The Opioid Epidemic: Medical, Nursing and Counseling Behavioral Treatment 2020030183, 2020030184, 9781536182170, 9781536183696

Table of contents :
Contents
Preface
Chapter 1
The Opioid Epidemic/SUD: Facts, Figures and Assessment Tools
Abstract
SBIRT (Screening Brief Intervention Referral to Treatment)
Case Example
Tools
Screening for Alcohol Problems
At-Risk Drinking
A. WHO - ASSIST V3.0
B. Who Assist V3.0 Response Card for Patients
C. Alcohol, Smoking and Substance Involvement Screening Test (Who Assist V3.0) Feedback Report Card For Patients
D. WHO Risks of Injecting Card – Information for clients
E. Translation and Adaptation to Local Languages and Culture: A Resource for Clinicians and Researchers
CAGE Questionnaire
Scoring
Clinical Opiate Withdrawal Scale (COWS)
Flow-Sheet for Measuring Symptoms for Opiate Withdrawals over a Period of Time
CRAFFT
Objective Opioid Withdrawal Scale (OOWS)
References
Chapter 2
The Neurobiology of Opioid Drug Addiction
Abstract
Case Study
Introduction and Overview
The Physiology of Addiction
Biologic Models of Addiction
Tolerance and Reverse Tolerance
Case Study Revisited
References
Chapter 3
Pharmacologic Concepts in Opioid Addiction Treatment Through the Continuum
Abstract
Pharmacokinetics and Pharmacodynamics
Case Study – Part 1
Treatment of Opioid Overdose
Case Study – Part 2
Withdrawal Management from Opioid Drugs
A Short History of the Detoxification Process
Case Study – Part 3
The Protracted Abstinence Syndrome
Case Study – Part 4
Medication Assisted Treatment
Medications Used in Maintenance Treatment of Opioid Use Disorder
Naltrexone
Methadone
Buprenorphine
Case Study – Epilogue
References
Chapter 4
Maternal Substance Use: Systemically Understanding Treatment and Recovery
Abstract
Introduction
Key Concepts in Maternal Substance Use
Prevalence and Correlates of Maternal Substance Use
Considering the Family Unit
Treatment Barriers for Maternal SUD
Cultural and Social Justice Considerations
Gender
Race and Ethnicity
Considering Intersectionality
Best Practices for Assessing and Treating Maternal Substance Use
Screening and Assessment
AUDIT
ASSIST
CAGE and CAGE-AID
Toxicology Testing
Evidence-Based Practices
Family-Centered Treatment
Trauma-Informed Care
Parenting Education & SUDs
Family Spirit Model (Center for American Indian Health at the Bloomberg School of Public Health at Johns Hopkins University)
Celebrating Families! (National Association for Children of Addiction, 2007)
Trauma & SUDs
Helping Women Recover: A Program for Treatment Addiction, Special Criminal Justice Edition (HWR) (Covington, 2000)
Seeking Safety (Najavits, Weiss, Shaw, & Muenz, 1998)
Opioid Use Disorders
Limitations of Current Treatment Models for Maternal Substance Use
Case Example: Mary
Treatment Considerations for Mary
Future Directions
Conclusion
References
Chapter 5
Opiate/Heroin Use in Pregnancy
Abstract
Introduction/Overview
Assessment
Medication Assisted Treatment
Post Induction/Maintenance Pregnancy Care
Neonatal Opioid Withdrawal Syndrome and Neonatal Outcomes
Conclusion and Clinical Pearls
Best Practice Pearls
References
Chapter 6
Complementary and Integrative Therapies for the Treatment of Opioid Abuse Disorder
Abstract
Foundational Concepts in Complementary and Integrative Health
Mindfulness Meditation
Mindfulness Based Relapse Prevention (MBRP)
Meditation Oriented Recovery Enhancement (MORE)
Acupuncture
Auricular Acupuncture
Neurofeedback
Alpha-Theta Protocol
Low Energy Neurofeedback System (LENS)
Emotional Freedom Technique (EFT)
Yoga
Trauma Sensitive Yoga and Trauma Informed Yoga
Integrative Restorative Yoga (iRest)
Spirituality
Future Implications and Considerations
Conclusion
References
Chapter 7
Adolescent Substance Use
Abstract
Adolescent Substance Use Disorder
Overview of Trends
Trajectories
Risk and Protective Factors
Treating Adolescent Substance Use Disorder
Access to Care
Assessment
Treatment
Therapeutic Approaches
Community-Oriented Programs
Pharmacotherapy
Contextualizing Treatment
Conclusion
Discussion Questions
Scenarios
Questions for the Scenarios
Screening Tools
CRAFT
CAGE-AID
Assessments
References
Chapter 8
Couple and Family Therapy Best Practices in Substance Use Disorders
Abstract
Introduction
Collaborative Care and Opioid Use Disorder
Why Collaborate?
Requiring versus Recommending
Myths and Realities of Collaboration
The Impact of Substance Use Disorder on Families
Carl’s Story
Key Issues Related to Treatment
Substance Use Disorder Systemic Metaframework for Assessment and Intervention
Culturally Informed Approach
Trauma Informed Approach
The Community Reinforcement and Family Training Approach (CRAFT)
Family Systems Perspective
Family Life Cycle
Genograms
Sample Questions for a SUD Focused Genograms are
Family Based Treatment Approaches
Functional Family Therapy
Multidimensional Family Therapy
Brief Strategic Family Therapy
Couple Therapy and SUD
The Russo’s Story
SUD Couple Therapy Approaches
Self of the Health Professional
Conclusion
References
Suggested Readings
Resources
Chapter 9
Understanding the Intersection between Trauma and Substance Use: Treatment Recommendations
Abstract
Trauma
Trauma and Substance Use
Trauma Informed Care Approach
Assessment
Treatment
Key Issues for Clinicians
Cultural and Social Justice Considerations
Case Example
References
Chapter 10
Drug Treatment Courts
Abstract
Introduction
Definition of Drug Treatment Courts
Origin of Drug Treatment Courts
Structure and Functioning of Drug Treatment Courts
Program Design and Implementation
Key Components
Episode of Care and Phases
Best Practices
Trauma Informed Care
Effectiveness of Drug Courts
Initiation of Drug Treatment Courts
Discussion Questions
References
Conclusion
Editor Contact Information
Index
Blank Page

