Transcript Integrating Substance Use Services

The Greater Houston Behavioral Health
Affordable Care Act Initiative
Understanding Approaches to Substance
Use Treatment and Integration
Overview of Presentation
• Understanding Substance Use Disorders
• Spectrum of Substance Use Disorder Services
• Substance Use Disorder Services for Specific Populations
• Integrating Substance Use Services with Mental Health and
Primary Care Services
Presenters
Mary Beck, The Council on Alcohol and Drugs Houston
Lauren Boe, Center for Recovering Families, The Council on
Alcohol and Drugs Houston
Cathy Crouch, SEARCH Homeless Services
Nadine Scamp, Santa Maria Hostel, Inc.
Andrea Washington, The Montrose Center
SUBSTANCE ABUSE DISORDERS
SIGNS, SYMPTOMS & TERMS
The Council on Alcohol and
Drugs Houston
ADDICTION

Working Definition: A pathological relationship with a
mood-altering substance or behavior characterized by
compulsion, loss of control and continued use in spite of
adverse consequences. Addiction is progressive and
chronic, but remissible through abstinence and recovery.
Will power and attempts at controlled use merely tighten
the grip of addiction.
CHRONIC DISEASE
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Addiction is a chronic disease similar to other
chronic diseases such as type II diabetes, cancer,
and cardiovascular disease.
Diseases and addiction can be inherited, physical,
psychological and environmental risk factors.
Diseases can be fatal if not treated.
ADDICTION HIJACKS
FRONTAL LOBE THINKING…
…WHERE EXECUTIVE FUNCTIONING LIVES
Executive Functioning includes
 Abstract; conceptual understanding
 Impulse Control
 Problem-Solving
 Decision-Making
 Judgment
 Ability to Feel Empathy
CONTINUUM OF USE

Experimentation

Occasional use

“Normal” Use

Abuse

Dependence
HOW THE BRAIN STARTS TO BECOME
ADDICTED - SURVIVAL MODE SETS IN
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At first, our brain thinks drugs are a reward (e.g.
Pavlov’s dog) because they produce dopamine
The brain will override safety in order to get
another reward (the substance)
The brain begins thinking the substance is no
longer a reward – but is necessary for survival
SIGNS & SYMPTOMS
Sneaking
Guilt/Persistent Remorse
Avoid Conversations about use
Rationalizing (excuses)
Social Relationship Decrease (isolation)
Narrow Range of Interests
Attempts to Control
Blackouts (memory loss)
Aggressive Behavior/Invulnerable
Ethical Deterioration (sacrifice values)
Loss of Control
WHAT ABOUT THE DSM?
DIAGNOSIS TO TREATMENT

DSM-5
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Levels of Care……when I return in a moment
THE COUNCIL ON ALCOHOL AND DRUGS
HOUSTON
Lauren Boe, LMSW
Treatment Therapist, Center for Recovering
Families
281-200-9376
[email protected]
Mary Beck, LMSW, CAI
Chief Operations Officer
281-200-9331
[email protected]
Spectrum of Substance Use
Disorder Services
Cathy Crouch
Lauren Boe
Pre-treatment
Services for
Substance Use
Disorders
Cathy Crouch, LCSW
Executive Vice-President
SEARCH Homeless Services
Why Pre-treatment?
n=100
Alcohol Drugs
% used in
past 6
months
80%
60%
High risk
65%
82%
Middle
risk
13%
13%
Low risk
22%
5%
Stage of
Change
Alcohol
Drugs
Precontemplation
54%
30%
Contemplation
40%
60%
Action
4%
10%
Stages of Change
Precontemplation – Not Seriously Considering
Change
 Contemplation – Thinking About Change
 Preparation – Getting Ready to Make A
Change
 Action – Making the Change
 Maintenance – Sustaining Change Until It’s
Integrated into Lifestyle
Relapse and Recycling – Returning to Previous
Behavior and Re-entering the Cycle of Change
Termination – Leaving the Cycle of Change
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Transtheoretical Model:
Experiential Processes of Change
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Consciousness Raising: Gaining information and increasing
awareness about the current behavior pattern or the
potential new behavior
Emotional Arousal/Dramatic Relief: Experiencing emotional
reactions about the current behavior and/or the new
behavior
Self-Reevaluation: Seeing when and how the current
behavior or the new behavior fits in with or conflicts with
personal values and goals
Environmental Reevaluation: Recognizing the effects the
status quo or new behavior has upon others and the
environments in which they function
Social Liberation: Noticing and increasing alternatives in
the social environment that help support change of the
current behavior and/or initiation of the new behavior
Transtheoretical Mode:
Behavioral Processes of Change
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Self Liberation: Accepting responsibility for and committing
to make a behavior change
Stimulus Control: Altering or avoiding cues/stimuli that
trigger a particular behavior; creating new cues to
encourage particular behavior
Counterconditioning: Substituting new, competing
behaviors and activities for the “old” behaviors; also
altering responses to cues
Reinforcement Management: Rewarding sought after new
behaviors while extinguishing (eliminating reinforcements)
from the status quo behavior
Helping Relationships: Relationships that provide support,
caring and acceptance (family, friends, peers, recovery
group, church)
Right Change Process at the
Right Time
From precontemplation to
contemplation
From contemplation to
preparation
Consciousness raising
Emotional arousal
Self reevaluation
Self reevaluation
Environmental reevaluation
Environmental reevaluation
Social liberation
What is Motivational
Interviewing
 Developed
by Bill Miller and Steven
Rollnick in the early ‘80s
 Based on “non-directive”, client-centered
therapy of Carl Rogers
 MI adds a guiding component – guiding
in the direction of change or resolution
12 Tasks in Learning MI
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The ‘spirit’ of motivational interviewing
OARS: Client-centered counseling skills
Identifying change goals toward which to move
Exchanging information and providing advice
Recognizing change talk and sustain talk
Evoking change talk
Responding to change talk in a way that strengthens it
Responding to sustain talk and discord in a way that does
not amplify it
Developing hope and confidence
Timing and negotiating a change plan
Strengthening commitment
Flexibly integrating MI with other clinical skills and practices
MI Spirit

