Prevention for the Next Generation: Addressing Adverse Childhood Experiences, Suicide, and Overdose

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, why understanding the intersection of suicide, overdose, and adverse childhood experiences is so critical to helping people live happy and healthy lives.

RACHAEL BANKS:
They think it's important, you know, clearly, for understanding what goes all into, you know, a health issue in addition to the data. It's very important from an empathetic place and to be able to match a story.

JESSICA KROEKER:
Trauma is incredibly prevalent. It was prevalent prior to the pandemic and has only increased.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: making the connections between addressing adverse childhood experiences, drug overdose, and suicide.

When a person attempts suicide or is rushed to the hospital because of an overdose, we ask ourselves, "Why? How did this happen?" We think about the present, but truly we should ask ourselves how might something in the person's past intersect with what's happening now. Did an experience from childhood set the stage for an overdose or suicide later?

Our guests call attention to the intersection of these public health challenges. They tell us how they approach the intersection, how the pandemic has impacted these issues, and why partnerships with community groups are key.

Jessica Kroeker is the initiative coordinator with Trauma Matters Omaha, a community-wide initiative that helps address trauma. She joins us later.

But first, we hear from Rachael Banks, director of the Oregon Health Authority and the state's division of public health, about the work her department has done to address the intersection of suicide, overdose, and ACEs, and about her own lived experience.

BANKS:
Yeah, we're doing a lot of things. I would break them down into a number of categories.

One is in the early childhood space and really, you know, addressing those adverse childhood experiences. Ultimately, we want to prevent them; and whereby they happen, we want to be able to support and mitigate further harm, help families to intervene, to get the right supports.

So, in the early childhood space, we have things like universally offered nurse home visiting screening program for newborns. So, we are on a trajectory to roll up—you know, clearly COVID has made us change the way we're thinking about home visiting in general, we have other programs that we support nurse-family partnership and the other home visiting programs—so, we've moved to telehealth and been able to modify some of those. But the universally offered home visiting for newborns is a newer program that's been funded by the legislature, ultimately with the goal to reach all newborns.

We also have what's called our Title V program—maternal, child, and family health Title V program—where we, you know, fund our local public health authorities to do a variety of community-, individual-, family-, systems-level interventions, really based on what the needs that they're seeing in their communities. So, those are a couple of the things that we support in the early childhood space.

In the adolescent space, it's really one of the things we've had great success in being able to have a comprehensive sex-ed law and program and support school districts in that. And it's not just about—I mean, obviously it's preventing, you know, sexually transmitted diseases and all of those things—but it's really more about healthy relationships that is meant to decrease some of the, you know, domestic violence. It's really about self-esteem building, relationship building skills, and how to address potential ACEs or things that maybe happening in the home.

And we are also working, through our Oregon climate and health program, to learn more about how climate change impacts youth with depression or mental health issues as well. So, really trying to come at that from a variety of spaces.

And then, the last I would say is opioid-specific work and culturally specific work. So, there's the variety of strategies around, you know, healthy pain management, changing the focus from, you know, a deficit-based addiction to here's the positive ways to cope.

We recently partnered with our nine federally recognized tribes, as well as our native American Rehabilitation Association, in the Tribal Opioid Summit, which had a variety of great tools and really linked to that cultural healing and cultural well-being.

And then, we work with community-based organizations across the spectrum, faith-based, and culturally specific organizations to really listen and understand what their communities are going through and what they need.

JOHNSON:
You have a lot of work going on around this topic, clearly. Have you been able to see any results yet from any of those programs you just listed?

BANKS:
Yeah, I mean, we're continuing and I think, you know, prevention is always hard to quantify, right? So, when I talked about, earlier, people thought, "Oh, our suicide rates might skyrocket," for example. I would like to think that's in part because of the programming that we're doing and how we're supporting folks and how we shifted during COVID to be able to support folks. So, that's one way to look at it.

