DSM V C 1 - Overview of Substance Use Disorders - Kanehl.pdf

8/14/2019 DSM V C 1 - Overview of Substance Use Disorders - Kanehl.pdf

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

April 26, 2012, Charleston, WV

Overview of Substance Use Disorders


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Your Mid-Atlantic Addiction Technology Transfer Center

serves West Virginia, KY, TN, and VA

VCU

We are located at

Virginia Commonwealth

University

http://www.attcnetwork.org/regcenters/indexmidatlantic.asp

[email protected]
http://www.attcnetwork.org/regcenters/indexmidatlantic.aspmailto:[email protected]:[email protected]://www.attcnetwork.org/regcenters/indexmidatlantic.asp


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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 fieldRM, ROS,

impact of HCR

Discuss implications of theabove for clinical practice


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Whos here?


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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?


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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?


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Drugs of abuse, trends, prevalence, basic addictionscience


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Emerging Drugs K2/Spice

diverse family of herbal mixtures marketed under many names, including fakemarijuana, Yucatan Fire, Skunk, Moon Rocks, and others. Products contain dried,

shredded plant material and presumably, chemical additives that are responsible fortheir 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 asheroin and morphine. Ingested by chewing fresh leaves or by drinking their juices. Driedleaves 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 isconsidering 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, notyet well understood but linked to alarming number of ER visits across the country


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Trends NSDUH April 2011 Report Overall underage (12-20) alcoholuse incl. binge drinking

showed gradual decline

12% of pop 12 & older (30.2 million) drove under the influenceof ETOH past yr. (down from 14.2 % in 2002)

Tobaccouse has declined; from 2002 to 2009, rate of past-month cigarette use fell from 13.0 percent to 8.9 percentamong 12- to 17-year-olds. Among young adults aged 18 to

25 years; rates of use fell from 40.8 percent in 2002 to 35.8percent in 2009

In 2010, 12th graders reported an annual prevalence rate of17% for hookahsmoking and 23% for the use of small cigars.


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Trends NSDUH April 2011 Report Dailymarijuanause 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 ofregular marijuana use also declined among 10th and 12th graders,suggesting future trends in use may continue upward.

Trends in lifetime use of amphetamineand methamphetamineindicate statistically significant declines from peak-year (1996) use

among high schoolers. Cocaineuse 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 ecstasyamong 8-10th gradersincreased from 2.2 percent to 3.3 percent


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Trends NSDUH April 2011 Report Rates of hallucinogenuse 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 inhalantsalso remained steady from 2009 to

2010 with 8% of 8th graders reporting past-year use.

Prescriptionand OTC medications accounted for most of thetop 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 medsremained high at 6.5 percent and 6.6 percent, respectively.


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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 olderneeded treatment for substance use

Half of all lifetime cases of mental and substance use disordersbegin 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) 11-

4629 Summary. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2011.


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Trends in West Virginia Spice Not the community, (synth et ic cannabinoids), & regular marijuana

Bath Salts DOPE not SOAP (Synthet ic cath inones)West Virginiais hoping to curb synthetic drug use with a ban. The legislature has approved a bill thatwould make buying, selling or possessing synthetic drugs illegal. The move came afterthe state's poison control center reported 80 cases of people using bath salts to get highsince 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-Significantopioid research at WVU

Methamphetamine pockets of abuse (DEA data)

Gambling

Health disparities plus access & capacity issues,stigma, poverty


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Meth Notes rebounding after decline rural areas experiencing greater

increases in use availability on the rise smurfing and shake & bakecontribute to this 19.3 = average age of initiation, need prevention & treatment

resources!


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

Drug overdoses now kill more West Virginians thancar accidents

Drugs are the leading cause of accidental deaths inour state

We have the nations highest rate of drug deaths

9 out of 10 of our overdose deaths involve at leastone prescription drug http://www.coalvalleynews.com/view/full_story/18083312/articl

e-FIGHTING-DRUG-ABUSE-IN-WEST-VIRGINIA
http://en.wikipedia.org/wiki/File:Seal_of_West_Virginia.svghttp://en.wikipedia.org/wiki/File:Seal_of_West_Virginia.svg


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

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


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

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


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

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


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Needing but Not Receiving Treatment for Drug Use Past

Year Persons 12 & Older in West Virginia

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


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DSM-V Revisions reflect

major change!

