CASAT: CASAT Podcast Network.

Bianca McCall: Welcome to the NOCE Dose Opioid Crisis Unplugged. The NOCE Dose Opioid Crisis Unplugged is a concise and insightful podcast offering a deeper dive into the realities faced by professionals combating the opioid epidemic. Join us as we reconnect with expert panelists from our listening sessions, providing a behind the scenes look at their work and insights into the pressing issues of prevention and diversion, harm reduction, opioid use, treatment, recovery and reoccurrence prevention. This listening session is being brought to you by the Nevada Opioid center of Excellence, also known by the acronym NOCE. My name is Bianca McCall. I am your moderator for today's event and we're doing things today that we've never done before. Now, this is the first of a two part series designed to examine how opioid use disorder impacts specific populations who experience distinctive health vulnerabilities. Today we'll hear from subject matter experts whose passions, purpose, promising work, engages, Nevada youth, neurodivergent groups and tribal nations. I'm looking forward to the attitude adjustments that are sure to happen today and for all of us to leave for lunch half past noon, having gained knowledge and being able to describe the risk and resilience factors in the onset and progression of opioid use disorder, which you're going to hear me refer to as OUD throughout this session and for us to be able to identify structural, systemic and environmental barriers to care, including those having the greatest impact on injury prevention, on treatment and on the recovery journeys for these special populations. Don't get me wrong, I love a good conversation, but the goal for today is action. It's demonstration of our adjusted attitudes and understanding of the role of lived experiences and community narratives as both valid and necessary data sources informing the design, the implementation and the evaluation of individualized, culturally responsive OUD interventions. There's only one golden rule for this session that I'd like to share with you. And I got to remind you, I'm a big teddy bear. Right? I'm a big teddy bear. Most of the time I'm Teddy. But if you don't follow this golden rule, I can be bear. Right? So bear with me with this. We're here to actively listen to the unique and diverse perspectives of the speakers. So the rule is to respect others viewpoints, maintain an open mind and willingness to learn and to hear different perspectives without the preconceived notions and also with the focus of, being on mutual validation and understanding. And now I do have the absolute Pleasure of introducing these champions of leadership and service in our opioid response communities. Everyone, please help me to offer a welcome as warm as the summer temperatures in the middle of the Mojave Desert to our expert panelists. First, we have Ryan Mills, who is a former professional BMX writer who faced a decade long battle with heroin addiction. His journey into substance abuse began after a BMX injury led to pain m management with prescription opioids, which eventually spiraled into heroin dependency. Despite his struggles, Mills managed to graduate from college while battling addiction. His life took a turning point when he was arrested, leading him to participate in a drug court program that helped him achieve sobriety. since overcoming addiction, Mills has rebuilt his life, regaining trust from family and friends and reconnecting with the BMX community. He now uses his experience to inspire others, me included, sharing his story story to raise awareness about addiction and recovery. And his return to BMX has been a testament to his resilience, providing the passion and determination that can help overcome even the darkest of challenges. Ryan's story is one of redemption, of, perseverance and hope. And he continues to advocate for recovery, demonstrating that life after addiction is possible and fulfilling now. Through his journey, he has become a beacon of inspiration for those struggling in dangerous relationships with substances and showing that with the right support and mindset, transformation is achievable. He now works as a health resource analyst Uh3 and a program specialist at the Division of Public and Behavioral Health. Welcome, Ryan. Thank you so much for joining us today. Next we have Dr. Crystal Lee, who is Danae, what we refer to as Navajo. She was born and raised on the Navajo Nation, and her tribal clans are Tachani, the chosen few, Red running into the water, Tabaha, Water's Edge and Sen Ji Ki Ni, Cliff dwellers and King I Chee I Red House. Dr. Crystal completed her undergraduate degrees at Arizona State University, earned a master's in public health, a PhD in public health from the University of Nevada, Las Vegas. Las Vegas.

Bianca McCall: She has a master's of legal studies in Indigenous People's Law at University of Oklahoma College of Law. I'm not even close to being done you all A pre doctoral fellowship at John Hopkins University Bloomberg School of Public Health, and her postdoctoral fellowship at the University of California, Los Angeles, the David Geffen School of Medicine. Currently, she is a faculty assistant professor at University of New Mexico College, of Population Health. And in addition, she was an Indigenous HIV AIDS research training fellow at the University of Washington. That's also one that I've got to cover my mouth on Go Cougs, Indigenous Wellness Research Institute for in seminar instructor at Harvard University Kennedy School School. She conducts infectious disease biomedical prevention research with a focus on Native American health and examines indigenous health policies. She's the founder and president of United Natives, named one of USA's today's, top nonprofits. Now United Natives has procedures, partnerships with l', Oreal, NFL Legends Alumni association, the NBA Legends Alumni Association, NASCAR Fiesta bowl and the Boston Red Sox. So there's still so much more involved in Dr. Crystal's body of work with incredible reach and impact in fashion, professional sports, participation in UN caucuses and achieving 40 under 40 awards. but yeah, thank you so much Dr. Crystal for joining us today. and not far from the reservation where you, your family and your tribe are going through an incredible honor today. So thank you for joining us. And the power of this three is a precedent set by the University of Nevada, Reno, Nevada Opioid center of Excellence. Which I have to say because I'm going to be giving another shout out to our Nevada Systems for Higher Education sibling rival right in introducing our next champion of service and leadership and likely disruptor who has sparked significant life saving changes. Dr. Tara Raines is the Deputy Director of the Children's Advocacy alliance of Nevada, a nonpartisan organization working to improve outcomes for Nevada's most vulnerable youth. She is a school psychologist by training. Dr. Raines brings deep expertise in early identification of behavioral and emotional risk, especially in school age children and how unaddressed needs can lead to involvement with the juvenile justice system. She's previously served as associate professor and director of clinical training in the Child, Family and School Psychology program at the University of Denver and an assistant professor at unlv. Her research, supported by the Institute of Education Sciences, focuses on universal screening for emotional and behavioral disorders in large diverse school districts with a particular interest in school based pathways to incarceration. Dr. Rains advocates for healing centered approaches to trauma, for culturally responsive care and oh my gosh, these are love languages, y' all love languages. And increased access to services for families affected by systemic inequities, including the intergenerational impacts of the opioid epidemic. Dr. Raines is a nationally recognized professional for her leadership in anti racist practices for police and schools reform and bilingual workforce development in mental health and education. On behalf of our panelists and our team here at NOCE we are absolutely delighted to have everyone on the line here today participating in today's session. And if you haven't Done so already. Please feel free to drop your name, your title, credentials, organizations, all of that jazz in the chat. And the NOCE team will be actively monitoring the chat. Your responses and comments throughout today's session, and we'll carve out some time at a couple of points today to reflect on those as they are welcomed and incredibly helpful for us to meet the event's objectives. So let's begin with raising some awareness around some of the issues that we're seeing impacting our special populations. I'd like to start with Dr. Raines. Dr. Raines, thank you again for joining us. let's jump right into it. I want to know what are the most common environmental risk factors in schools and community contexts that predict progression of mental health crises characterized by the substance use disorders in adolescents?

