating services. That we’re all working towards the same goal so we can really map out a plan.

What’s really great about coalitions is this is about each individual community, so often we talk about these problems globally and yes, that’s important, but each community has a reason it’s happening in that community and coalitions drill down to what’s really happening whether it’s a rural community, whether it’s a community right outside the city that’s more suburban and really look at what’s happening there and the data that’s happening so they can make strategic choices to really affect the problem. It’s our job to bring people to the table to talk about these issues.

Alex: I was going to say you mentioned a little bit but coalitions, they’re different in every single place they’re at. We talk a little bit about our experiences in our office and what she did in Coffee County was a lot different than what I did in Williamson County.

Host: Because you’re reacting to the needs of the community.

Alex: Exactly, they’re a completely different community, so it really is all about community coalition of different people who all might think that they’re working on different things and towards different goals, but really it was our job to take them on and say no like we really are all in the same funnel, towards the same goal and just doing different things around that.

Host: You mentioned the Coffee County background that you have and this organization has and so could you take us back to that and describe some of how that got off the ground and why you decided to go in that direction?

Christina: Tennessee was really interesting and back in around 2006, 2007, they really started establishing these coalitions and counties with what was called the Strategic Prevention Framework State Incentive Grant going around and teaching people how to do this coalition building. In that, came the needs assessment. Really getting the data. What does DUI rates look like? What does our ER rates look like in these small communities.

In Coffee County, in 2006 they really started bringing these people together. We got funding and we also received federal funding called the Drug-Free Communities Grant and that really allowed us to even open up more data by doing a student survey. We started looking at sixth, eight, tenth, twelfth graders in an anonymous survey and then seeing what was happening in terms of access, 30-day use, perception, everything going on.

Even though our alcohol rates were high, we kept seeing that there was use and we knew stuff was happening, but it wasn’t pointing to the drugs we are talking about which was alcohol, marijuana, stimulants and so we started pulling suspension and expulsion data and realized that 66% of those kids were being suspended or expelled because of sharing prescription drugs in school.

Then we started to dive deeper into why they were using access issues with some focus groups and some parents surveys and that’s when it really came to be that they were self- medicating. I think that’s what something so important that Alex and I talk about a lot and that is a misnomer out there is that less than 3% of these youth are using to get high. A lot of them is because of anxiety issues, depression issues, suicidal thoughts, things like that, they’re really trying to medicate for so we’ve realized that’s a different set of strategies than someone using to get high when we’re trying to impact these students.

That’s when we first realized that we have something going on in 2009 around prescription drugs and that’s when we petitioned the state of Tennessee to put prescription drugs in these surveys so we could really start tracking the changes we can make.

Host: Previous to that, it wasn’t even in the survey?

Christina: No.

Host: They were just saying, “Okay, we got alcohol, we got marijuana,” and they’re just, “No, because it wasn’t on the survey.”

Christina: Inhalants, stimulants, and even meth, of course, was on there but no, we were not talking about prescription drugs and particularly what we think is so important is something we’ve done in Coffee County is we don’t just say prescription drugs. It’s like, “Are you taking anxiety meds? Are you taking painkillers?” Because again, those are all different strategies to impact those different uses. It became really important for us to really pinpoint what was being used and why it was being used so we could tackle the issue.

Host: Right, and you’re talking about the coalition is for each community that’s getting to know the community. You’re saying like, “Okay, you’re not taking inhaling to get high, you’re taking an anxiety medication because you’re feeling stressed or whatever,” and that’s the thing you have to turn to so it lets you know what the needs are.”

Christina: What I think was really interesting at the time the meth was big and everyone in Tennessee was talking about and there’s a lot of meth awareness campaigns going on. A lot of the students [unintelligible 00:08:23] behind the counter, policies and everyone was like, “Why isn’t your county tackling meth?” We got a lot of pushback on it honestly and I was like, “Because it’s not that it wasn’t an issue in Coffee County but it wasn’t an issue for under 21-year olds because we were funded for 12 to 24-year-olds at the time.”

It was a 30-plus population problem and that is something important that needs to be worked on, but for what we’re trying to impact this is what we saw was going on, and so if we did, we got some pushback at first because it wasn’t what was nationally and statewide being talked about.

Alex: Which is interesting now thinking you got pushback then because now that’s the topic is no prescription pills.

Host: Yes, that’s a good example of how people who are in the community can be ahead of the curve and say like, “Okay, this is what we’re actually seeing even if the narrative that’s made its way up the chain is something else.”

Alex: Because their coalition knew it was an issue before really I think maybe not before the state knew but I think before the state was really thinking like, “Oh, we need to actually push for funding to come for this.”

Christina: Yes, it wasn’t worked in any state plans yet because the partnership for success grant hadn’t come out which was working on Rx, it was the first time anyone was really seeing it in the communities and so it was really about getting to the heartbeat of your community to find out what was going on.

Host: Yes, I know a little bit about of what kind your mission is now but how did you get there from this point where you’re finding out prescription drugs are an issue? How did you decide that lowering pills and doing take backs was one of the main things to do?

Alex: Now, I know you are talking a lot that you were there, I was not.