Partnership
•
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Acceptance
•
•
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collaborative
unconditional positive regard
Supporting their autonomy
Compassion
Evocation
•
motivation for change, and the ability to move
toward that change, reside mostly within the
client
Harm Reduction
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Philosophically congruent with the TTM and MI
Respectful of client autonomy
Works to minimize harmful effects of alcohol
and/or substance use
Options for use range from severe abuse to
abstinence
Does not attempt to minimize or ignore the
real dangers associated with alcohol and/or
drugs
Choices: A Program for Women
About Choosing Healthy Behaviors
 Intervention
for nonpregnant women of
childbearing age
 Designed to prevent alcohol-exposed
pregnancies
 Addresses risky drinking and ineffective or
no use of contraceptives
SBIRT: Screening, Brief Intervention
and Referral to Treatment
 Used
in emergency departments,
community health centers, primary care,
EAPs
 To identify, reduce and prevent
problematic use of alcohol and drugs
SBIRT: Screening
Cutoffs
AUDIT
DAST
Brief Intervention
0-15
0-2
Brief Treatment
16-19
3-8
Referral to
Treatment
20-40
9-10
SBIRT: Brief Intervention
 Typically
15-30 minute sessions
 Standard protocol to follow
 Client can have up to six sessions
 Master’s level staff
SBIRT: Brief Treatment
 Hour
long sessions
 Can be customized based on the setting
and resources
 Houston Council had a 4 session template
initially with optional 12 sessions from our
manual
 Provided by master’s level counselors
Treatment Levels
Experimentation
What is experimentation?
Drink alcohol or try a drug for the first time.
Usually infrequent or occasional use.
Intervention/Treatment
When someone is using drugs or alcohol
experimentally, they do not typically need
treatment or an intervention.
Education may be helpful to prevent future
abuse.
Normal Use
What does it mean to drink normally?
Normal drinking amounts depend on body eight,
but average one drink per hour.
Taking prescription medications as directed
Intervention/Treatment
For adults generally treatment is not needed
Education may be helpful to identify limits and
reasons for drinking.
Treatments for Normal Use
For adults who are drinking normally, that
is 1 drink per hour or less, treatment is
generally not necessary.
Education may be helpful to help this
person identify limits and reasons for
drinking.
Treatment for Abuse
Individual/Family Therapy
Intensive Outpatient Treatment
12-Step Programs
Self-Help Groups
Treatment for Dependence
Inpatient/Detoxification
Residential Treatment
Intensive Outpatient Treatment
12-Step Programs
Self-Help Groups
Treatment
No one treatment is right for everyone
Behavioral therapies are most common, but
definitely not the only ones used
Other therapies include MI, family-systems,
psychodynamic, experiential etc…
Should address all aspects of a person,
including mental and physical health
Family and/or friends should be educated and
included throughout treatment
12-step and other peer supports
The Council on Alcohol and
Drugs Houston
Lauren Boe, LMSW
Treatment Therapist, Center for Recovering Families
281-200-9376
[email protected]
Mary Beck, LMSW, CAI
Chief Operations Officer
281-200-9331
[email protected]
Substance Use Disorder
Services for Specific Populations
Lauren Boe
Nadine Scamp
Andrea Washington
Co-occurring Disorders
Please refer to the handout entitled
“Co-occurring Disorders.”
Santa Maria Hostel
The mission of Santa Maria is to
empower women and their families
to lead successful, productive,
self-fulfilling lives
Santa Maria Hostel, Inc.
Women – Differences in Patterns of Substance Use
• More likely to initiate substance use through significant relationships
• More likely to temporarily alter use in response to caregiver responsibilities
• Move faster from initiation of use to development of substance related negative
consequences
• Less time from initiation to development of substance use disorders than men
• More likely to have co-occurring trauma, depression, other mental health
disorders
• Increased risk for HIV/AIDS, sexually transmitted diseases
Santa Maria Hostel, Inc.
Special considerations – Pregnancy and Birth Outcomes
•
5.9% current drug use, 8.5% current alcohol use, 15.9% current cigarette use
•
1,764 pregnant women admitted to Texas DSHS funded treatment programs