Dr. Tara Raines: Yeah, thank you so much for asking that. I want to apologize for any background noise. I am in an airport. And I also apologize. I'm going to slip out a little bit early, so I. I have to start by talking about my lens. So I was raised by a father who's in the military from Jersey City, New Jersey. My mother is from Savannah. She grew up in segregation in Savannah. And so discipline, rules, appearances, right, Were things that were very. They were core values in my home. And I think when we think about, the systems that impact the. The onset of mental health, we think about the systems that impact, the early development. We have to think about our perspective on rules and discipline and learning. Right? And those, Those core values, those core beliefs that we share. So now we know that as a, as a culture, as a society, we've not been great about being prevention oriented.

Dr. Crystal Lee: Right.

Dr. Tara Raines: Like, folks like to see the output from intervention. And so for that reason, the investment has not been made in those early warning signs, in the early identification of youth, in finding, looking at, the behaviors, at the speech, at the things that we know later develop into mental health disorders. Right. It's very difficult for folks to invest in screening. Now, we're excited because SB165 just passed and was signed by the governor in Nevada. And what that means is that we're going to develop a workforce in Nevada of folks who are trained to do that screening. Excuse me, that prevention, that early intervention work, so that we can start to shift our systems to looking to the front. Right. Instead of having all of these systems that look and wait until there are behavioral issues or their emotional issues or there's the full development of mental health disorders before intervening. I hope that answered your question.

Bianca McCall: It did. Thank you so much. Before we move on to the next question, I'd love to know, from your perspective, how do these gaps in early childhood mental health systems that you're talking about, the gaps in screening and early intervention and things, how do those contribute to later vulnerability to opioid use disorder and what interventions could shift that trajectory?

Dr. Tara Raines: Yeah, so I think it's, it's the preventative oriented interventions, it's the screening, right. Those, those gaps allow the distress to continue. So, if you've got a child who is a school refusal child, right. Who hm, does not want to go to school because they're being bullied, because they're anxious, because, you know, they don't have the right clothes because of any number of reasons that kids don't go to school, and we suspend that child from missing school, right. We then exacerbate the issue. We're keeping them from education. Instead of having people in the schools having a system that looks to see the why, we're not spending enough time looking at the why. We're seeing some of these things that we don't want to see in children and adolescents. And so those gaps just grow over time. Right. If you think about a kid missing, I think it. We've got a stat from one of our national partners, it's between 30 and 50% of Nevada youth are chronically absent.

Dr. Krista Hales: Right.

Dr. Tara Raines: And so if you think about those gaps growing, like them missing school over time, right. What are they doing during that time? Who's supporting their mental health? Where are the positive, influences? Where's their, the cultivation of that love of learning that will help them keep going and encourage them to make choices that will benefit them in the long run. And so I think, I think when we talk about what interventions need to be done, like easily, we could start with universal screening for behavioral emotional risks. And I'm specific in saying screening for risk, right? Not screening for disorders. We want to screen for risk. So if we were to look at it from a food perspective, like we're looking for the, if we were screening for heart disease, we'd be looking for folks who eat McDonald's every day and smoke cigarettes and do the behaviors that are aligned with the later development of heart disease, right? So we don't want kids, we're not screening for depression, we're not screening for anxiety. We're screening for the kids that have the markers that show that they could later develop depression and anxiety so that we can get in there before the full blown, development and teach them some Strategies, teach them some skills, give them some tools so that the likelihood of acute disorders is minimized.

Bianca McCall: Yeah, no, thank you so much. And if anybody is confused, in, the audience here, Dr. Raines is speaking up and speaking out for the special population of youth. Right. And thank you so much for those examples, of universal, screening that needs to occur and of those interventions of how we can, impact our youth, populations. And really what I hear is it's starting with schools. Right? And, that's where they spend most of their time. And so why not? Why not, in the school Systems? Thank you, Dr. Raines. Dr. Lee, I'd like to move to you and ah, talk about some of the challenges for your special population being Native, indigenous. And what challenges do Native people face in accessing culturally competent care. Right, that cultural responsiveness when it comes to oud treatment.

Dr. Crystal Lee: Yes. Hi everyone. glad to be here. Just wanted to premise with that. and so our population is a little bit different. I feel. Not a lot of people know too much about Native Americans. maybe some of you do know that there are 574 federally represented recognized tribes currently in the United States. That's inclusive of Alaska Native, tribes as well, in addition to Native American tribes. So people want to kind, of put us in one box as we're just one big, ah, tribe of Native Americans. But in reality, we're all very different. 574 different tribes equates to different languages spoken, different, societal structures, different, ways of leadership and reservations and access to resources within those reservations and even non reservation systems. Because a lot of tribes also don't have reservations. So we're going through a list, of varied demographics. and when you, think about how to work with tribes and also our political sovereignty, is also a big part of our unique status. Because Native American tribes are not considered a racial ethnic group here in the United States. We're actually considered a political group because of our sovereignty. So then you're counting all these layers of us and wanting to work with tribes to address opioid, use and addiction. so we're starting from, cultural responsive services. does that tribe have an Indian health Service? do they not have, any points of care? If they do, do they have clinicians and that are staffed well to keep up with the mental behavioral health within that community? and if they do, does the community want to utilize them? Because some of us come from very small communities. And if we're talking about, opioid disorders. If there's a lot of shame or judgment that we feel that's associated the stigma, we're not gonna want to go into the Indian Health Service in our community where our aunt and uncle might work to seek, oud treatment. So there's just so many layers of how you contextualize, for us, access to points of care, culturally responsive points of care, and especially, accounting for the resources in the community as well. So those were just some, touching points that I could elaborate on. But just to give a very comprehensive of what it's like in every tribal community, it's very different.

