Interview with Rosemary DenOuden


Rosemary DenOuden is the CEO of the Humboldt Independent Practice Association and the COO of North Coast Health Improvement and Information Network. This interview took place on September 21st, 2018.


To start off it would be helpful for the audience if you briefly described your background and your roles and responsibilities.


My name is Rosemary DenOuden and I am the CEO of the Humboldt Independent Practice Association and the COO of North Coast Health Improvement and Information Network, which is two separate organizations under one roof. The Independent Practice Association is an IPA that is delegated by insurance payers to process claims, provide utilization management. etc. in Humboldt County. The North Coast Health Improvement and Information Network is a nonprofit health information exchange and a healthcare improvement agency. That is my ‘day job’, but I'm also the co-chair of the Rx Safe Humboldt Coalition and that's that's why we are talking today. 


Just a little bit about my background: I have been working in healthcare for over 20 years, mostly in health care administration. I have been here at IPA for 8 years and I really have a special interest in finding solutions to improve the health and well-being of those who live in Humboldt County. About 5 years ago it felt like all conversations we were having centered around the issue of chronic pain and the treatment of chronic pain. At that point we formed a chronic pain subcommittee and over time it evolved into the coalition that we have today. On a personal note, I am really drawn to the work of Rx State Humboldt and dealing with the opioid epidemic because I have two children--they are 25 and 23. I raised them here in Humboldt. My youngest daughter is 23 and has been out of high school now for almost 5 years. Within these past 5 to 6 years, she has lost 5 friends to opioid related overdoses. That’s really impacting me and my family on a personal level. 


Over your 20 years of working in healthcare, and seeing what’s been happening in Humboldt County, what has been the most memorable experience you’ve had? Whether it’s something someone said or a memory you had. 


That’s an interesting question. I think coming from the healthcare point of view, the most memorable thing that sticks in my mind is what brought us to this point. 15 years ago I worked as an administrator in a local health center and I saw firsthand what was happening from multiple perspectives. How we dealt with the patients who came to our center with chronic pain, and the marketing that was happening for the treatment of chronic pain. At the time I did not see that there was problem at all, but now looking back, it is as plain as day. I can really see how ineffective we were with the treatment of chronic pain and that it takes much more than a prescription to deal with chronic pain. At the time we only knew what we knew, but hindsight is proving different. I have to wonder what are we going to look back to 10 years from now? Are we going to look back to what we’re doing today and know something different? Probably. But all we can do is learn from the past and move forward. 


I know that some months ago the New York Times had an article about the opioid crisis in Humboldt County, and I know that it was a somewhat bleak picture. What was the reaction in the county when that article came out? 


It was a bleak picture. But the reaction in the community was, “it is not the entire picture.” It was very one-sided, and it was unfortunate that the article did not tell the entire story of Humboldt County. However on some level it made sense that when an ‘outsiders’ is looking in, it could appear that we’re “not doing anything here.” And that is not the case at all. We have been working hard within the Rx State Humboldt Coalition and with our partner organizations to effectively find strategies to combat the opioid epidemic, and the substance use epidemic as a whole. Humboldt County has a lot of issues that we deal with day to day, like many communities, but Humboldt County has many positive things as well. We are a rural isolated community in Northern California, about 5 hours north of San Francisco and that in and of itself brings a lot of challenges. When we read that article, we wished a more holistic view had been presented and that other perspectives were taken into consideration. Since that time, a lot of good news has come out. The opioid prescribing rate and the opioid related unintentiaonal overdose rate is going down. This is due in part to our community and organizations coming together and finding solutions. 

Looking forward, what do you see as the major challenges that Humboldt County has to face as its residents work to alleviate the opioid crisis? 


This is a big ship to turn around. Over the last several years the Humboldt County prescribing rate was 2-3 times the state average. This rate is lowering however we’re still higher than the state average. Safe prescribing of opioids is one of the missions of the coalition as opioids are  appropriate in certain situations, but they are not for all situations. We are addressing that, we’re doing a lot of academic detailing for health care providers, local physician champions and other health care providers are meeting with their colleagues to ensure they are aware of the standards and guidelines that are recommended and ensuring they understanding how to safely taper their patients off of opioid prescriptions. In addition, there’s been a huge increase in harm reduction strategies. The coalition and our partners are working hard to make sure Naloxone is available to everybody who wants and needs it. We have a fantastic story that came out a few years ago because of these efforts.  A local librarian who was trained to recognize the signs and symptoms of overdose administered Naloxone at the library. She recognized that an overdose may have been occurring, and administered Naloxone and was able to reverse the overdose. It is an important part of this work to ensure that we get Naloxone in the hands of those who need it. 