[laughter] I do know the history though because I do talk about it a lot but-

Christina: Really why again we wanted the target is get to the data. We found out, yes, we have this problem now but why do we have this problem? The first thing when we started to talk to parents and educators, were like, “Well, they must be getting it from the internet. They are buying it online.” It was just very much like this has got to be this problem with these other people coming into our community and affecting our children.

We started to ask them and built our focus groups and adult survey. It showed that the majority of these students were getting the pills from either taking them from their parents or their grandparents or sharing their own medication. We knew that one of the major issues was access. Then when we started talking to parents and doing some perception surveys, it came up that they would rather their kids do prescription drugs than “street drugs” because at least they are safer and prescribed by a doctor because there is-

Host: That’s what a lot of people thought, like I’m, “Yes”.

Christina: Because it was doctor prescribed and FDA approved there was this belief this generation of WebMD yourself that they are going to be safer because doctors prescribed them and so people felt that they would rather their kids be using them because they didn’t understand it’s connected just like heroine and that you are setting yourself up for a life long substance use disorder.

It really did take a lot and we figured out those are the two main issues. There is perception of harm and access. It allowed us to say, “Okay, so what are the strategies we can do to affect this?” For access, it was obviously we got to get them out of the home. We got to get people tracking it and not just keeping their meds on a lazy sues and in the middle of a whole table like I grew up with.

Alex: Our parents still do that. I told them every time I’m like, “Come on.”

Host: I was going to say. I think this is still an issue in a lot of communities.

Christina: It is because a lot of people and I understand. That’s why I always say and I know that Alex also had this issue, that when we had a health fair we were talking to really, we were always at the table that people make the big arc around because they were like, “Don’t have that issue in our house.”

I think what, if anything positive has come from the opioid epidemic, has been the idea that it has touched every single house hold that every single not matter what your social economic class, your education level, it doesn’t matter that it’s being impacting people. I think it’s opened up where people are like, “Wait, this isn’t just something that happens on the other side of the tracks. It’s something that’s happening in our households. It’s happening at neighbor, it’s happening to our principal.” I mean we’ve seen it surge across the spectrum but for us it has been the perception of harm to realize that these medications are just as deadly as having a gun on the table. We should be putting them behind lock and key. We should be having discussions with our youth and our children about the idea that you only take medicines prescribed to you and as they are prescribed. The idea that we should get rid of them and not keep them in the house. We have a lot of orders that keep medicines very far.

Host: Might need it or someone I know might need it.

Alex: Or they have someone who, I can’t tell you how many times we had here in Brentwood actually the drug take backs that we had with the coalition and every single time without fair, there would be at least one or two people who would come with a couple of trash bags because somebody passed away who was very ill and it was there, pass medication they didn’t use or whatever it might-

Host: So the trash can’s full.

Alex: Yes, full of pills. A lot of times it wasn’t bottles with pills in it. It was like the lose pills that they dumped out and then disposed off the bottle. It was crazy, but lot’s of people hold on to medicine.

Host: Yes, and so as you grew, you started putting on these drug take back events. Could you say a little bit about how that came to be and why that’s became a focus?

Christina: Yes, so actually drug take back events, the first one in Tennessee happened in Washington county and the coalition there. They had read about happening it in another state and they did it. Then they came and trained at our retreat. We have a coalition for us to do it. We are one of the second and third to take it on in the state. We did the first one and it was wildly successful. Like she said, trash bags were full. We were at the time counting every individual drug that came in. Whether it was controlled or vitamin C, we were counting everything that came in.

The law enforcement was like, “We can’t do this once a year.” At the time the drug enforcement measures was not doing these national drug take backs like you see now and so we started doing them every six months. Then the DEA jumped on was doing them but we realized that we needed something more permanent and that’s when we started putting the boxes into law enforcement stations.

Host: Sure and this would have been like what year?

Christina: This was around 2010. 2011 we really started pushing this around and Franklin County was one of the first to have boxes as well because they saw it and then we put one on every law enforcement site. Then over the year, the Tennessee Department of Environment and Conservation (TDET), they started putting one their goal was to get one at every single law enforcement office in Tennessee. They are the ones who really got us to 95 counties having at least one disposal site that’s permanent and open to the public on most days of the week at least.

Host: These are like Franklin County, Washington County, these are rural counties, I imagine that?

Christina: Yes, Washington is a little more urban because they have Johnson City but Franklin county, definitely yes. Just very similar to Coffee County. I think they have a few thousand more than us.

Host: As you are building this now, like now you say you are in every county, what was the process like of expanding and a big part of what you do is training and adapting to what these communities need and building these relationships. What was that process like or is like?

Alex: You jump in because part of this I think happened before I was there. Where did this start? Was it Department of Health really that kind of–

Christina: Yes.

Alex: You can edit this part. It really started Department of Health, and they were a huge supporter of [unintelligible 00:15:55] actually was when I was with Williamson County coalition. I received many grant to have a start up care basically for Count It, Lock It, Drop It, CLD. They gave us a sack, it had a lot of give away stuff but then a lot of the accounting brochures that we have, the prescription drugs briefs, a lot of informational pieces as well as the radio PSAs and the campaign kit which has all the information that you can take and implement in your county just depending on how you want to implement it and your county’s needs.

That’s where I think CLD really started. They pinpointed a few coalitions across the state. Not really where it started but really where it started blossoming, I guess from just being in Coffee County. A lot of the smaller coalitions were kind of taking that on. Then in 2016, Blue Cross Blue Shield, correct? Blue Cross Blue Shield Health Foundation is– Really I should not be the one talking about this because you are the one who was the director at that time. I was not.

