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Project CARA

Learning How to Heal for Two

The day Becca found out she was pregnant, she panicked.

She was actively using and using a lot - she wasn't sure how she was still alive much less pregnant. Suddenly, she had someone else's life to consider. This was a sobering thought. So was her fear that if she continued using, she'd lose custody of her baby after delivery. That was what happened with her son, who she thought about every day.

Becca knew she didn't want to lose another child. She also knew she needed help.

A friend told her about Project CARA, a perinatal substance use treatment program at MAHEC Ob/Gyn Specialists in Asheville.

"She assured me Project CARA was different," Becca remembers. "She told me they really cared and wouldn't judge me."

"I didn't believe her," she admits. "The fact that I've used is in my medical records. I think it's important for people to have this information. But every time I've needed medical care, what I've gotten is harsh looks."

"Nobody can get healthy with that kind of treatment," Becca adds. "The judgment is even harsher if you're pregnant."

She decided to risk the shame anyway. What she received instead was a warm welcome.

Project CARA: Care that Advocates Respect, Resiliency, and Recovery for All

"At my first appointment, Mel walked in with a big smile on her face and asked how she could support me," Becca remembers with a smile of her own. "MAHEC picked the right staff - everyone here is very understanding and compassionate."

Melinda Ramage, FNP-BC, CARN-AP, affectionately known as "Mel" to her patients and fellow team members, is Project CARA's medical director and co-founder. She knows how important it is to meet women wherever they are in their substance use or recovery process.

"Pregnancy presents a unique opportunity for women to break the cycle of addiction and trauma," Mel shares. "Nearly 70 percent of pregnant women with substance use disorders tell their ob/gyn provider first."

"Our job is to ensure our patients feel safe enough to tell us what's going on and then help them access the resources they need to have a healthy pregnancy and birth," she adds.

Breaking the Cycle with Comprehensive Care

In addition to prenatal care, Project CARA provides onsite trauma-informed counseling, medication-assisted treatment for patients with opioid use disorder, group support, birth planning, and help securing legal aid, housing, food, and transportation assistance if needed.

Team members include ob/gyns, nurses, licensed addictions specialists, counselors, pharmacists, dietitians, hospital delivery planning staff, social workers, lawyers, and certified peer support specialists. This integrated community-based approach ensures patients get the support they need at each prenatal visit.

"I had access to so many different support people," Becca recalls. "Whenever I needed to talk to someone or check in, they were always available to meet with me before, during, or after my prenatal visit."

This comprehensive care is what helped Becca break her family's cycle of addiction.

"One of the reasons I kept using was to numb the pain from losing my son," Becca shares. "Project CARA helped me stay clean, have a healthy baby, and get my son back. My life has totally turned around."

Healing the Next Generation by Training this One

Project CARA is one of the few programs of its kind in North Carolina and across the country.

Since the Project CARA's inception in 2014, the number of patients has increased by nearly 300 percent. In 2018, the program supported 242 patients from 19 rural Western North Carolina counties. Nearly 80 percent of them attended every prenatal visit, almost 60% were free of illicit drugs at delivery, and 100 percent felt supported in reaching their treatment goals.

The program's emphasis on keeping mothers and babies together after pregnancy reduces additional trauma to the family system and encourages ongoing recovery.

Project CARA also eases the pressure on limited community resources. Every baby born at term saves roughly $47,000. Babies who don't need treatment for neonatal abstinence syndrome save an additional $50,000. And every child who stays with its family saves a minimum of $26,000 a year in foster care.

In order to ensure that more families can access this life-saving care, UNC Health Sciences at MAHEC is committed training the next generation of healthcare providers.

Project CARA provides clinical training for health sciences programs affiliated with the academic health center including learners from the UNC School of Medicine (SOM) Asheville Campus, UNC Eshelman School of Pharmacy, and UNC Gillings School of Global Public Health. These future healthcare professionals see first-hand how trauma, substance use, and stigma impact health outcomes and access to care.

Changing the Way We Think About Addiction

Third-year UNC SOM Asheville campus student Nico Lenze had the opportunity to work with many Project CARA patients during his clinical rotation. It changed the way he thought about substance use disorders.

"Opioid dependence is not a moral failing," Nico explains. "The women I met were amazing. They wanted nothing but the best for their children. Most of them had complex trauma histories and limited access to resources."

During his hospital rotation, Nico visited a patient he had seen many times in clinic who was scheduled for a C-section later that afternoon. When she was brought into the operating room for the procedure, he happened to be there.

"Is Nico here?," the patient asked from behind the drape.

The attending physician indicated that he was, but he assured her that Nico would only be observing.

"Oh, I was just asking," she replied. "I want him to be here."

That moment made all the studying worthwhile and reminded Nico of the kind of doctor he wanted to be - one who takes the time to listen to his patients because listening matters.

Learning to Overcome Stigma

Marie Gannon, LCAS, LPC, CSI, Project CARA's behavioral health director and co-founder, couldn't agree more.

"The more providers we educate, the more we are able to decrease the stigma associated with substance use disorders and improve access to treatment for this chronic medical disease," Marie shares.

"Having to explain to learners why we approach things in a certain way helps our faculty grow as well," Marie adds. "It's important for us to keep questioning our assumptions to ensure we deliver the best care we possibly can."

The recent integration of clinical pharmacy residents is a great example of how teaching practices like Project CARA can promote innovation.

MAHEC is a national leader in clinical pharmacy practice, training, and opioid stewardship. The program attracts pharmacy residents from all over the country who are interested in safe opioid prescribing and medication-assisted treatment.

Gwen Seamon, Pharm.D., is one of those residents. Growing up in rural Indiana, she saw the toll the opioid epidemic took on her small community. In high school, she worked part time at a local pharmacy and saw how challenging it was for people with opioid use disorder to access treatment. There was only one buprenorphine prescriber in town, and the nearest methadone clinic was a two-hour drive away.

After graduating from pharmacy school, Gwen joined the residency program at MAHEC to gain more experience in ambulatory care and opioid stewardship. She's getting an opportunity to practice both while working with Project CARA.

Building on a Foundation of Trust

Medication-related questions typically come up during the initial medical intake, so Gwen began doing them, which streamlined the workflow and enabled medical support staff to perform other vital services.

As the first provider who meets with patients during prenatal visits, Gwen works to establish trust and a good rapport right away. She has taken cues from veteran Project CARA staff who are careful to use non-stigmatizing language and a patient-centered approach. Because she sees patients every two weeks, Gwen has developed a deeper understanding of her patients' complex histories and medical challenges.

"Having a substance use disorder can be so stigmatizing," Gwen shares. "You can't understand what these women have experienced until you sit with them and hear their stories. This is what it takes to shift your perspective."

"These moms are just like any other mom. They want to do what's best for their baby," she explains. "And they have a chronic medical condition that requires extra support so they can be their best."

Becca is no exception, and she's grateful for the extra support she received.

When asked about her goals for the future, she doesn't hesitate.

"I focus on one day at a time," she replies. "Take care of my baby, take care of my son, take care of myself. I know the rest will take care of itself."

With what she's learned by participating in Project CARA, odds are it will.

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