Here is your resource to

follow the progress:http://www.dsm5.org/Pages/D

efault.aspx


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DSM-Vhttp://www.dsm5.org/Pages/Default.aspx

Proposed changes affecting former

Dx of substance abuseand dependence Coming out May 2013

Field trials underway in large academic-medical settings and small solo/grouppractices

Two previous comment periods; third andfinal planned for spring 2012


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Substance Use & Addictive Disorders

(formerly Substance-Related Disorders)

Substance Use Disorders

Substance Intoxication Substance Withdrawal

Gambling Disorder

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

Substance Induced Disorders

Also to be listed in chapter with disorder


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R 00-10 Substance Use Disorders

R Substance Use DisorderR 00 Alcohol Use DisorderR 01 Amphetamine UseDisorderR 02 Cannabis Use DisorderR 03 Cocaine Use DisorderR 04 Hallucinogen Use Disorder

R 05 Inhalant Use Disorder

R 06 Opioid Use Disorder

R 07 Phencyclidine Use

DisorderR 08 Sedative, Hypnotic, or

Anxiolytic Use Disorder

R 09 Tobacco Use Disorder

R 10 Other (or Unknown)Substance Use Disorder
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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 physicallyhazardous

continued substance use despite having persistentor recurrent social or interpersonal problems

Tolerance

Withdrawal

to # 11


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Specifiers

Severitymoderate to severe

With/without physiological dependence

Courseearly full remission, earlypartial, sustained full, sustained partial,on agonist therapy, in controlledenvironment


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Why they got rid of abuseProblems identified with the DSM-IV division between

abuse and dependence led to many studies of the

structure of the abuse and dependence in a varietyof general population and clinical settings. Giventhe empirical evidence, the DSM-5 Substance UseDisorders Workgroup recommends combining

abuse and dependence into a single disorder ofgraded clinical severity, with two criteria required tomake a diagnosis.


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Substance IntoxicationR 11-21 Substance

Intoxication

R 11 Alcohol IntoxicationR 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 IntoxicationR 19 Phencyclidine Intoxication

R 20 Sedative, Hypnotic, orAnxiolytic IntoxicationR

21 Other (or Unknown) SubstanceIntoxication
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Substance Withdrawal

R 22-30 SubstanceWithdrawal

R 22 Alcohol Withdrawal

R 23 AmphetamineWithdrawal

R 24 Caffeine Withdrawal

R 25 Cannabis Withdrawal

R 26 Cocaine Withdrawal

R 27 Opioid Withdrawal

R 28 Sedative, Hypnotic, orAnxiolytic Withdrawal

R 29 Tobacco Withdrawal

R 30 Other (or Unknown)Substance Withdrawal
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Substance-Induced Disorders Substance-Induced Psychotic

Disorder

Substance-Induced BipolarDisorder

Substance-Induced DepressiveDisorder

Substance-Induced AnxietyDisorder

Substance-Induced Obsessive-Compulsive or RelatedDisorders

Substance-Induced Dissociative

Disorder

Substance-Induced Sleep-Wake Disorder

Substance-Induced SexualDysfunction

Substance-Induced Delirium

Mild Neurocognitive DisorderAssociated with Substance

Use Major Neurocognitive

Disorder Associated withSubstance Use
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Whats new? Changes in the addictions field

Definitions

Research

Laws

Services


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What is addiction?

-ASAM August 2011:

Addiction is a primary, chronic disease

of brain reward, motivation, memoryand 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 dysfunctionalemotional response

ASAMs full public policy statement may be found here:

http://www.asam.org/research-treatment/definition-of-addiction


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Bringing the

Full Power of Scienceto Bear on

Drug Abuse& Addiction


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Your Brain on Drugs in the 1980s


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Your Brain on Drugs Today

YELLOW

shows places inbrain where

cocaine binds

(e.g., striatum)

Fowler et al., Synapse, 1989.