I think the other is really relationship building and resilience for communities. So, working with and being able to support tribes, to fund tribes. We had another example of, you know, just dramatically increasing the funding that went to tribes for tobacco prevention, and they're really approaching that as a holistic not just tobacco prevention, but looking at alcohol and drugs as well.

And so, I think that's a really significant outcome: both the increased finances but also the flexibility of our system to listen to communities and, you know, not silo how we might want to—"But this is tobacco and this is this, and that's in different parts of our agency," to you all, as a community, really need to address this holistically—and how to we align our funding to support that flexibility and autonomy.

JOHNSON:
Are you using the shared risk and factors framework to guide any of these initiatives?

BANKS:
Absolutely. And I think from a community perspective and all of the work I've been blessed to be able to do with the community, right, it's always holistic. And folks don't really appreciate being dissected based on their disease of the day or based on whatever the health problem is. It is a much more shared risk and protective factors framework. So, we absolutely use it.

It's absolutely supported, you know, obviously through our research and best practices, but particularly from a community perspective where we are getting much more fruitful conversations by asking, "What are the sorts of communities and relationships that folks need to be healthy?"

I think one great example of that is our state health improvement plan, which is called Healthier Together Oregon, and rather than kind of a disease focus as it has been in the past, it really brings together what is the framework for shared risk and protective factors.

So, it has things like addressing institutional bias, it has a focused on behavioral health, it has the social determinants of health, of safe housing, economic resilience and stability, and all of those things that we know creating those conditions will have benefits for multiple different conditions or diseases or our health problems that we're trying to address.

JOHNSON:
You mentioned community partnerships. Those have got to be right in the middle of this planning, right? I mean, you can't really solve any of these problems without help.

BANKS:
Yeah, absolutely. The major thing has been able to fund community-based organizations to both, you know—and COVID specifically, for example, it's been to provide wraparound supports, it's been to provide contact tracing and case investigation, it's been to provide outreach and education.

But from a public health standpoint—of course, contact tracing and case investigation is a core public health strategy—but we found really early on that people in isolation and quarantine was absolutely dependent on having that financial assistance, on them knowing that we had policies in place where they would lose their homes, if they work with community-based organizations to identify contacts where they knew that they could really isolated or be in quarantine if needed without losing their jobs.

So, being able to provide community-based organizations the funding for those social determinants of health and the funding to build the infrastructure in their organizations has just really been crucial.

JOHNSON:
We started this conversation talking about the intersection of suicide, overdose, and ACEs, and we've talked about a lot of different projects and programs that you have going there in Oregon. To someone who's not really aware of how all this goes today, they might think we're no longer talking about suicide, overdose, and ACEs—but we are, right?

BANKS:
Yeah, we absolutely are. And, I mean, I think, you know, earlier on one of the questions that we talked about is kind of what was my personal experience with suicide, overdoses, and ACEs. And I initially thought about it in, you know, a professional way of saying, oh, I've worked on different diseases and, you know, with each disease, you think you're a specific factor—you know, say tobacco for example—but then you work on something else and it's like, hmm, there's something else here. And it has to deal with people's experiences of toxic stress and racism. So, that's one of the professional learnings.

But I'll say, you know, when the more I thought about it more personally, I thought back to an experience that I had where. at about 10 years old, I walked in on an attempted suicide by my father, and I didn't totally understand what was happening there. I understood that my family was in turmoil, I understood that there was alcohol and drug use, I understood that there was job loss.

I didn't totally understand how the historical piece fit in, but as I think about it now—and, you know, perhaps other people who've experienced a loved one or family member who has overdosed, or attempted or completed suicide, and you look back—there's just those of variety of factors that do have to do with what was their earliest childhood experiences.

In my dad's case, it was exposure to alcohol and drug use by parents, it was not having a father parental figure. There was some saving grace in playing basketball and having coaches and people that poured in that mitigated some of what that risk would have been as an adolescent. And then, in adulthood, as those unaddressed traumas came up, as a job loss came up, as the alcohol and drug use came up and the corresponding family problems, then that hopelessness kicked in, and I think as well as experiencing racism.

