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Overview of Substance Use Disorders

Sandy Kanehl, M.Ed., CSAC, Mid-Atlantic ATTC


April 26, 2012, Charleston, WV

Your Mid-Atlantic Addiction Technology Transfer Center serves West Virginia, KY, TN, and VA

We are located at Virginia Commonwealth University

VCU
http://www.attcnetwork.org/regcenters/indexmidatlantic.asp sjkanehl@vcu.edu

Our objectives today:


Learn current info on drugs of abuse, trends, prevalence, basic addiction science Understand proposed changes for SUD Dx in DSM-V Identify new trends in the field RM, ROS, impact of HCR Discuss implications of the above for clinical practice

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?

One more context slide


How many of us personally know someone who has struggled with SUD? know someone who has tried but could not access services? Why? know someone whos been administratively discharged from Tx for exhibiting the Sx of the illness for which they are being treated? What is the general publics view of addiction treatment?

Drugs of abuse, trends, prevalence, basic addiction science

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

Trends NSDUH April 2011 Report


Overall underage (12-20) alcohol use incl. binge drinking showed gradual decline 12% of pop 12 & older (30.2 million) drove under the influence of ETOH past yr. (down from 14.2 % in 2002) Tobacco use has declined; from 2002 to 2009, rate of pastmonth cigarette use fell from 13.0 percent to 8.9 percent among 12- to 17-year-olds. Among young adults aged 18 to 25 years; rates of use fell from 40.8 percent in 2002 to 35.8 percent in 2009 In 2010, 12th graders reported an annual prevalence rate of 17% for hookah smoking and 23% for the use of small cigars.

Trends NSDUH April 2011 Report


Daily marijuana use increased among 8th, 10th, and 12th graders from 2009 to 2010. Among 12th graders, use was at its highest point since the early 1980s, at 6.1 percent. Perceived risk of regular marijuana use also declined among 10th and 12th graders, suggesting future trends in use may continue upward. Trends in lifetime use of amphetamine and methamphetamine indicate statistically significant declines from peak-year (1996) use among high schoolers. Cocaine use gradually declined between 2003 and 2009 among people aged 12 or older (from 2.3 million to 1.6 million). From 2009 to 2010, lifetime use of ecstasy among 8-10th graders increased from 2.2 percent to 3.3 percent

Trends NSDUH April 2011 Report


Rates of hallucinogen use remained unchanged from 2009 to 2010, although significant increases were reported by 12th graders for annual and past-month use of LSD. Past-year use of inhalants also remained steady from 2009 to 2010 with 8% of 8th graders reporting past-year use. Prescription and OTC medications accounted for most of the top drugs abused by 12th graders in the past year. Nonmedical use of Vicodin decreased from 9.7% to 8.0% however, nonmedical use of Oxycontin remained unchanged, & has increased among 10th graders over the past 5 years. Nonmedical use of Adderall and OTC cough and cold meds remained high at 6.5 percent and 6.6 percent, respectively.

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.

Trends in West Virginia


Spice Not the community, (synthetic cannabinoids), & regular marijuana Bath Salts DOPE not SOAP (Synthetic cathinones) West Virginia
is hoping to curb synthetic drug use with a ban. The legislature has approved a bill that would make buying, selling or possessing synthetic drugs illegal. The move came after the state's poison control center reported 80 cases of people using bath salts to get high since the start of 2011. That's compared to three in all of 2010. (WTAP News, 3/19/2011)

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!

From the Governors desk in Coal Valley News, April 3, 2012

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

Illicit Drug Dependence Past Year Persons Aged 12 & Older in WV

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2006, 2007, and 2008.

Nonmedical Use of Pain Relievers Persons Aged 12 or Older in WV

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2006, 2007, and 2008.

Alcohol Use Past Month among Persons Aged 12 -20 in WV

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

Substance Use & Addictive Disorders


(formerly Substance-Related Disorders)

Substance Use Disorders Substance Intoxication Substance Withdrawal Gambling Disorder


Non-substance addictions recommended for inclusion this moved from Impulse Control Disorders, NOS

Substance Induced Disorders


Also to be listed in chapter with disorder

R 00-10 Substance Use Disorders


R Substance Use Disorder R 00 Alcohol Use Disorder R 01 Amphetamine Use Disorder R 02 Cannabis Use Disorder R 03 Cocaine Use Disorder R 04 Hallucinogen Use Disorder R 05 Inhalant Use Disorder R 06 Opioid Use Disorder R 07 Phencyclidine Use Disorder R 08 Sedative, Hypnotic, or Anxiolytic Use Disorder R 09 Tobacco Use Disorder R 10 Other (or Unknown) Substance Use Disorder

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

Why they got rid of abuse


Problems identified with the DSM-IV division between abuse and dependence led to many studies of the structure of the abuse and dependence in a variety of general population and clinical settings. Given the empirical evidence, the DSM-5 Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity, with two criteria required to make a diagnosis.

