On Board for Recovery

The size of a large U-Haul truck, TCU’s Mobile Health Unit began visiting underserved neighborhoods in Tarrant County in July 2022 as part of an ambitious multimillion-dollar research project intended to serve drug users with or at risk for HIV.

A collaboration between the College of Science & Engineering, the Anne Burnett Marion School of Medicine, the Harris College of Nursing & Health Sciences and the JPS Health Network, the vehicle ventures out two days a week with a staff that includes a health care provider, social worker and driver.

On a typical outing, the truck pulls into a parking lot — outside a big box store or a hotel or apartment complex. A person who uses drugs and is living with or at risk of contracting a serious infectious disease and who may be involved in the criminal justice system climbs into the truck to meet first with Ahrein Bennett.

The 26-foot TCU Mobile Health Unit is a living laboratory involving the Institute of Behavioral Research, Harris College of Nursing & Health Sciences, Burnett School of Medicine and College of Science & Engineering.

Bennett, a public health associate with TCU’s Institute of Behavioral Research, begins each appointment with a needs assessment. She inquires about medical issues or problems with housing, transportation and jobs.

“They are dealing with a lot of issues,” Bennett said. “After prioritizing their needs, we make what we call active referrals: not just giving them a phone number to call but calling someone for them and scheduling appointments.”

Patients then move to the rear of the truck. In a curtained-off area they meet with Dr. Hunter Scarborough ’14 of Fort Worth’s John Peter Smith Hospital’s street medicine team or Lynnette Howington ’94 (DNP ’11), associate professor of professional practice and director of undergraduate nursing at TCU.

“Overwhelmingly the persons we’re speaking with are so appreciative of the fact they can get so many needs met in one location,” Howington said.

For people needing medication, she finds a pharmacy. For high blood pressure, she’ll offer treatment options and discuss lifestyle choices. Howington connects people with ongoing medical needs to health care services through the county hospital.

She and Scarborough also speak with patients about struggles with alcohol and drugs, particularly opioids and methamphetamines. They encourage people at risk of contracting HIV to begin a course of preventive medicine.

“The No. 1 thing in taking care of patients using opioids is that they don’t like doing it and would like help,” Scarborough said. “Injection use has gotten scarier and scarier with people at risk for all kind of infectious diseases.

“They spend all day trying to pull together enough money so they don’t have withdrawal. They are sick and they don’t feel good when they are using, which makes people really motivated to stop.”

SERVICE IN ACTION

The Mobile Health Unit is the living laboratory at the heart of ACTION, short for Addressing Risk Through Community Treatment for Infectious Disease and Opioid Use Disorder Now Among Justice-Involved Populations.

Led by faculty from TCU, Yale University and the UT Southwestern Medical Center, the five-year research project is funded by the National Institute on Drug Abuse. The study seeks to determine best practices to prevent infectious diseases such as HIV and treat substance use disorders.

Drug use experienced an alarming uptick during the Covid-19 pandemic. The 2022 National Drug Control Strategy revealed that 105,000 Americans died from drug overdoses between Nov. 1, 2020, and Oct. 31, 2021.

The National Institute on Drug Abuse allocated $11.5 million for the study, which seeks to determine which treatment option is more effective: seeing participants in a traditional office setting versus mobile health units.

“With our research, the entire focus is on addressing substance use problems and HIV risk in the community,” said Kevin Knight ’91 PhD, a professor of psychology and director of TCU’s Institute of Behavioral Research.

In partnership with TCU Nursing and John Peter Smith Hospital, the county-funded hospital in Fort Worth, the Mobile Health Unit seeks to improve access to health care, a major barrier to drug treatment.

Many of the participants are referred through probation offices.

From left: Lynnette Howington, Sabrina Roberson, Ahrein Bennett and Stephanie Villaire, a graduate researcher and driver of the TCU Mobile Health Unit, wait for patients in a mall parking lot.

“We are targeting Tarrant County justice-involved individuals — for example, the 15,000 individuals currently on probation who are using opioids or methamphetamines,” Knight said. “Substance use and HIV risk often go hand in hand among those in the criminal justice system.”

Participants are using opioids like heroin as well as prescription medicines including hydrocodone, oxycodone and morphine. Fentanyl, a synthetic opioid, shares many of the characteristics of morphine but is 50 to 100 times more powerful.

Since 1999 in Tarrant County, opioid deaths have quadrupled.

Even though someone might come out of incarceration clean or detoxed, “their rate of return to substance use is high,” Knight said. “There are medications that are highly effective in cutting their cravings for drugs, but it’s a challenge to get them medication.”

Knight has long believed the “just say no to drugs” mentality does a disservice to people struggling with substances.

“We had an individual who broke down crying because they were so thankful to have access to health care,” Knight said. “These aren’t hardened criminals you see on TV, and it’s not a matter of not wanting to use. This is a difficult problem that’s a public health and community concern.”

