Roads to Recovery
In Rural Maryland, a New ‘Been-There-Done-That’ Approach to the Opioid Crisis Offers Hope on Four Wheels
A Caroline County Health Department van carries counselors for opioid use disorder to rural areas. A UMD researcher is studying the effect of peer support in clients' treatment.
Photos by John T. Consoli
In the parking lot outside the First Church of God in Federalsburg, Md., at an intersection sparsely flanked by an auto parts store, a boxy warehouse and a few tired-looking houses, a white van quietly offers what many people in rural parts of Maryland desperately need but often can’t get: treatment—and genuine understanding—for opioid use disorder.
The 38-foot Mobile Treatment Unit (MTU) operated by the Caroline County Health Department is part doctor’s office, part counseling center and part support group meeting. Clients board, meet with a registered nurse in the back to check their vitals, enter a booth outfitted for virtual visits to see a doctor at the University of Maryland School of Medicine (UMSOM) in Baltimore, stop at a restroom to give a urine sample, and wrap up by chatting with a substance use counselor in her office in the front of the RV.
A patient’s guide through the process, though, is a peer—someone who’s experienced the ravages of addiction and can listen without judgment to the stories people using drugs may be too ashamed to tell a doctor or a nurse: the sex traded for drugs, the possessions stolen from relatives and pawned, the children neglected in the haze of a heroin high.
On this mild June Monday, Jessica Anthony is a burst of color in an otherwise drab landscape. Sporting an orange chevron dress and a blond pixie cut, she is as bubbly as you’d expect a woman who never leaves the house with unpainted toes to be.
Today, Anthony is observing how the MTU’s staff handles patient visits, but it wasn’t long ago that she was on the other side, climbing the van’s steps to get help for an addiction to methamphetamine and prescription opiates. Now, she’s part of a University of Maryland, College Park study examining how peer treatment can be a bulwark for recovery—a project with sweeping possibilities that stretch from this rural hamlet to struggling neighborhoods in Baltimore to impoverished shantytowns on the other side of the world.
The study is led by the director of UMD’s Center for Substance Use, Addiction and Health Research (CESAR), Jessica Magidson Ph.D. ’13, with UMSOM Associate Professor of medicine Dr. Sarah Kattakuzhy and funded by a nearly $4 million grant from the National Institutes of Health. The work builds off of Magidson’s research training lay people in the U.S. and sub-Saharan Africa to become leaders in grassroots health care in areas where hospitals, doctors or other elements of health care infrastructure are hard to come by.
“It’s essential to get community buy-in,” says Magidson, who is also an associate professor of psychology. “The peer model of having someone who’s from your community, who’s been a patient of the service—it’s so important to establish that trust and lived expertise.”
Without the preppy panache of St. Michaels or the boisterous energy of Ocean City, Caroline County and its towns are mostly sleepy stretches of farmland punctuated by gas stations, churches and the odd convenience store.
“We were tickled pink just a few years ago when we got a Walmart,” says Sarah Lepore, clinical supervisor in the county health department’s behavioral health unit. “That was a huge deal to our community, because we had to drive 40 minutes to get to one.”
Maryland is one of just eight states where drug overdose death rates are higher in rural counties than urban ones, according to the Centers for Disease Control and Prevention’s most recent data, from 2020. Across the state, fentanyl caused 2,034 overdose deaths in 2022, a slight decrease from 2,338 the year before. Caroline County, with a population of roughly 33,000, saw 14 fatal overdoses in 2022; by June 2023, there had already been 13. Nationwide, the CDC reported that a record 109,680 Americans died from drug overdoses in 2022, largely from fentanyl, and estimated that only 1 in 10 people who use drugs receive medical treatment.
Factors that fuel the market for drugs are numerous in Caroline County, and mirror other drug-plagued communities in the U.S. According to data from 2014–18, nearly 57% of the population lives below the state poverty line. Jobs are scarce, and many people lack reliable access to transportation to get them to work.
The generational inheritance of addiction is also potent. “We’ve got grandparents, parents and grandchildren coming to the MTU,” says Carla Penny, an MTU coordinator with the health department. “They thought this was the way of life, and we’re showing them a different way of life.”
As the opioid epidemic sank its claws into Maryland and the nation, there was no physician trained in addiction who served the county, and the closest rehab centers were in Cambridge or Chestertown—distances too great, either logistically or psychologically, for many Caroline County residents to travel.
Seeing the myriad challenges facing the area, Dr. Eric Weintraub ’80, a professor of psychiatry at UMSOM who specializes in addiction, proposed to the local government in 2018 that they work together to pursue a federal grant for a telemedicine vehicle. He and his team had already been providing telemedicine visits and prescribing buprenorphine to wean patients off opioids through the building that housed the health department, but many residents couldn’t get to the office. On the other hand, the van would be able to meet residents where they are.
Now operating out of two RVs with a team of five doctors, a registered nurse, a social worker, two coordinators and two peer recovery specialists, the MTU has become an institution of sorts in the county. For Magidson, the innovative model of the MTU—which treats about 120 people per month—provides an opportunity for her to examine the impact of peer counseling in hard-to-reach rural areas.
“Not only do we not have enough prescribers, we also don’t have enough psychiatrists or psychologists anywhere, to say nothing of in these rural communities,” says Magidson. “We’re aiming to figure out how we can best train peers, with their own personal experiences of substance use and recovery, in the interventions that will work best and most efficiently to help support people.”