Host: You’ll pick it up from Blue Cross Blue Shield?

Alex: I know that’s not helpful so Blue Cross Blue Shield, you take that-

Christina: As Alex mentioned, Department of Health funded about 20 counties and then this state was lucky to get Partnership for Success RX funding until they funded additional coalitions to do it. We were at about 30 counties at that time, 35, maybe.

Host: Is that a national organization or is that a partnership for–

Christina: Partnership for Success is a federal grant that the state of Tennessee received. At the Department of Mental Health and Substance Abuse Services basically funneled that money down to us to asses these coalitions as one of the many projects they do. With the opioid epidemic and so we were in about 35 counties when Blue Cross Blue Shield, they were looking to get more involved in Tennessee. They obviously saw the issues we are having, not only within their own insurance system but across Tennessee and so they came to us and was like, “We are looking to push somethings state wide,” and wanted to work with us.

We started working with them in 2016 together in every county in Tennessee. We are officially in all 95 counties now. What’s been interesting you asked how it kind of came to be. It is different in every single county. Some of it is county coalitions taking it on. Some of it is health department is taking it on. Some of it it’s police department in Clarksville Montgomery County. Clarksville PD is amazing. They do a ton of great work with it.

Sometimes it’s just a small group of people who have decided to do it. It’s different. We wanted to do something with people, not to them. It’s really important to us coming from the coalition world that we found people that were devoted in that community that we could just provide the skills and the materials too and then they could run with it because I think we’ve both have been in a position where someone thought they knew better about our communities and tried to do something to our communities. We really wanted to build something that was sustainable and support it in infrastructure and these smaller and larger communities to really bring people together to work on this. For us it was really about finding these key people in each of these counties that take this project on. We weren’t just a campaign, we were kind of a grass root effort happening in these communities.

Host: Yes, and just to find the people who care who can sustain it because you guys can’t do everything.

Alex: Right and exactly, no we can’t.

Host: Back to Blue Cross Blue Shield just for a moment, because that is big here in Tennessee. I mean it’s big in a lot of places, but it’s the biggest health insurance here in Tennessee. I know like some other podcast guests and other things I’ve read have said well, insurance companies had a lot to do with creating this epidemic and in some ways still do because they haven’t caught up to supporting other non-medication therapies and stuff in the same way that they would support prescribing a pill. With this partnership, do you view that as a model for those companies to become more involved in the solution?

Christina: I do because on of the things I’ve loved about with Blue Cross Shield on this in Tennessee was that they were instituting different policies and it wasn’t just about having a public education campaign. They literally they were putting more restriction on how much people could prescribe within their providers. They were throwing out providers who were overprescribing. They went through and really–

Host: They were making changes to their practice to their policy based on they’re starting to get to know you guys and their work?

Christina: Yes. They really want a couple having this public education campaign in helping Tennessee-ans with strategic changes they’re making within their business, and how they were doing business. They did make a lot of internal changes that matched what they’re putting out there in the public working with us. I think, yes, as a model for other insurance companies and other businesses in general, it was a great model and it’s a great public service they did, showing how you could make these changes still be profitable, and be helping people. It was a good partnership for sure.

Host: Yes. It’s interesting that it seems like it’s educating somebody’s grandma about having pills on table. It’s educating people who you think or they should be the experts. It’s like health insurance companies. Educating them about what their choices have effects down the line.

Christina: Even the providers that work with the insurance companies, I think Alex and I still we were at a TriMED Summit where we were being presenters and vendors. I can’t tell you how many doctors we had come up to us and be like, “Oh, I don’t have anything to do with this. I just prescribe them.” I’m like, “Oh, no.”

Host: It sounds like a big fire. [crosstalk]

Christina: It’s still really educating. Providers have come a long way and we’ve worked with a lot of great pharmacists and doctors. There’s still a wall there that needs to be broken down that there could be a huge solution, and part of it is working the providers.

Host: Yes. What are some of the main things that have stood out to you, like statistics, things that have surprised you as you’ve seen how big of a problem this is as you’re bringing in these trash bags full of pills? What are some things that stand out to you from your experience so far?

Alex: I think that exactly what you just said, the number, the pill poundage that comes in every single time. When I was doing it with the coalition here at Williamson County, we literally went up every single time. We did more outreach. There was more awareness I think about it which helped, but I do think that just that every single time just blows my mind. We were having four and five locations across the county here, and we’re having 400, or 500, 600 pounds being turned in a single day.

Host: In each location or across the–

Alex: Across the county. That’s with having five or six permanent disposal units that people can use pretty much anytime they want. With those, that one day event, just the amount, it always blew my mind. I think it still continues to, because now, I get to see across the whole state what everybody is bringing in. It’s mind-blowing every single time. I don’t know if you feel the same.

Christina: Yes. I feel like one of the major pushbacks we’ve gotten with the campaign, and the program, in the prevention we do, is that people are saying, “We’re trying to keep people from getting the meds they need.” I think once you hear all the numbers, and I think it’s easy to read newspaper articles and be like, “Okay, that’s a lot of pills. We’re still third in prescribing.” Once you sit there and see the amount of pills that are coming back, you realize this isn’t about keeping pills from people who need them. There’s a lot of pills out there that don’t need to be out there, until you’re sitting there on the take back.

