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Public Health Social Work and Substance Use Disorders
DeborahMilbauer, MPH, MSWPublic Health ConsultantPart Time Instructor, Northeastern University
Learning Objectives
Learning ObjectivesProvide a brief overview of national scope and trends of substance use disorder in USExplain the brain science, and identify the diagnostic criteria, for substance use disorderDefine stigma and harm reduction, and discuss the impact it has on substance use and misuse health outcomesDefine the continuum of care, domains of influence and the strategic prevention frameworkPresent case studies and discuss the relevance for public health social workersIdentify action steps upon conclusion of the training
National Scope and Trends
Definitions, national scope and trendsPublic health model of substance use and misuseThe science of preventionCase studies and the role of public health social workersWhere do we go from here?
Overview: Why People Use Substances
Key Terms: Changing Definitions
Substance ‘use’simply means using a substance.Substance ‘misuse’means using a substance in a way that either causes harm (binge drinking) or is illegal (taking someone else’s prescription pills); any alcohol use by someone under 21 is considered misuse because it is illegal.Substance use ‘disorder’means a diagnosis that meets clinical criteria. One can use or misuse regardless of diagnosis. More on this later.“Drugs”can mean anything such as alcohol, tobacco, prescription pills and illicit substances such as marijuana, cocaine , opioids (heroin) and inhalants“Illicit Drugs”are those that are not legal.“Addiction”is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequenceshttps://www.ncbi.nlm.nih.gov/books/NBK519702/https://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basicshttps://www.drugabuse.gov/publications/media-guide/glossary
Why Do People Take Drugs?
To feel goodTo feel betterTo do betterCuriosity and social pressure
Why do we need to know why?
Drug Classifications
National Trends
Good newsRates of substance use have been decreasing for decades among both adolescents & adults 18+Attitudes, policies and practices are beginning to shift towards a public health framework and away from a criminal justice framework in some communitiesWe know more about what works and what doesn’t based on decades of ever-evolving researchGood sources:https://www.samhsa.gov/data/report/trends-substance-use-disorders-among-adults-aged-18-or-olderhttps://www.drugabuse.gov/related-topics/trends-statisticshttps://www.cdc.gov/publichealthgateway/didyouknow/topic/alcohol.htmlhttps://www.centeronaddiction.org/https://www.healthcenterinfo.org/priority-topics/substance-use-disorders/https://addiction.surgeongeneral.gov/
National Trends
Bad NewsNew emerging substances & methods of use may reverse progress made over many yearsNew state marijuana laws pose complicated public health challenges (legalization of medical and recreational marijuana)Current opioid epidemic is devastating a people and communities across USHealth inequities and unequal burden of disease among low income and communities of color continuesThe shift towards use of public health approaches is playing out differently depending on socioeconomic status and race/ethnicityRecent political changes on federal level have impacted funding, research and laws
National Scope
Alcohol
is the most used legal drug in the country
Marijuana
is the most used illicit drug in the country
Lifetime prevalence for substance use disorder is 15% of population (ever having had a SU disorder)In 2016, 20 million people (6% of US population) aged 12+ had a substance use disorder of alcohol and illicit drugs:15 million with alcohol use disorder7.4 million with illicit drug use disorder (marijuana most common)Of 20 million needing treatment, only 3.8 million received it (19%)Lifetime prevalence is 15%Many more used substances than were diagnosed (aged 12+):Tobacco: 51 million current usersAlcohol: 136 million current users, 65 million binge users and 16 million heavy usersIllicit Drugs: 28 million current users (10% of US population). Primarily marijuana (24 million) and prescription pain killers (3.3 million)
Marijuana: Most Used Illicit Drug in the Country
National Scope
Rates of Use Among 8th, 10th and 12th Graders in 2017Alcohol No decrease for the first time in decades after years of declining useCigarettes Declines continue and at historic lows. (Future increase suspected as vapers graduate to cigarettes)Marijuana Slight increase for first time in 7 years after decades of declineVaping Relatively new phenomenon but levels of flavoring, marijuana and nicotine are “considerable”. “Vaping has become a new delivery device for a number of substances and this number will likely increase in the years to come.”Inhalants Significant increase among 8th graders after a decade of declineHeroin & Opioids Heroin use remained low. Misuse of Prescriptions continuing to decline
Video
Public Health Burden of Substance Use, Misuse, and Disorders
Tobacco is the leading cause of preventable deaths in the US (480,000)Alcohol is the 3rd leading cause of preventable death in the US (88,000)For teens, alcohol is involved in more than 60% of accidental teen deathsOverdose killed 72,000 people in 2017; (70,000 from opioids). More than:Motor vehicles (40,000 in 2017)Guns (38,000 in 2016)HIV/AIDS (50,000 in 1995)Soldiers in the Vietnam war (58,000 by 1972)
Drug Overdose Deathshttps://www.cdc.gov/nchs/products/databriefs/db329.htm
Opioid Deaths in US 1999-2014
Opioid deaths were initially primarily due to pills and heroin, and now are mostly due to Fentanyl (50-100 times stronger)2014: 24 deaths per 100,0002016:52 deaths per 100,000
Other Emerging Trends of Concern
Vaping, E-cigarettesENDS: Electronic Nicotine Delivery SystemsLegalization of recreational and medical marijuana, oil, and food productsSynthetic marijuana (K2, spice, etc.)Fentanyl laced opioids
Unequal Public Health Burden
Which subpopulations may be at increased risk for substance use disorders?