Bianca McCall: Yeah. So it almost seems like the greater challenge, that we're really talking about is first we've got to educate people on that. Because I'd be interested to look at the chat here, throughout the session of how many people just learned ten new things in your response, Dr. Crystal? I think education is key and understanding, the diaspora and the nuances of, native indigenous people across regions, across, the different cultural factors that you named, that's gotta be an incredible barrier, to be able to access care if, you are unknown to the providers of that care. Wow. thank you so much. we're going to move to, speaking with Ryan Mills. M. Ryan and I'd love for you to expand upon, your special population, special group, as you're answering this question, but how much of a struggle, is it to, I think one, secure an identity, an identity in your special group, to secure an identity and then also, within that identity, do things like find employment, you know, with a criminal background and, and. And to, stay persistent in recovery. Right. And as being a part of your, Your special population.

Ryan Mills: Well, yeah, it. It's difficult to go from the top to the bottom and. And not, lose your identity. And then, yeah, once you do lose your identity, to find it again, and to kind of start, from the ground up to find a meaning. when I first got sober, I could, not find a job for the life of me. I was in drug court at the time, and that took some of my time out of the day. So it was a little difficult to align schedules with employment, employers and I would go and drop off job applications and with a criminal background and drug charges on my background, like the poll said, not a lot of people can trust, people with addiction problems. So it was pretty difficult. I was fortunate enough to, reach out to a friend and get a job in a warehouse, doing tile and marble stuff, like Moving tile, marble. $10 an hour in the Vegas heat. It was torture. but it was all I could find and did, that for a year and was barely making ends meet. And I was just thinking, like, why did I get sober? All it's. All it's is worse than, you know, trying to find drugs every day and live on the street. So I got fortunate enough and just happened to see someone that worked for the state of Nevada and went up to them and said, how do I get involved in, doing work for people in addiction? How can I reach back down and help people get sober? Like I did. This was about a year and a half into it. and she was like, ah, email me. And so I emailed her that night and she emailed me back and said, there's someone that wants to do a documentary. they're. They're looking for their last section for Hope. would you like to do it? And I said, sure. I went on there. It's like a week later there. They flew down to Vegas. They're from Reno, and they filmed the process of me getting out of drug court, having my felony dropped. and then kind of, you know, went on and it ended up winning an Emmy. and then somebody saw that in the state and offered me a job. and through CASAT, actually, I did the peer support specialist and the community health worker certifications and, ended up landing a job in the opioid field, for the Nevada Overdose, overdose Data to action. I was a, project coordinator, program coordinator at that time. yeah. And so I found a job like that. I was extremely lucky. I did have a college education, so that was a little helpful too. But just knowing that having, lived experience is kind of a superpower in this, in this field, and it's like super needed. I would have never known. So I think, like, if we could somehow make some awareness that there's a lot of options. You don't have to go sit in a tile in marble warehouse breaking your back for $10 an hour. and there's a space for you. I think that's pretty important.

Bianca McCall: Yeah, no, absolutely. What I love about the groups that you are, shining a light on is you talked about this fall, this loss of identity. And really what we talk about in our communities is like a fall from grace from you being a professional athlete, and experiencing that fall from grace, that loss of identity, as being uplifted, praised, iconicized and everything for your talents in your sport. to now, you mentioned working the torturous, jobs, the laborious jobs, and trying to find an identity out of that. And so many people in the recovery journeys, can relate to that rebuilding of trust and reshaping identity, that process, it can be more than challenging. I think challenging is saying, putting it mildly. And to overcome that just, what an incredible, what an incredible feat and inspiration. your story, you mentioned completing drug court. And so I wonder, Ryan, how have your experiences, with that, in particular with completing drug court, how have your experience inspired, this ah, advocacy, for change. Right, change in the diversion and drug court models. what would you suggest, in order to improve those outcomes for young people at high risk for opioid reoccurrence?

Ryan Mills: that is a great question. it's a tough question to answer. I think, if you could answer it, you would, you'd be saving a lot of lives. one of the things that I experienced in drug court was it was extremely strict. I thought maybe if there's a little more leniency, for example, I was living in a sober living house. It was an hour and a half bus ride to get to the drug court counseling every day. So if you relate to drug court counseling, by one minute they would shut the door, not let you in, remand you, throw you in jail for the weekend, and make it kind of feel impossible. and it could be as simple as the bus breaking down or some. Something out of your control, and they throw you in jail. There's no excuses. It's whatever, it's. It's too little, too hard. I think, I think if there was some more leniency in that, a lot of, A lot of people couldn't pay off their fines in time. And the drug court cost, I think it's 15 or 1500 for the year. But a lot of people don't have that kind of money, especially when they're just starting back into real life, and they weren't able to graduate drug court until they paid it off. So a lot of people end up being in there for two or three years and in that time you end up getting in trouble for something and then it all goes down the drain. And it's just. A lot of people give up easily and there's a stigma about drug court that it's made to have you fail which made me not want to go to drug court for a long time. I was arrested 14 times, mostly for drug charges and, petty theft and stuff. but I never got offered drug court until the 14th time. And even then I was like, that's impossible. I don't want to do that. Let me go do my prison sentence for five years. And then I called my mom, luckily, and she was like, just try it. And I said, I guess, and I stuck it out. Luckily, I, I was never late to class. I just always very paranoid about not getting there. So I'd show up an hour early and just spent my entire existence on getting through that first year, which was very helpful indeed. I did need the structure. I did need all that, but just a little more leniency, especially for the youth. throwing them back in jail for being a minute late is a little crazy to me.

