Connecticut Best Practices Technical Assistance and Building Prevention Capacity to Address...

Connecticut Best Practices

Technical Assistance and Building Prevention Capacity to Address

Prescription Drugs, Tobacco, Marijuana, and Heroin

Wethersfield, CT

Nov 29, 2010

Jo Romano, CAPT NE RT Associate

Matt Myers, CAPT NE RT Associate

Objectives for the Day

• Increase knowledge and deepen understanding about the impact and consequences of Prescription Drug Misuse, Tobacco, Marijuana, and Heroin

• Identify Risk Factors and Evidence Based Strategies for the prevention of Prescription Drug Misuse, Tobacco, Marijuana and Heroin.

Objectives for the Day (cont’d.)

• Determine shared risk factors and strategies across problem areas including underage drinking, Prescription Drug Misuse, Tobacco, Marijuana and Heroin

• Examine sample community logic models for Prescription Drug Misuse, Tobacco, Marijuana and Heroin to provide effective TA to local communities

• Identify challenges and solutions for TA

Overview of Prescription Drug Misuse, Tobacco, Marijuana and Heroin

Share what we know about:• Prescription drug use and misuse• Tobacco• Marijuana• Heroin• Cultural considerations• Availability• Onset usually under 18• Low perception of harm

Prescription Drug Consequences

• Opioids, including OxyContin and Vicodin, depress the respiratory system and may be fatal if taken in large doses.

• Prolonged use of central nervous system depressants like Valium and Ambien can lead to serious withdrawal symptoms, including seizures1.

Prescription Drug Health Consequences

• High doses of stimulants like Adderall and Dexedrine can cause irregular heartbeat, high body temperature, and cardiovascular failure1.

• Excessive amounts of dextromethorphan, the active ingredient in over-the-counter cough medicine, can lead to vomiting, increased heart rate, high blood pressure, and impaired coordination1.

Sample Strategy

Social Access/Availability

Community Norms

Prior Marijuana Use

Early Initiation

Prescription DrugsRisk Factors and Strategies

Project Northland

Coalitions / Marketing

Lock Medicine Cabinet

Take Back Program

Parent Monitoring

Reconnecting Youth

Parental Internet Controls

Sample Strategy

Community Mobilization

Skill Enhancement Training

Information Dissemination

Strengthening FamiliesParent Approval

Parent/Sibling Use

Lack of Awareness

Perception of Harm

Transitions School Climate Change

Prescription Drug Risk Factors and Strategies (cont’d.)

Logic Model

Community- Specific Risk Factors

Long-Term Outcomes

Short-Term Outcomes

Strategies Resources and Inputs

Sample Community Logic Model Problem: Prescription Drugs

Community- Specific Risk

Factors

Long-Term Outcomes

Reduction in Use

Delayed Onset

Reduction in Availability

Access Ease of

Availability

Short Term Outcomes

Increased awareness of risk of improper

storage

Increased use of safer storage and/or

disposal practices

Increased demand for take-back programs

Increased perception of harm or social

disapproval


Community Norms

Perceived Risk

Drug Dispersal Take-Back Program

Social Marketing Lock Up Your

Medicine Cabinet

Collect and analyze data on the intervention

Recruit local DEA or police department to staff take-back event.


Develop a marketing plan

Partner with media

Secure earned and paid media

Prescription Drug UseSome Considerations for TA Providers

• What drug(s)? – Pain relievers, stimulants, psychotherapeutics

• Non medical use or misuse (with prescription)

– Different risk factors and strategies

• Poly-substance abusers

• Communities may not have resources to work with prescription monitoring programs

• Sources for young people are mostly social

Prescription Drug UseSome Considerations for TA Providers

• What are challenges and pitfalls communities may face when planning and implementing for Prescription Drug Misuse Prevention?

• What resources can you provide and/or will you need to provide effective TA?

Tobacco: Health Consequences

• Heart disease is the leading cause of death in Connecticut. Smoking is the leading cause of heart disease3.

• Women who reported smoking during pregnancy were 1.5 times more likely to experience premature labor.

• Connecticut reports spending over $1.6 billion on health care expenditures attributable to tobacco use each year.

• The consequences of secondhand smoke include increased risk of respiratory illness and asthma6.