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

Bringing the Full Power of Science to Bear on

Drug Abuse & Addiction

Your Brain on Drugs in the 1980s

Your Brain on Drugs Today

YELLOW shows places in brain where cocaine binds (e.g., striatum)

Fowler et al., Synapse, 1989.

Addiction Is A Developmental Disease that starts in adolescence and childhood


% in each age group who develop first-time dependence
1.8% 1.8% 1.6% 1.6% 1.4% 1.4% 1.2% 1.2% 1.0% 1.0% 0.8% 0.8%

TOBACCO CANNABIS ALCOHOL

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.

Addiction is Like Other Diseases


it is preventable, it is treatable, it changes biology, if untreated, it can last a lifetime Decreased Brain Metabolism in Drug Addicted Patient Decreased Heart Metabolism in Heart Disease Patient
High

Low

Healthy Brain

Diseased Brain/ Cocaine Addicted

Healthy Heart

Diseased Heart

Research supported by NIDA addresses all of these components of addiction.

Addiction is a Chronic illness & public health issue


With similar characteristics, including relapse rates, to other chronic illnesses Substance use disorders should be insured, monitored, treated and evaluated like other chronic diseases
McLellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695. Addiction Hypertension

Diabetes

Asthma

Relapse Rates are Similar for Addiction and Other Complex Chronic Diseases

McLellan et al., retrieved from NIDA website

Addiction is Similar to Other Chronic Illnesses Because:


It has biological and behavioral components, both of which must be addressed during treatment.

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/

How many people in the US are in recovery?

Best data we have suggest 20 to 40 million

Emerging science of recovery


Why do people seek recovery? What are the benefits of recovery? What do typical addiction careers look like? How many people drop out before completing Tx? Why? Could we have done anything so they would stay and complete? If so, what? What is most important to support long-term recovery?

Typical addiction career


Number of abstinent periods one month or longer followed by return to drug use (prior to current abstinence & outside of a controlled environment)

One 17%

20 & over 10% Ten to 19 17%

Two 22% Three 11%

Six to nine 7% Four to five 16%

50% reported 4 or more abstinent periods followed by return to active addiction

Typical treatment career


Over half of outpatient clients have had 3 or more previous episodes
Ten + 14% Five to nine 21% One 15% Three-four 17% Two 12% None 21%

Laudet, Stanick & Sands, Eval Review, 2007

National average Tx completion rate for outpatient modalities = 36%


Completed 40% Left before completion 60%

NYC Outpatient treatment outcome


Laudet, Stanick, & Sands, JSAT 2009

Reasons for leaving treatment


Qualitative analyses: What is the most important reason why you dropped out of the program? *
Dislike program/staff/clients Tx interferes w/other activity (e.g., job) Using Convenience (e.g., transport) Family/personal issues Do not want help Finances Not helpful
0

31.6% 18.8 12 12 12 12 9.4 8.5


5 10 15 20 25 30 35

* 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)?

Greater flexibility in scheduling 23%

Practical assistance 11%

Help with other areas of functioning 18%

Better individualized services 23%

Better, more caring staff 25%

Promoting abstinence alone is not enough


Asked at outpatient admission (N=314): What are the top priorities in your life right now?
Get/Stay clean Get a job Educ/Voc/Training Get kids back Housing Relation w.family Get life together Complete tx

Abstinence is top goal but not only goal!!

10

20

30

40

50

HoweverExtended Abstinence is Predictive of Sustained Recovery


After 5 years if you are sober, you probably will stay that way.

It takes a year of abstinence before less than half relapse

Dennis et al, Eval Rev, 2007

Sources of support in long-term recovery


N = 52 CCAR Members median abstinence duration = 12 years
ith a f / y t i itual r i p S ily Fam eers p g erin v o c Re use Spo ngth e r t er s n n i / f Sel nds e i r F ns a i c i Clin
53% 53 43 18 17 11 7
0 10 20 30 40 50 60

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

What else is driving change?


Affordable Care Act and Parity Law
More people covered More services in primary care settings Large number of people with SUDs still will not have coverage SAPT Block Grant

Distribution of Substance Use Problems


Alcohol, Illicit and Non-Prescribed Drugs
2.3 Million Specialty Treatment

Severe
~23 Million Addiction Dx for comparison Diabetes~24 million

Substantial Moderate

Harmful Use Dx ~60 Million (SBIRT now covered)

Mild
Little or no use (Prevention now covered)

None
(Rawson, & Freese), (McLellan)