Bianca McCall: Yeah, no, thank you so much for sharing that, sharing that perspective. And, you know, when. When anybody talks about, changing systems, right? I'm like, did somebody say changing systems? And that's somewhat of a calling card for Dr. Tara Raines. And so I'm going to shift the conversation to Dr. Raines and ask how do, these systemic, the systemic infrastructure, right. The institutional policies, things like, zero tolerance, for school discipline and restrictive Medicaid regulations, how do those contribute to the gaps in early OUD intervention for, for your population that you were speaking of?

Dr. Tara Raines: Yeah. So, Ryan, first, thank you for sharing your story. We don't hear your voice. We don't hear your stories nearly, nearly enough. And so I appreciate you for being here and for sharing, but there's so much of what you said that, like, I was having all types of sensations and I'm not great with my, my facial expressions, but, you know, when you talk about the punitive nature, right. The inability to see the humanity and people, that is what these policies are doing. Like, people aren't robots. Like, buses are late, people oversleep. Things happen. Now, we do want folks to, to respect and try to adhere and do some things with some discipline. And there's these zero tolerance policies, you know, some of the ways in which, you know, organizations like Medicaid have historically, historically worked, don't give that latitude for humanity, you know, and now we, we're in a federal context where they're talking about making additional hurdles and additional barriers for folks to get access to services through Medicaid. And so it's, I mean, for me, it's. It's incredibly frustrating, right? Like the moment we decide we're going to look at a rule and we're going to look at it without considering the context, we've let folks down, you know.

Bianca McCall: Absolutely, absolutely. And so. And I know that we've just got a couple of minutes Left with you, Dr. Rains. how do you apply, you know, some of those. How do you apply that, that insight into, you know, policies for schools, and how do you apply that to some of the policies, the regulations that we're seeing through Nevada Medicaid? how do we have an impact on the early intervention that, you proposed, for youth overall?

Dr. Tara Raines: Yeah, I think it's a couple of things. One, you should all run for office. So anyone who's on here who's thinking they maybe run for office, they should definitely run for office. Right? Because we need decision makers who can think in nuance. And right now we've got folks who see everything as categorical and everything is this or it's that, it's this or it's that. Right. And in reality, the only things that are this or that are probably like life and death. Right. Everything else is on a spectrum somewhere. And so until we can really start to see that things are on a spectrum, we're going to struggle. And we need decision makers who can make policy that recognize that spectrum. So if you think about restorative practices, restorative practices are fantastic. And we, we saw an incredible bill from the late assembly member Tyrone Thompson several years ago that really pushed restorative practices in schools because they look at the kids as human beings. They give them any opportunity to make repair. They teach them to make repair. Right. They teach them that their behavior, their choices, has an impact on their community. Right. And help them see that impact on the community. but then we saw that roll back in the 2023 session. and so I think we really just have team to keep our leaders accountable. We have to keep our decision makers accountable and remind them that kids and adults, right, I mean, teens, I'm sure, struggle with drug flare because the amount of rigidity and the inability to see that their brains are still developing even. Right. So, anyway, all that to say, thank you for your time and I need you all to run for office because we need smart decision makers. I know that wasn't what I came here to say, but I just feel like there's someone on this call that needs to hear that to help us move our systems, because it's really. It's baked into our system.

Bianca McCall: Absolutely. Thank you so much, Dr. Rains, for contributing to today's discussion. We do know that you've got to hop on a plane, and my apologies for getting you all riled up right before you hop on a plane. Ah, but, but thank you so much for. For your time today. And I'd like to actually, take this opportunity to look at, Who else have we riled up? I'd like to ask Jamie to. Let's look at the chat, see what questions, comments are coming out of the chat. while we have Dr. Raines gracefully, exit stage left. Thank you so much for your time. but, Jamie, who else is riled up out there?

Dr. Krista Hales: Yeah, well, first we had a lot of feedback, from Ryan's story, and a lot of people wanting to hear about what the specific job resources and training programs that you were referring to. so if you have any other information that we can share with the audience on that.

Ryan Mills: I don't necessarily have resources, but I know you can. They're. They're out there. I know, through CASAT, you can do peer support and community health worker certificates. and that's like a. A great entry into working for the state or for an entity that is like, giving back to the community. Anyone doing opioid stuff like Shine a Light and Sober living houses and all those things, rehabs, everyone needs help, with people with lived experience. Because if you don't have lived experience, people kind of don't want to listen to you. in. When you're a drug addict, you. You go to these counseling meetings and there's someone with a degree out of a book, and no one wants to trust what they're saying. They're like, how could you talk behalf of me? You don't know what we've been through. m. Me, personally, I. I wanted to listen to everything they had to say, but everyone around me was collapsing because of the lived experience. And it was like the number one thing that people need to hear from is, like, the people with lived experience. So they need to open up trust for more people with addiction. And, yeah, I think if you just Google search it, you'll find. You'll find what you're looking for.

Dr. Krista Hales: We'll also include some links in the chat box. We maintain a job board, that has a lot of peer report, peer recovery support specialist positions and community health worker positions. And also include some links to our peer recovery support specialist training program and CHW training program as well. Well, so that people have that, information there in the chat box. Yeah.

Bianca McCall: And Jamie, if I could say too, just thank you again Ryan, for sharing your perspective on this and being a voice for lived experience. I think that is so important. Especially since again we've prioritized this as a part of the conversation, for this conversation and for quite a few, through the NOCE program. And thanks for the shout out to our peer recovery and support specialist, certification training.

Bianca McCall: This is the time for lived experience. And what you're surfacing is there's stigma and there's shame, that's occurring. That's really isolating our peers with lived experience. when we are professionals, in the space and providers of this care, we can't have this us versus them mentality. We can't have this ah, inflated sense of professional experience over lived experience. Right. There's a role and responsibilities for all of us. What we're up against some of these statistics with oud, impacting Nevada communities. What we're up against is larger than the supply that we have of people that are able to connect and have that impact. And so we need all of us, just one equals all. so thank you so much Ryan. I just wanted to express gratitude for you sharing that perspective in challenging all of us to incorporate lived experience in our programming. Thanks Jamie. I see lots of great questions coming through. What do we got next?

Dr. Krista Hales: Yeah, the next question is for Dr. Crystal. in your opinion, how do urban Indian health centers influence the health and well being of Native individuals and families? Living in the chat keeps moving. Living in the urban areas as well as those living on reservations.