Addiction I s A Developmental Disease


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National Epidemiologic Survey on Alcohol and Related Condi tions, 2003.

Age

0.0%0.0%

0.2%0.2%

0.4%0.4%

0.6%0.6%

0.8%0.8%

1.0%1.0%

1.2%1.2%

1.4%1.4%

1.6%1.6%

1.8%1.8%

55 1010 1515 2121 2525 3030 3535 4040 4545 5050 5555 6060 6565

%ineachagegroupwho

developfirst-time

dependence

CANNABISALCOHOL

TOBACCO

Addiction I s A Developmental Disease

that star ts in adolescence and childhood

Age at tobacco, alcohol, and cannabisdependence per DSM IV


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Addiction is L ike Other Diseases

it is preventable, it is treatable, it changes biology,if untreated, it can last a lifetime

Healthy Brain Diseased Heart

Decreased Heart Metabolismin Heart Disease Patient

Decreased Brain MetabolisminDrug Addicted Patient

Diseased Brain/

Cocaine Addicted

Healthy

Heart

High

Low

Research supported by NIDA addresses all of thesecomponents of addiction.


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Addiction is a Chronicillness & 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 chronicdiseases

McLellan AT, Lewis DC, et al.JAMA 2000; 284:1689-1695.

Hypertension

Diabetes

Asthma

Addiction


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Addiction is Similar to Other Chronic I l lnesses Because:

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

Recovery from it--protracted abstinence and restoredfunctioning--is often a long-term process requiring repeatedepisodes of treatment.

Relapses can occur during or after treatment, and signal a need

for treatment adjustment or reinstatement.

Participation in support programs during and followingtreatment can be helpful in sustaining long-term recovery


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What is recovery?

SAMHSA , December 2011

Recovery from Mental Disorders and

Substance Use Disorders:

A process of change through which

individuals improve their health andwellness, live a self-directed life, andstrive to reach their full potential.


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Through the Recovery Support Strategic Initiative, SAMHSA hasdelineated four major dimensions that support a life in recovery:

http://blog.samhsa.gov/2011/12/22/samhsa%E2%80%99s-definition-and-guiding-principles-of-recovery-%E2%80%93-answering-the-call-for-feedback/

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 creativeendeavors, and the independence, income and resources

to participate in society; andCommuni ty: relationships and social networks that

provide support, friendship, love, and hope.


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How many people in the US are in recovery?

Best data wehave suggest

20 to 40 million


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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 stayand complete? If so, what?

What is most important to support long-termrecovery?


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Typical addiction career

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

20 & over

10%

Ten to 19

17%

Six to nine

7%

Four to five16%

Three11%

Two

22%

One

17%

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


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Typical treatment career

None21

One15

Two12

Three-four17

Five to nine21

Ten +14

Over half of outpatient clients have had

3 or more previous episodes

Laudet, Stanick & Sands, Eval Review, 2007


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National average Tx completion rate for outpatientmodalities = 36%

Completed40

Left beforecompletion

60

NYC Outpatient treatment outcome

Laudet, Stanick, & Sands, JSAT 2009

f


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Reasons for leaving treatment

Qualitative analyses:What is the most important reason why you dropped out of the program? *

8.5

9.4

12

12

12

12

18.8

31.6%

0 5 10 15 20 25 30 35

Not helpful

Finances

Do not want help

Family/personal issues

Convenience (e.g.,

transport)

Using

Tx interferes w/other

activity (e.g., job)

Dislike

program/staff/clients

* Add to > 100% because up to 2 answers were coded;

Laudet, Stanick, & Sands, JSAT 2009, 37:182-190


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Minimizing attrition: What could have been d one di f ferent ly so that youwould have cont inued at tending (among yes)?

Practicalassistance

11 Help with otherareas of

functioning18

Better, morecaring staff25

Betterindividualized

services23

Greater flexibilityin scheduling23


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Promoting abstinence alone is not enough

0 10 20 30 40 50Complete tx

Get life together

Relation w.family

Housing

Get kids back

Educ/Voc/Training

Get a job

Get/Stay clean

Abstinence is top goal but not only

goal!!