Screening, Brief Intervention


A single event can influence individuals to reduce substance use for up to a year May reduce mortality rates by ~ 25% Significantly reduces substance-related accidents and hospital visits

http://www.drugabuse.gov/nmassist/

Distribution of Funding
Current Funding Sources Tx System HCR Funding Sources

Residential
Medicaid

Outpatient
Block Grant Medical Detox System

Insurance Medicaid Insurance Self pay

MAT

SUD
services

Self pay

Recovery Support

Block Grant

HEALTH CARE REFORM

ROS, HCR & Integrated Care


In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010
-from SAMHSA website

Overarching goals of health reform Make health care more


1) accessible 2) affordable 3) efficient, and 4) effective

Key strategies in 4 major areas:


Coverage expansion
Cant deny people for pre-existing conditions, or charge higher premiums based on health status, caps on coverage, dropping people when they get sick, expands Medicaid eligibility, requires coverage beg. 2014

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

Delivery system redesign (integration, chronic


illness management, health homes), and

Payment reform

Prevention will be huge


Including within chronic disease initiatives Co-payments removed from screening for depression, substance misuse, smoking cessation Prevention & Public Health Fund will support EBPs for programs that foster health, e.g. smoking cessation and combating obesity.

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

Anticipated need for

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

Impact of ACA on BH Workers Coverage Expansion


We will need an More screening expanded AND more will efficient identify even more workforce people

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)

Impact of ACA on BH Workers Billing, Block Grants

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

Impact of ACA on BH Workers Service Integration

Behavioral Health and Primary Care


By some estimates will reduce overall health care costs by 30% = $700 billion/year
While improving quality of care
This report is available online at http://www.nachc.com/research-data.cfm.

Federal, state, local partners


ACA is federal law, however states will decide much about how it is enacted
Health exchanges, coverage for SUDs, billable services (licensed?, certified?, peers?)

All health care is local


Community partnerships, what linkages make sense, PC sites using SBI, who provides MAT, organizations involved in developing ROS may be ahead of the curve

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/

A few of the Health Centers in West Virginia

Pineville Childrens Center

Growth of new types of services

focused on recovery
And recovery-oriented services Informed by science Recovery management - key Cultural change Advocacy

Recovery Model

Acute Care Model


Substance Abusing Patient

Treatment

Therapies, Meds, JCAHO, CARF, EBPs, etc.

White (2008) Recovery Management & Recovery-Oriented Systems of Care: Scientific Rational & Promising Practices

Non-Substance Abusing Patient


Adapted from presentation by Tom McLellan, Ph.D.

Shifting to a recovery-focused model means

...shifting the emphasis of treatment from brief biopsychosocial stabilization to one of sustained recovery management

Recovery Management includes


pre-recovery support services to enhance recovery readiness, in-treatment recovery support services to enhance the strength and stability of recovery initiation, and post-treatment recovery support services to enhance the durability and quality of recovery maintenance.

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,

Examples of pathways to recovery


Mutual support groups

AA, NA, Al-Anon, SOS, etc.


Professional treatment inpatient, outpatient, etc. Recovery Community Organizations SAARA of Virginia Faith-based support services Celebrate Recovery, etc.

Medication-assisted recovery
methadone, buprenorphine, etc. Justice system programs drug courts, TCs, etc.

Recovery capital; problem severity, treatment failures and other


reframes

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

Types of recovery capital


Personal RC - can be
Physical, e.g. health, financial assets, insurance, safe housing, etc., or Human, e.g. values, knowledge, educational/vocational skills, credentials, problem-solving skills, self-esteem, hopefulness, sense of purpose, interpersonal skills
White & Cloud, 2008

Types of recovery capital


Family and social RC - intimate
relationships, family and kinship relationships (defined here non-traditionally, i.e., family of choice), and social relationships that are supportive of recovery efforts. Family/social recovery capital is indicated by willingness of partners and family members to participate in treatment, the presence of others in recovery within the family and social network, access to sober outlets for sobriety-based fellowship/leisure, and relational connections to conventional institutions (school, workplace, church, and other community organizations). White & Cloud, 2008

Types of recovery capital


Community RC - encompasses
community attitudes/policies/resources related to addiction and recovery that promote the resolution of alcohol and other drug problems. Community recovery capital includes: active efforts to reduce addiction/recovery-related stigma, visible and diverse local recovery role models, a full continuum of addiction treatment/recovery resources, recovery mutual aid resources that are accessible and diverse, local recovery community support institutions (recovery centers, recovery homes, etc. and sources of sustained recovery support and early re-intervention
White & Cloud, 2008

Early scientific findings


Recovery capitalboth its quantity and quality plays a major role in determining the success or failure of natural and assisted recovery (e.g., recovery from AOD problems without or with participation in professional treatment or a recovery mutual aid society) Increases in recovery capital can spark turning points that end addiction careers, and trigger recovery initiation
White & Cloud, 2008