So needle exchanges or supervised injection sites are some things the county is looking at?


It has been looked at, and at this point it is not something that is being implemented. If you think about any issue, what one person needs isn’t necessarily what another person needs and that is hard to understand at times. Taking an individual approach for this issue has been our strategy. In order to effectively address whatever needs somebody has, a community needs to have a lot of different approaches. Whether that is safe prescribing, or providing medication assisted treatment, or needle exchange, or ensuring an individual has Naloxone on hand, it is about meeting that patient or individual where they are and making sure that they are safe, and when they are ready to make a change or take the next step, we are there to support that need, and to make sure our community has the resources to do that. 

What are your thoughts about Medication Assisted Treatments like methadone or buprenorphine?


Our community has been an advocate for medication assisted treatment for years. One of our partners, Open Door Community Health Center, has been providing buprenorphine clinics for patients for over a decade. We believe  that medication assisted treatment offered in the primary care setting is a best practice and are encouraging other primary care practices to offer MAT to their patients. The CDPH opioid dashboard provides a lot of data for counties in California including data showing the buprenorphine prescribing rates. Humboldt County has one of the highest prescribing rates of buprenorphine in the state. 


In Humboldt County, what do you think is the single biggest barrier or bottleneck that prevents individuals with opioid use disorder from receiving professional help including MAT?


Access is the single biggest issue. As I’ve said previously, the coalition is supporting health care providers in the process to get their X waiver so they can prescribe MAT within their practices and over the last few years the number of MAT prescribers has grown and  access to MAT is expanding. It’s really important to have availability on demand. The moment an individual is ready to get help or treatment, it needs to be open and available. That is not always the case. We need to get to a place where it is essentially on demand.


I know that other parts of California and the nation have seen an increasing problem with Fentanyl. Sometimes Fentanyl has been mixed in with other drugs without the knowledge of the end user. Has Humboldt County seen anything like that with Fentanyl?  


We have seen a little bit. But not what other communities are experiencing. We know that the threat is out there, and so the coalition and our partners are ensuring that the community is informed and prepared as much as possible.


In a rural area like Humboldt County, it seems like with a smaller population, each overdose and each overdose death is felt a lot more by the community. Like what you were saying about your daughter having 5 former classmates who died from opioid overdoses. What kind of impact does that have on the community? 


It has a huge impact. We don’t have nearly the same number of overdoses as some urban communities, but per capita, we are typically the highest or second highest in the state. In a rural community, when you know almost all of your neighbors and you’re seeing everybody at the supermarkets, it has a much greater impact. It’s your friends, family, people you’re going to school and church with, and that makes it feel more personal. There’s so many people who have been taking opioids for years and that might be safe for some, but others its not. In our community we have focused tremendous efforts on opioids however we are starting to recognize that we can’t lose sight of other harmful substances like methamphetamine and alcohol. Our community and other communities have much greater burden (morbidity and mortality) from alcohol related health issues. The coalition and a lot of our partners are actively trying to figure out how to balance our work with opioids while developing effective strategies that are not only focused on the opioid epidemic, but that can span all substance use disorders. We want to ensure that the strategies we are putting in place can be effective across that continuum, otherwise it becomes a  ‘whack-a-mole’ situation. We see that overdose deaths from opioids are going down, but methamphetamine deaths are starting to rise in the community. It is a reminder to us that we have to develop a comprehensive approach and not just narrowly focus on one substance. 


I know there are a lot of news articles where they talk about the opioid crisis and they will have a lot of statistics about overdose deaths or the economic cost of the crisis. How do we present a narrative that could be a little more personal, that people can relate to, when we talk about the opioid crisis? 


In healthcare especially, we tend to focus on years of life lost. I don’t know if you’re familiar with that statistic, but if I die at age 27, and the average life span is age 72, all of those years between age 27 and 72 are potential years of life lost. The reverse of this could be calculating wellness years of life gained. This concept is something that I am really interested in. We might not be able to capture the cost of the crisis, but we could capture the gains and possibly change our framing a bit. How many wellness years could someone gain if they had treatment?


