Addiction: Current Trends in Substance Use Disorder, Treatment Innovation and Prevention GOSNOLD ON CAPE COD NEW ENGLAND’S ADDICTION TREATMENT PROVIDER

POPULATION PREVALENCE In Treatment: 2.5 million Total Addicted: 25 Million Harmful Use: 60 Million Little or No Use U.S. Population: 312 Million Addicted: 25 Million--8% Abusers: 60 Million--19% Family of Addicted: 95 Million--30% Total Affected: 180 Million--58%

 18 Million addicted to alcohol  7 million addicted to to other drugs ( 5 million to opiates)  9.5 % are adults  2.5 % are adolescents GOSNOLD ON CAPE COD NEW ENGLAND’S ADDICTION TREATMENT PROVIDER Scope of Addiction in the USA

Prescription Opioid Patterns in USA  17% of all scripts written are for an opioid  5% of world’s population; consume 80% of pain meds  79.5 million opioid scripts in 2009  Most prescribed med in America is Vicodin

 Philosophy of Pain Treatment  No One Should Suffer  Subjective Assessment of Pain  Defensive Medicine  Ignorance about Addiction How Did this Happen?

How Did Opioid Users Start?  36% with a Legitimate Doctors Script  68% Medicine Cabinet or Friend  93% of those not starting with heroin ended up using it  Profile: 32 years, 75% white, gender parity, started in High School

Overdose Deaths Exceed DWI Deaths

 7,000 a day in Emergency Rooms  Overdose deaths exceed Drinking Driver Deaths  Since 1998, 117% increase in ODs  53% of OD deaths re: to pharmaceuticals  80% of 42,000 OD deaths in 2012 were unintentional Impact of Opiate Crisis

 Use & procurement behaviors despite negative events  Return to use after periods of abstinence  Inability to consistently control use  Preoccupation with use/procurement  Cognitive changes (over-valuation, de-valuation, minimization/denial) What is Addiction?

Addiction is a Brain Disease Caused primarily by neurochemical dysregulation of the dopamine system:  Genetic vulnerability  Exposure to a drug

W e would not: ➢ View prior tx failure as a poor prognostic indicator ➢ Convey the expectation that patients should achieve enduring sobriety following single, brief treatment episode ➢ Punitively d/c for becoming symptomatic ➢ Relegate continuing care to an afterthought ➢ Treat the condition in episodes of self-contained and unlinked interventions What if we REALLY Believed Addiction was a Chronic Disorder? White and Kelly (2011)

➢ “ Addict” or “User” vs. Addiction Patient ➢ “Dirty” urine vs. Positive Lab Test ➢ “Clean & Sober” vs. Remission ➢ “Relapse” vs. Recurrence of Acuity or Regression ➢ Substance Abuser (cf eating disorder, not food abuser) ➢ Behavioral Health implying that “bad behavior” is responsible ➢ Talk of “graduation”. ➢ Challenge Patient Motivation (“he/she’s not ready”) ➢ If patient “uses” in treatment, we “kick them out” We Wouldn’t Talk the Way We Do 12

➢ Admit Discharge Admit Discharge ➢ A fixed treatment duration can resolve the problem ➢ Clinical aim is to place patients in a “program” & get them to “complete” treatment ➢ Reinforces Perception that Treatment Doesn’t Work Addiction Treatment Paradigm 13

 Diagnosable, Predictable, Treatable  A Course and Pattern Similar to Other Chronic Illnesses (Diabetes, Arthritis, Hypertension)  Characterized by Alternating Periods of:  Stabilization  Symptom Activation (Relapse) Addiction--A Chronic Illness

 Effects of treatment do not last very long after care stops  Patients who stop receiving treatment are at an elevated risk for a return to the acute stage GOSNOLD ON CAPE COD NEW ENGLAND’S ADDICTION TREATMENT PROVIDER In Chronic Illnesses..

Successful Outcome for Chronic Disease?  Patient has increasingly extended remission periods  When acute symptoms recur, intervention occurs, the patient is re-stabilized & care plan is modified  Patient engaged in a program to manage the disease  Patient experiences overall improved functionality (health, family, etc.)

WE CAN DO BETTER

Moving from focus on acute emergency care to prevention, early intervention, primary care and extended engagement It’s Time to Invert the Triangle 18

 Prevention, Identification and Early Intervention  Integration with General Medical Care (PCPs, hospital, etc.)  Extended Patient Engagement (Recovery Coaching)  Whole Family Involvement  Anti-Craving Medications  Technological Monitoring  Tele-Health The New Paradigm

➢ Screening and Brief Interventions (SBIRT, PHQ-9, GAD) ➢ Factors related to stress, non-compliance, coping style, sleep, diet, exercise, social supports ➢ Emphasis on prevention and self ‐ management approaches ➢ Partner with patient to build resiliency ➢ Consultation and co ‐ management of psychiatric disorders I. The Behavioral Health Clinician in PCP Office

➢ Care doesn’t End at “Graduation” ➢ For Patient & Family ➢ Improve Treatment Compliance ➢ Help Patient Integrate into a Recovery World ➢ Improve Life Functioning— Social Determinants ➢ Rapid Re-stabilization if Acute Symptoms Recur II. Extended Engagement-Recovery Management

ACHESS—measures progress, educates, maintains engagement, networks patients. My Strength- Sober Grid Steps Away III. Self Management Tools 37

GOSNOLD ON CAPE COD Extended Engagement Outcomes

GOSNOLD ON CAPE COD ◦  Naltrexone/Vivitrol  Suboxone  Methadone Medication Assisted Treatment

Psychiatric consult during the clinical visit Tele-Psychiatry

GOSNOLD ON CAPE COD NEW ENGLAND’S ADDICTION TREATMENT PROVIDER Prevention- Community Approach

 Law Inforcement  Academia  Medical  Community  Legistlators/Government GOSNOLD ON CAPE COD NEW ENGLAND’S ADDICTION TREATMENT PROVIDER Coalitions and Partnerships

GOSNOLD ON CAPE COD NEW ENGLAND’S ADDICTION TREATMENT PROVIDER Gosnold Prevention Division  Clinicians Integrated in Medical Practices  School Based Counseling  Overdose Intervention Program  Clergy Education  Physician & Prescriber Education  Charlie Wilkerson Memorial Community Lecture Series  Dental Society Education  National Prescription Drug Take Back Day  Project Sticker Shock  Lock Your Meds Campaign- Ongoing  Community Forums  Compliance Checks – Falmouth (twice annually)  Playing Above the Influence-A Collaboration with the Cape Cod Baseball League Teams  Collaborative Partnerships

Thank You! LORI J. MCCARTHY NATIONAL DIRECTOR OF CLINICAL OUTREACH LADC, CAI GOSNOLD ON CAPE COD NEW ENGLAND’S ADDICTION TREATMENT PROVIDER