Discussion
Table 1. Quantitative Results of CME Analysis 
Community and university partners brought together community members, public health professionals, university colleagues, local students, and health care professionals for the study’s CME sessions to discuss a topic of critical public health significance and to gather information that could be used to combat the opioid crisis more effectively. Addressing the opioid crisis requires an interprofessional and multipronged approach if solutions are to be found (Brooks et al., 2018; Broyles et al., 2013). Collaborations spanning public health, education, health care, law enforcement, tribal health, and social services are necessary to eliminate opioid overdose, to improve health equity, and to eliminate disparities in impact (Juarez, 2017).
The fact that many provider responses indicated stigma and bias toward individuals with SUDs was of great concern to the communityuniversity team. The results of this study inspired community and university partners to facilitate training and education designed to reduce the impact of stigma in the community and local health care settings. They adapted training materials to specifically address negative attitudes toward SUDs and encouraged community members and health care providers to self-evaluate their own words and behaviors.
Through community-engaged research conducted at community forums, via focus groups, and in technical assistance projects intended to increase patients’ and providers’ access to evidencebased treatments for OUD, our team has gained an even greater appreciation for the depth and nature of the stigma and the difficulties in addressing it. We have learned that one of the most effective ways to combat stigma is to provide an opportunity for an individual in SUD recovery to share their story of substance use and recovery or for a wellrespected individual from the community (e.g., a health care provider or Tribal Elder) to share a story of their family member’s struggles with an SUD. Both community members and health care professionals have reported this approach to be effective in changing the way that they view SUDs; these testimonials help community members and providers understand that those with SUDs are not any different from their own friends and family and that SUDs are a clinical condition rather than a moral failing.
This study’s implications, combined with lessons learned through other methods of community engagement, may inform new models for professional training in health care, education programs, current practitioners, and communities looking to improve patient care that want to explore interprofessional solutions to combat SUDs. This study has been critical in adapting public health approaches to work with health care providers in northeastern Minnesota, as it has allowed for a greater understanding of provider education needs and attitudes toward SUDs that will continue to inform new programming. Future work will focus more specifically on interventions that hope to address health care providers’ barriers toward treating patients with SUDs, improve patient access to SUD care, and minimize the burden of stigma.
While this study illuminated the influence of provider barriers on SUD treatment, it also confirmed that this group of health care providers recognized some of the burdens that are known to face patients who are seeking care (AndrakaChristou & Capone, 2018; Deering et al., 2011; Haffajee et al., 2018; Mendiola et al., 2018; Mojtabai et al., 2014; Peckham et al., 2018). Over half of the collected surveys contained providercentric concerns, even though the questions were patient-centric in nature. Results indicate a need to provide additional education on SUD as a clinical condition and more information on appropriate treatments for SUDs, including medicationassisted treatment. These findings suggest that CME attendees had significant concerns about the impact of the opioid crisis on their practices, which could hinder their care of patients with SUDs and their likelihood of suggesting or dispensing naloxone.
The community-university team will improve care for individuals with SUDs by advancing interprofessional collaboration with the help of improved local data availability. Using results from this survey, the interdisciplinary team sought to improve care by pursuing interventions that capitalize on partnerships and collaboration. These interventions focus on improving treatment availability, reducing stigma toward individuals with OUDs, increasing education of the community and health care providers, and increasing communication and collaboration.
Community-Focused Interventions
Health care providers in this study indicated that more education for the community and health care providers alike was desperately needed to improve outcomes for individuals with SUDs in their communities. These findings have inspired additional community-based interventions. Community and university partners conducted focus groups with individuals in long- and short-term SUD recovery to learn more about community-level factors that might help or hinder recovery, and the partners have disseminated the findings from these focus groups to public health leaders and policy-makers to support investments in housing, chemical-free social activities, and treatment facilities in rural parts of the state (Palombi, Hawthorne, et al., 2019). Recognizing the role of mental health in the SUD trajectory, faculty and community partners also became trained in Mental Health First Aid, and they educate community members, treatment and recovery professionals, and health care providers across Minnesota. The community-university team has conducted community forums in several of these communities since the time of this study to facilitate collaboration; to learn more about community needs; and to educate the community on SUD prevention, intervention, and recovery (Palombi, Olivarez, et al., 2019).