Another way we are looking at this issue is the  associated costs. For example, if a person has unaddressed substance use disorder and other issues such as unaddressed mental health needs, homelessness etc., these costs can add up.  By effectively addressing the substance use disorder and then begin to address housing and other social determinants of health factors, you can lessen the overall costs to communities. We are not really able to capture those costs effectively yet, but we’re working across our community to develop systems so that we can. This in turn would allow us to quantify not only potential wellness years gained, but also cost savings associated with prevention and treatment.  


I know that there are counties in California that when it comes to something like drug disposal when people have leftover drugs there are ways for them to dispose of them and ways that can avoid diverting for other purposes. I know some counties have been able to get pharmaceutical companies pay for those programs. What role or responsibilities do you think pharmaceutical companies should have in the effort to alleviate the opioid crisis? 


I think pharmaceutical companies do have an obligation to support take-back or disposal of unused medication, similar to paint and other producer responsibility requirements. For us here in Humboldt, the coalition, through grant funding, has provided financial resources to establish 12 disposal bins across our community and pay for the disposal costs for these bins. Each of these bins are in a community pharmacy, at the sheriff’s office, or the police department. In the absence of funds, it is difficult to see how we could sustain this. It is not cheap to dispose of these medications because they are controlled substances and the disposal process is highly regulated. Fortunately, the coalition has grant funding but is is unclear if we will in the future. In the first 2 years of having the disposal bins, we collected over 3000 pounds of unwanted medication. 

If someone gave you a magic wand that allowed you to change any rule or any law to help more effectively alleviate this opioid crisis, which rule or law would you change?


I am really coming from a healthcare perspective, so my answer is going to be a little more high level, but I think that we need drastic healthcare payment reform and healthcare system reform. Right now, it is so difficult to provide adequate healthcare, mental healthcare and substance use treatment because of the systems that pay for it or regulate it. If I am a primary care provider, in order for me to provide medication assisted treatment in my practice, I have to get the additional waiver, but I may or may not be able to get reimbursed because one plan might pay for it, another might not, or one plan might require prior authorization, another might not. There is no consistency across Insurance types. Data exchange is another big issue. If I have a substance use disorder issue and I am seeking treatment at my local treatment center, that data cannot seamlessly be transferred to my primary care provider. There are so many rules and regulations and unclear guidelines and interpretations of the guidelines that make it very difficult to promote a coordination of care. It is almost impossible to effectively communicate between mental health, substance use, and primary care or other healthcare entities. We are working very, very hard here in my organization, because we are the health information exchange, to understand those rules, to put in appropriate infrastructure and to be compliant with those rules, but it is taking so much time and resources, and unfortunately our patients and our community is suffering because of it. The Affordable Care Act was one step, but a very minimal step, in that everybody has access to insurance, but that is not the end of the story. The healthcare system needs dramatic overhaul, and the payment infrastructure is so arduous that it is nearly impossible to navigate at times, and it just becomes so difficult to provide the care that an individual needs. We spend so much time and money everyday in every healthcare, mental health, substance use treatment organizations to navigate this. In my organization at the IPA and the Health Improvement and Information Network, we work hard to help navigate this for our partners and to find solutions to improve communication and coordination, but it is a very long road.

It seems like that change, if it can be implemented, would make such an enormous difference, not just with the opioid crisis, but with the overall administration of healthcare and mental and behavioral services in general. Are there any additional thoughts or ideas you’d like to share?  


I’d just like to underscore my comment earlier that the opioid crisis has taken a lot of attention, rightfully so. There is a  headline about this almost everyday. But it is really important for communities to take a comprehensive approach and understand the extensiveness of what substance use disorder involves, and that solely focusing on opioids is not going to solve our problems. We have to look at this issue comprehensively, provide opportunities to create solutions that are upstream and downstream, not only so that we are helping those with substance use disorder, but working hard to prevent future substance use disorder issues. Working with our youth, working in schools, working with pregnant mothers, and others are all very important parts of this work that we cannot forget about. Humboldt County is working hard to address our issues and at the end of the day we feel like we’re moving in the right direction regarding the opioid epidemic as well as working to address all of the other issues that are peripheral to it.