Besides, in Coffee County, we’ve been doing this since year 2009, 2010. We’re a small rural community. Still, even with the permanent boxes being used as much as they are, we get 50 to 70 pounds every take back of pure pills. That’s in a small community and consistently doing it over all these years. It just the amount that keeps coming back, and a lot of them are of these controlled substances. It makes it very easy to see that this is an issue. I encourage anyone, please volunteer at the take back event with your local coalition.

Host: They need your help.

Christina: Yes, and it’ll put new perspective for you. It’s not just the number when you see that amount of pills coming and you’ll be like, “Wait. This isn’t about taking pills out of people who need them.” We have too much out there.

Alex: Yes. It’s not just people bringing back vitamins and Ibuprofen. I can’t even tell you the number of times that it’s just been people have brought back fentanyl patches and things of that nature. I’m just going, “Oh, my gosh.” I’m glad they’re bringing it back.

Host: That could kill someone.

Alex: Yes, exactly. They just handed it to me in my hands and I saw it and I threw it. That’s a complete real story. People bring back. It really isn’t just vitamins. I think it could be a really great experience for anybody who hasn’t seen a drug take-back event to do one.

Christina: I think the other probably biggest data that we keep saying that is frustrating we know we’re on the right track with the work we’re trying to do, is that we still get feedback from surveys and talking to people that the number one place their kids are getting meds is not from their parents and grandparent’s cabinets, even though in Tennessee, we see that in individual counties across the nation, they still feel like, now it’s just the prescriber’s issue. It’s only providers overprescribing. That’s where kids are getting all the meds.

Though it’s true that it’s an access point, the number one place that youth are still getting these is from their parent’s and grandparent’s cabinets. It isn’t because we have bad kids. I hate when people say that, “This is just simple, normal, adolescents are struggling with something.”

Host: The same thing happened with alcohol for decades.

Christina: Kids are struggling, think about everything that’s out there now. They have anxiety. They have depression, and then you have all these commercials that tell you how to treat it. They’re looking at it online and that’s in their parent’s cabinet.

Host: Maybe that would help. They see that as a solution.

Alex: Exactly.

Christina: That’s where accidental drug dealer really came from is, I talked about when I was at high school, and I had my wisdom teeth out. I was given Hydrocodone. I cannot take any type of pain med. It makes me very ill. I gave them to my friend. I wasn’t thinking I was doing anything wrong. They had a headache. I had pain meds, and so I gave it to them because I couldn’t take it. Now, looking back as adult, A, that was drug dealing and I could get in a lot of trouble in school, but you don’t think about that at that time. These kids aren’t thinking about this way, these youth aren’t.

The thing is I’m struggling with ADHD, or I’m struggling with depression. This is what I’ve been given, so I’m going to share it with you. They don’t realize the implications. It doesn’t come from a place of these youth drug seeking as much as they’re struggling. They’re trying to help each other in a way that isn’t as productive as we would like it to be.

Alex: Even you said they’re struggling, I think that with everybody who’s dealing with a substance use disorder, I said this a lot when I was with the coalition, I still say it a lot now, you don’t just wake up one day and say, “Oh, I think I’m just going to be addicted to prescription pills.” That’s what’s going to start. It all starts somewhere. There’s a lot of different layers, usually, that are attached to it.

I have a good friend. He’s in recovery now. He lives here in Brentwood. He talks about his story all the time. He talks about how he went to a trauma therapist. She was like, “Well, I want to go back as far as we can. As far as we can.” He got in about car accident when he was 18. She’s like, “No, I don’t want to talk about that. I don’t want to talk about that. I want to go back to middle school.” When he was six, seven, eight grade. He had an ear surgery back then. He had to have some weird things happen when he was little. He said he always felt out of place, and like a freak, because he was in and out of school. He always had bandages on his head. She said, “I want to start right there with that, because that’s when you started feeling different.” That’s when this coping mechanism that he had to start using started and led him down the path of using alcohol at a young age, using tobacco at a young age, and using marijuana, and then kept going from there.

Things kept piling on, but really, it all started with something that most of us would never think that that would be the pinpoint of something like that. She was like, “No, we’re starting right there,” and that unfolded a lot for him which I found really interesting.

Host: Yes. The substance can change even if it’s a behavior, or a process, or whatever, it can change, but we’re all finding ways to survive.

Christina: Yes. As Alex said, it’s really about coping mechanisms. People use substances because it makes them feel better. That’s the number one reason they’re doing it. You don’t know, and I always say this to people, “You’ll never know where your line’s going to be.” I say that I’m not someone who struggle to the substance use disorder, but I said, if I lost my child tomorrow, or my husband, or something like that happened, you don’t know where your line is. When something’s going to happen and you’re going to feel like you need something like that to get by, it’s so important that we realize, and that’s one thing we really are working with, this next year with Count It, Lock It, Drop it, is we want to really talk about stigma reduction, and really start talking to providers about how we need to talk about substance use disorder the way we talk about high blood pressure, the way talk about diabetes. It needs to be a conversation.