Tobacco: Mental Health Consequences

• 45% to 88% of individuals with schizophrenia smoke cigarettes and 40% to 60% of individuals with clinically significant depression use cigarettes. These rates are substantially higher than those of the general population7.

• ADHD is associated with higher rates of smoking and an earlier onset of smoking7.

Sample Strategy

Coalition Development

Cessation Interventions/NOT

Mentoring / “Across Ages”

Environmental Strategies*Access and Availability

Community Norms

Prior Use/Mixed Drugs

Onset of Use

Parent/Sibling Use SMART Leaders/Life Skills

Tobacco Risk Factors and Strategies

Sample Strategy

Prevention Policies

Information DisseminationPerception of Harm

Workforce

Tobacco Risk Factors and Strategies (cont’d.)

Sample Community Logic ModelProblem: Tobacco


Factors

Long-Term Outcomes

Reduction in Lifetime Tobacco Use

Easy Access to Tobacco

Short-Term Outcomes

Decrease in Compliance Failure

Rates

Increase in Accurate Perception of Smoker

Prevalence

Increase in Intentions Not to Smoke


Normative Beliefs

Prevalence estimates;

Motivation to comply with

othersmokers; Beliefs

Compliance Checks

Normative Education

Curriculum infusion


Recruit staff and/or train youth to conduct compliance checks

Develop and distribute vendor education packets


Identify staff to design and implement intervention

Vendor Education

Tobacco UseSome Considerations for TA Providers

• There are possibilities for efficient of use youth across tobacco and alcohol

• Youth can be effective in working on policy initiatives

• Counter-advertising may be an efficient, low-cost strategy

• Environmental scanning is a useful assessment method coalitions can employ to gather visible information on local conditions surrounding tobacco

Tobacco UseSome Considerations for TA Providers

• What are challenges and pitfalls communities may face when planning and implementing for Tobacco Prevention?


Marijuana Consequences

• Of those individuals who initiate use during adolescence, one in six will go on to become marijuana dependent4,6.

• Heavy adolescent users have shown deficits in learning, attention, and memory even after one month of abstinence9.

Marijuana: Mental Health Consequences

• Marijuana users may have an increased risk of schizophrenia. In fact, researchers have estimated that 14% of schizophrenia diagnoses could be prevented if marijuana use was similarly prevented3,4.

• Heavy marijuana use has also been linked to depression, suicide, and panic disorder3,5.

Community Mobilization

Project Northland

Environmental Strategies

Keepin’ It R.E.A.L.

Sample Strategy

Access/Availability

Community Norms

Early Age of Onset

Peer Approval

Marijuana Risk Factors and Strategies

Social Refusal Skills

Guiding Good Choices

Drug Free School Zone

Social Norms Campaign

Sample Strategy

Prior Use/Mixed Use

Peer Use

School Performance

Perception of Harm

Marijuana Risk Factors and Strategies (cont’d.)

Sample Community Logic ModelProblem: Marijuana


Factors

Long-Term Outcomes

Reduction in Lifetime Marijuana Use

Reduction in Delinquency

Academic Failure

Short-Term Outcomes

Increase in School Bonding

Improved Academic Achievement

Reduction in Problem Behavior


Lack of CommitmentLow Bonding to

School

Academic Skills Enhancement

Enhanced SocializationSocial Support


Purchase curriculum,train teachers, providebooster sessions

Collect and analyze data on the intervention (e.g., Raising Healthy Children)

Provide teacher/ staff development workshops

Provide booster session

Interactive Curriculum

Marijuana UseSome Considerations for TA Providers

• Available literature is largely focused on illicit drug use

• The relationship between drugs and crime is key

• Perception of harm and social disapproval are influenced by the observance of peers using

• Reduced influence of parental attitudes from middle to high school

• Easy social access is a strong factor

• Environmental strategies are being studied

• Parental monitoring shows promise

Marijuana UseSome Considerations for TA Providers

• What are challenges and pitfalls communities may face when planning and implementing for Marijuana Prevention?


Enjoy Lunch!

Heroin: Health Consequences

• 35% of admissions to drug and alcohol treatment programs in Connecticut during 2006 listed heroin as the primary substance of dependence3.