Citation preview

SUBSTANCE ABUSE ASSESSMENT, INTERVENTIONS AND TREATMENT

THE OPIOID EPIDEMIC MEDICAL, NURSING, COUNSELING BEHAVIORAL TREATMENT

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

SUBSTANCE ABUSE ASSESSMENT, INTERVENTIONS AND TREATMENT Additional books and e-books in this series can be found on Nova’s website under the Series tab.

SUBSTANCE ABUSE ASSESSMENT, INTERVENTIONS AND TREATMENT

THE OPIOID EPIDEMIC MEDICAL, NURSING, COUNSELING BEHAVIORAL TREATMENT

ALBERT ANTHONY RUNDIO, JR. AND

STEPHANIE BROOKS EDITORS

Copyright © 2020 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Simply navigate to this publication’s page on Nova’s website and locate the “Get Permission” button below the title description. This button is linked directly to the title’s permission page on copyright.com. Alternatively, you can visit copyright.com and search by title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact: Copyright Clearance Center Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470

E-mail: [email protected].

NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the Publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data Names: Rundio Jr., Albert Anthony, editor. Title: The Opioid Epidemic: : medical, nursing and counseling behavioral treatment / Albert Anthony Rundio Jr., Drexel University, Philadelphia, PA, US, Stephanie Brooks, Associate Dean Division of Health Professions, College of Nursing and Health Professions, Drexel University, Philadelphia, PA, US, editors. Description: New York : Nova Science Publishers, [2020] | Series: Substance abuse assessment, interventions and treatment | Includes bibliographical references and index. | Identifiers: LCCN 2020030183 (print) | LCCN 2020030184 (ebook) | ISBN 9781536182170 (hardcover) | ISBN 9781536183696 (adobe pdf) Subjects: LCSH: Opioid abuse--United States. | Medication abuse--United States. | Substance abuse--United States. | Substance abuse--United States--Treatment. | Substance abuse--United States--Alternative treatment. | Substance abuse--United States--Psychological aspects. Classification: LCC RM146.7 .S83 2020 (print) | LCC RM146.7 (ebook) | DDC 362.29--dc23 LC record available at https://lccn.loc.gov/2020030183 LC ebook record available at https://lccn.loc.gov/2020030184

Published by Nova Science Publishers, Inc. † New York

This book is dedicated to those who suffer from Substance Use Disorders and for the many who maintain long term sobriety and recovery. Throughout my career in this field I have learned so much from each patient. This book is also dedicated to the all of the interprofessional health care team members that are on the front-line in this epidemic. They are the true heroes! Albert Rundio

Thank you to the countless families including my own who taught me what they really need from a couple and family therapist. Stephanie Brooks

CONTENTS Preface Chapter 1

ix The Opioid Epidemic/SUD: Facts, Figures and Assessment Tools Albert Anthony Rundio, Jr.