•
Pregnant women with substance use disorder more likely to have late or no prenatal care
•
Use in pregnancy associated with increase risk of poor maternal and birth outcomes
•
Increased risk for miscarriage, stillbirth, low weight gain, low birth weight in infants,
physical health problems in both mother and infant
•
Withdrawal concerns – sudden stopping of opiods can lead to fetal distress or death
•
Neonatal Abstinence Syndrome
Santa Maria Hostel, Inc.
Comparison of the effects of alcohol and
other drugs on prenatal development
Special considerations – Pregnancy and Alcohol Use
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Fetal Alcohol Spectrum Disorder – umbrella term to describe range of
negative effects of alcohol on fetal development
Binge drinking greater than 4 drinks particularly impacts fetus
Negative effects can occur at even one drink per week – no safe amount
Prevalence rate similar or greater to that of autism
Single leading cause of mental retardation
People prenatally exposed have significantly higher likelihood to need
special education, be in foster care, be in the criminal justice system,
develop substance use and co-occurring disorders
Santa Maria Hostel, Inc.
Special considerations – Criminal Justice Involvement
•
In up to 72% of cases for women, substance use came first then crime
•
Tend to be incarcerated for offenses related to substance use (prostitution, forgery)
•
Number of mothers incarcerated has increased 122%
•
Mothers who are incarcerated more likely to have substance use and co-occurring
disorders and to be victims of abuse than father
•
Mother more likely to be primary caregiver – children more likely to witness arrest
and to be transferred to care of a non-parental caregiver after arrest
Santa Maria Hostel, Inc.
Relationship to Involvement with
Child Protective Services Involvement
•
Parental Substance Use significantly raises risk of child
maltreatment
•
Length of time spent in the child welfare system often longer for
substance involved families
•
Estimates of up to 2/3 of cases involve substance using parents
Santa Maria Hostel, Inc.
Special considerations - Trauma
•
Women who use substances more than twice as likely to have
PTSD as men
•
Estimates of 50-99% of women in substance abuse treatment
program have history of trauma
•
Women self-medicate to mask trauma symptoms
Santa Maria Hostel, Inc.
Adverse Childhood Experiences (ACE) Study
Adverse events and trauma in childhood negatively impact future adult
health behaviors (Ferttiti el al, 1998)
Childhood Trauma – Social/emotional/cognitive impairment – adoption of
high risk behaviors – disease – early death
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Major adverse events on ACE checklist:
Physical, emotional, sexual abuse
Emotional or physical neglect
Alcoholic or drug user in family
Incarcerated family member
Family member with mental illness or depression
Mother treated violently
Santa Maria Hostel, Inc.
Adverse Childhood Experiences (ACE) Study
Graded relationship between ACE scores and increased
risk for ischemic heart disease, chronic lung disease, liver
disease, cancer, unintended pregnancy, early death
Exposure to four or more categories compared to those
with no exposure:
• 2-4 fold increase in risk for smoking, STDS
• 4-12 fold increase for alcoholism, drug abuse, depression,
suicide attempts
Santa Maria Hostel, Inc.
Unique Barriers to Treatment
• Stigma
• Interrelation of trauma, relationships
• Lack of safe and adequate childcare
• Fear of CPS involvement/legal involvement
Santa Maria Hostel, Inc.
Best Practices
•
Gender-specific groups
•
Integrated trauma informed care approach
•
Residential treatment allows children to accompany the mother,
other treatment ensures safe child care options while mother
engages in treatment
•
Holistic approach that addresses relationships, caregiver role,
reproductive health issues, mental/physical health needs,
economic/housing stability, violence/trauma, case management
Santa Maria Hostel, Inc.
LGBT SUD Community as a
Special Population
Substance Abuse Rates in LGBT
Community
• It is estimated that 20 – 30 % of LGBT people abuse
substances, compared to about 9 % of the general
population.
Tobacco
• LGBT people smoke tobacco between 50-200 % more
than their straight peers, with bisexual men and women
having the highest rates of any subgroup.
