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Your Mid-Atlantic Addiction Technology Transfer Center serves West Virginia, KY, TN, and VA
VCU
http://www.attcnetwork.org/regcenters/indexmidatlantic.asp sjkanehl@vcu.edu
Whos here?
Context
What are the most stigmatized illnesses in our culture? How does the public view substance misuse/people with SUDs? How do professionals view people with SUDs?
Emerging Drugs
K2/Spice
diverse family of herbal mixtures marketed under many names, including fake marijuana, Yucatan Fire, Skunk, Moon Rocks, and others. Products contain dried, shredded plant material and presumably, chemical additives that are responsible for their psychoactive effects. Sold in head shops, gas stations, and via the Internet
Salvia
herb with main active ingredient salvinorin A, a potent activator of kappa opioid receptors in the brain; different receptors from the commonly known opioids, such as heroin and morphine. Ingested by chewing fresh leaves or by drinking their juices. Dried leaves can also be smoked as a joint, consumed in water pipes, or vaporized and inhaled. Not regulated yet but DEA has listed Salvia as a drug of concern and is considering classifying it as a Schedule I drug, like LSD or marijuana.
Bath Salts
newer fad, synthetic powders sold under names like Ivory Wave, Red Dove, Blue Silk, Zoom often amphetamine-like chemicals, used orally, by inhalation, or injection, not yet well understood but linked to alarming number of ER visits across the country
National Data
The annual total estimated societal cost of substance abuse in the United States is $510.8 billion In 2009, an estimated 23.5 million Americans aged 12 and older needed treatment for substance use Half of all lifetime cases of mental and substance use disorders begin by age 14 and three-fourths by age 24
Source: Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSAs Roles and Actions 2011-2014 Executive Summary and Introduction. HHS Publication No. (SMA) 114629 Summary. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.
Public confusion As evidenced by public comments on above article Pain meds/pill mills Growing problem of illegal sales of Rx drugs-Significant
opioid research at WVU
Methamphetamine pockets of abuse (DEA data) Gambling Health disparities plus access & capacity issues,
stigma, poverty
Meth Notes rebounding after decline rural areas experiencing greater increases in use availability on the rise smurfing and shake & bake contribute to this 19.3 = average age of initiation, need prevention & treatment resources!
Drug overdoses now kill more West Virginians than car accidents Drugs are the leading cause of accidental deaths in our state We have the nations highest rate of drug deaths 9 out of 10 of our overdose deaths involve at least one prescription drug
http://www.coalvalleynews.com/view/full_story/18083312/articl e-FIGHTING-DRUG-ABUSE-IN-WEST-VIRGINIA
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2006, 2007, and 2008.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2006, 2007, and 2008.
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2006, 2007, and 2008.
Needing but Not Receiving Treatment for Drug Use Past Year Persons 12 & Older in West Virginia
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2006, 2007, and 2008.
DSM-V Revisions reflect major change! Here is your resource to follow the progress: http://www.dsm5.org/Pages/D efault.aspx
DSM-V http://www.dsm5.org/Pages/Default.aspx Proposed changes affecting former Dx of substance abuse and dependence
Coming out May 2013 Field trials underway in large academicmedical settings and small solo/group practices Two previous comment periods; third and final planned for spring 2012
SUD Definition
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
recurrent substance use resulting in a failure to fulfill major role obligations recurrent substance use in situations in which it is physically hazardous continued substance use despite having persistent or recurrent social or interpersonal problems Tolerance Withdrawal to # 11
Specifiers
Severity moderate to severe With/without physiological dependence Course early full remission, early partial, sustained full, sustained partial, on agonist therapy, in controlled environment
Substance Intoxication
R 11-21 Substance Intoxication R 11 Alcohol Intoxication R 12 Amphetamine Intoxication R 13 Caffeine Intoxication R 14 Cannabis Intoxication R 15 Cocaine Intoxication R 16 Hallucinogen Intoxication R 17 Inhalant Intoxication R 18 Opioid Intoxication R 19 Phencyclidine Intoxication R 20 Sedative, Hypnotic, or Anxiolytic IntoxicationR 21 Other (or Unknown) Substance Intoxication
Substance Withdrawal
R 22-30 Substance Withdrawal R 22 Alcohol Withdrawal R 23 Amphetamine Withdrawal R 24 Caffeine Withdrawal R 25 Cannabis Withdrawal R 26 Cocaine Withdrawal R 27 Opioid Withdrawal R 28 Sedative, Hypnotic, or Anxiolytic Withdrawal R 29 Tobacco Withdrawal R 30 Other (or Unknown) Substance Withdrawal
Substance-Induced Disorders
Substance-Induced Psychotic Disorder Substance-Induced Bipolar Disorder Substance-Induced Depressive Disorder Substance-Induced Anxiety Disorder Substance-Induced ObsessiveCompulsive or Related Disorders Substance-Induced Dissociative Disorder Substance-Induced SleepWake Disorder Substance-Induced Sexual Dysfunction Substance-Induced Delirium Mild Neurocognitive Disorder Associated with Substance Use Major Neurocognitive Disorder Associated with Substance Use
Whats new? Changes in the addictions field Definitions Research Laws Services
What is addiction?