1

Chapter 2

The Neurobiology of Opioid Drug Addiction William J. Lorman

Chapter 3

Pharmacologic Concepts in Opioid Addiction Treatment Through the Continuum William J. Lorman

45

Maternal Substance Use: Systemically Understanding Treatment and Recovery Jessica Chou and Rikki Patton

67

Chapter 4

Chapter 5

Opiate/Heroin Use in Pregnancy Kathleen Bradbury-Golas

Chapter 6

Complementary and Integrative Therapies for the Treatment of Opioid Abuse Disorder Rita Cola Carroll

33

103

117

viii

Contents

Chapter 7

Adolescent Substance Use DeAnna Harris-McKoy and Ebony Okafor

Chapter 8

Couple and Family Therapy Best Practices in Substance Use Disorders Stephanie Brooks and Shiricka Fair

171

Understanding the Intersection between Trauma and Substance Use: Treatment Recommendations Heather Katafiasz and Trish Caldwell

201

Chapter 9

Chapter 10

Drug Treatment Courts Adriatik Likcani and F. Ryan Peterson

149

217

Conclusion

241

Editor Contact Information

243

Index

245

PREFACE The Opioid Epidemic is one of the major events that has occurred in the United States during the past few years. Several factors have contributed to this epidemic. Accrediting bodies identifying pain as the 5th Vital Sign certainly addressed patient’s pain but also accelerated the use of prescription narcotic pain medications as first line therapy rather than utilizing other types of pharmacologic agents that are not narcotics as well as trying other non-pharmacologic interventions such as holistic health modalities. Dependent upon the type of narcotic pain medication prescribed, patients can develop a dependence upon the medication which then leads to addiction. Purchasing such medications can be rather expensive. Many patients then turn to purchasing less expensive drugs, such as Heroin, off of the street. Compounding the problem today is that much of the heroin is tainted with other drugs, such as Benzodiazepines and Fentanyl. Fentanyl is far more potent than heroin. The end result is that many young people as well as older people are dying from overdoses. If someone is not available to administer Naloxone immediately the end result is death. There have been many strategies implemented by both the federal government and individual states governments to combat the opioid epidemic. Many states have implemented Prescription Drug Monitoring Programs (PDMP) that report the prescriptions for controlled substances that a patient purchases. Legislation has been passed to promote addiction

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Albert Anthony Rundio, Jr. and Stephanie Brooks

treatment centers and medicated assisted treatment programs. Although there has been a noted decreased in opioid related deaths, there is still a long way to go to combat this epidemic. Care rendered to the patient with opioid substance use disorders needs to be interprofessional and inclusive of Medicine, Nursing, Counseling and other behavioral modalities. Such interprofessional care will yield the best treatment outcomes. Chapter 1 - This chapter discusses the history and also provides facts and figures on the opioid epidemic currently affecting the USA. In addition to various graphs that tracks and trends the epidemiology of the epidemic the second part of the chapter displays the various assessment tools for substance use disorders. As many individuals have co-dependencies these assessment tools are not only tools for assessing opioids but also other substances. Chapter 2 - interactions between biologic and environmental factors. The risk for addiction in individuals with mental illness is significantly higher than for the general population. Although there are psychological elements involved in the addictive process, the pleasure-seeking behaviors leading to euphoria are the result of a physiological process in the brain. Ultimately, active addiction is maintained because of the physiologic process of cravings. The more common models of addiction are presented. Chapter 3 - To understand addiction treatment, one must understand the pharmacokinetics and pharmacodynamics of the opioid drugs: what the drugs do to the body (especially the brain) and how the body initially reacts and ultimately tolerates those drugs. When drugs are taken in at a rate in excess of how the body can cope, there is an overdose condition and unless intervened, death may occur. When the intake of drugs ceases, the body/brain is in a state of instability and physiologic withdrawal occurs. This can be treated medically to reduce the severity of symptoms. In order to control cravings and the persistent anxiety associated with drug abstinence, protocols for medication-assisted treatment have been developed to prevent relapse. Chapter 4 - The impacts of the substance use epidemic on the United States population are well-known and widely documented. Women are