Dr. Crystal Lee: that's a great question. So for demographic purposes, currently, According to the U.S. census in 2020 now between 70 to 75% of Native Americans now live in urban areas. and so when we kind of think about the larger picture where the Indian health service systems and infrastructures are set up, they're predominantly are in reservation based territories. there's very limited hospitals and Native clinics in urban areas now where about majority of our people live and also the funding mechanism through the Indian Health Service, only about less than 5% of the total Indian Health service budget is allocated to urban Indian health services. So when you really look at it, the urban Native population, there's a huge gap of disparities on access to, to healthcare and resources. if you even just look in Las Vegas, there is a Las Vegas Piute clinic, neighboring downtown area of Las Vegas. But because it's a clinic and Not a full scale hospital. a lot of Native community members that I do know personally actually travel to Arizona. Phoenix Indian Medical center is one of the closest, a full scale hospital, that we have that's closest to Vegas and then also one on the Colorado, the crit, Indian Reservation. Colorado Indian Tribes Reservation. So a lot of our people don't have health insurance and a lot of us don't even know how to properly navigate. going into different types of clinics and hospitals that are not Indian Health Service based. Because a lot of us did grow up on the reservation. There was the Indian Health Service and that was our point of care. And then when we leave the reservation, the navigation can get a lot, a lot more trickier. So I mean I think this kind of understanding our points of care is a huge issue in general. and well even currently right now, I'm actually on the Navajo Nation right now. So I apologize. I'm actually sitting in my car, have my cell phone propped up and about 25ft away from me. My mom's actually running for an elected tribal leadership position. Today is voting day on my tribe and I'm actually here to support her. And so. But I'm around a lot of my community and the constituents, that is voting for my mom. M. One of the largest, recommendations is infrastructure. there's limited access to Internet and a lot of areas here on the Navajo Nation only 30% of our native population have water. Only 40% have electricity. and so even if you just look at basic amenities of access to basic water and Internet or electricity, I mean if you just really look even just kind of considering meeting people's needs, right? If people don't have access to running water, and or electricity yet they need all these, they need points of addiction care, counseling, behavioral health, hospitals, clinics. But yet we're looking at a scale of how do we treat our community members, in the most richest country in the world that should. Everyone in the United States should have access to clean running water. But people are hauling water and so they're looking day to day to survive. And so in a lot of those contexts, access to health and going to the hospital and the clinic seeking treatment is not probably going to be on the top of your list if you need to heat your house and go chop wood and get running water. So I just want to have a contextualization because I grew up on the Navajo Nation and I tell a Lot of people when we come home, I have to chop wood, I have to use the outhouse. it's not like me just living in Las Vegas where I just turn on the light and I go to the bathroom. It's a whole different way of life. And every reservation is different. Granted. But a lot of us do, have a lot of the same outcomes, is limited access to basic amenities, let alone access to, high tier quality health care systems and resources.

Bianca McCall: Thank you so much, Dr. Lee. That said a mouthful. And what resonates with me is we talk about this all the time. When basic needs aren't being met. When you talk about running water, shelter, electricity, food, insecurities, when those needs are not met, it's very challenging. It increases the challenge, it increases the barriers, to accessing quality health care. And then you get to that access point. And when we don't see, there's not the case management and support to be able to help, natives, navigate the system and be able to even ensure, coverage or anything of that nature.

Bianca McCall: The call to action is how do we outreach, how do we, support and mend some of those gaps, because we're to your point, it's infrastructure. And then Also I see Dr. Raines, before she left, she was calling to action that we need to get involved in the politics and the policies and the infrastructure. And you've kind of echoed that. you know, what's going on with your family. And I do see lots of well wishes and good luck to your mom as well. So thank you, thank you.

Dr. Crystal Lee: Appreciate that. also, could I just make a point as a provider, I have a friend of mine. She is, half dinette and half Hopi nations. She's an md, and she works here in Phoenix, as a family physician. But, her understanding as a provider and how she gauges her questions, especially if there's adherence, to medications or adherence to different, points of care. She really. And I think that the question to the why, it's often blamed on the patient or the client that, well, they're to blame because they're not adhering to their points of care. but if you, I mean, just kind of look at the social determinants of health. I love how my friend really breaks it down when she talks to her patients and she asked the proper questions. Do you have, do you have transportation? If you don't, how do you get here? And she really, dives deep, into and, and she tries to meet her patients where they're at. Okay, well, now that I know that you have a hard time making it here, can we mail you your medications? you know, how can we support you as a provider to make sure that we're doing our part and understanding your situation as a whole? Versus I need you to take these medications. I need you to come here three times a week. I need you to do this, this, and this, but not really, taking in the scope of the patient and where they're coming from.

Bianca McCall: Yeah. No. Thank you so much for talking about what works. I think that's a great segue into the next section of our listening session. Talking about solutions. Jamie, I know that there's been, so many great questions, and, you know, this isn't a shock, this isn't a surprise when we talk about special populations. We're going to get, all of us in a room and we're starving for resources, right? We're desperate and we're starving for the information, for those connections, for those resources, for some very basic needs. this is not a surprise to me, and I don't believe, for most of us on the line. And so we will address, some of these questions and we'll carve out some time before we end today to go back to the chat and then also, to provide those resources and things, following the listening session. But I'd love to get to the part where we are talking about solutions to increase our reach and our impact for our special populations that we're talking about today. and I want to get real. I love the realness, the authenticity, authenticity from the lens of lived experience. I love that, Both Ryan and Dr. Crystal are, contributing to the conversation in that meaningful way. I, know that we've just lost Dr. Raines, but Jamie, I'm to understand that, she left some information with you in us asking, how can schools become more, central to the public health response to oud, particularly in under resourced communities. Communities, where we, face those intersecting risks that she, she shared with us early on. Jamie, do you have a response for that?