We both have worked with pediatricians. They’re like, “We don’t really need to be involved. We’re just working with young people,” but the conversations need to there about mental health. She said, “Talking with 6th grade and he’s having surgeries.” Someone should have been talking to him about how you’re feeling about this? How’s school going? This is affecting your hearing. You know you’re out of school, because that could have been the difference between that changing what the outcome was later on for him. We just need to start talking about substances and mental health every time we go to a doctor’s appointment, the same way we take someone’s blood pressure and weight. It just needs to be a constant part of the conversation.

Host: Yes. It’s so important to remind people that no one’s immune to this. I’ve had Linda Leathers from The Next Door, I don’t know if she’s remaining with that organization, but they do a lot of work with women in criminal and justice system. She said she had a great, [unintelligible 00:30:10] and it was like, people think people who are in prison, they’re different, that’s not me, that’s just so far removed. She said, “Even for me, it’s like I’m a couple of decisions away from being in prison,” like you said, I don’t know where that line is that could change my trajectory. Powerful.

I want to talk a little bit about the events themselves, we’ve touched on them a little bit, I’ve always been curious, what happens to all those pills? You say you have trash bags of pills, they’re not safe for people to have, who gets them? What’s the process?

Alex: With the DEA ones that are put on the DEA takes, I just lost my word. Takes–

Christina: Custody.

Alex: Custody, thank you. The DEA takes custody of the pills and they’re incinerated. I’ve not actually ever seen one in person, have you ever seen one in person where they incinerate? We may not be allowed to, I don’t know, you may have to be a special–

Host: You don’t want to be around those fumes.

Alex: That’s true. They get incinerated, it’s TDEC– Is it TDEC or CDC that came up with a ruling for that to be the most effective?

Christina: I know that TDEC is the one who decided in Tennessee and said this was the way it was going to happen.

Host: Addiction coalition or what’s TDEC?

Christina: Sorry, Tennessee Department of Environmental Conservation.

Alex: Sorry, I forget, there are so many. [laughs] That’s what happens with them and TBI is the one, it’s different I guess for the events in the permanent disposal of boxes. With the permanent disposal of boxes that are out law enforcement, TBI goes around and picks those up and takes custody of those and they’re incinerated by TBI as well. It’s all incinerated just maybe different depending on who takes custody of it.

Christina: With pharmacy drop boxes which we haven’t touched much on those is after the DEA changed their ruling where originally you could only do it through law enforcement sites, you had to have a law enforcement officer, they had to take chain of custody just like if there’s a drug raid. They would take it, it goes through judgment, it’s sitting there in their custody lockers with all their other evidence and then it would go to Tennessee Bureau of Investigation or to the DEA to be destroyed the way they would destroy any other evidence. When it started where we could change to pharmacies which was so great because people want to go where they get their meds and that’s where they were taking them. There is also some people feel weird about going to local law enforcement.

Host: Yes, that’s intimidating, for me I can’t remember the last time I was in a police department office. That’s not something you think about.

Christina: Even as someone who works with police all the time, I still feel I’m in trouble every time, I know I shouldn’t feel that way, but it’s like, you’re going in–

Host: I know we called to interview this meeting, but we also want to talk about this warranty you have.

[laughter]

Christina: You feel weird like you’re carrying your meds and I get it, it’s a great place, a lot of people use it especially in small communities who their officers are their next door neighbors, but it could still be hard especially if maybe you’ve been involved with law enforcement before you’ve gotten into trouble, it can feel uncomfortable. We really want to get more pharmacies, more hospitals involved with these disposable sites, and the way theirs works is that they have to go through reverse distributor who picks those up or they ship them back in approved boxes, again they go straight to an incineration site.

No matter what, whether it’s going through law enforcement or through a reverse distributor, it goes straight to incineration from there. No one touches it after we get the pills it goes straight to each of them.

Alex: Don’t flush them.

Christina: Don’t flush them.

Host: Don’t flush them. I’ll wrap up with any tips or misconceptions you have. I want to talk about the drop off stuff. You mentioned that’s, I think, something that I remember you saying you want to do more of, you wanted to spread that out in a wider range of places. What are some of the challenges you face? Why isn’t that already more of a thing?

Alex: With the pharmacies having boxes?

Host: Yes, with non-police department 24/7 boxes.

Alex: I think what I have seen doing this our first round this fall with pharmacies we worked with the Tennessee Pharmacies Association and a lot of the pharmacies who wanted to do them were like mom and pops small pharmacies. We had a small grant that went out that we covered the cost of the box and we covered first two reverse distribution services.

After that, part of the grant was they would have to take it on for so many reverse distributions or it’s so long. A lot of them came back and said, “We’re a really small pharmacy, we’re a mom and pop organization in the middle of wherever and we just can’t afford to do that.” I think that was probably a lot of the people’s biggest barrier I think, because we got a lot of applications, we got 25 boxes put in and everything, but I think there would have been even more if the funding would have been completely covered. We wish we could do that for all of them, but we can only do so much. I think honestly that was probably the biggest piece.

Christina: I think the other is some are worried about liability issue, feeling like–

Host: Being responsible for them.

Christina: I think that was a little concern and we have the company we work with for reverse distributing RP returns is really great about educating them. I think we were able to cross that barrier with them understanding everything is so lock and key, you’re not touching anything, your people, two people have to be there to even unlock it because there’s two different keys. The way it’s all sealed up, it’s shipped off, I think we really help quell those concerns. We also help them put policies in place so we have simple policies to help them do it. I think that was, I definitely think the money was an issue, what was great is that our relationships with coalitions and health departments helped us connect some of those pharmacies with someone else who might be able to fund it.