Early scientific findings


Such turning points often result after several years and multiple episodes of professional treatments Recovery capital is not equally distributed across individuals and social groups. Members of historically disempowered groups often seek recovery from addiction lacking assets that are taken for granted by those seeking recovery from a position of privilege White & Cloud, 2008

Early scientific findings


Most clients with severely depleted family and community recovery capital gain little from individually-focused addiction treatment that fails to mobilize family and community resources Long-term recovery outcomes for those with the most severe AOD problems may have more to do with family and community recovery capital than a particular treatment protocol

White & Cloud, 2008

The concept of recovery capital


reflects a shift in focus from the pathology of addiction to a focus on the internal and external assets required to initiate and sustain longterm recovery from alcohol and other drug problems.
White & Cloud, 2008

Federal Initiatives to support ROS


Addiction Technology Transfer Center (ATTC) Network

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.

Federal Initiatives to support ROS


Access to Recovery (ATR)

(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.

Federal Initiatives to support ROS


Recovery Community Services Program (RCSP)
The Recovery Community Services Program is a SAMHSA grant program which funds organizations to provide peer-to-peer recovery support services for people in or seeking recovery from alcohol and drug problems. Initiated in 1998, RCSP has seeded the development of numerous recovery community organizations.

Targeted Capacity Expansion-Local Recovery-Oriented Systems of Care (TCE-ROSC)


SAMHSAs Targeted Capacity of Expansion (TCE) Local RecoveryOriented Systems of Care (TCE-Local ROSC) grants assist in the development of Recovery-oriented Systems of Care (ROSC) at a local level.

BRSS TACS Bringing Recovery Supports to Scale - current

Federal Initiatives to support ROS


Partners for Recovery (PFR) Partners for Recovery is a SAMHSA initiative that supports the development of recovery-oriented policy, systems and services. It engages diverse stakeholders including Federal agencies, states, tribes, local governments, professional/ trade associations, faithbased groups, health care professionals, nurses, social workers, and recovery support services providers to accomplish this.

ROS Implementation challenges


Need for more science we still know comparatively
little from the standpoint of science about the prevalence, pathways, and styles of long-term recovery

Integration of professionally directed services and peer-based recovery support who best to provide, where are the boundaries and
ethical guidelines

Service capacities how ought resources to be


reallocated and how does this affect service capacity
White, Kurtz, Sanders, 2006

ROS Implementation challenges


Historical and conceptual momentum
we are steeped in the acute care model, # days or sessions, continuing care almost non-existent

Reimbursement and regulations all


based on the acute model

High staff turnover in the


workforce precludes continuity of contact

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

Another example: Philadelphia


System transformation process began 2004 Involved multiple constituencies, especially individuals and families in recovery Inventoried system relationships, created shared vision, developed consensus power to partnership Engaged in recovery resource mapping Highlighted benefits of recovery partnerships
Lamb, Evans & White (2009) The Role of Partnership in RecoveryOriented Systems of Care: The Philadelphia Experience

Virginias Statewide RCO


Substance Abuse and Addiction Recovery Alliance http://www.saara.org/
SAARA of Virginia is a grassroots recovery community organization. All friends of recovery are invited and welcome to join. Our members include individuals in recovery from alcohol and other drug addiction, their families, friends, and dedicated community supporters. Across the Commonwealth of Virginia, we are seventeen affiliates strong and growing. SAARA promotes social, educational, legal, research and health care resources and services that support accessible, effective and accountable addiction prevention, intervention, treatment and Recovery. We envision the day when the stigma of addiction will be eradicated, and all who seek recovery will find it. Recovery happens! Please take a look around our website and let us know if you have any comments or questions.

RCOs can foster ROS in systems


By providing service coordination and modeling person-centered, strengthsbased services By putting a face on recovery By supporting multiple pathways to recovery

RCOs can foster ROS in systems


By providing recovery coaching and assertive linkages to communities of recovery By supporting recovery housing

RCOs can foster ROS in systems


By encouraging hope & optimism about recovery through peers

By addressing stigma

RCOs can foster ROS in systems


By focusing on and modeling strategies for engagement and motivational enhancement
This NOT This

ROS Outcomes: System Numbers


Philadelphia
36% 50% 46% 62% 40% 25% in crisis utilization after 1 year cost of inpatient psychiatric services in number of people served statewide in use of acute care in outpatient care in annual cost per client

Connecticut

Outcomes: Individuals Seeking Recovery


SAARA Center for Recovery in Virginia

Recovery Oriented Services


Have a growing evidence base for their effectiveness Fit perfectly into the priorities for HCR Include lower-cost interventions for disease/recovery management

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.

Implications of the above for clinical practice

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

Implications for clinical practice


What do clinicians need to know about recovery management/chronic care? Do clinicians have a role in systems change toward recovery-oriented services and systems? Other?

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?

New environments, new challenges, new options

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