Additionally, many community members, health care providers, and coalition members in these rural communities have taken advantage of the valuable e-learning opportunities that several Project ECHO (Extension for Community Healthcare Outcomes) hubs in Minnesota provide. Project ECHO aims to provide crosssite learning among rural clinics focused on opioid and controlled substance topics and to give rural communities access to experts (CHI St. Gabriel’s Health, n.d.; Hennepin Healthcare, n.d.). Similar to the Project ECHO model, the study’s CME events served as an opportunity to provide mentorship and knowledge sharing among health care professionals. Online prevention, treatment, harm reduction, and naloxone training resources provided by university partners were shared at these events.
Comprehensive CHAs have been completed in the counties participating in this project, and assessments will be repeated in 2021 to determine if community concerns regarding SUDs and the opioid crisis have become less critical than other public health issues. Currently, substance use remains one of the top priorities reported in the CHAs for participating counties. CHAs and community health improvement plans continue to shed light on how community-university partnerships can improve care for individuals with SUDs, prevent new SUDs, and improve community and health care professionals’ attitudes toward SUDs. In line with the local CHAs, the communityuniversity team has conducted surveys specifically examining the views and practices of pharmacists, emergency medical service providers, and dentists related to the opioid crisis locally and statewide in order to identify areas for potential further collaboration and education.
Use of Best Practices in Community Engagement
This project involved faculty researchers working with rural community members and professionals toward a common goal, and all stakeholders developed a deeper and more authentic partnership as the work progressed (CCPH Board of Directors, 2013). Rural community members and professionals drafted the vision for this project together, and university partners co-orchestrated the design, implementation, and evaluation of this research. While the faculty researchers excelled in data analysis, community partners were well positioned to disseminate the findings to the public, and a power-sharing balance of responsibilities developed that harnessed each partner’s strengths. Relationships between public health and faculty partners deepened as a result of this project, and partnerships expanded to new public health departments and new faculty members. New relationships led to related projects aimed at engaging health care professionals in the opioid crisis. Community partners joined faculty as copresenters at local and statewide meetings and conferences, and faculty joined community partners at local coalition meetings to disseminate findings, gather further community input, and share the benefits of the partnership’s accomplishments.
This partnership was responsible for transformative experiences on multiple levels; individuals learned about SUDs as a clinical condition rather than a moral failure, which translated into broader institutional, community, and political transformation (CCPH Board of Directors, 2013). The partnership also led to new federally funded projects that provide technical assistance focused on opioid and substance use to the rural communities involved in the described project, including interventions in their school systems, substance use prevention infrastructure, treatment and recovery circles, health care and public health infrastructure, criminal justice system, and community norms. Additionally, this project led to policy changes related to substance abuse in the local public health departments, health care systems, and schools.
These partnerships are successful because participants understand that the community and public health partners, faculty members, and individuals with SUDs or in recovery from SUDs are equals (CCPH Board of Directors, 2013). While the stakeholders in this project each have their different strengths, they understand that each partner brings their own wisdom and experiences to shared projects. The stakeholders have seen how much more can be accomplished together, leveraging individual strengths, than by working individually. The partners in this project listen to each other and apologize if they find themselves in error or insensitivity. They learned how to feel comfortable sharing grand ideas yet also know how to manage the small details as a team, which is vital for success. The partners are united by a common purpose, the heartbreak shared for those who continue to suffer, and the hope that communities can do better.
The team has developed authentic friendships within the community, allowing for sustained collaborations across multiple projects. The team has been able to build a positive reputation due to this authenticity and humility, and the described work has expanded to include partnerships with new communities that are often less receptive to working with universities because of the mistreatment they have experienced in the past (and may unfortunately continue to experience). Being honest about the past and current shortcomings and failures of the university allows for more open and fruitful dialogue and opens up the potential for stronger relationships and lasting change.