Dr. Krista Hales: Yeah, I have the pleasure of reading Dr. Rain's response that she submitted in advance. She says schools are often the place where kids spend most of their day, and sometimes it's where they feel the safest. We know this is not always true for youth of color. That said, schools are still one of the best places to notice when somebody's. When something's wrong. Early on, like when a student is showing signs of stress, trauma or substance use. In under resourced communities, schools are sometimes the only place where kids regularly see a caring adult. So if we train school staff, not just teachers, but counselors, nurses and even coaches, to recognize early warning signs and respond with support, we can catch problems before they grow. That's why the new behavioral health and wellness practitioners created through Nevada's SB165 are such a big deal. These bachelor's level professionals can work in schools and other settings to help kids before things get worse. They're trained to focus on prevention, build trust with students and families, and connect them to care when it's needed. This new role will help schools become a stronger part of our public health system, especially in communities that haven't had enough resources for too long. It's a step toward making sure every young person has someone in their corner before they're in crisis.

Bianca McCall: thank you so much for sharing Dr. Rain's perspective and I did see it float through the chat earlier. yes, you will have the contact information of all of our subject matter experts and panelists. we also have a quick shout out to the NOCE Dose podcast, that always follows the listening sessions where you'll be able to take a deeper dive into some of these perspectives, and comments made by our panelists. and so, but thank you Jamie for making sure that Dr. Raines, viewpoints on that are heard and understood here. And Ryan, speaking for yourself when we're talking about assessing risk and things like that, and again with your population, is so unique when we talk about youth that are involved in sports and with friends, physically demanding lifestyles, such as yourself, as you were going through, your journey, when we talk about performance, youth especially that are performing well, whether it be in sports, academics, music, arts, entertainment, when we talk about performing youth, how can we better assess risk where otherwise we're so hyper focused on their, on nurturing their talent. Right. And praising kind of their talent in the sport. How do we better assess when they might be in some trouble?

Ryan Mills: Good question. I, think, yeah, I mean the signs will be there. I think if things are starting to go south, I think preventing that is probably a little easier. making sure kids aren't getting injured and getting thrown back into the game too soon, making sure they're not being over trained, maybe even having, I think what Dr. Rains left with us was there's going to Be people at the schools being able to do this stuff. going to the practices and letting the coaches know, the kids know, the parents know that what can happen if you get injured and you take a pill, what the doctor ordered and you put your trust in that doctor. you don't always have to take those pain meds. You can take an ibuprofen and probably alleviate pain a little better with that. yeah, so I think, yeah, just prevention beforehand. and if you see someone kind of going south, taking them aside and assessing the situation right then and there, M. And taking care of it before it gets bad.

Bianca McCall: I love that you're bringing up, especially for our youth in today's sports culture and performance culture, that it's actually a business, it's a job for our youth that are engaged in, in competitions. and it's in, I know as, as adults in, in these performing youth's lives. we definitely feel like it's a, in this extra job. Right. that, that comes with expenses, that comes with sacrifice and things. but as a part of that job, and then being exposed to in extreme cases a little bit of the sports or labor kind of trafficking, right, that we are, we're forcing kind of this sacrifice and for them to perform, with adult expectations that they are over trained, that we are asking them, they're overwhelmed with the expectations, and the demands that we're placing on them in performance and again performance in sports, in academics and school, in some cases the workforce right early on. And so, I love the point of upstream prevention. and let's stop doing that. Let's start there. and then we'll be able to earlier, recognize the signs of trouble, of stress, of things going south. Thank you so much for, for bringing up those important points. and Dr. Lee, shifting to your special population. you know there's so much that you said, but there was so much that you didn't say in your last comment. Right. When we talk about some of the intergenerational trauma and forced relocation. I mean you talked about having to you know, transportation and things and having to drive to Arizona for services and things like that. But let's talk about the initial distancing and relocation of your people. and how do the intergenerational trauma. How do the forced relocation continue to shape the opioid risk environment in tribal nations today and what protective cultural factors support their resilience?

Dr. Crystal Lee: absolutely. I absolutely was going to touch on this, Bianca, so thanks for bringing this up. Yes. I don't really know. I know there's just a lot of people on the call today. for those that are not native and really have limited information on our background, when we're talking about historical trauma and oppression, we're talking about, the formation of colonization here with the United States, and the genocide of our people and the removal of our original homelands, which was, land genocide as well. a lot of people may not know that a lot of our spiritual, cultural and even societal, cultures have been rooted in our connection to the land. so when you displace, whole tribal populations and move them westward, to occupy more land, and that consistent, mobilization, also has been, displacing. Not only, are people geographically, but also, culturally, spiritually. Because a lot of our traditions, our songs, our language is rooted in our home environments. that's why a lot of people ask, if it's so bad on the reservation, why don't you just leave? and I'm like, no, because our spirituality is here. and we just can't just get up and leave. And we're losing a lot of our sense of ourselves. So if we go back into, the landscape of the history between tribes and the United States government, so first it was, efforts of genocide. Then it goes into, land removal. And then after land removal, it goes into boarding schools to where a lot of our community members were forced to have their children as early as 1, 2, 3, kidnap, literally go in the communities, kidnap the kids, take them to a, boarding school, where they were physically, sexually and verbally abused. we couldn't speak our language. We couldn't practice our culture. there was a lot of, sexual abuse that occurred, in the boarding school and systems. and then now you're leaving. Not only are people physically disabled displaced, but also linguistically, community displaced because although they're native, they weren't allowed to be native. And then when they go home to community, they don't really know who they are. There's a big sense of loss of identity, of trying to come back to community because they were gone in those boarding schools for so long. and so the eruption of alcohol and substance abuse really has been coincided with, our historical trauma, experiences. And in addition, this was only two generations ago. it really irks me when people say, well, you know what? This happens hundreds of years ago. you guys should Just get over it. you know, like US is still a very young country. It's only about 200 years old, as the formation of the United States government. So we're still relatively young. if you look at intergenerational trauma within, indigenous, slash, Native American, Alaska Native and even Native Hawaiian populations, we're only about two generations off from these boarding school systems. And so that's just like my grandmother's age, where there was a lot of, experiences, hence a lot of alcohol abuse that's associated with that. And then that's passed down generationally. and now we have these other, forms of drug abuse such as opioid, but they all go hand in hand. and so I think a big. For me, I'm not co dependent on the United States government to solve my problems and my community's problems because in a sense, the US Government is the one that created in the first place, from colonization to now. and so how do we identify culturally responsive, services that really speak to healing our people? And so that is just the reinvigoration, of who we are, our food sovereignty, our political sovereignty, of our traditional, ways and practices. And mind you, it wasn't until 1978 that the Native American Religious Freedom act was passed. So prior to 1978, our communities were not even allowed legally to practice our culture, but otherwise we would be jailed or imprisoned. That was just. 1978 was not that long ago. so prior to that we weren't free to be who we were and are. And now, because it's just been a continuous ray of political policies, the healing has to start with our heartbeat, which is our song, which is our language, which is our land, and which is our community. it has to start there. And so, and that's why when I come home, I love being home. Because I can speak my language with my community members. I can go to ceremony, all the time. And it's such a different, it's so different than mainstream America because although I grew up in the United States, I definitely feel like I grew up in a different country and, and I didn't grow up in the United States, if that makes sense. So I know I said a lot, but, I'll just stop there. We could move on. So thank you.