Asked at outpatient admission (N=314): What are the top

pr ior i t ies in yo ur l i fe right now?

However Extended Abstinence


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HoweverExtended Abstinenceis Predictive of Sustained Recovery

It takes a year

of abstinence

before less thanhalf relapse

Dennis et al, Eval Rev, 2007

After 5 yearsif you are sober,

you probably will stay that way.


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Sources of support in long-term recovery

7

11

17

18

43

53

53%

0 10 20 30 40 50 60Clinici

ansFrien

dsSelf/innerstreng

thSpo

useRecove

ringpee

rsFam

ilySpirituality

/faith

N = 52 CCAR Membersmedian abstinence duration = 12 years


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The mere action of making wellness

a bona fide outcome will reinforce the

fact that recovery from addiction is areality for many. By extension, this

can give hope to the many individualsand families affected by SUDs andsupport them in their search for the

solution that will work for them.Laudet, 2009


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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 nothave coverage

SAPT Block Grant

Distribution of Substance Use Problems


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Severe

Substantial

Moderate

Mild

None

Alcohol, Illicit and Non-Prescribed Drugs

2.3 Million Specialty Treatment

~23 Million Addiction Dxfor comparison Diabetes~24 million

Harmful Use Dx ~60 Million

(SBIRTnow covered)

(Rawson, & Freese), (McLellan)

Little or no use

(Preventionnow covered)


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Screening, Brief Intervention A single event can influence individuals

to reduce substance use for up to a year

May reduce mortalityrates by ~ 25%

Significantly reducessubstance-related accidentsand hospital visits


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

Distribution of Funding


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Medical

System

SUD

services

Residential

Outpatient

Detox

MAT

Block Grant

Medicaid

Insurance

Self pay

CurrentFundingSources

Tx System

Block Grant

Medicaid

Insurance

Self pay

HCRFundingSources

Recovery

Support

Distribution of Funding


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HEALTH CARE REFORM


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ROS, HCR & Integrated CareIn 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


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Overarching goals of health reform

Make health care more

1) accessible

2) affordable

3) efficient, and

4) effective


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Key strategies in 4 major areas: Coverage expansion

Cant deny people for pre-existing conditions, or charge higher premiums basedon 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 includesubsidized plans, basic required benefits, including MH/SUD services at parity

Delivery system redesign (integration, chronicillness management, health homes),and

Payment reform


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Prevention will be huge Including within chronic disease initiatives

Co-payments removed from screening for

depression, substance misuse,smoking cessation

Prevention & Public HealthFund will support EBPs for

programs that foster health,e.g. smoking cessation andcombating obesity.


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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 forbrief and specialty MH/SUD treatment

Those with the most serious MH/SUDs aretwice as likely to be unemployed andtherefore still uninsured


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Anticipated need for BH workforce

HCR has broad

implications for the

behavioral healthworkforce, not just in

terms of capacity, but

related to need for

training and education

to fulfill shifting or

new roles


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Impact of ACA on BH WorkersCoverage Expansion

More peoplegain health carecoverage withparity

20-30%will haveMH/SUD

Morescreening

willidentifyeven morepeople

We willneed anexpanded

AND moreefficientworkforce


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Impact of ACA on BH WorkersWorkforce Development

In order to improve patient satisfaction and healthoutcomes, 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 sufficientworkforce to meet public need Plan to recruit &train 60,000 new counselors over next

decade (depending on funding)


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Impact of ACA on BH WorkersBilling, Block Grants

We dont know more than we know

about a lot of how things will play outMcLellan

Level and use of block grantfunding will be impacted by whois/isnt covered and gaps that

remain as more people gain coverage

Organizations not proficient in billing mayneed to learn about billing models for HCR


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Impact of ACA on BH WorkersService Integration

Behavioral Health and Primary Care

By some estimates willreduce overall health carecosts by30% = $700 billion/year

While improvingquality of care

This report is available online athttp://www.nachc.com/research-data.cfm.