“We had an individual who broke down crying because they were so thankful to have access to health care. These aren’t hardened criminals you see on TV, and it’s not a matter of not wanting to use. This is a difficult problem that’s a public health and community concern.”
Kevin Knight

UPENDING THE TRENDS

Jennifer Becan ’03 (MS ’08, PhD ’10), an investigator in the project, also is the project director for the TCU hub of the Justice Community Opioid Innovation Network, a program to care for adults involved with the justice system.

As director on the Family Assessment, Motivation and Linkage Intervention project, she works to develop and test a caregiver-youth intervention designed to assist families in finding help for minors on probation who struggle with drug use.

“Families are under lots of pressures and stress in life, and prioritizing their youth on probation to get treatment doesn’t always happen,” said Becan, a research scientist for the Institute of Behavioral Research.

Treating problems with substances is a medical need, like treating diabetes, she said. Her research focuses on pragmatic solutions. She’s developing an app-based intervention that probation officers can use. The brief intervention, in the form of a digital questionnaire, helps determine whether someone might need drug treatment.

“The majority of youth on probation are also using substances,” she said. “Any time you’re able to improve health outcomes for youth, it’s a perfect place to intervene and make a difference.”

Scholars across TCU believe a combination of treatments, including behavioral therapy and medications, offers the best chance of changing lives.

Lynnette Howington takes a blood pressure reading on board the TCU Mobile Health Unit. She offers treatment options to substance users seeking help.

“There is no magic bullet for treatment,” said Dr. Ken Hopper, a former faculty member at the Anne Burnett Marion School of Medicine. “It requires grit by the individual to overcome a substance use disorder. Medications alone won’t ever take care of this, although they are proven to assist in reducing urges.”

In his private psychiatry practice, Hopper often saw patients struggling with drugs and alcohol. “If they have an ingrained habit, they really need a residential setting to get away from social influences,” he said. He also believes a 12step program like Alcoholics Anonymous can offer lasting hope.

“No matter the substance — alcohol or amphetamines or opiates — the signals all come through the reward center of the brain,” he said. “Calling your sponsor or going to a meeting can help you get through as your body is driving you toward the reward center input.”

HOPE AND HELP

Psychiatrist Dr. Debra Atkisson, also a former Burnett faculty member, said substance use disorder is “one of the top medical problems in the country today.”

For people who struggle with drugs and alcohol, she said, “It becomes a convenient way to deal with negative feelings and emotions.”

She recommends her patients embrace mindfulness instead of turning to the numbing effect of substances. Mindfulness, she said, “is when something happens and you have an emotional reaction, but you allow yourself in the moment to notice and observe how you’re feeling in that place and time.”

Hallmarks of substance use include ever-increasing thoughts about using, taking larger amounts of a given substance and engaging in risky behaviors like drunken driving. Other indicators can be weight changes, secretive behavior and irritability.

Eric Wood, director of counseling and mental health at TCU, said that 20 percent of students enter TCU with high mental health needs, which can include problems with drugs and alcohol.

According to a spring 2022 TCU survey, 12.4 percent of undergraduates reported thinking they had a problem with alcohol or other substances within the prior 12 months.

“College is one of the few times in life where every aspect of their lives can change — where they sleep, where they eat, a whole new social environment and so on,” he said. “Age 18-24 is also a time when a lot of psychological problems emerge, including depression, anxiety and bipolar disorder.”

TCU takes a three-part approach to helping students with substance use issues.

Ahrein Bennett, center, and Lynnette Howington, right, consult with a patient in the TCU Mobile Health Unit, which is part of a five-year project funded by the National Institute on Drug Abuse.

The university starts by stressing education. Caroline Sahba ’13 MEd (MBA ’20), assistant director of TCU’s counseling and mental health center, talks to student groups about the negative impacts of drug and alcohol use and the help available on campus to support sobriety.

Support can range from clinical counseling to outpatient treatment through an off-campus facility. While students pay nothing for mental health services on campus, families typically work with their private insurance for a residential or outpatient treatment program.

Sahba also runs the Collegiate Recovery Community. About 60 students are affiliated with the community, and attendance at weekly meetings averages eight to 12 students.

“Alcohol is the No. 1 used substance on every college campus,” Sahba said. “What I’ve heard in those meetings is a sense of being different: ‘I am trying to drink like everyone else, but I can’t have just two drinks and have fun.’ ”

She and Wood said social connection can prove a powerful ally in helping students stay sober.

“Students can be a safety net for one another,” Wood said. “One really positive thing about TCU is that the help-seeking on the part of students has increased, as has the visibility of the resources we provide.

“It has become a part of the campus culture.”

Wood emphasizes that problems with drugs and alcohol affect every kind of student, regardless of demographic and socioeconomic status. A sophomore literature major and a middle-age probationer with HIV may seem worlds apart, but substance use problems and difficulties navigating the traumas of life can unite them.

“Most people want to thrive,” Knight said. “If given the opportunity and the tools, most people will embrace a drug-free life.”