Bianca McCall: No, I appreciate it. Dr. Lee, I, What I hear when I think of resilience factors for your people, I hear, language and spirituality, connection to land, homeland. Right. Return to Homeland. I hear those as being, resilience factors. And, and I think that's so important for, for all of us, to, to take from that because we, we're constantly saying how language is important. Right. With any of our populations. Ryan. Right. We're, we're constantly saying the, the way that you communicate that, the way that language shapes the experience is so significant in, in the outcomes. and, and What I heard, Dr. Lee, you kind of take that, you know, a step forward. that language is, is, is a powerful healing source. Right? It's, it's a, it's a, resilience factor. It's. Yes, it's important, but it's, it's a, it's an important resilience factor. Right. Language community, and, and land. Right. Return to homeland. So thank you so much for, for sharing that. now I have some questions, questions that I want to ask you both to answer. one of them is, and this is just very quick, I know I'm putting you on the spot, but if you could redesign the first 48 hours of an intervention from someone who's been newly identified with opioid misuse or use disorder in your special population, this is the first 48 hours. What would that immediate support system look like clinically, culturally and or relationally? All right, so that's a big question that I'm throwing on you, for a response, but what does the first 48 hours look like for your population, clinically, culturally, relationally? Dr. Lee, I saw you come off mute. I see that, ah, finger point about to happen. So let's have you start.

Dr. Crystal Lee: again, I can only speak for myself, not representing my tribe or all Native Americans, and only speak to how I grew up. what I would love, if some of you, never been on a reservation, it's pretty rural. and so again, our reservation, there's a lot of ruralness, so there's a lot of land. one of the things I would really love is land based therapy. coming back and being one with the land by learning how to, like, again, we're talking about food sovereignty, about just knowing how to live on the land. But also as a part of therapy, I would love to bring the first 48 hours, in the middle of nowhere on the reservation, of course, to have RNs, in case of. Because we know it's dangerous, especially, coming down off of different types of drugs, how physically damaged, how physically harming that could be if not properly, attended to. So Definitely have our medical care, but also, have some of our traditional healers heal as well, to add on to the Western care medicine. But really the medicine people would come with their own herbs, to help assist and facilitate, the first. Because I know the first 48 hours could be pretty tough on a lot of folks, and so just to help them, in a holistic sense, and have our medicine people with the herbs here in addition to that, but also understanding the land that's surrounded and how significant that piece is as well on reaching sobriety, again in your life. So I think just kind of the hybrid of Western versus our traditional healing on our homeland, that that speaks to land based therapy.

Bianca McCall: Yeah, and I'm going to echo the sentiments, that has been spoken, throughout today's session is that we've got to get involved in the legislative processes to ensure that we as providers are empowered with the ability to be able to provide such a service as land therapies to the ability to be able to integrate, traditional healing, that is culturally appropriate, when, when treating, you know, members of, of Native, native, indigenous, tribal nations. thank you Dr. Lee, for that. Ryan, what do you think? What do the first 48 hours look like?

Ryan Mills: So the, the only first 48 hours I've ever experienced is in booking. You got, in jail, laying on the floor under the bench, freezing cold, getting kicked by other inmates, being called names, and just being left to rot and then being verbally abused, sometimes physically abused by the cops. so I would change all of that. I would. Maybe as they assess you, as they do as you walk in, they give you a whole list of what are you on? And you have to give them what drugs you're on. I think they should expedite that, for those people to go straight to the medical unit, have the care that they need from the beginning. I had many times where I thought I was gonna die on the floor in those booking cells. So, maybe a little more compassion there and getting people upstairs faster and giving them maybe some soup to eat instead of the nasty trays or food that they give you. I don't know. It's. Yeah, it's a rough first 48 hours, first two weeks, first month, it's rough. so I can only speak on the way. I, know and it's the jail way. I've never got the easy, nice little rehab, cushy room and Cool groups to go to and all this stuff. So yeah, that's, I guess that's my special population there.

Dr. Krista Hales: So.

Bianca McCall: Yeah, well, and it's, it's I don't think it's a coincidence. What you have effectively described is, you know, diversion, it's community based organization, it's living room model. it's not call, 911, go straight to jail and be, left on the floor of the booking rooms. what you described is, the ideal, the intent, the inspiration of a crisis now model, that's working effectively. and we are, our direction is there certainly, but this certainly, your shared experience, for me it lights a fire a bit for us to develop those community based organizations, to develop those living room models within, our own systems and programming and meet people with compassion. I loved it. I love it. next question I have for you both to answer is how do you each define the value of lived experience as data? And what would a data system that honors those narratives alongside the clinical metrics? What would that look like in practice? And this time I'll have you start, Ryan.

Ryan Mills: Okay, so, the value of lived experience as data. I, I mean I said it earlier. I think it's probably one of the most important things to have someone with lived experience to connect with the people in recovery. but you also need the clinical side. You need to have both. You need to have facts and you need to have someone there you can trust. So, yeah, I mean, I think it's very valuable. and I think if you have both, you have a winning model there.

Bianca McCall: And Dr. Lee, I'm going to ask you that same question, but before I do, I'd like to ask Ryan, just how is your sharing your story from the documentary and how that story has evolved to even now today on the listening session. But how has sharing your story changed your understanding of recovery? And what, what advice would you give to the professionals that are on the line, the community members that are on the line, anybody who has, any effort or impact in designing these, these programs for people whose stories may still be unfolding in real time?

