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Substance Abuse 101 Catherine McAlpine, Ph.D., LCSW-C Manager, Behavioral Health and Crisis Services 401 Hungerford Drive, Rockville, MD 20850 [email protected] v

Substance abuse 101

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Page 1: Substance abuse 101

Substance Abuse 101

Catherine McAlpine, Ph.D., LCSW-CManager, Behavioral Health and Crisis Services

401 Hungerford Drive, Rockville, MD [email protected]

Page 2: Substance abuse 101

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

Page 3: Substance abuse 101

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Constitution (1919, repealed 1933), The Controlled Substance Act of 1970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

Page 4: Substance abuse 101

Challenges

• Binge Drinking

• Workplace – 70% are employed

• Aging Baby Boomers

• Co-occurring mental health & medical

• Abuse of Prescription Medications

• Pharmacotherapy – Buprenorphrine– Antagonists & Agonists

Page 5: Substance abuse 101

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

Page 6: Substance abuse 101

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

Page 7: Substance abuse 101

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%

Page 8: Substance abuse 101

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

Page 9: Substance abuse 101

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)

Page 10: Substance abuse 101

Where Do We Begin?

Page 11: Substance abuse 101

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

Page 12: Substance abuse 101

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?

Page 13: Substance abuse 101

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.

Page 14: Substance abuse 101

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

Page 15: Substance abuse 101

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

Page 16: Substance abuse 101

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

Page 17: Substance abuse 101

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.

Page 18: Substance abuse 101

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

Page 19: Substance abuse 101

Your Examples & Discussion

Page 20: Substance abuse 101

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

Page 21: Substance abuse 101

Stages of Change: A Trans-theoretical Model

Page 22: Substance abuse 101

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

Page 23: Substance abuse 101

Vision Statement from SAMHSA

• A Life in the Community for Everyone.

• Prevention Works.

• Treatment is Effective.

• People Recover.

Page 24: Substance abuse 101

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

Page 25: Substance abuse 101

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)

Page 26: Substance abuse 101

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.

Page 27: Substance abuse 101

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

Page 28: Substance abuse 101

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

Page 29: Substance abuse 101