TCU’s Mobile Health Unit helps substance users get on the road to health and hope.
THE SIZE OF A TYPICAL U-HAUL TRUCK, TCU’S MOBILE HEALTH UNIT BEGAN VISITING HISTORICALLY 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 with the College of Science & Engineering, the Harris College of Nursing & Health Sciences, the Burnett School of Medicine at TCU and the JPS Health Network, the 26-foot vehicle ventures out two days a week with a staff that includes a health care provider, community health worker and driver.
On a typical outing, the truck pulls into a parking lot, sometimes outside a store like Home Depot 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 then climbs into the truck to meet first with Ahrein Bennett.
Bennett, a public health research associate with TCU’s Institute of Behavioral Research, begins each appointment with a needs assessment. She inquires about everything from medical issues to 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.”
Clockwise from top left: Sabrina Roberson and Ahrein Bennett prepare to greet visitors to the unit. Those visitors “are dealing with a lot of issues,” Bennett says; Lynnette Howington takes a blood pressure reading on board the unit. She offers treatment options to substance users seeking help; Staffers keep Narcan on the unit in case they need to treat an overdose; Stephanie Villaire, a graduate researcher and driver of the TCU Mobile Health Unit, chats with Randi Proffitt while they wait for patients in a mall parking lot.
Once that part of their visit wraps up, patients move to the rear of the truck. There in a curtained-off area they meet with Dr. Hunter Scarborough, who is part of the street medicine team at Fort Worth’s John Peter Smith Hospital, or Lynnette Howington, a nurse practitioner.
“Individuals are on the unit anywhere from 30 minutes up to an hour and a quarter, depending on the complexity and the number of topics we’re trying to cover,” said Howington, 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,” she said.
For people needing medication, she finds a nearby pharmacy. If someone has high blood pressure, she’ll offer treatment options while also discussing lifestyle choices. Howington works to connect 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, in addition to general health concerns. They encourage people who are 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 with it,” 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.”
After the medical part of the visit, the health professional and a community health worker sit down with the study participant to strategize about next steps.
“I love this project because it’s working to meet the needs of very vulnerable populations,” Howington said. “And I love the promise of this project, the ability to go to at-risk patients with substance abuse issues and provide them resources.”
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, ACTION is a five-year research project 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 in Tarrant County and around the country 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 report said that synthetic opioids like fentanyl played a role in two-thirds of those deaths.
The National Institute on Drug Abuse allocated $11.5 million for the study, which seeks to determine how effective innovative treatment options, including mobile health units, might be.
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.
The truck, which Magnum Mobile in Phoenix spent months customizing with plenty of purple, includes the exam room, a restroom and a blood draw chair.
“With our research, the entire focus is on addressing substance use problems and HIV risk in the community,” said Kevin Knight, 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. Other obstacles include available child or elder care, transportation, economic woes and a mistrust of the health care system and providers.
Many of the participants are referred through probation offices.
“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 potent 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, Knight said.
Even though someone might come out of incarceration 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.”
105,000
Americans died from drug overdoses between Nov. 1, 2020, and Oct. 31, 2021.
Source: 2022 National Drug Control Strategy
UPENDING THE TRENDS
Jennifer Becan oversees the TCU hub of the Justice Community Opioid Innovation Network, a five-year 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.”
Many researchers and practitioners across TCU believe a combination of treatments, including behavioral therapy and medications, offers the best chance of changing lives.
“There is no magic bullet for treatment,” said Dr. Ken Hopper, an associate professor at TCU’s Burnett 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 sees patients struggling with drugs and alcohol, which he said can have long-term and life-changing impacts on an individual’s physical health.
“If they have an ingrained habit, they really need a residential setting to get away from social influences,” he said. He also believes a 12-step 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
Hopper’s medical school colleague, associate professor and psychiatrist Dr. Debra Atkisson, 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 often recommends that her patients embrace mindfulness instead of turning to the numbing effect of substances.
“Mindfulness 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,” she said. “You allow yourself to experience the emotion instead of compartmentalizing.”
Dr. Brian Dixon, a child and adolescent psychiatrist who is an assistant professor at the Burnett School of Medicine, said, “You don’t pass judgment in the moment.”
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.
Withdrawing from friends and performing poorly at school might also point to problems among children and adolescents.
“The growing brain is more susceptible to these kinds of substances,” Dixon said.
Dixon encourages parents to model what they want their kids to do and reminds them that kids who witness parents drinking excessively or smoking marijuana are more at risk of engaging in those behaviors.
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.
Ahrein Bennett, center, and Lynnette Howington are members of a team that brings comprehensive health care to the streets of Fort Worth through a Mobile Health Unit.
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.
The university starts by stressing education. Caroline Sahba, assistant director of TCU’s counseling and mental health center, goes out with her team to talk with 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.
The third piece is post-intervention, supporting students as they navigate recovery. Sahba runs the Collegiate Recovery Community, which meets in a Jarvis Hall lounge. 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,” said Sahba, who works with first-years to graduate students. “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.”
Comprehensive Collaborative Care
At TCU, addressing student mental health is a campuswide priority.
Dr. Eric Wood, Director of Counseling & Mental Health
Eric Wood saw an increasing demand for mental health services among college students and imagined a new method for meeting their differing needs with a limited professional staff.
The Comprehensive Collaborative Care Model, developed by Wood as TCU’s director of counseling and mental health, is now the standard to follow in higher education. The model was built on three key observations:
- Twenty percent of students seeking mental health treatment take up about half of all campus counseling center appointments.
- The majority of college counseling center clients have previously received services.
- Responding to students in crisis contributes to burnout among already overburdened counselors.
His solution leans into collaborating with community partners, peer support groups and a dedicated professional counseling team to help students thrive during college.
Students with basic needs can utilize free, brief campus counseling sessions and get connected to a variety of peer support groups, from Dungeons & Dragons game nights to communities focused on grief or body image issues. Those are modeled after recovery groups and intended to build community.
TCU secured a grant from the U.S. Department of Health and Human Services to fund a crisis and triage team, staffed by therapists with no scheduled caseload.
For high-need students, such as those considering self-harm or coping with trauma, TCU partners with off-campus facilities to provide on-campus therapy.
In the Comprehensive Collaborative Care Model, students find engagement and support on and off campus — from the Student Activities office and pastoral counselors to Student Success Coaches, professional therapists and one another.
“We’re asking families to send their student here, to live here, sometimes from thousands of miles away,” Wood said. “We’re charging ourselves with the care of the student. We have to support them.”
COURTESY OF TCU MARKETING & COMMUNICATION
BY LISA MARTIN
PHOTOGRAPHY BY JOYCE MARSHALL