Preface

xi

uniquely impacted by substance use initiation, addiction severity, treatment, and recovery. As such, it is critical to consider the intersection of substance use among women’s lives in an effort to determine best practices in prevention, treatment, and recovery. To address this need, this chapter provides an overview of key concepts in maternal substance use and best practices for assessing and treating maternal substance use. A case application is included to contextualize the factors that impact maternal substance use and related treatment and recovery. Further, future directions are considered within the context of current knowledge and best practices. Chapter 5 - Opioid Use disorder has become a major health issue in the United States. The pregnant woman has not been exempted from this disorder, with numbers increasing significantly in recent years. However, management of the pregnant patient requires comprehensive interprofessional collaboration among obstetric care, addiction medicine, social/behavioral health, and pediatric care providers. This chapter addresses assessment/screening recommendations, management strategies to reduce pain and medication assisted treatment (MAT) during and after pregnancy. Neonatal Opioid Withdrawal Syndrome is also reviewed. Chapter 6 - With high levels of morbidity and mortality, opioid abuse disorder is a public health emergency that shows little sign of abating. Generally, Medication Assisted Therapies (MAT), such as methadone, buprenorphine and naltrexone, combined with psychological support, are considered to be the most effective, but with high relapse rates, there is a call for innovative and comprehensive approaches to treatment. Complementary and integrative therapies (CITs) offer non-pharmaceutical options that may be integrated into conventional treatment to boost the effectiveness, with limited or no side effects. A complementary and integrative approach promotes an individualized, holistic plan of treatment. These therapies can also be used long-term as foundational practices for a healthy lifestyle that supports well-being of the mind, body and spirit, as well as sustainable recovery. In this chapter the authors will explore several complementary and integrative health practices, each with a proven track record in the area of addictions treatment, particularly treatment for opioid dependency.

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Chapter 7 - Adolescence is a developmental time period where a myriad of problematic behaviors could rise such as substance abuse. Over time, adolescents have decreased their use of certain substances and increased their abstinence from others. However, the increased use of marijuana and vaping of nicotine and marijuana are having continued negative consequences on adolescents. In addition, the misuse of prescription drugs adds a new level of complexity to dealing with adolescent substance abuse. Due to the potential life changing negative consequences of any substance use, such as prolonged usage well into adulthood, it is imperative that health professional address substance use during the period of adolescence to ensure greater well-being. This chapter addresses trends in substance use over time, trajectories of substance use, risk and protective factors, access to care, treatment through: therapy, community-oriented programs, and pharmacotherapy and ways health professionals can be culturally conscious in assessing and treating adolescent substance use disorder. Chapter 8 - Substance use and misuse is a public health problem impacting families across the life cycle. The opioid epidemic is devasting for all families often resulting in relational cut offs, couple and family distress, health problems and untimely death. Understanding family relationships, interactions, protective and risk factors are foundational to assessment, determining interventions and supporting recovery. Therefore, this chapter aims is to provide an overview of the types of difficulties couple and family members experience living with substance use disorder. It includes best practices such as using cultural and trauma informed lens along with evidence informed couple and family approaches. Implications for self of the health professional is introduced as a practical tool for promoting self-care and therapeutic effectiveness. Chapter 9 - This chapter focuses on the intersection between trauma and substance use disorders. After outlining a definition of trauma, the chapter identifies the statistics and theoretical conceptualizations explaining the relationship between trauma and substance use. The characteristics of trauma informed care and its distinction from trauma specific treatments are also outlined. Then, recommendations for concurrent assessment and treatment of trauma and substance use disorders are discussed. Additionally,