Unequal Public Health Burden
Which subpopulations may be at increased risk for substance use disorders?Lower socioeconomic statusCommunities of colorVeteransHomeless individualsLGBTQSomeone with substance use in familyRural communitiesEnglish as a second languageNative American IndianMental health disorders (depression, anxiety)Others?
The Health Burden of Racial Discrimination
Half of the 2.3 million people incarcerated in the US have an active substance use disorder; 1 in 5 have a diagnosable substance use disorderMost jails and prisons do not provide adequate treatment, if any, for substance use disordersJails and prisons are overrepresented by inmates of colorWhites are more likely to be adjudicated to treatmentNon-white more likely to be adjudicated to jails and prisons – See Jay Z’s War on Drugs video forsynoposishttps://youtu.be/HSozqaVcOU8
Substance Use and Public Health Social Work
SU is a major PH issue! With more than 650K social workers—half employed in health, behavioral health and substance use—this is a major issue for social work professionSubstance use disorders are bio-psycho-social behavioral health issuesRepresent a clinically significant impairment that causes health problems, disability, and failure to meet major responsibilities at work, school, or home.Effects 20 million people and their families with diagnosed SUD; 10% of children live with a parent with alcohol problemsMost public and private institutions encounter individuals and families with substance use disorders of all backgrounds
Public Health Model of Substance Use and Misuse
National scope and trendsPublic health model of substance use and misuseThe science of preventionCase studies and the role of public health social workersWhere do we go from here?
Word Brainstorm
Activity
Language of Stigma
NegativeJunkieAddictAbuserUserPot headHabit/drug habitClean/dirtyReplacement or substitution therapy
Non-judgmentalPerson with a substance use disorder (person- first descriptions)Person with an alcohol and drug diseasePerson engaged with risky use of substances, misusing/misusePatient (if in treatment)Addiction survivor (mimics cancer survivor)Substance free or negative/positiveMedication assisted treatment, medication, treatment“People from the substance using community”
Activity
Substance Use Disorders
Moral/Criminal ModelIndividuals are bad people if they use substancesSubstance use is a choiceIt’s all about will powerSomeone deserves to be locked up because of their behaviorBehaviors related to substance use should be punished, not treatedWhat else?
Medical/Public Health ModelSubstance use disorder is a brain diseaseDiseases should be treated as a health problem, not a criminal problemLike all diseases, SUDS can be studied and understood using a population health approach, which reaches far more people than an individual level approach and includes preventionSystemic solutions are more effective than working with one individual at a time
Activity
MoralModel versusMedicalModelCriminal JusticeorPublic Health Model?
The Language of Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5):‘Substance abuse and substance dependence’ no longer used‘Substance use disorders’ now used based on diagnostic criteriaDiagnosed as mild, moderate or severeCriteriaRecurrent use causes clinically and functionally significant impairmentHealth problemsDisabilityFailure to meet major responsibilities at work, home and/or schoolImpaired control social impairment, risky use and pharmacological criteria
http://blogs.scientificamerican.com/mind-guest-blog/2013/05/20/dsm-5-caught-between-mental-illness-stigma-and-anti-psychiatry-prejudice/
‘Substance Use Disorder’: 11 Criteria (Symptoms) as Defined in the DSM 5
Taking the substance in larger amounts or for longer than you're meant to.Wanting to cut down or stop using the substance but not managing to.Spending a lot of time getting, using, or recovering from use of the substance.Cravings and urges to use the substance.Not managing to do what you should at work, home, or school because of substance use.Continuing to use, even when it causes problems in relationships.Giving up important social, occupational, or recreational activities because of substance use.Using substances again and again, even when it puts you in danger.Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.Needing more of the substance to get the effect you want (tolerance).Development of withdrawal symptoms, which can be relieved by taking more of the substance.