Ryan Mills: yeah, sharing, sharing my story has been super important to me, getting my truth out there, kind of unloading off of myself. and I mean I know a lot of like the AA and N A meetings, they, they want you to kind of pipe down and not be loud about this stuff. But I think it's helped a lot of people by me talking I use my platform on Instagram and Facebook to reach out to many, many, many BMX people and sports people that go through things. I get tons of DMS all the time, like hundreds and hundreds a year of people needing help. So I think just talking about it and not being afraid of what people think about you and I think it, Yeah, I think it did give me some sort of identity back too. It gave me a voice again. So I think it's important to talk about things. So more of that.

Bianca McCall: Talk of Tuesday. I love it. Thank you so much ryan for that. Dr. Lee, posing the same questions to you, starting with how do you define the value of lived experiences, data? And what would a data system that honors these narratives? What would that look like alongside the clinical metrics?

Dr. Crystal Lee: I kind of have a lot to say. My thoughts are all over the place about this, because I'm a data nerd, as a scientist, actually I'm an infectious disease research doctor by academic training. We understand science from a very Westernized framework, of clinical trials, of getting all these quantitative data mechanisms in place that speaks to the validity of the science. but also I'm not just any researcher. I'm also an indigenous researcher. And so there's been this new wave of indigenous research methodologies, where a lot of our indigenous researchers, at the global level, have really started to retake the narrative of, of using qualitative data as valid science. because our stories are in our, in our cultural traditional ways. we have a lot of oral storytelling to pass down different wisdom, aspects of our tribe, of our culture, different herbal wisdom, different you know, origin stories, that help shape our culture or songs in our ceremony. So we do, storytelling is really huge in our indigenous, indigenous communities. And so, there's actually, I just published one of my research, articles in a peer reviewed publication. But what I really loved about this was it, it's from New Zealand, from our Maori relatives, in New Zealand that started this indigenous well being, and healing journal. but what I do love about this is the lead scientist has to be indigenous, to publish in this specific publication. and I have found between, publications between hard science, and what seemed as again more quantitative versus qualitative, we as indigenous people, we have to have that qualitative side, because again that speaks to our lived experiences, from a narrative that no one else can place but us. and then also using our Lived experiences to help hone and guide the research. one thing that is really frustrating for me is when there's kind of that inside, outside, external, internal research approach where a lot of researchers who are not from the community come in and they kind of practice this helicopter research. I mean they're not even asking the right questions. They don't know the people, the resources. And so how can you really produce, very good science based, quantitative studies that are based on surveys that have been developed, these survey instruments that have been developed by people who don't understand the community. anytime I work with all of my research projects, I always have an advisory board even though I am native. But I, although I don't have every lived experience as a native person. So I bring in, whether it's a youth based research, project. I make sure I have native youth at the forefront of my research because they're the experts and they're only. They know the terminology, they know what their peers talk about. I don't. I'm an outsider because I'm not a youth. and so I always bring the people to the table and they're involved in my research a thousand percent of the way. Not only do they help me develop or adapt or modify the survey or these quasi focus group, from the development of the instrument all the way to the publication. Because, for example, we did a huge project with native youth and we were looking at resilience factors to address mental health and suicidal ideations. And so we started with the youth and they helped us figure out what questions were important. But after we actually allocated the data and we started to analyze the data, I'm like okay, these are all these data points. What relationships in these data points are these coral, that you want to correlate to see what type of outcome. So they wanted to see how these factors had impact on these questions. And so we analyzed the data using the native youth. and so, and that's what I.

Bianca McCall: Hear a lot of is that it supports the storytelling, the lived experience, support, supports and informs the direction of the research. Right. It helps shape those data sets. And I can completely appreciate that, tying that into the culture as well, as being very culturally relevant. I'd love to give the panelists an opportunity to kind of give their mic drop. Final thoughts in a minute or less, to be able to share with the folks, before we jump off the line today. And so starting with Ryan, final thoughts. Anything if you're, if you're reaching one person out of this whole listening session, if this 90 minutes meant something to one person, what, what is that? what is that thought? What do you want people to take away?

Ryan Mills: I just always want to end with you can do it statement. because if I can do it, you can do it type of thing. I was real bad off. give your loved ones grace if you're, if they're dealing with substance use disorder. it's good to have someone in your corner if you're dealing with that. and I know it can be hard to, have trust in, you know, family members that continually kind of screw you over, but to be there for them once they decide to make the choice on their own to get help, if you're there for them, then that's the most important part.

Bianca McCall: Yeah, you can do it. Thanks, Ryan. Dr. Crystal, what do you think? What do you got?

Dr. Crystal Lee: just meeting the community where they're at, and finding, using the community and the people that you're trying to positively impact. you know, we might have all the degrees in the education, but I guarantee the people who live in the community who are experiencing, the disparities that they are, they have the solutions. And if you just take time to truly listen, from a humble capacity about what the solutions are, to counteract the barriers, I guarantee that you will find some really good, proactive solution based nuances, in there that you can, that you can make come alive and actually give those, strengthen the community and to help mobilize them in that, in that capacity by really listening to them. So that's, that's what I have.

Bianca McCall: Thank you so much. And thank you again to Ryan, to Dr. Crystal, to Dr. Rains, who's in the air above. Thank you so much for joining us for today's listening session. Thank you for listening to the NOCE the Opioid Epidemic Unplugged. we hope that you found this episode compelling and informative and we ask that you please share this episode with your friends and your colleagues. And if you want to learn more, please visit our website at www.nvopioidcoe.org. the NOCE Dose podcast is brought to you by the Nevada Opioid center of the of Excellence, or NOCE NOCE is dedicated to developing and sharing evidence, informed training and offering technical assistance to professionals and community members alike. Now, whether you are a care provider or a concerned community member, NOCE provides resources to support those affected by opioid use. Funding for this activity was made possible in whole or in part by the Nevada Nevada Department of Health and Human Services DHHS Director's Office through the Fund for Resilient Nevada.

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CASAT: This podcast has been brought to you by the CASAT Podcast Network, located within the center for the Application of Substance Abuse Technologies, a part of the School of Public Health at the University of Nevada, Reno. For more podcast information and resources, visit casat.org.