It’s been great like AleX said, the mom and pop pharmacies, these local pharmacies had been the first to really say, we want to do something and yes Walgreens and CVS have been putting in their own boxes and such but these mom and pop ones have been really successful and we’ve had one, it’s was at Perkins? They’ve already had two shipments go back, they’ve been pushing it, they want it in a second location so they’re really devoted not just to have the box but they’re also handing out the counting brochures and having discussions with their patients about the addictive nature of their meds, they really trying to make a change in what they’re doing. It’s been really cool to see that happen and we really hope next year we could see more hospitals and hopefully the VA the veterans really get on board with this as well because we know that’s will be great access points to have them there.

Host: That’s what I was going to ask, where do you see this growing and will there be funding to make it sustainable, to make it happen? We’re hoping in this next year to work more with Veterans Affairs because veterans are close to my heart, my father was in the Air Force, I’m an Air Force brat, I’m also the wife of an army veteran. For me and I’ve seen the substance use coming from that, we really want to get in and work with Veterans Affairs, get boxes in there and get materials in there to assist them. Also, in bigger hospitals where we know that the people are using, whether it’s an ER that’s really frequented that we could get those boxes into, those are our main goals this next year.

Host: We’ve talked a lot about the take back portion of what you do, but that’s not all what you do. Could we talk a little bit about the prevention education side and what are some of the different issues you see people dealing with as you have to adapt to different communities, you’re looking at Nashville is different than Coffee County, what are the education opportunities that you’re seeing with that?

Christina: We’ve had great work in Memphis particularly, we’re working really hard with Nashville right now with the mayor’s office, National Prevention Partnership to figure out what this would really look like on a big scale. I think one of the things that people miss out on in coalition world we’re dedicated to really make a cultural shift we need policy change. For us it’s about changing, like I said, the way doctors are speaking to their patients about this, really screening for substance use disorders upfront for asking about history with substances and screening for pain differently. We’re working hard to really look at those changes we can make in individual offices and practices.

In Nashville, it’s easy to say, this is going to be a ton of money because we’re talking about putting out lock boxes and counting brochures, but when talking about something like policy change, it just takes a lot of committed people coming together. For some of the bigger cities, that’s what we’re working towards it’s how can we make some shifts in some major hospitals, some major providers in the area so that we could do it that way and then get out our materials through them.

Memphis has done an incredible job, in terms of they have their mayor involved doing PSAs, they have their health department handing out materials, they have pharmacies that are changing the way they’re doing business around Count It, Lock It jobs. They’ve been away to see how an urban area can really take this on bus wraps, they have billboards. They have taken on the PR part and now are working more to that policy change part. It is different depending on the community you’re in, but you can really make it happen.

Alex: It really is different per community but we work really closely with our communities that we’re connected with. I think that’s one piece that I think is really important to talk about with CLD and just to mention because you can sign up for a lot of different things like this campaigns around alcohol prevention or tobacco. A lot of them are massive scales where you’re not going to have like a one-on-one connection with somebody. All of our communities have my phone number, my email address, Christina’s email address, Christina’s phone number, which maybe we should have– We got that sometimes.

[laughter]

Just kidding. They have a one-on-one connection with people who have been there, who have done similar work in the community. We have seen the same type of obstacles that they come up with. You really have two people who have been there training you and helping you figure it out for your community. I think a lot of people when they first come on, especially if they’re not already coalitions, if we have, some of these health departments or police departments coming on wanting to do CLD in their community, they’re like, “Okay what do we do?”

We can come in with two people who have done the work and give them some ideas of where to start and just some avenues to try out and see if it works for their community. Some people it doesn’t work and they try something else out because there’s a lot of different ways that could work in your community. I think that was my favorite part about utilizing CLD here in Williamson County, was just you could really make it your own to see how it worked. All the messaging is still the same, but just the way you use it could be different.

Christina: We’re in several other states now too. What we pride ourselves in, as I mentioned earlier, is we want to do something with you, not to you, is that we’re open to changing certain things. Yes, as Alex mentioned, the message is the same, and we want you to use some of the tools and there’s certain framework, but when it comes to how you implement and the order you do it, sometimes you need to get the campaign out there first, sometimes you need like Nashville to work on the policy first.

We’re really there to help you make it work for you because our main goal at the end of the day is to see a reduction in substance use disorders, to see reduction and access. If we can help you get there, we’re not going to mandate anything special way to do it, we’re here to get the best for your community, and Rhode Island’s very different than Tennessee. Even the way they’re set up is regionally, we dealt with a lot of different things than we did in Tennessee and some of our rural counties.

We’re really open to just working with people and working the process and just building that infrastructure and helping you build it to bring the right people to the table to, yes, to implement CLD, but also many other things that are going to help make your community better.

Alex: I don’t think we’ve ever said no to anybody completely. We’re like, “Okay. How can we make this work where it’s still keeping on the CLD message, our mission is still there, but it’s still making it work for your community.” I think we’ve always worked with people however they see that it fits for them.

Host: What’s an example of a difference in Rhode Island, for example, it compared to Tennessee?