‘Substance Use Disorder’: Severity as Defined in the DSM 5
Mild: 2-3 symptomsModerate: 4-5 symptomsSevere: 6 or more symptoms
‘Substance Use Disorder’: 10 Classes of Drugs as Defined in the DSM 5
AlcoholCaffeineCannabis (marijuana)HallucinogensInhalantsOpioidsSedativesHypnotics, or anxiolyticsStimulants (including amphetamine-type substances, cocaine, and other stimulants)TobaccoOther or unknown substances
IOM Continuum of Care – DESIGN SUPPORT NEEDED
Discussion
The Key to Prevention: Adolescent Brain Development
Adolescent brain not fully developed until age 25Brain has great growth spurt just prior to pubertyTeens highly driven by reward and peer influence, at the same time that judgement, self control and problem solving are still developingExposing a teen brain to substances is different than when an adults’ fully developed brain is exposed to those same substanceshttp://clbb.mgh.harvard.edu/juvenilejustice/
The Key to Prevention: Delay First Use
Almost all substance use disorder (SUD) starts in the teens (90%) and is considered a pediatric brain diseaseFor every year a teen delays their first use, it protects the developing brainRisk of later life disorder is reduced 10% for every year first use is delayedEven if disorder does not develop, many negative social and health consequences result from use and misuse(Chen,Storr& Anthony, 2009)
Social and Health Consequences
Drunk drivingSexual activity including assaultPoor decision making from clouded judgementInjuries while drunk/highVomiting or chokingPoor grades and disciplinary actionImpaired relationships with friends and familyLoss of jobSuspended or kicked off sports teamsProperty damageWeight gainImpaired memory and reduced cognitionDepression and anxietyDifficulty concentratingER VisitsArrestsBrain damageLiver diseaseHIV/Hepatitis
When Use Turns Into Disorder: Why Don’t People Just STOP if They Know it’s Bad????
Substance Use Disorders change BRAIN CHEMISTRY.Knowingdoesn’t change behavior.“It is like telling a person who has diabetes that exercise and willpower will be enough to helptheir pancreas to begin producing insulin”(Getz, 2018)
When Use Turns Into Disorder: Why Don’t People Just STOP if They Know it’s Bad????
“With continued use, a person's ability to exert self-control can become seriously impaired; this impairment in self-control is the hallmark of addiction. Brain imaging studies of people with addiction show physical changes in areas of the brain that are critical to judgment, decision-making, learning and memory, and behavior control. These changes help explain the compulsive nature of addiction.”Szubiakhttp://www.socialworktoday.com/archive/JA18p10.shtml
Treatment Overview
Medicated Assisted Treatment
Medicated-Assisted Treatment (MAT) is the use of FDA- approved medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders for opioids, alcohol and smoking.There are three medications commonly used to treat opioid use disorder:Methadone – clinic-based opioid agonist that does not block other narcotics while preventing withdrawal while taking it; daily liquid dispensed only in specialty regulated clinicsNaltrexone – office-based non-addictive opioid antagonist that blocks the effects of other narcotics; daily pill or monthly injectionBuprenorphine – office-based opioid agonist/ antagonist that blocks other narcotics while reducing withdrawal risk; daily dissolving tablet, cheek film, or 6-month implant under the skin
Where Addiction Medications are Offered in Prisons and Jails in US
Only 1 state offers all 3 medications to all inmates in prisons and jails (Rhode Island)5 other states offer Methadone and Buprenorphine to some inmates in certain corrections facilities38 offer Vivitrol upon re-entry“MAT…can cut mortality in half”Dr. NoraNolkow, NIH Director
What is Harm Reduction?
Discussion
What is Harm Reduction?
Harm Reduction
“Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”https://harmreduction.org/about-us/principles-of-harm-reduction/
Discussion
The Science of Prevention
National scope and trendsPublic health model of substance use and misuseThe science of preventionCase studies and the role of public health social workersWhere do we go from here?
Domains of Influence
Environmental interventions targetorganizational,communityandpublic policydomainsThe higher the domain, the bigger the population impact
Activity
Big Picture Change: Targeting the Environment
Environmental Prevention Strategies focus on changing aspects of the environment that contribute to use of alcohol, tobacco and other drugs such as:Social norms tolerant of use and misusePolicies enabling use and misuseLack of enforcement of laws designed to prevent use and misuseInadequate negative sanctions for use and misuseInadequate zoning that does not regulate outlet density or signage
Prevention Strategies
Discussion
Substance Use and Misuse Prevention
Prevention relies on PLANNINGThe DOING comes later
Public Health Approach to Community Planning: Social Work Plays Critical Role
Conduct needs assessmentBuild capacityMake a planImplement the planEvaluate the planMake it sustainableMake it culturally responsive
Discussion
Video
Where Do I fit into Prevention Planning?The Role of the Public Health Social Worker
What structures are in place in your organizations to initiate or support a planning process?Who will assess, plan, implement and decide program, policy or systems changes?Who are the key stakeholders who should be involved in the planning?What is your role in advocating, encouraging, leading, teaching,shepardingor even recommending change? If not you, then who?What are the practice/policy/training changes appropriate for your work with clients?What are the practice/policy/training changes appropriate for your department?Your entire organization?You or your organizations’ relationship with community partners?You or your organizations’ role in local, state and federal laws?Research, policy and practice changePrevention planning (strategic prevention framework)Community organizingLocal, state and federal legislation
Activity
Case Studies and the Role of Public Health Social Workers
National scope and trendsPublic health model of substance use and misuseThe science of preventionCase studies and the role of public health social workersWhere do we go from here?