Continued and Future Work
This community-university partnership took action to seek out additional voices of community members, including people in recovery, to find ways to improve access to treatment and referrals in response to the emerging concern among providers that SUD treatment is currently unavailable or lacking. Since the initial assessment of provider perceptions of the causes and consequences of the opioid crisis, shared decisionmaking has led to more targeted efforts to identify and refer patients who would benefit from SUD treatment. Community and university partners became trained as trainers in screening, brief intervention, and referral to treatment (SBIRT), an evidence-based screening tool to support and refer individuals with SUDs. The partners now work to implement SBIRT in area clinics and county programs such as child protective services and Women, Infants, and Children (WIC) programs, among others.
Local public health professionals and leaders from the University of Minnesota continue to work with health care providers and pharmacies within the study region to provide education focused on medication-assisted treatment and to implement opiate antagonist protocols. These protocols require a prescriber to sign off on a standing order, allowing an at-risk individual, or an individual with a loved one at risk of opioid overdose, to receive naloxone without a prescription. Additional trainings available to both professionals and community members have and will continue to be scheduled within the region to address naloxone, signs of an overdose, the administration of naloxone, and the idea of SUDs as a disorder as opposed to a moral failing. Collaborating on opiate antagonist protocol implementation allows for both university and community partners to work toward mutual goals that serve and benefit the shared communities in this region. While causation cannot be proven, notable improvements in naloxone dispensation by pharmacists (Erickson, 2019) and reductions in opioid prescribing by providers (Johnson, 2020) have occurred in the communities that participated in this project.
Providers participating in this study noted a need to improve communication and collaboration among various health care providers and between the health care providers and the community. Since the time of this study, more focused efforts have been initiated with prescribers not well represented at the CME sessions to address opioid prescribing, medication take back, and stigma. University resources including faculty and staff time continue to support local coalitions in their efforts to address the opioid crisis. Health care providers have been encouraged to join these coalitions. Community members and professionals joined faculty in their efforts to educate and engage interprofessional student audiences on addressing the opioid crisis, and the results of this study have been used as a discussion point in these endeavors.
The results of this study were carefully considered in creating a subsequent research study that examined the recovery experience for individuals living in rural Minnesota; the results have been shared prepublication with local health care systems so that health care providers can learn more about the startling ways that bias and stigma serve as barriers for individuals seeking treatment. The subsequent study serves as yet another way to share the “voices” of individuals in recovery so that health care providers as well as public health professionals, faculty, and community members can become more supportive of the recovery process. This study has led to new understandings of how specific populations (e.g., individuals who identify as LGBTQIA) experience more severe bias from the medical community that leads to even greater disparities in care. This research would not have been possible without the strong relationships with community members and recovery professionals that were created as a part of the described work.
Future work will include evaluating the beliefs of other health care professions and bringing the diverse voices and wisdom of the recovery community to these groups. The University of Minnesota College of Pharmacy continues to partner with local public health departments across northeastern Minnesota in an everwidening geographical area as these partners assess and evaluate ways to engage additional health care professions and various community voices within the region. Using the expertise of the University of Minnesota College of Pharmacy and the lessons learned through this study, local public health officials can streamline their assessment and evaluation processes when focusing on other health care populations. The innovative approach described in this publication can be replicated not only for a variety of health care professions but also in regions across the nation.
Community engagement is a valuable tool for transformational change that is desperately needed to reduce substance use and to create systems that support recovery across the United States. In partnership with community, our colleges and universities remain “one of the greatest hopes for intellectual and civic progress” and are still called—just as they were many years ago—to become a “more vigorous partner in the search for answers to our most pressing social, civic, economic and moral problems” (Boyer, 1996, p. 18). The opioid crisis is a critical public health emergency with social, civic, economic, and moral components that requires university partners to embrace new roles and responsibilities for the good of all.
Limitations
One limitation of this study is that the providers who attended the CME sessions were likely more interested than a representative sample of providers would be in investing time to find solutions to the opioid crisis. Pharmacists made up a large percentage of the attendees, which may bias the overall study response. Attendees were also not required to complete the survey, so it is possible that only the most engaged attendees filled out the survey; such a situation could lead to even more positively biased results.