• Heroin dependence is associated with serious withdrawal symptoms, including vomiting, cold flashes, joint pain, insomnia, intense craving for the drug, and involuntary movements. If a heavily dependent user is already in poor health, sudden heroin withdrawal may lead to death4

Heroin: Health Consequences

• Street heroin can contain toxic additives that damage the cardiovascular system, causing serious and permanent damage to vital organs. Questions around drug purity and dose can lead to fatal overdose4.

• Prolonged use can lead to collapsed veins, diseases of the liver and kidney, infection of heart valves and lining, and serious damage to the respiratory system4.

• Injection of heroin can put users at risk for infectious disease, including HIV/AIDS and Hepatitis4.

Heroin: Mental Health Consequences

• Psychiatric disorders are common among those with substance use disorders. National data have demonstrated that about 20% of those with a current substance use disorder also have at least one current mood disorder, and 18% have at least one current anxiety disorder6.

• Nearly one-third of adolescents in treatment for heroin dependence/abuse have a co-occurring psychiatric disorder5.

Heroin Cultural Considerations

• Heroin abuse among women who are pregnant may result in spontaneous abortion4.

• Heroin abuse during pregnancy and associated factors like poor prenatal care and nutrition can lead to low birth weight, which can put babies at risk for later developmental delay4.

• Infants born to mothers who have regularly abused heroin during pregnancy may be born heroin dependent, which can result in serious medical complications for the baby4.

Project Northland

Harm Reduction Approach

Civil Anti-Drug Remedies

Sample Strategy

Access/Availability

Prior Use

Age of Onset

Heroin Risk Factors and Strategies

Treatment

Counseling

Family Management

Sample Strategy

Family Conflict

Child Abuse

Heroin Risk Factors and Strategies (cont’d.)

Sample Community Logic ModelProblem: Heroin


Factors

Long-Term Outcomes

Reduction in Lifetime Heroin Use

Reduction in Delinquency

Perception of Harm

Short-Term Outcomes

Increased Perception of Harm of Heroin

Use

Increased Access to Mental Health and Treatment Services

Improved Access to Parenting Skills

Training via Drug Court Referrals


Low Parental Care

Family Conflict

Curriculum

Drug Court


Curriculum, teacher training

Hire and train community outreach workers


Court and enforcement partnerships

Community Outreach Worker

Education and Referral

Heroin UseSome Considerations for TA Providers

• Difficult to influence access to diverted pharmaceuticals

• Can be difficult to define and access the target population

• Some strategies are considered risk reduction

• Non-traditional sectors need to play strong roles– Prescribers, treatment, criminal justice, hospitals

NKassas

not clear. should use a different word.

Heroin UseSome Considerations for TA Providers

• What are challenges and pitfalls communities may face when planning and implementing for Heroin Prevention?


What is a Health Disparity?

Health disparities (also called healthcare inequality in the U.S.) refer to gaps in the quality of health and health care across racial, ethnic, sexual orientation and socioeconomic groups.

The Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care."

Special Populations

• Sexual Orientation: LGBT• Active Military and Veterans• Homeless• Older Adults• Women • Youth• Race• Ethnicity: African Americans, Alaska Natives, American Indians,

Asian Americans, Hispanics/Latinos, and Pacific Islanders

Contributing Factors to Disparity

• Poverty• Access to health care• Individual and behavioral factors• Educational inequalities• Disability• Geographic location: urban or city• Mental Illness

How Are Disparities Interrelated?

Example: Education and Health

• High level of education brings longer life span, easier access to health services

• Less education predicts higher levels of health risks such as obesity, substance abuse and violence

• Good health is associated with academic success

• Poor health predicts substance abuse, inadequate physical activity, emotional abuse, teen pregnancy, and poor performance in school

Multi-Cultural Risk Factors and Strategies

Sample Strategies

Integrated Care FamiliesVeterans/Military

Educational Inequity

Young Mothers

Lock The Medicine Cabinet CampaignPoverty

Project Northland

Home Visits

Guiding Good Choices

Maternal Smoking

Mental Health

Nurse/Family Partnerships

Cognitive Behavioral Therapy

Common Risk Factors Across Multiple Problems

• Tobacco, alcohol, marijuana, prescription drug misuse, heroin, other drug use, anti-social behavior, depression, sexual behavior and drunk/drugged driving are common among young people (Biglan, Brennan, Foster, & Holder, 2004)

• These problems are interrelated; moreover the same young people tend to engage in multiple problem behaviors

• The approach should concentrate on affecting the risk and protective factors influencing the involvement with multiple problems

Behavioral Health Connections to Substance Abuse

Success with Common Risk Factors

The Seattle Social Development Project (SSDP) shows that 15 years after a childhood intervention ended:

• 11% had fewer mental health disorders*• 12% had fewer STDs*• 9% were at or above the median in socio-economic *attainment

SSDP is a long term study and intervention that looks at the development of positive and problem behaviors among adolescents and young adults.