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the impacts of working with trauma on clinicians, under the umbrella of indirect trauma, is also explained, as well as the risk and protective factors associated with the development of the negative impacts of indirect trauma. Lastly, cultural and social justice considerations are discussed, particularly in reference to the vulnerable population of incarcerated persons. The chapter culminates with a case example to better elucidate these concepts. Chapter 10 - Substance use disorders (SUDs) and their devastating impact on individuals, families and the society continue to be a significant public health issue. Our societal response in the recent decades has continually adjusted from the war on drugs and criminalizing drug addiction to more emphasis one treatment and prevention as science on SUDs continues to emerge. Drug treatment courts have emerged as one effective method to treating SUDs, reducing drug-related crime in our communities, and helping individuals and families find recovery. They are a step forward in our society towards decriminalizing drug addiction and offering hope and a pathway to recovery for individuals and families in or seeking recovery. Instead of imprisonment for nonviolent drug offenses, the justice system defers prosecution of an individual’s case and offers them participation in court-ordered drug rehabilitation program. A drug court involves a multidisciplinary team of professionals under the leadership of the presiding judge. This chapter is designed to help you become familiar with drug courts, definition of drug courts, their structure and functioning, design and program components, best practices, and their effectiveness. In addition, the authors provide some practical tips and insight from our experience with the initiation, development, and implementation of a new drug treatment court program.

In: The Opioid Epidemic Editors: A. Rundio and S. Brooks

ISBN: 978-1-53618-217-0 © 2020 Nova Science Publishers, Inc.

Chapter 1

THE OPIOID EPIDEMIC/SUD: FACTS, FIGURES AND ASSESSMENT TOOLS Albert Anthony Rundio, Jr., PhD Nurse Practitioner Addictions Nursing; College of Nursing and Health Professions, Drexel University, Philadelphia, PA, US

ABSTRACT This chapter discusses the history and also provides facts and figures on the opioid epidemic currently affecting the USA. In addition to various graphs that tracks and trends the epidemiology of the epidemic the second part of the chapter displays the various assessment tools for substance use disorders. As many individuals have co-dependencies these assessment tools are not only tools for assessing opioids but also other substances.

According to the Centers for Disease Control (CDC) over 700,000 people have died from a drug over dose between the years of 1999 to 2017.



Clinical Professor of Nursing Drexel University. Corresponding Author’s Email: [email protected].

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Albert Anthony Rundio, Jr.

Approximately 68% of over 70,200 drug overdoses in 2017 results from an opioid. Deaths involving opioids was 6 times higher comparing 2017 to 1999. Such opioid deaths results from prescription opioids, heroin and illicitly manufactured fentanyl, which is now a leading cause of overdose in the United States. On average at least 130 Americans or more die each day in the United States from an opioid overdose (CDC, 2019); (CDC, National Center for Health Statistics; 2017). CDC outlines 3 waves that have contributed to the rise in opioid overdose deaths: Wave 1: Increased prescribing of opioids that began in the 1990s; Wave 2: A rapid increase in opioid overdose deaths secondary to heroin starting in 2010; Wave 3: An increased number of overdose deaths secondary to synthetic opioids, most notably illicitly manufactured fentanyl. Today much of the heroin, counterfeit pills and even cocaine contain fentanyl [1, 2, 3]. Figure1 displays these 3 waves:

Figure 1. 3 waves in the rise in opiod overdose deaths, deaths per 100,000population.

The Opioid Epidemic/SUD

3

Figure 2 demonstrates that 130 or more Americans die each day from opioid overdose.

Figure 2. 130 or more Americans die each day from opioid overdose.

There are four primary factors that have contributed to the development of this epidemic. The four major contributing factors are the following: 1. 2. 3. 4.

pharmaceutical companies accreditation standards providers patients

Let us discuss each of these factors. Pharmaceutical companies developed the first opioids that were used for pain management in the United States. It soon became a billion-dollar industry. There were no incentives for pharmaceutical companies not to develop more opioids for pain control. In 1995 pain was identified as the fifth vital sign. In 2001 the Joint Commission on Accreditation of Healthcare Oganizations developed standards for pain as a quality indicator. The American Academy of Medicine, most commonly known as the Institute of

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Albert Anthony Rundio, Jr.

