substance abuse 101
TRANSCRIPT
Substance Abuse 101
Catherine McAlpine, Ph.D., LCSW-CManager, Behavioral Health and Crisis Services
401 Hungerford Drive, Rockville, MD [email protected]
Workshop Objectives
• Understand what is “use” and “abuse” of alcohol & other drugs
• Understand how substance use & co-occurring disorders intersect with homelessness and other social problems
• Learn the basics of “treatment matching” using medical necessity criteria (ASAM)
• Gain basic knowledge of the County’s continuum of care & how adults access treatment services
Historical Perspectives
• Early identification of alcoholism as an illness (B. Rush)
• Incarceration, Insanity or Intervention?• Criminalization – The Volstead Act, 18th Amendment to the U.S.
Constitution (1919, repealed 1933), The Controlled Substance Act of 1970
• Self help (1935) – when all else fails find a friend• Medical Science challenges the Moral Model• The Minnesotta Model• Professionalization of Treatment• Recovery Management
Challenges
• Binge Drinking
• Workplace – 70% are employed
• Aging Baby Boomers
• Co-occurring mental health & medical
• Abuse of Prescription Medications
• Pharmacotherapy – Buprenorphrine– Antagonists & Agonists
What’s Normal
• More than 60% of adults use alcohol on a regular basis (lowest after age 65).
• Estimates are that 8-12% are problem drinkers or alcoholic (over life span).
• Males 12-20 report binge alcohol use 21% & overall 28.4% use in past 30 days
• Female 12-20 report binge alcohol use 16% & overall 27% use in past 30 days
When is use abuse?
• Relief seeking
• Impacts social network or employment
• Abuse – misuse, use other than as directed, negative incident related to intoxication or use (arrest)
• Dependence – loss of control, tolerance, denial, and continued use despite negative consequences
What is a Problem?
• World Health Organization– Simple message: 4 for women, 5 for men
• Five Substances are 96% of admissions– Alcohol 40%– Opiates 18%– Marijuana 16%– Cocaine 14%– Stimulants 9%
Signs of AOD Dependence
• Significant impairment or distress resulting from use (role functioning, suicidal)
• Failure to fulfill roles at work, home or school• Persistent use in physically hazardous situations• Recurrent legal, financial , interpersonal or social
problems related to use• Continued use despite life problems and/or
deterioration despite assistance & support– Or …
• The person is not improving despite assistance
Is addiction a disease?
• Disease is defined as …• (noun) 1. An abnormal condition of an organism
or part, especially as a consequence of infection, inherent weakness, or environmental stress, that impairs normal physiological functioning. 2. A condition or tendency, as of society, regarded as abnormal and pernicious. (American Heritage Dictionary of the English Language, 1979)
Where Do We Begin?
Assessment
• Seven domains of a person’s functioning, similar to biopsychosocial spheres– Primary diagnosis of substance use/abuse– Acuity of intoxication and/or withdrawal– Emotional, behavioral & cognitive conditions– Readiness to change– Relapse, continued use or problem potential– Recovery environment
What Is It? The Intersection of Co-occurring Conditions
• Which came first?• Which do you treat?• How can you have an
impact on chronic conditions?
• What about chronic pain or pain management?
• Where do you begin so you can set goals and begin to work?
Signs and Symptoms
• Unclean, poor personal care, poor physical and oral health.
• Tired, confused or seems spacey.
• Poor memory or poor historian on past events.
• Losses things, arrives late and “forgets.”
• Multiple services with little or no progress.
Goals of Treatment
• Abstinence reduces morbidity & MH sx
• Increase employment, housing & social connectedness
• Reduce criminal involvement
• Increase access to services & retention
• Improve client perception of + outcome
• Use evidence-based practices
ASAM Levels of Care
• .5 is early intervention or education
• Level I is outpatient (1-8 hour week)
• Level II is intensive outpatient (9+)• Level III is residential with a variety of
service types: halfway house (3-9 months), long-term (6+ months), detox (1-5 days) & intermediate care (28 day)
• Level IV is acute care, hospital based
Quadrants & Levels of Care
Low/Low (misa)
.5 Education
Level I + 12 Step
Low/High (miSD)
Level II – IOP
Level III
High/Low (MIsa)
.5 Education
Level I + 12 Step
High/High (MISA)
Level II – IOP
Level III
Treatment Matching
• Match the “dose” of services to the illness– Severity of impairment & ability to participate– Least restrictive environment– Prior treatment– Social support– Readiness to change– Willingness to accept recommendation– Plus medical & social necessity criteria– Residency, age, gender, insurance etc.
What Works?
• Screening/Brief Intervention (SBRIT)• Physician’s Office for Opioid Management• Cognitive Behavioral Therapy• Motivational Enhancement• Relapse prevention – 12 Step, anxiety
management, social support & employment
• Integrated for Co-occurring – Comprehensive Continuous Systems of Care– Integrated Dual Disorders Treatment
Your Examples & Discussion
Respectful Understanding
• Good treatment begins with an empathic, hopeful relationship, is strengths based
• Knowledgebase – you must have a factual understanding of principles of addiction & treatment, go to sites & self-help meetings
• Use of reflective listening & paraphrasing• Accept that client will be dishonest• Acceptance of chronic, relapsing disease• Continue relationship thru non-compliance
Stages of Change: A Trans-theoretical Model
Stages of Change
• Precontemplation - behavior not a problem, no change • Contemplation - behavior is perhaps a problem, may
have a need to change, considering that change may have benefits, no change yet
• Preparation - begins to plan for behavior change, further consideration of benefits, no change yet
• Action - behavior change occurs, trying out new behavior, integrating into daily life, change occurs
• Maintenance - behavior occurs regularly, some relapse to prior behavior, relapse is then validated and reviewed, new behavior resumes.
• Relapse – return to prior behavior, recognize failure
Vision Statement from SAMHSA
• A Life in the Community for Everyone.
• Prevention Works.
• Treatment is Effective.
• People Recover.
Recovery is …
• Grounded in resilience
• Supported by a foundation of hope
• An ongoing, dynamic, interactive process
• An interplay of a person’s strengths and vulnerabilities
• A personal journey
• Continuous, even when symptoms recur
Characteristics of Recovery
• Multiple Pathways
• Holistic Change Process
• Supported by Peers and Allies• Is a Process of Stages: engagement,
recovery initiation and stabilization, recovery maintenance and ongoing recovery (adapted from Changing for Good (1994), Prochaska, Norcross, and DiClemente. NY: Avon Books)
Social Forces Support Change• Successful recovery often includes:
– connections to family – stable sober housing – employment – follow-up on healthcare & nutrition – extended course of treatment
The longer people participate in a treatment regimen, the more likely they are to remain abstinent and achieve a sustained recovery. This has been verified via case study and research data.
Local Resources
• Primary Adult Care (PAC)
• Access Team
• Crisis Center
• Jail-based services
• Avery Road Treatment Center
• Access to Recovery (ATR)– Care Coordination– Gap Services
Publicly Funded Programs
• Primary SUD– Avery Road Tx. Center– Avery Road Combined– Journeys for Women– Bi-lingual Counseling– Family Health Center– KHI (Family Services)– Outpatient Addiction &
Mental Health Services– Medication Assisted Tx.– Adventist Behavioral health– Journey to Self
Understanding
• Primary Mental Health– Threshold Services– St. Luke’s (have merged)– Family Services, Inc.– Crisis Center (crisis beds)– Fenton House– Adventist Behavioral
Health– Adult Behavioral Health – Outpatient Addiction &
Mental Health Services