And so, those all came together in this inability to, you know, take care of my family; the shame around, "I don't have the supports that I need," or "I've had these experiences that are unaddressed that are kinda eating me up," if you will; the self-medicating behavior that has that cycling effect. And it all really came together in those personal stories.

So, I wonder for people, as they think about those personal stories, if they're able to see how all of those things fit together to really show some of the backstory with ACEs, suicide, and overdose.

JOHNSON:
You are a person with a lived experience and you're in a position to really tackle these challenges there in Oregon. How else are you integrating people who have similar stories into these programs to try and make them better, to make the more effective?

BANKS:
Yeah, thank you, great question. I mean, we have a number of ways. We are working with peers in our opioid overdose prevention work. We are working and providing mini grants, for example, with our LGBTQ+ population for suicide prevention and self care and positive relationships. We're working with community-based organizations that both serve people with lived experience and are people with lived experience in our culturally specific efforts—which include folks from rural Oregon, and also includes culturally specific from a racial and ethnic perspective, you know, sexual orientation and gender identity—so, all of those different lived experiences.

And I think the challenge is, then, as a system, that we also need to be able lift up articulate and quantify the importance of lived experience for our employees and the people that we hire and the folks that we contract with.

So, we're also on a journey to really make sure that our position descriptions and that our system's able to recognize and compensate that lived experience as well as other professional or educational experiences.

JOHNSON:
Why is that important?

BANKS:
I think it's important for a variety of reasons. I think it's important, you know, clearly for understanding what goes all into, you know, a health issue in addition to the data. It's very important from an empathetic place and to be able to match a story. You know, people—we in public Health have huge data sets and we talk about a lot of data—but people relate to those stories. Our communities tell those stories. Having staff who have lived those stories or know people is important, and it's important from a community relations and public relations perspective.

We've seen in COVID and other things, people are talking about trusted messengers and then needing to see people that look like them, people that think like them, people that have similar experience, have the same faith tradition, whatever it may be. And so, there's a myriad of reasons, and those are three that come to mind.

JOHNSON:
Finally, can you summarize for your peers who are listening to this conversation right now the keys, as you see them, to addressing the intersection of suicide, overdose, and ACEs during this phase of the pandemic?

BANKS:
Yeah. I think, for me, it's really starting from that community or person perspective because when any of us—as individuals or as communities—think about what we need, it's not specifically dissected in the ways in which our systems are constructed or in the ways that our funding is allocated, which just very disease-specific, it's siloed.

So, I think part of it is starting with that community perspective and being willing to be flexible. Maybe we're engaging community because we want to tackle tobacco use, or COVID, or whatever particularly is the top of our mind. But being able to really hear and listen to what folks are saying they need to get to that shared and protective model I think is the key. Starting with community will force us to do a lot of things that I also think are necessary.

Secondarily, you know, being flexible, braiding and blending funding. I think COVID has given us an opportunity to really blend communicable disease model with social determinants of health model, shared risk and protective factors. And because the interventions that we needed to implement to stop the spread of disease, we've also seen have had some impacts on other social determinants—housing, jobs, education, you know, we've seen racial uprisings and an increase in racism and discrimination—so all of those things can be part of the solution.

Addressing those things as we move forward and say, "What does COVID recovery and, more importantly, resilience look like?" so we all have an opportunity to create our resilience and recovery plans in a way that address all of those factors.

JOHNSON:
Jessica Kroeker is the initiative coordinator with Trauma Matters Omaha, an organization that partners with those who encounter trauma, like first responders, educators, social workers, and medical professionals.

KROEKER:
So, when I talk about trauma, I define it as an event that overwhelms one's ability to cope. And if we look back over the last year and a half, it's really hard to consider that there's been anybody in our community that hasn't been impacted, who hasn't experienced an event in the last year and a half that's overwhelmed with their ability to cope.