Medicine (IOM) reported on patient satisfaction with pain management, and the Center for Medicare and Medicaid Services (CMS) developed the HCAHPS (Hospital Consumer Assessment of Health Providers & Systems) scoring system for hospitals which assesses patient satisfaction. Reimbursement is tied to patient satisfaction. Thus pain management became a critical indicator in healthcare and the goal was to control or eliminate patient’s pain. Providers are the ones who prescribe pain medication to patients. Oftentimes providers are too willing to prescribe opioids for pain management rather than exploring other non-narcotic options. And then there are patients themselves. It is estimated that 50 million Americans have chronic pain. It is also estimated that at least $560 billion are spent annually on managing patient’s pain. It is a well-known fact that patients with chronic pain will have increased depression, posttraumatic stress disorder, and substance use disorders. The end result of these factors is the opioid epidemic as we know it. At least 81% of the opioids are prescribed in the United States so it is truly a United States issue. Heroin is an illicit opioid in the United States. Its usage has dramatically increased over the past several years. Let us now take a look at some statistical information. There has been a 50% increase in use of heroin by males between 2004 to 2013. There is an increase of 100% use of heroin during the same time period. When we look at age groups there is a 109% increase in use by individuals between the ages of 18 to 25. There is a 58% increase in the use of heroin by individuals above age 26. When we look at household income, there is 62% increase in the use of heroin in individuals with a household income less than $20,000 annually. There is a 77% increase in the use of heroin when the household income level is between $20,000 to $49,999. There is a 60% increase in the use of heroin in households with an income level of $50,000 or more. When we look at health insurance coverage in patients who have no health insurance coverage there is a 60% increase in the use of heroin.

The Opioid Epidemic/SUD

5

Patients who have private or other types of insurance there is a 63% increase in the use of heroin. And for those patients with Medicaid there is no significant use of heroin (Figure 3).

Figure 3. Heroin use by demographic group (2002-2004 vs. 2011-2013)/addiction and deaths by overdose.

Let us now review data secondary to opiates. Tracing back to 1999 through the year 2017 there has been a dramatic increase in the number of opioids deaths. In 1999 there were less than 5,000 deaths per year. It has increased every year since, in 2017 there were 70,237 – deaths from opioid use. Heroin accounted for 15,958 deaths. Natural and semi-synthetic opioids accounted for 14,948 deaths. Synthetic opioids other than Methadone accounted for 29,406 deaths. There were 14,556 deaths from Cocaine, 10,721 deaths from Methamphetamine and 3295 deaths from Methadone (Figure 4). Figure 5 displays the states with highest opioid death rates.

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999-2017 on CDC WONDER Online Database. Figure 4. Drugs involved in U.S. overdose deaths, 1999 to 2017.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics Figure 5. US states with highest opioid death rates.

The Opioid Epidemic/SUD

7

SBIRT (Screening Brief Intervention Referral to Treatment) SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders.   

Screening Brief intervention Referral to treatment

The primary goal of SBIRT is to identify substance use disorders early so that referral for clients to appropriate treatment can be accomplished. SBIRT assesses the following. 1. 2. 3. 4. 5.

Abstinence Moderate use (lower risk use) At-risk (higher risk use) Abuse Dependence

Brief intervention is a brief motivational awareness raising awareness for interventions provided to at risk or problematic substance users. BNI stands for Brief Negotiated Interview. The BNI is a semi-structured interview process that has its roots in motivational interviewing. It is a validated evidence-based practice tool that can be completed in 5 to 15 minutes of time [4]. BNI Steps in the Process are: 1. Build rapport with the client in a non-threatening manner. a. Raise the subject. Start with a general conversation. b. Ask the client for permission to talk about alcohol and/or other substances. c. What happens if the client does not want to discuss his/her alcohol or substance use? Discuss the pros and cons of use. For example,

8

Albert Anthony Rundio, Jr. what are the good things about using alcohol or drugs? What are some of the bad things about using alcohol or drugs? d. Apply Motivational Interviewing – use open ended questions. This encourages the client to talk freely and opens the door for exploration. Use reflective listening. Reinforce what has been stated. Demonstrate careful listening skills. Summarize the information provided. Utilize a pro and con checklist. 2. Provide honest feedback. a. Request permission to provide information b. Discuss relevant screening findings c. Make the link of substance use behaviors to consequences of substance use d. If the Client elicits a positive reaction then proceed moving forward. e. If the Client elicits a negative reaction then revisit the pros and cons of substance use 3. Encourage a readiness for change. a. Ask permission to talk a few minutes about the client’s interest in making a behavior change. For example, one could present a scale from 1 to 10 with 1 being not ready at all to make a change and 10 being completely ready to make a change in the client’s substance use. 4. Negotiate a plan for change. a. Develop with the client a plan to reduce use to a low-risk level or complete abstinence. b. Propose an agreement for the client to follow-up with specialized treatment services.