Christina: They were very dedicated in getting it in the urban areas first. They wanted to work with their sports teams, their hockey teams and things like that to get the messaging out, and also with their public transportation with one-on-one with bus stops and getting things. Instead of directly review pharmacies and providers where it’s traditionally where we come from, they really wanted to work where they saw people would read messaging and start getting it, so their brochures and ideas about policy change actually came from public transportation, and what the people that were getting on the buses and how they could meet people where they were, so to speak, and working with their major sports teams.

It was different way of going about it. Now they’re working towards more with providers and seeing it, but they’ve done it across their state, they’re very successful at the messaging and how their coalitions are working on it, it was just a different approach than we took in Tennessee.

Host: Yes. I know you mentioned a little bit about the education that you do with people in the healthcare profession. You even mentioned that doctors like, “Oh, I just prescribed it. Yes. I don’t have anything to do with this problem.” What are some of the challenges when you’re dealing with doctors, people in the healthcare field and trying to maybe educate them or train them in some way of how they can make a difference?

Christina: I think for me the number one thing is this is why it’s so important with coalition to have the right people at table, for pharmacists, talk to pharmacist really well, doctors talk to pharmacists, I’m a coalition leader, so I don’t have a medical degree. They’re not going to listen to me the way they’re going to listen to one of their peers. For us, it’s that connection of having doctors that are on our team who believe in what we’re doing, pharmacists that are willing to tell the message.

For us, it’s the right vehicle to get it across and to tell them that, yes, you should listen to these people, they’re not crazy, that we’re going to tell you something, that you could do a change. Again, one of the other major barriers is people just not seeing that they could be part of the solution, even if they’re not prescribing. Dentists are one of the first place that kids ever get a prescription for an opioid for getting their teeth out. It took us a long time to get dentists on board because they’re like, “We don’t do it that often.” They don’t, but statistics show that they have very few amount that they prescribe, but they’re the first place that people are getting prescribed, so it’s important for them to be part of that.

Same thing with veterinarians. We have a lot of depressed cats, a lot of hurt dogs out there. They’re the same medications. A lot of people don’t know if you’re not animal persons, a lot of same medications you get at Walgreens for anxiety or on hydrocodone just like we are. All of them need to be part of that discussion and part of the solution, and really just getting them to realize that it’s important and they can be part of it and it’s not going to take too much time.

For us, it’s about we can get your office manager involved. We can get one of your CNAs involved. We can find a way to make it work for you where you don’t feel like you’re taking on too much more because what we always say is “We’ve all sat in a doctor’s office too long.” How can we make this in a way that’s quick and simple? That’s why when you’re developing the materials we brought pharmacists and doctors and dentists to the table to make them with us. It was them talking to their peers and helping us facilitate it so it worked for them, because we don’t want to make a burden for anyone. We want to make it easy.

Alex: I was going to say, I think a lot of this comes back to just education around stigma reduction. There’s this an idea that “I know I’m not involved in that,” or, “I don’t have to deal with that.”

Host: Even like a dentist, they put it like, “Well, we don’t even want our name associated with this crisis.”

Alex: Exactly. It’s just educating people through that and that everybody can be a part of the solution we all have to work together on it. I think that’s the biggest piece is just that. That’s not necessarily just with doctors or pharmacists. This is with everybody. Like you mentioned, people walk around our table when we’re at a health fair, they’re just like, “No, that’s not me. I don’t have any kids in the home.” “Can you tell me how many people?” “I don’t have any grandkids. I don’t have any kids. I’m like, “That’s not really– Just no? Okay.” I think that’s the biggest piece, is just stigma reduction.

Host: For medical professionals, people in the treatment industry who might be listening, what are some ways that you would encourage them to either partner with you guys or another organization in their area that’s similar, or other ways they can take action to promote this mission?

Christina: As Alex mentioned, we have a point person every county. We’d love to hook them up with the person locally that they could work with, but they can always work directly with us too and we can help facilitate any conversation. Just reach out and we can really help you figure out an easy way to have these discussions. We first want people to just be talking to their patients and consumers in general about drug safety, about how something they might be prescribing could end up as a substance use disorder, and just having really honest conversations about pain and mental health.

We have all the the resources to help you do that and to set up a policy or some type of program within your practice. We’d love to help in any way we can to do that. I don’t know if there’s anything you want to–

Alex: That was good.

[laughter]

Host: Then just in general, like we were saying, don’t flush the pills. What are some other misconceptions that are still clinging to the American psyche?

[laughs]

Alex: That’s a big one, don’t flush your pills.

Christina: Don’t flush your pills. Also, don’t feel like people could just get over this. It is something that-

Host: Over the addiction.

Christina: Yes, over substance use. As we talked about before, this is a human problem, and we’re all human. We’re all affected by it. Each person just having conversation with someone, just talking to your own doctor and being like, “Hey, I think it would be great if you would talk more about mental health and substance use disorder when I come in.” Everyone can be an advocate for this. Really what we’re talking about, I think that’s why we work so well with Health Department, is a lot of this is health literacy.

Be your own advocate. Encourage your providers. Encourage people in community to have these discussions. Ask really how someone is, and have a discussion with people if you know in your community that they have a kid struggling with a substance use disorder and themselves, and have the conversation about it. I know it can be awkward, but the more we talk about it and we normalize it in the way that it’s happening to everyone, the more people realize they can be part of the solution, and we can all be there to support each other, that it doesn’t have to be a lonely road.