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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 ROSmay be ahead of the curve

THOUGHTS


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The work of HCR is just beginning; we will

learn as we go The future of the behavioral healthworkforce, including SUD services can bedecided in large part by how well preparedwe are

Our profession has a track record ofevolving to meet the demand for services

THOUGHTS


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Partnering FQHCsFederally 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 40million 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/


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A few of the Health Centers in West Virginia

Pineville Childrens Center


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Growth of new types of services

focused on recovery

And recovery-or iented serv ices In formed by sc ience

Recovery management - key

Cultural change Advocacy


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Recovery Model Acute Care Model

White (2008) Recovery Management &

Recovery-Oriented Systems of Care: Scientif ic

Rational & Promis ing Practices

Substance Abusing Patient

Non-Substance Abusing Patient

Treatment

Therapies,

Meds,

JCAHO,

CARF, EBPs,

etc.

Adapted from presentation by Tom McLellan, Ph.D.


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Shifting to a recovery-focused model means

...shifting theemphasis of

treatment from briefbiopsychosocialstabilization to one

of sustainedrecoverymanagement


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Recovery Management includes pre-recovery support services to enhance

recovery readiness,

in-treatment recoverysupport services toenhance the strengthand stability of recovery

initiation, and post-treatment recovery support services to

enhance the durability and quality of recoverymaintenance.


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RM also includes Emphasis on resilience and recovery

processes (asopposed to pathologyand disease processes),

Recognition ofmultiple long-termpathways and styles of recovery,


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Examples of pathways to recovery

Mutual support groupsAA, NA, Al-Anon, SOS, etc.

Professional treatment

inpatient, outpatient, etc.

Recovery Community OrganizationsSAARA of Virginia

Faith-based support services

Celebrate Recovery, etc.

Medication-assisted recoverymethadone, buprenorphine, etc.

Justice system programs

drug courts, TCs, etc.


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Recovery capital; problem severity, treatment failures and otherreframes

Recovery capital (RC) isthe breadth and depth of internal andexternal resources that can be drawnupon to initiate and sustain recoveryfrom severe alcohol and other drugproblems White & Cloud, 2008


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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


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Types of recovery capital

Family and social RC - intimaterelationships, family and kinship relationships(defined here non-traditionally, i.e., family of choice), and socialrelationships that are supportive of recovery efforts.Family/social recovery capital is indicated by willingness ofpartners and family members to participate in treatment, thepresence of others in recovery within the family and social

network, access to sober outlets for sobriety-basedfellowship/leisure, and relational connections to conventionalinstitutions (school, workplace, church, and other communityorganizations).

White & Cloud, 2008


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Types of recovery capital

Community RC - encompassescommunity attitudes/policies/resources related to addiction and

recovery that promote the resolution of alcohol and other drugproblems. 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


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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 withparticipation in professional treatment or a recoverymutual aid society)

Increases in recovery capital can spark turningpoints that end addiction careers, and triggerrecovery initiation

White & Cloud, 2008


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Early scientific findings

Such turning points often result after several yearsand multiple episodes of professional treatments

Recovery capital is not equally distributedacross individuals and social groups. Members ofhistorically disempowered groups often seekrecovery from addiction lacking assets that aretaken for granted by those seeking recovery from aposition of privilege White & Cloud, 2008


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Early scientific findings

Most clients with severely depleted

family and community recovery capital gain littlefrom individually-focused addiction treatment thatfails to mobilize family and community resources

Long-term recovery outcomes for those with the

most severe AOD problems may have more to dowith family and community recovery capital than aparticular treatment protocol

White & Cloud, 2008


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The concept of recovery capital

reflects a shift in focus from the

pathology of addiction to a focus onthe internal and external assetsrequired to initiate and sustain long-term recovery from alcohol and other

drug problems.