* Results are in comparison to the control group used for the study.

Finding the Fit

The following are three criteria that determine the best fit to include in a comprehensive prevention plan:

• Conceptual fit: Is the intervention relevant? • Practical fit: Is the intervention appropriate? • Strength of evidence: Is the intervention evidence- based?

Working Across Sectors

• Start with who is at the table

• Think strategically about new partnerships

• Develop an outreach strategy

• Create a plan for tracking changes in multiple problems

Ris

k Fa

ctor

Ris

k Fa

ctor

Ris

k Fa

ctor

Community Specific Risk Factor(s)

Strategy

Sector or DomainStrategySector

Primary Priority

Secondary Priority

Ris

k Fa

ctor

Goal: To identify a risk factor that is common to both underage drinking and your second priority •Pre-populate the chart. Include:

– Community-specific risk factors (your choice) for underage drinking

– Identified strategies

– Community sectors with which you are already working

•Add your second priority– Include risk factors, strategies, and sectors with which you

will work

•Analyze– Review the chart. Look for risk factors that have the

potential to efficiently impact multiple drugs or problems

– Look for similar strategies in the same sector or domain

Cross-Walking Risk Factors

Cross-Walking Risk Factors

Enfo

rcem

ent

Leve

ls

Early

Initi

atio

nAc

cess


Strategy

Partner or Sector1) Party Patrols

1) Law Enforcem

ent

Underage Drinking

Marijuana

Soci

al C

ompe

tenc

e

1) Compliance Checks

1) Business

2) Project Alert

2) School

1) After-School Program

1) School2) School

2) After-School Program

Already Identified

Risk Factors

Already Identified

Risk Factors

Data Sources in Binder

Data Sources in Binder

Strategy Tables in

Binder

Strategy Tables in

Binder

Risk Factor for Second Priority

Literature Review in Binder

Risk Factor for Second Priority

Literature Review in Binder

Already- Identified

Risk Factors

Already- Identified

Risk Factors

Cross-Walking Risk Factors : Create An Example

Text

Text

Text


Strategy

Partner or Sector

Underage Drinking

Prescription Drugs

Text

Primary Health Care Talking Points for TA Providers• Substance abuse, mental health and primary

health care share risk factors

• Substance use and abuse contributes to physical and mental health conditions early on

• Poor primary care contributes to substance abuse

• Patients not diagnosed and often not treated

Analyzing Risk Factors

Thinking through Risk Factors that Cross Multiple Problems

Gambling and AlcoholConceptual Model of Hypothesized Predictors of Youth Problem Behaviors

Socialization FactorsParental Monitoring,

Peer Delinquency

Individual FactorsImpulsivity, Moral

Disengagement

Gambling

Alcohol Misuse

Delinquency

Drug Use

Socio-demographic Factors

Gender, Age, Race, SES

Source: Shared Predictors of Youthful Gambling, Substance Use, and Delinquency 2007

Suicide and Alcohol

Depression

Alcohol Use

Selecting Common Risk Factor(s)Considerations for TA Providers

• Resources, focus on primary priority– Efficiency is critical with the secondary priority

• Relative strength of the relationship of risk factor to the priority– All risk factors are not equal

• Age of target population– Factors gain and lose strength as the target ages

• Similar strategies and domains– Practical, conceptual, levels of evidence

Risk Factors Across Problem AreasSome Considerations for TA Providers

• What are challenges and pitfalls communities may face when planning and implementing for Risk Factors across Problem Areas?


TA Challenges and Next Steps

• Identify challenges and pitfalls you may face when providing TA

• Find solutions to meet those challenges

Next Steps: Planning for TA

• Strategic plan for TA roll-out

• Guidance document

• Community training

• Community assessment tool

• Tool development

• What resources do you need from whom?

• What else?

Resources and Take-Aways

Connecticut Best Practices Technical Assistance and Building Prevention Capacity to Address...

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