These families a lot of times feel like they’re in this by themselves. The more connected, we know and coalition, it’s a true statistic, the more connected we are as an community, the less substance use there is, the less mental health issues we have. We need to be connecting to each other. That’s the number one thing we need to be doing. Just reaching out everyone, as Alex mentioned, is part of the solution. Just reaching out and finding a way you can be part of that solution, I think, is the best thing. You don’t feel like there’s nothing you can do, because a small act of kindness can go a long way with this.

Host: Everybody plays a part.

Christina: They do.

Alex: Yes, they do, for sure. I think too, nobody’s bulletproof with this. Like you mentioned it earlier, it doesn’t matter what age you are, it doesn’t matter what color your skin is, it doesn’t anything. Where you live, you live in Williams County, if you live in Coffee County. Wherever you live doesn’t really matter, you’re not immune to having a substance use disorder, your family is not immune to it. That was like my tip of the podcast, right there.

Christina: I think for us, we want people stop being reactive and start being proactive. If we had these conversations upfront, prevention is really important. Obviously treatment is, we know it but if we start having these discussions upfront, then we can prevent some of them ever having this issue if we start having this conversation. Thinking about being proactive instead of reactive to this is going to be so important in the long run. For not just opioid but any type of crises we see when it comes to substance users.

Alex: Yes.

Host: Right, because it’s much easier to prevent it than to pick up the pieces. All right. We’ll just wrap up with this last question, unless was there anything else?

Alex: Don’t flush your pills.

Host: Don’t flush your pills.

[laughter]

Host: You said, don’t flush your pills, that’s because it will get in the water supply, right?

Alex: That’s right, yes.

Christina: Yes, and what’s frustrating for us is all the government systems know this, except for the FDA continues to put out – Food and Drug Administration – that the best thing you can do is put it in kitty litter, flush it but it does, it gets–

Host: Put it in kitty litter?

Christina: Yes, if you grind it in kitty litter.

Alex: Yes, like grind it up because people have time to do that.

Christina: Or flush it.

Host: Never heard of that one.

Christina: Yes, those are the two things they’ll you. Or to flush it and it does, it gets in your water supply, it affects the wildlife. We’re starting to see it in our children even hormonal things happening. I know that some people are like, “Incinerating doesn’t sound great,” but out of all of our options, it’s the best one we have thus far than getting it in our water and soil and so yes please, don’t flush.

Host: The FDA is still saying that, they haven’t– Is that correct?

Christina: If you go to their website and pull up how you should dispose it’s still on there, even though the Drug Enforcement Administration has all the drop box listed on their site. We’re trying, there’s a disconnect there. [laughs]

Alex: I think it goes back to we all need to communicate as well, I think that’s a tip. Communication is very important in all aspects of life but especially this.

Host: Yes. All right, we’ll just wrap up with this last question. Everyone who, especially in non-profit world, but everyone who plays a part in the solution, in working in treatment and in any kind of grassroots recovery support or whatever it is, they have their own reasons why they want to be a part of this, why they want to keep fighting this fight because it’s hard. Could you guys wrap up by kind of saying why this is so important to you, to help educate people and give them practical ways to prevent this from happening.

Alex: I know what I want to say it’s just like, condensing it all. [laughs]

Host: Take your time, yes.

Alex: I think a lot of it for me, it goes back a little bit to my family and seeing what my family went through and seeing my cousin dealing with his substance use disorder. For me, I feel like it goes back to the future of our world and my future children. I don’t have children now, but I hope to one day and their future and I feel like I’m a big advocate of just mental health in general. I guess being passionate about mental health and people’s well-being and just it frustrates me to know and to hear people and how we talk about mental health and substance use disorder. That it’s just this moral failure and that people are bad. I used to be one of those people that thought that before this, I know I was. Because I remember when I saw my cousin going through that, I was just like, “Why can’t he just get over it.” Like, “Why does this keep happening?” Just remove yourself from the situation and you’ll be fine. Now, knowing what I know, it’s so much more than that. I think that really is kind of the reason that I wanted to just continue to fight this fight and be a part of the solution. Just being passionate about people’s well being and their mental or physical health, their future. Words. [laughs] You are more eloquent.

Christina: No, no. I would say honestly to me it’s just about family. I think if you’ve ever loved someone, I think that’s why Alex’s point was, you never want to see them go through this and you want to be part of the solution. For me, with my child, and I always say this, no one has a child and looks at it and says, “I hope they have a substance use disorder or they struggle with mental health.” You see that they’re going to be an architect or ballerina. You have all these hopes and dreams when you look at your child. I think about that every single time and these families struggling with this and you’re like, everyone has that feeling. They want something more for their family and their child.

If I can just be a small part in helping them realize that and keeping people healthy, then that’s everything. I just think it’s so important, it goes back to community to me. I think we’re going to be better off as people, as Americans, if we get back to the point that the one thing we all have in common no matter what, is we love our families and we want the very best for them.

That common denominator can just change everything if we just get back to the basics that in the long run, that’s really what we want. Just getting back to that, it just makes me passionate about helping families and want people to be healthy and happy and to be their very best self because we all benefit from that.