-ASAM August 2011: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry
- characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with ones behaviors and interpersonal relationships, and a dysfunctional emotional response ASAMs full public policy statement may be found here: http://www.asam.org/research-treatment/definition-of-addiction
0.6% 0.6%
0.4% 0.4% 0.2% 0.2% 0.0% 0.0%
5 5
10 10 15 15
21 21 25 25 30 30 35 35 40 40 45 45 50 50 55 55 60 60 65 65
Age
Age at tobacco, alcohol, and cannabis dependence per DSM IV
National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
Low
Healthy Brain
Healthy Heart
Diseased Heart
Diabetes
Asthma
Relapse Rates are Similar for Addiction and Other Complex Chronic Diseases
Recovery from it--protracted abstinence and restored functioning--is often a long-term process requiring repeated episodes of treatment.
Relapses can occur during or after treatment, and signal a need for treatment adjustment or reinstatement. Participation in support programs during and following treatment can be helpful in sustaining long-term recovery
What is recovery?
SAMHSA , December 2011
Recovery from Mental Disorders and Substance Use Disorders: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery:
Health: overcoming or managing ones disease(s) as well as living in a physically and emotionally healthy way; Home: a stable and safe place to live; Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; and Community: relationships and social networks that provide support, friendship, love, and hope.
http://blog.samhsa.gov/2011/12/22/samhsa%E2%80%99s-definition-and-guidingprinciples-of-recovery-%E2%80%93-answering-the-call-for-feedback/
One 17%
* Add to > 100% because up to 2 answers were coded; Laudet, Stanick, & Sands, JSAT 2009, 37:182-190
Minimizing attrition: What could have been done differently so that you would have continued attending (among yes)?
10
20
30
40
50
The mere action of making wellness a bona fide outcome will reinforce the fact that recovery from addiction is a reality for many. By extension, this can give hope to the many individuals and families affected by SUDs and support them in their search for the solution that will work for them.
Laudet, 2009
Severe
~23 Million Addiction Dx for comparison Diabetes~24 million
Substantial Moderate
Mild
Little or no use (Prevention now covered)
None
(Rawson, & Freese), (McLellan)
http://www.drugabuse.gov/nmassist/
Distribution of Funding
Current Funding Sources Tx System HCR Funding Sources
Residential
Medicaid
Outpatient
Block Grant Medical Detox System
MAT
SUD
services
Self pay
Recovery Support
Block Grant
Insurance reform
Wellstone/Domenici Parity Act removes limits on coverage that do not apply to other physical ailments , states will have Insurance Exchanges that include subsidized plans, basic required benefits, including MH/SUD services at parity
Payment reform
Numbers
32 million more Americans expected to be insured by 2014 Of these, 20-30% will have MH and/or SUDs Increased screening will raise demand for brief and specialty MH/SUD treatment Those with the most serious MH/SUDs are twice as likely to be unemployed and therefore still uninsured
BH workforce
HCR has broad implications for the behavioral health workforce, not just in terms of capacity, but related to need for training and education to fulfill shifting or new roles
20-30% will have MH/SUD More people gain health care coverage with parity
Impact of ACA on BH Workers Workforce Development In order to improve patient satisfaction and health outcomes, Title V of the legislation includes scholarship and loan programs
For work in underserved areas, schools For skills development in EBPs, cultural competence, C&A services
DOL defines SUD as a distressed profession, i.e. lacking sufficient workforce to meet public need
Plan to recruit &train 60,000 new counselors over next decade (depending on funding)
We dont know more than we know about a lot of how things will play out
McLellan
Level and use of block grant funding will be impacted by who is/isnt covered and gaps that remain as more people gain coverage Organizations not proficient in billing may need to learn about billing models for HCR
THOUGHTS
The work of HCR is just beginning; we will learn as we go The future of the behavioral health workforce, including SUD services can be decided in large part by how well prepared we are Our profession has a track record of evolving to meet the demand for services
Partnering
FQHCs Federally Qualified Health Centers are safety net providers for underserved populations
141 in WV, 132 in VA (from HRSA Data Warehouse)
With Medicaid expansion & funding for new sites, target is to double patients served to 40 million by 2015 Likely sites to be Health Homes If youve seen one FQHC, youve seen one
great variability among areas, pop. Served, etc.