• Smoking rates among LGBT youth are estimated to be
considerably higher (38% to 59%) than those among
adolescents in general (28% to 35%).
Alcohol
• 25% of LGBT people abuse alcohol, compared to 5-10%
of the general population.
• LGBT adults are twice as likely to binge drink, with
bisexual adults having even higher rates.
• LGBT adults are nearly 5 times as likely to ride in/drive
a car when the driver has had too much to drink.
• LGBT youth are 1.6 times as likely to use alcohol
before the age of 13.
Drugs
• Men who have sex with men (MSM) are 3.5 times more
likely to use marijuana than men who do not have sex
with men.
• MSMs also are 12.2 times more likely to use
amphetamines (crystal meth) and 9.5 times more likely
to use heroin.
• LGBT youth are 3 times more likely to use hard drugs.
• Alarmingly, estimated rates of drugs use with
transgender people is as high as 40-46%
“In a world where intolerance still reigns, many
LGBT individuals struggle with unique stressors
that can lead to [substance] abuse in a n effort to
cope. From estrangement from family members to
fears associated with the coming out
process…some [rehab] options can heighten these
stressors, particularly if individuals in recovery do
not receive the tolerance and acceptance they
deserve.”
Other issues of consideration:
• Heterosexism and strict gender expectations (espeically
in residential tx settings)
• Safety from other residents or group members
• Whether significant others (SO) are welcomed and
treated with respect
• Focus on treatment not on substance use but rather their
sexual orientation
• Rigidity regarding 12 step program, religion and
spirituality
• Lack of cultural competency in providers
THANK YOU!
www.montrosecenter.org
713.529.0037
Integrating Substance Use Disorder
Services with Mental Health and
Primary Care Services
Cathy Crouch
Andrea Washington
Nadine Scamp
Mary Beck
Health Behavior
Change using
SBI
Cathy Crouch, LCSW
Executive Vice-President
SEARCH Homeless Services
SBI: Screening
 Use
of the SF-36 which is a health-related
quality of life instrument
 First used on Hogg Foundation grant in
2003
 In 5th year using it on a SAMHSA SSH grant
with baseline and quarterly
administrations
 Use QualityMetric web site for data entry
and reporting features
SF-36 Domains
 Physical
functioning
 Role physical
 Bodily pain
 General health
 Vitality
 Social functioning
 Role emotional
 Mental health
Reporting
 Screening
conducted with client and
data entered real time into QM database
 Colorful report producing two composite
scores
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Physical health
Mental health
Normed by age and gender
SBI: Brief Intervention
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Ask permission to share results
Elicit concern or ask which domain they’d like
to see improve
Compare current results to historical
administrations, noting areas that have
improved (affirming client for their progress),
been maintained, or gotten worse.
Use an SBI-style protocol, using basic
motivational interviewing skills
SBI Session Checklist
MI/BI Initial Session Checklist
 ___ 1.
Introduce self and MI style, with “choice” noted
 ___ 2.
Complete screen
 ___ 3.
Provide brief feedback from screen, express concern
 ___ 4.
Identify target behavior(s) with patient
 ___ 5.
Decisional balance exercise (with target behavior)
 ___ 6.
Importance ruler, scaling questions (with target behavior)
 ___ 7.
Confidence ruler, scaling questions (with target behavior)
 ___ 8. Readiness ruler, scaling questions (with target behavior)
 ___ 9. Obtain & record goal (e.g., cutting down, stopping)
 ___ 10. Close with summary
 ___ 11. Make follow-up appointment for BI, BT if applicable
Organizational Examples of Integration of
Substance Use Services
• The Montrose Center
• The Council on Alcohol and Drugs
Houston
• SEARCH Homeless Services
• Santa Maria Hostel
Integrating Substance Use Services
•
Integrating substance use services into an existing health care
facility – Santa Maria Caring for Two PPI program at Lone Star
Family Health Center FQHC
•
Integrating primary health care into an existing substance abuse
treatment facility – Santa Maria Hostel Care Clinic
Santa Maria Hostel, Inc.
Thank You!
• Please fill out and turn in two feedback
forms:
• Participant evaluation
• Form for input on IHC needs and interests
• A copy of the presentation will be e-
mailed to all attendees.