White & Cloud, 2008


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Federal Initiatives to support ROSAddiction Technology Transfer Center (ATTC) Network

SAMHSA/CSAT funds a network of 14 regional

ATTCs, which provide training and technicalassistance to states. The ATTC network publishesguides, toolkits and monographs supportingtreatment and recovery systems and services.These include numerous publications on recovery-specific topics. Each of the ATTCs has establisheda ROSC implementation support team to assiststates in implementing ROSC.
http://www.attcnetwork.org/index.asphttp://www.attcnetwork.org/index.asphttp://www.attcnetwork.org/index.asphttp://www.attcnetwork.org/index.asp


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Federal Initiatives to support ROSAccess to Recovery (ATR)

(ATR)is a Substance Abuse and Mental Health

Services Administration (SAMHSA) programwhich awards competitive grants to states andtribes to implement voucher systems forpurchasing substance use disorder treatmentand recovery support services. ATR providesstates and tribes with an excellent mechanismfor developing systems and services that moreeffectively support long-term recovery.
http://www.atr.samhsa.gov/http://www.nattc.org/learn/topics/rosc/rss.asphttp://www.nattc.org/learn/topics/rosc/rss.asphttp://www.atr.samhsa.gov/


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Federal Initiatives to support ROS Recovery Community Services Program (RCSP)

The Recovery Community Services Program is a SAMHSA grant programwhich funds organizations to provide peer-to-peer recovery support services

for people in or seeking recovery from alcohol and drug problems. Initiatedin 1998, RCSP has seeded the development of numerous recoverycommunity organizations.

Targeted Capacity Expansion-Local Recovery-Oriented

Systems of Care (TCE-ROSC)

SAMHSAs Targeted Capacity of Expansion (TCE) Local Recovery-Oriented Systems of Care (TCE-Local ROSC) grants assist in thedevelopment of Recovery-oriented Systems of Care (ROSC) at alocal level.

BRSS TACS Bringing Recovery Supports to Scale - current
http://www.samhsa.gov/grants/2011/ti_11_004.aspxhttp://www.samhsa.gov/grants/2010/TI-10-007.aspxhttp://www.samhsa.gov/grants/2010/TI-10-007.aspxhttp://www.samhsa.gov/grants/2010/TI-10-007.aspxhttp://www.samhsa.gov/grants/2010/TI-10-007.aspxhttp://www.samhsa.gov/grants/2011/ti_11_004.aspx


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Federal Initiatives to support ROS Partners for Recovery (PFR)

Partners for Recoveryis a SAMHSAinitiative that supports the developmentof recovery-oriented policy, systems andservices. It engages diversestakeholders including Federal agencies,states, tribes, local governments,professional/ trade associations, faith-

based groups, health care professionals,nurses, social workers, and recoverysupport services providers to accomplishthis.
http://www.pfr.samhsa.gov/http://www.pfr.samhsa.gov/


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ROS Implementation challenges Need for more sciencewe still know comparatively

little from the standpoint of science about the prevalence, pathways,and styles of long-term recovery

Integration of professionally directedservices and peer-based recovery supportwho best to provide, where are the boundaries andethical guidelines

Service capacitieshow ought resources to bereallocated and how does this affect service capacity

White, Kurtz, Sanders, 2006


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ROS Implementation challenges

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

Reimbursement and regulationsallbased on the acute model

High staff turnoverin theworkforce precludes continuity of contact


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Recovery Community Organizations have grown andpaved a way forward one example:

Founded 1997

RCSP and state grants, consistentlyincreased grant funding, regular

state funding Huge face on recovery

Huge advocacy presence

Multiple Recovery CommunityCenter sites

Recovery housing network

Recovery Coach training program

Product development

National leader for partnering withstate systemshttp://www.ccar.us/default.htm
http://www.ccar.us/default.htmhttp://www.ccar.us/default.htm