Case Study: Public Health Social Work in Action
Neighborhood Substance Use Prevention Coalition3-year opioid overdose state grantRequired to conduct SPFAssessment took over a year3 evidenced-based, data driven strategies chosen
Case Study: Public Health Social Work in Action
Case Study: Public Health Social Work in Action
A role for public health social workers in primary prevention and public policy
Case Study: Harm Reduction in Action
Safe Injection Facilities (SIF) and Drug Consumption Rooms (DCR)What role should Public Health Social Workers play?
Case Study: Recovery High Schools
More potential roles for public health social workers…
Where Do We Go From Here?
National scope and trendsPublic health model of substance use and misuseThe science of preventionCase studies and the role of public health social workersWhere do we go from here?
Moving PHSW and SUDs Forward
Education and professional training in prevention & interventionIntroduce and expand training in schools of social work with required and elective courses, specialization and field placementsTrained masters level social workers are needed to research and implement evidenced-based interventions, policies and practices at both the clinical level and the broader domains of influence (community, institutional and societal) .Community-based prevention scienceBuild community partnerships and coalitions in which public health planning and decision making gives true power and inclusion to the population it intends to targetLanguageModernize the language and terminology we use to discuss individuals with substance use disordersPlay a leadership role in shaping the way public health social workers model the use of language to improve health outcomes, saves lives and promote social justice(Wilkey, Lundgren & Amodeo, 2013)
Moving PHSW and SUDs Forward
Stigmatization and criminalizationOvercome policy and practice barriers presented by stigmatization of substance use and misuse presents through research and sound prevention scienceUse the unique role of public health social workers to foster de-stigmatization and de-criminalization of a chronic, relapsing brain disorder, especially in poor and marginalized communities of colorAdvocate for data-driven, evidenced-based policies and practice at the local, state and federal levels that explicitly and intentionally address stigmatization and criminalization.Engage in the surveillance and research critical to this effort.Behavioral health treatmentDemand parity in the treatment of substance use disorders by integrating MAT (Medicated Assisted Treatment) into behavioral health systems of care. The full menu of medications should be available to any individual with substance use disorder in the way that the full menu of psychiatric medications are available to individuals with mental health disorders.Play a role in demanding parity via the tools of research, advocacy for best practices and public policy, and leadership in directing the national conversation(Wilkey, Lundgren & Amodeo, 2013)
Moving PHSW and SUDs Forward
AdvocacyInfluence policies and practice that perpetuate social norms that encourage use.Document and advocate against criminalization of substance use in communities of colorIntegrate the mission of racial and ethnic health equity for individuals with SUDS into everything PHSW’s do, not as a side issue or taskCall out practices, institutions and societal structures that stigmatize and criminalize people with the brain disorder of SUDS(Wilkey, Lundgren & Amodeo, 2013)
Conclusion and Next Steps
Name 1 nugget of wisdom or ‘aha’ moment that you are walking away with today. What stood out for you or what stuck with you?Name 1 action step you will commit to that promotes the integration of public health and social work in the important arena of substance use prevention and intervention.
DeborahMilbauerMPH, MSW
DeborahMilbauer, MPH, MSW, has worked in the field of Public Health Social Work for over 25 years. She holds a dual-degree Masters in Public Health and Masters of Social Work from Boston University, teaches Public Health part-time at Northeastern University and is a consultant for the Milton Substance Abuse Prevention Coalition. Her behavioral health and prevention programming and policy experience includes substance use disorders, harm reduction, opioid overdose prevention, homelessness, HIV and reproductive health. Deborah currently runs a private Public Health consulting practice in the Boston area.
Acknowledgements
The Advancing Leadership in Public Health Social Work Education project at Boston University School of Social Work (BUSSW-ALPS), was made possible by a cooperative agreement from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number G05HP31425.We wish to acknowledge our project officer, Miryam Gerdine, MPH.Thanks also to Sara S. Bachman, BUSSW Center for Innovation in Social Work and Health, and the Group for Public Health Social Work InitiativesThe ALPS Team:Betty J. Ruth, Principal Investigatorbjruth@bu.eduMadi Wachman, Co-Principal Investigatormadi@bu.eduAlexis Marbach Co-Principal Investigatoralexis_marbach@abtassoc.comNandini Choudhury, Research Assistantnschoud@bu.eduJamie Wyatt Marshall, Principal Consultantjamiewyatt1@gmail.com

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Title Slide - ciswh.org