Case Example JR is in an automobile accident. He was unconscious at the scene. Intranasal Naloxone was administered and he woke up. He was transported to the local hospital emergency department for further evaluation and care. JR had a complete physical assessment. Laboratory studies were ordered including a drug screen and a serum blood alcohol level.

The Opioid Epidemic/SUD

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JR’s drug screen was positive for opioids and his serum blood alcohol level was elevated. JR had a laceration on his right forearm. The emergency department physician, who was suturing his arm, questioned JR asking him had he ever considered that he may have a problem with drugs and alcohol and that these substances had contributed to his having a motor vehicle accident as well as his loss of consciousness. By addressing these issues in a non-threatening manner, the physician can illicit if the patient has a substance use disorder versus this being a one time event. The physician then can recommend assessment by a provider experienced in substance use disorders. This is where SBIRT comes in. Secondary to the opioid epidemic in the United States, many accrediting bodies have recommended that every patient admitted to a hospital be evaluated for SBIRT. The earlier one is diagnosed with a possible substance use disorder the earlier interventions can be initiated.

Tools There are several tools available for the assessment of opioid use disorders:     

AUDIT Assist Tool CAGE OOWS – Objective Opioid Withdrawal Scale COWS - Clinical Opioid Withdrawal Scale

    

CRAFFT DSM 5 – Diagnostic Statistical Manual Version 5 Screening Tools Buprenorphine Referral Form for Opioid Use Disorder NIDA Modified ASSIST Drug Use Screening Tool National Institute on Drug Abuse. A short screening tool to assess a patient’s risk level based on a Substance Involvement (SI) score.

New studies suggest that ED initiated buprenorphine outperforms SBIRT.

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The Brief Negotiation Interview (BNI) and Emergency DepartmentInitiated Buprenorphine/Naloxone for Moderate/Severe Opioid Use Disorder The following section displays assessment tools.

SCREENING FOR ALCOHOL PROBLEMS Ask Current Drinkers (NIAAA questions):   

On average, how many days per week do you drink alcohol? On a typical day when you drink, how many drinks do you have? What’s the maximum number of drinks you had on a given occasion in the last month?

CAGE C: Have you felt you ought to CUT down on your drinking or drug use?

A: Have people ANNOYED you by criticizing your drinking or drug use? G: Have you ever felt GUILTY about your drinking or drug use? E: Have you ever had a drink or used drugs first thing in the morning (EYE OPENER) to steady your nerves, rid hangover, or get your day started?

CRAFFT C: Have you ever ridden in a CAR by someone (including yourself) who was high or was using alcohol or drugs? R: Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in? A: Do you ever use alcohol or drugs while you are by yourself? (ALONE) F: Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? F: Do you ever FORGET things that you did while using alcohol or drugs? T: Have you gotten in TROUBLE while you were using alcohol or drugs?

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AT-RISK DRINKING AT-RISK DRINKING PER WEEK PER OCCASION Per Week > 14 DRINKS Per Occasion > 4 DRINKS >14 Drinks >4 Drinks WOMEN > 7 DRINKS > 3 DRINKS >7 Drinks >3 Drinks >7 Drinks >3 Drinks

MEN

Men Women Age >65

Not ready

Very ready

SBIRT: Brief Negotiated Interview (BNI) Steps 1. Screen patient 2. Raise subject

(use NIAAA, CAGE or CRAFFT)

• Hello, I am _______. Would you mind taking a few minutes to talk with me about your alcohol/ drug use?

3. Provide feedback Review screen

• From what I understand you are drinking/using [insert screening data]… We know that drinking above certain levels can cause problems, such as [insert facts]…I am concerned about your drinking/drug use.

Make connection

• What connection (if any) do you see between your drinking/ drug use and this medical visit? If patient sees connection: reiterate what patient has said If patient does not see connection: make one using facts

Show NIAAA guidelines & norms

• These are what we consider the upper limits of low risk drinking for your age and sex. By low risk we mean that you would be less likely to experience illness or injury if you stayed within these guidelines.

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Albert Anthony Rundio, Jr.

SBIRT: Brief Negotiated Interview (BNI) Steps (Continued) 4. Enhance motivation Readiness to change

• [Show readiness ruler] On a scale from 1-10, how ready are you to change any aspect of your drinking or seek treatment?

Develop discrepancy

• If patient says: >2 ask Why did you choose that number and not a lower one?