Substance Abuse 101Catherine McAlpine, Ph.D., LCSW-CManager, Behavioral Health and Crisis Services 401 Hungerford Drive, Rockville, MD 20850 Catherine.email@example.com
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Insanity or Intervention?• Criminalization – The Volstead Act, 18 Amendment to the U.S. th Constitution (1919, repealed 1933), The Controlled Substance Act of 1970• Self help (1935) – when all else fails find a friend• Medical Science challenges the Moral Model• The Minnesotta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)
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 CareLow/Low (misa) Low/High (miSD).5 Education Level II – IOPLevel I + 12 Step Level IIIHigh/Low (MIsa) High/High (MISA).5 Education Level II – IOPLevel I + 12 Step 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
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• 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 • Primary Mental Health – Avery Road Tx. Center – Threshold Services – Avery Road Combined – St. Luke’s (have merged) – Journeys for Women – Family Services, Inc. – Bi-lingual Counseling – Crisis Center (crisis beds) – Family Health Center – Fenton House – KHI (Family Services) – Adventist Behavioral – Outpatient Addiction & Health Mental Health Services – Adult Behavioral Health – Medication Assisted Tx. – Outpatient Addiction & – Adventist Behavioral health Mental Health Services – Journey to Self Understanding