http://findahealthcenter.hrsa.gov/
focused on recovery
And recovery-oriented services Informed by science Recovery management - key Cultural change Advocacy
Recovery Model
Treatment
White (2008) Recovery Management & Recovery-Oriented Systems of Care: Scientific Rational & Promising Practices
...shifting the emphasis of treatment from brief biopsychosocial stabilization to one of sustained recovery management
RM also includes
Emphasis on resilience and recovery processes (as opposed to pathology and disease processes), Recognition of multiple long-term pathways and styles of recovery,
Medication-assisted recovery
methadone, buprenorphine, etc. Justice system programs drug courts, TCs, etc.
Recovery capital (RC) is the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery from severe alcohol and other drug problems White & Cloud, 2008
SAMHSA/CSAT funds a network of 14 regional ATTCs, which provide training and technical assistance to states. The ATTC network publishes guides, toolkits and monographs supporting treatment and recovery systems and services. These include numerous publications on recoveryspecific topics. Each of the ATTCs has established a ROSC implementation support team to assist states in implementing ROSC.
(ATR) is a Substance Abuse and Mental Health Services Administration (SAMHSA) program which awards competitive grants to states and tribes to implement voucher systems for purchasing substance use disorder treatment and recovery support services. ATR provides states and tribes with an excellent mechanism for developing systems and services that more effectively support long-term recovery.
Integration of professionally directed services and peer-based recovery support who best to provide, where are the boundaries and
ethical guidelines
Recovery Community Organizations have grown and paved a way forward one example:
Founded 1997 RCSP and state grants, consistently increased grant funding, regular state funding Huge face on recovery Huge advocacy presence Multiple Recovery Community Center sites Recovery housing network Recovery Coach training program Product development National leader for partnering with state systems
http://www.ccar.us/default.htm
By addressing stigma
Connecticut
Addiction is visible everywhere in this culture, but the transformative power of recovery is hidden behind closed doors. It is time we all became recovery carriers. It is time we helped our community, our nation, and our world recover Recovery is contagious. Get close to it. Stay close to it. Catch it. Keep catching it. Pass it on. (White, 2010)
Where shall we go, what shall we do, and how can you help? Implications for clinical practice
Stigma New definitions of addiction, recovery based on science Chronic vs. acute illness model new services, peer providers DSM-5 Other?
A study of stigmatized attitudes towards people with mental health problems among health professionals. In J Psychiatr Ment Health Nurs. 2009 Apr;16(3):279-84.
Summary: 108 health professionals from acute and mental health settings completed questionnaires. Participants had highly stigmatized attitudes towards patients with active substance use disorders. Attitudes were less stigmatized to people with SUDs who were recovering/in remission.
The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review.
Hello, my name is Tara and I am in long-term recovery which means
Addiction. 2012 January; 107(1): 3950. Summary: Effective strategies for addressing social stigma include communicating positive stories of people with substance use disorders. For changing stigma at a structural level, contact-based training and education programs targeting medical students, clinical and other professionals (e.g. police) are effective.
Stigma of addictions
What is our responsibility for our own and others professional attitudes? What is our responsibility for community education to fight stigma? What, if any, is the responsibility of recovering professionals/others to advocate?
Do you think our services system as it exists today reflects the new, more broad definition of recovery? How/How not?
The future of addiction treatment hinges on our ability to connect treatment with recovery!
The emerging science of recovery supports extending the acute care model to a model of recovery-oriented services that supports sustained recovery management Several states, communities and treatment organizations have begun to transform their systems Models for recovery management are already working
DSM-5, etc. implications for clinical practice What is clinicians responsibility re: the new DSM? Offering feedback? How can clinicians prepare for greater integration of behavioral health and primary care? What other implications can you think of from our discussion today?
http://www.williamwhitepapers.com/