In 2010, Magidson (right) was a UMD doctoral student in clinical psychology studying HIV/AID and substance use in Washington, D.C., when she traveled to in Cape Town, South Africa, to teach a public health course on the intersection of apartheid and the HIV/AIDS epidemic. There she saw the legacy of colonialism and apartheid: poverty, shantytowns, a lack of access to basic medical care, let alone mental health or substance use services.
Wracking her brain for ways to provide help in the face of profound need, Magidson honed in on what would become the focus of her career: peer-led behavioral health services. She met laypeople who’d survived addiction and were now helping others navigate its treacherous ground, working alongside physicians, psychologists and other health care workers.
Several years later, Magidson began postdoctoral training at Massachusetts General Hospital (MGH) and Harvard Medical School, with an emphasis on global mental health in sub-Saharan Africa. Upon returning from a trip to South Africa, she was in a meeting with several addiction medicine doctors discussing how to embed peer recovery coaches into primary care practices at MGH. “It occurred to me that this model of training laypeople was exactly what we were doing in South Africa, but here (in the U.S.), we were behind in knowing how to best train, supervise, and support this workforce,” she says.
Magidson, who has been awarded $14 million in funding from the National Institutes of Health since joining UMD’s faculty in 2018, now leads seven clinical trials across South Africa, Detroit, Baltimore and Maryland’s Eastern Shore. In each location, she and her team train peers in evidence-based techniques to support recovery, including behavioral activation—a treatment originally developed for depression that emphasizes engaging in fulfilling substance-free activities. Peers also learn problem-solving strategies to address barriers to taking medication and staying in care, and how to share their own stories in a way that will resonate with patients.
Under the guidance of Magidson and her team, Jessica Anthony will be working with MTU clients on new ways to approach recovery, discussing how to find new meaningful ways to spend time and engage with others that does not involve use, and how to navigate barriers to staying in treatment.
All those who work on the MTU say peers are critical to making inroads against addiction. It’s a truth Anthony knows firsthand.
Growing up in Denton, Md., Anthony was raised mostly by her paternal grandparents while her mother and father struggled with addiction. Though she began drinking socially in high school, she knew from personal experience when to call it quits.
But in 2017, Anthony’s 11-year marriage began to falter. She began drinking—a lot, by her own estimation; wine, at first, and then beer, rum, whatever she could get her hands on. She found a new circle of friends and began dating a man who she quickly realized was using drugs. Until age 36, Anthony had never touched an illegal drug, but she replaced her Adderall prescription with methamphetamine and started using opioids soon after.
“I started to self-medicate, because I didn’t want my primary care physician to know that I was going through a divorce,” she says. Her doctor treated her whole family, and in the roughly 5,000-person town of Denton, news travels fast.
Police found drugs in her car during several traffic stops, and she admits she was dodging her court dates when officers arrested her in August 2021 as she arrived to pick up her father’s lost dog at the county shelter.
Roger McKnight and Jessica Anthony, above in orange, are peer specialists who share their own experiences with addiction to help MTU clients like Rachel, above with back to camera, navigate a path to sobriety. Every weekday, the vehicle parks in a different spot to serve residents throughout Caroline County.
She was released from jail three and a half months later, and as part of her probation, she was ordered to get drug treatment through the MTU. She found a confidant there in Roger McKnight, an MTU administrator since its 2019 launch. With his ever-present U.S. Air Force baseball cap and gold hoop in one ear, McKnight brings his own experience to the role: He began using alcohol and marijuana during the Vietnam War to cope with the trauma of combat, and has been in recovery for 35 years.
“I went through 12-step programs,” he says. “I kept seeing other people like myself suffer, and everybody wasn’t from Skid Row. There were doctors, lawyers and everybody else in there. This thing can hit anybody, anywhere.”
That kinship is essential to the relationship between peer recovery specialists and MTU clients. “People who have been in addiction understand each other,” says Rachel, an MTU client who asked to be identified by only her first name. “If you tell a peer that it’s been a hard week and you feel like getting high, they’ll say, ‘Wait a minute, are you sure you want to do that? Two and a half years ago, you were a hot mess. Now you’re straight. Do you really want to go back?’”
A shortage of providers trained in mental health and substance use isn’t unique to Caroline County; across the world, especially in impoverished and rural areas, these kinds of professionals are hard to come by.
“We need to identify strategies to increase access to care everywhere,” says Magidson. “The peer workforce has proliferated across the U.S. in recent years, and ultimately we hope the model we are evaluating could be incorporated into peer curricula nationwide.”
MTU nurse Linda Tetrick meets with Maureka, who has been an MTU client for five years. Clients give a urine sample and discuss any concerns with Tetrick before meeting virtually with a University of Maryland, Baltimore physician specializing in addiction.
Cost effectiveness is also a crucial component of Magidson’s work. Utilizing a peer recovery specialist could help avoid expensive emergency room or urgent care visits, and could lead to better employment opportunities for patients.
It’s not just patients who benefit from the peer-to-peer model. “I consistently hear from our peers across studies the meaning and value it provides to themselves by being able to share their story and have a positive impact on patients, other providers and communities,” says Magidson.
Anthony hopes to be one of those beneficiaries-turned-benefactors. When Anthony began coming to the MTU after her stint in jail, she didn’t have a home, a driver’s license or even a toothbrush. Now she owns her own house and, in addition to her work with Magidson’s research team, works at an Auto Zone in Denton—changes she attributes to the peer team at the MTU.
“It fits me perfect,” says Anthony. “I can use my personal experience to help others create a path to recovery and build a more hopeful future. It’s almost too good to be true.”
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