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Virginias Statewide RCO

Substance Abuse and Addiction Recovery Alliancehttp://www.saara.org/

SAARA of Virginia is a grassroots recovery community organization. All friends ofrecovery are invited and welcome to join. Our members include individuals inrecovery from alcohol and other drug addiction, their families, friends, anddedicated community supporters. Across the Commonwealth of Virginia, weare seventeen affiliates strong and growing. SAARA promotes social,

educational, legal, research and health care resources and services thatsupport accessible, effective and accountable addiction prevention,intervention, treatment and Recovery. We envision the day when the stigma ofaddiction will be eradicated, and all who seek recovery will find it. Recoveryhappens! Please take a look around our website and let us know if you haveany comments or questions.
http://www.saara.org/http://www.saara.org/


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RCOs can foster ROS in systems By providing service coordination and

modeling person-centered, strengths-

based services

By putting a face onrecovery

By supporting multiplepathways to recovery


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RCOs can foster ROS in systems

By providing recovery coaching and

assertive linkages to communities ofrecovery

By supporting recovery

housing


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RCOs can foster ROS in systems By encouraging hope & optimism about

recovery through peers

By addressing stigma


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RCOs can foster ROS in systems By focusing on and modeling

strategies for engagement andmotivational enhancement

This

This

NOT


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ROS Outcomes: System Numbers Philadelphia

36% in crisis utilization after 1 year

50% cost of inpatient psychiatric services Connecticut

46% in number of people served statewide

62% in use of acute care

40% in outpatient care

25% in annual cost per client

Outcomes: Individuals Seeking RecoverySAARA Center for Recovery in Virginia


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Recovery Oriented Services

Have a growing evidence base for theireffectiveness

Fit perfectly into the prioritiesfor HCR

Include lower-cost

interventionsfor disease/recoverymanagement


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Addiction is visible everywhere in thisculture, but the transformative power of

recovery is hidden behind closed doors. Itis time we all became recovery carriers. Itis time we helped our community, ournation, and our world recover Recovery

is contagious. Get close to it. Stay closeto it. Catch it. Keep catching it. Pass iton. (White, 2010)


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Where shall we go, what shall we do, and how canyou help? Implications for clinical practice


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Stigma

New definitions ofaddiction, recoverybased on science

Chronic vs. acute illness modelnew

services, peer providers DSM-5

Other?


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A study of stigmatized attitudes towards people with mentalhealth 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 attitudestowards patients with active substance usedisorders. Attitudes were less stigmatized to people

with SUDs who wererecovering/in remission.


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The effectiveness of interventions for reducing stigma relatedto substance use disorders: a systematic review.

Addiction. 2012 January; 107(1): 3950.

Summary: Effective strategies foraddressing social stigma include

communicating positive stories ofpeople with substance use disorders.For changing stigma at a structurallevel, contact-based training andeducation programs targeting

medical students, clinical and otherprofessionals (e.g. police) areeffective.

Hello, my nameis Tara and I am

in long-termrecovery which

means


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Implications of the above for clinical practice

Stigma of addictions

What is our responsibility for our own andothers professional attitudes?

What is our responsibility for communityeducation to fight stigma?

What, if any, is the responsibility ofrecovering professionals/others toadvocate?


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Do you think our services system as it exists today reflectsthe new, more broad definition of recovery? How/How not?


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The future of addiction treatment hinges on our ability toconnect treatment with recovery!

The emerging science of recovery supports

extending the acute care model to a model of

recovery-oriented services that supportssustained recovery management

Several states, communities and treatment

organizations have begun to

transform their systems Models for recovery management

are already working


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Implications for clinical practice What do clinicians need to know about

recovery management/chronic care?

Do clinicians have a role in systemschange toward recovery-orientedservices and systems?

Other?


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DSM-5, etc. implications for clinical practice

What is clinicians responsibility re: the

new DSM? Offering feedback?

How can clinicians prepare for greaterintegration of behavioral health andprimary care?

What other implications can you thinkof from our discussion today?


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New environments, new challenges, new options


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http://www.williamwhitepapers.com/books_monographs/


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http://www.williamwhitepapers.com/
http://www.williamwhitepapers.com/books_monographs/http://www.williamwhitepapers.com/books_monographs/


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DSM V C 1 - Overview of Substance Use Disorders - Kanehl.pdf

Documents

Transcript of DSM V C 1 - Overview of Substance Use Disorders - Kanehl.pdf