The isolation. the stress of not knowing what's going to happen next, the fear of illness and loss of loved ones that certainly impacts our ability to cope—and so, trauma is incredibly prevalent. It was prevalent prior to the pandemic and has only increased.

And then, when we consider how access to support access to services, all of that was dramatically impacted by the pandemic. And so, we're just now starting to have more capacity to open up mental health services or community programming. And so, everyone in every age group is really feeling the impacts of that and the impacts that that's had on their mental health and well-being.

JOHNSON:
We've been talking a lot, in the public health community, about the intersection of suicide, overdose, and adverse childhood experiences. What are those issues like in your area? What are you dealing with as it relates to those three issues and the way they fit together?

KROEKER:
Yeah, so, our state and local agencies really need to understand that ACEs is a public health crisis, that adverse childhood experiences have a dose effect—so for each additional adversity in childhood that somebody experiences, they are in an increased risk for negative long-term health and wellbeing outcomes. So, those who've had four or more adverse childhood experiences are 12 times more likely to attempt suicide. Those that have four or more adverse childhood experiences are also more than four times more likely to use illicit drugs.

And so, if we look at what the data and research is showing us, and if we look at communities that are really impacted by overdose, by suicide, by illicit drug use, if we look at what's underneath the surface, or what's some of the causes and sources of that, the data's really pointing to trauma.

And so, across our nation, we're seeing an increase in things like suicide and overdose. And so, we really need to look at what's underneath the surface, what some of the source have some of these issues, and the data's really showing us that trauma's part of that.

And so, as communities, as public health officials, we really need to be considering what are ways that we can build resilient communities? How can we prevent adverse childhood experiences? How can we create environments and families within our communities that are able to be resilient from the impacts of these traumas and adverse childhood experiences?

JOHNSON:
As a community organization, then, how are you interfacing with your local public health jurisdictions there in Nebraska to do that kind of work?

KROEKER:
So, one of the main roles that Trauma Matters Omaha in particular has taken on is this awareness building, really working on normalizing these conversations to talk about trauma and adversities in childhood, or overdose, or suicide. It's really, really difficult to talk about those things, they're really taboo.

And so, through our trainings and awareness building, we're really trying to normalize those conversations and help people understand that the impact that trauma has on our brains and our bodies, and then the long-term implications, the long-term implications being things like a greater likelihood for substance use and abuse, or suicide attempts, those types of things. And so, that awareness is first and foremost, and then normalizing these conversations.

And then, also partnering within these organizations that are the first responders to trauma. So, for instance, we've been working with Omaha Police Department on how to provide trauma informed interviewing. And on the surface, having law enforcement that's trained in trauma informed interviewing, maybe it doesn't seem like that ACEs and suicide prevention work. But if we kind of break it down, we can see those connections; that if we have those victims that have experienced really traumatic events, and they're able to go to law enforcement and be heard because those law enforcement officials know how to interview in a trauma sensitive way and still get the information they need for their investigations, then those victims feel heard, law enforcement has the information they need to hold offenders accountable, and we can see how that can be healing and provide for a more resilient community and have implications on reducing suicide, or overdose, or those types of things.

JOHNSON:
As a community organization, are you able to do things that public jurisdictions cannot do? Are you able to help them in ways that, if you weren't involved, they wouldn't be able to approach on their own?

KROEKER:
I think we can all do some bits of this. I think being willing to have these conversations. Certainly, we have different resources and access to different things. So, I get really excited when we started to partner with public health because. in the public health community, they have access to more prevention resources than maybe us in the nonprofit. So, we might be able to respond to mental health crisis whereas the public health community can do more prevention campaigns. Or—we sometimes forget how access to healthcare, affordable living, health insurance, or access to healthcare, having food and groceries, and all of those things that are basic necessities for life—how having those things are actually improving the quality of life of those in our community.

It builds their resilience. It builds their capacity to bounce back when inflicted with trauma or adversity. And so, those are things that our public health sector really have an influence over in a way that sometimes non-profit and other sectors don't. So, it's a lot of that kind of up the stream or prevention work that they can do that I get excited because we haven't had the capacity to do that as much as they have been able to, or they could.

JOHNSON:
So, that's the benefit for an organization. A jurisdiction partnering with you—what benefits do you bring to them?

KROEKER:
The awareness and training capacities would be some of the things that we bring. The kind of boots on the ground—so, we partner with some organizations that use, like, suicide survivors as a means for responding to those who've been impacted by suicide. So, we partner with the Kim Foundation, for instance, and we had the Metro Area Loss Team, which is kind of a post-vention intervention. So, when there's family members or friends, who've been impacted by a loss, by a suicide, these suicide survivors can come and provide some support and assistance to those other people who are affected by these suicide losses.

And the beauty of that is when you have peer support or other people who have experienced something similar and they're offering their insight and support, there's capacity for hope and healing in a way that I don't think happens through other means. That being with somebody who's been there and done that really allows others to see the hope that we can get through this, that you see the light, that these days are hard but that there is a hope.

And so, those are some of the things that I think these other organizations provide that can be really relied upon by the public health sector.

JOHNSON:
You're able to bring those grassroots, credible voices to the table—people who've been down these same horrible roads and now are willing to talk about it and help others.

KROEKER:
Absolutely.

JOHNSON:
What about reducing stigma? Do you work on those issues? Is that another way you support jurisdictions as they go about their work?

KROEKER:
Yeah. So, our county health departments collaborated amongst four counties, their health departments got together and actually included the ACEs questionnaire in their community health needs assessment. And when they realize the prevalence of ACEs in our community, they went to the community and said, "What do you want us to do now? How do you want us, as health officials, as the community health organizations in these counties? How do you want us to respond?"

And it was almost unanimous throughout these counties that they wanted more support in mental health. The mental health needs were what was most desired to be addressed.

And so, there's been partnerships in our community. We partner with the well-being partners who have done this anti-stigma campaign, which is really getting local voices to share about what their experiences with mental health struggles has been like. And it's really normalizing in showing the community that there's other people in the community who are experiencing mental health struggles and they're seeking help, and let's normalize talking about these things. And then, through that campaign, also making it more readily available, the services that are out there. How can we have one spot on the internet where people can go to find the counseling services that they need so that they don't have to search everywhere for it?

So, what started out as adding ACEs to the community health needs assessment has led to a lot of anti-stigma campaigns and more access to resources.

JOHNSON:
What sort of feedback do you get from the jurisdiction to work with? Are they appreciative of having you at the table, bringing your resources to bear on these issues?

KROEKER:
I feel like it. What we've often talked about is public health has often been researching and understanding, you know, food deserts, and our parks, and bike ways, and how can we get our community more active. And to see in our community how our public health departments have really been getting behind this movement to address mental health and trauma has been really powerful. And it's been a new area for them to learn and explore, but they've jumped right in and have been doing a fabulous job.

JOHNSON:
We like to leave our audience with a take-away, and so here it comes. We'd like to get your advice for jurisdictions who are thinking about building or encouraging community partnerships when working to address the intersection of suicide, overdose, and ACEs. What's your best counsel to them?

KROEKER:
Yeah. My best counsel to them would first become familiar and aware of what the statistics are in your community. Start asking, researching what is ACEs in your community and the rates of suicide. And then, I think if I could shout this from the rooftops, I would say never underestimate how housing, access to healthcare, how all the things in our community that help people live resilient lives—those are suicide prevention strategies. Housing, food, addiction prevention, all the things I said—that is suicide prevention.

JOHNSON:
Thanks for listening to Public Health Review. If you like the show, please share with your colleagues.

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This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.