Public Health Social Work and Substance Use Disorders

Public Health Social Work and Substance Use Disorders Deborah Milbauer, MPH, MSW Public Health Consultant Part Time Instructor, Northeastern University

Learning Objectives • Provide a brief overview of national scope and trends of substance use disorder in US • Explain the brain science, and identify the diagnostic criteria, for substance use disorder • Define stigma and harm reduction, and discuss the impact it has on substance use and misuse health outcomes • Define the continuum of care, domains of influence and the strategic prevention framework • Present case studies and discuss the relevance for public health social workers • Identify action steps upon conclusion of the training

National Scope and Trends 1. Definitions, national scope and trends 2. Public health model of substance use and misuse 3. The science of prevention 4. Case studies and the role of public health social workers 5. Where 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 consequences https: //www. ncbi. nlm. nih. gov/books/NBK 519702/ https: //www. drugabuse. gov/publications/media-guide/science-drug-use-addiction-basics https: //www. drugabuse. gov/publications/media-guide/glossary

Why Do People Take Drugs? To feel good To feel better To do better Curiosity and social pressure Why do we need to know why?

Drug Classifications Class Examples Depressants (‘downers’) Slows down activity in the brain Alcohol, marijuana, sleep medication, Librium, barbiturates, benzodiazepines Opioids Slows down activity in brain. Too much slows and stops breathing Heroin (illicit meaning illegal) Prescription painkillers (prescribed) Codeine, Methadone, Vicodin, Oxycontin, morphine, Fentanyl Stimulants Speeds up activity in the brain Methamphetamines, cocaine, caffeine, Ritalin, Focalin Hallucinogens Distorts perception of reality Psychoactive Peyote, LSD, ecstasy, MDMA (‘molly’), PCP, mushrooms, ketamine (‘special K’) Benzodiazepines Sedatives, slows activity in the brain Klonopin, valium, Xanax, Halcion, Ativan Nicotine Addictive chemical in tobacco Cigarettes, vaping pens Inhalants (chemical vapors) Psychoactive, mild altering Gases, volatile solvents, aerosols, nitrates; household products, whip cream, hair spray, spray paint, felt tip markers

National Trends Good news • Rates 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 communities • We know more about what works and what doesn’t based on decades of ever-evolving research Good sources: https: //www. samhsa. gov/data/report/trends-substance-use-disorders-among-adults-aged-18 -or-older https: //www. drugabuse. gov/related-topics/trends-statistics https: //www. cdc. gov/publichealthgateway/didyouknow/topic/alcohol. html https: //www. centeronaddiction. org/ https: //www. healthcenterinfo. org/priority-topics/substance-use-disorders/ https: //addiction. surgeongeneral. gov/

National Trends Bad News • New emerging substances & methods of use may reverse progress made over many years • New state marijuana laws pose complicated public health challenges (legalization of medical and recreational marijuana) • Current opioid epidemic is devastating a people and communities across US • Health inequities and unequal burden of disease among low income and communities of color continues • The shift towards use of public health approaches is playing out differently depending on socioeconomic status and race/ethnicity • Recent political changes on federal level have impacted funding, research and laws

National Scope 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 disorder • 7. 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 users • Alcohol: 136 million current users, 65 million binge users and 16 million heavy users Alcohol is the most used legal drug in the country Marijuana is the most used illicit drug in the country • Illicit 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

Video National Scope Rates of Use Among 8 th, 10 th and 12 th Graders in 2017 • Alcohol No decrease for the first time in decades after years of declining use • Cigarettes 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 decline • Vaping 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 8 th graders after a decade of decline • Heroin & Opioids Heroin use remained low. Misuse of Prescriptions continuing to decline

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 3 rd leading cause of preventable death in the US (88, 000) • For teens, alcohol is involved in more than 60% of accidental teen deaths Overdose 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 Deaths https: //www. cdc. gov/nchs/products/databriefs/db 329. htm

Opioid Deaths in US 1999 -2014 Opioid deaths were initially primarily due to pills and heroin, and now are mostly due to Fentanyl (50100 times stronger) • 2014: 24 deaths per 100, 000 • 2016: 52 deaths per 100, 000

Other Emerging Trends of Concern • Vaping, E-cigarettes • ENDS: Electronic Nicotine Delivery Systems • Legalization of recreational and medical marijuana, oil, and food products • Synthetic marijuana (K 2, 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 status • Communities of color • Veterans • Homeless individuals • LGBTQ • Someone with substance use in family • Rural communities • English as a second language • Native American Indian • Mental 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 disorder Most jails and prisons do not provide adequate treatment, if any, for substance use disorders Jails and prisons are overrepresented by inmates of color Whites are more likely to be adjudicated to treatment Non-white more likely to be adjudicated to jails and prisons – See Jay Z’s War on Drugs video for synoposis https: //youtu. be/HSozqa. Vc. OU 8

Substance Use and Public Health Social Work • SU is a major PH issue! With more than 650 K social workers—half employed in health, behavioral health and substance use—this is a major issue for social work profession • Substance use disorders are bio-psycho-social behavioral health issues • Represent 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 problems • Most public and private institutions encounter individuals and families with substance use disorders of all backgrounds

Public Health Model of Substance Use and Misuse 1. National scope and trends 2. Public health model of substance use and misuse 3. The science of prevention 4. Case studies and the role of public health social workers 5. Where do we go from here?

Word Brainstorm Activity

Activity Language of Stigma Negative Non-judgmental • Junkie • Person with a substance use disorder (person- first descriptions) • Addict • Abuser • User • Person with an alcohol and drug disease • Pot head • Person engaged with risky use of substances, misusing/misuse • Habit/drug habit • Patient (if in treatment) • Clean/dirty • Addiction survivor (mimics cancer survivor) • Replacement or substitution therapy • Substance free or negative/positive • Medication assisted treatment, medication, treatment • “People from the substance using community”

Substance Use Disorders Activity Moral/Criminal Model Medical/Public Health Model • Individuals are bad people if they use substances • Substance use disorder is a brain disease • Substance use is a choice • It’s all about will power • Someone deserves to be locked up because of their behavior • Behaviors related to substance use should be punished, not treated • What else? • Diseases should be treated as a health problem, not a criminal problem • Like 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 prevention • Systemic solutions are more effective than working with one individual at a time Moral Model versus Medical Model Criminal Justice or Public Health Model?

The Language of Diagnosis The Diagnostic and Statistical Manual of Mental Disorders 5 th Edition (DSM-5): • ‘Substance abuse and substance dependence’ no longer used • ‘Substance use disorders’ now used based on diagnostic criteria • Diagnosed as mild, moderate or severe Criteria • Recurrent use causes clinically and functionally significant impairment • Health problems • Disability • Failure to meet major responsibilities at work, home and/or school • Impaired 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 1. Taking the substance in larger amounts or for longer than you're meant to. 2. Wanting to cut down or stop using the substance but not managing to. 3. Spending a lot of time getting, using, or recovering from use of the substance. 4. Cravings and urges to use the substance. 5. Not managing to do what you should at work, home, or school because of substance use. 6. Continuing to use, even when it causes problems in relationships. 7. Giving up important social, occupational, or recreational activities because of substance use. 8. Using substances again and again, even when it puts you in danger. 9. 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. 10. Needing more of the substance to get the effect you want (tolerance). 11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

‘Substance Use Disorder’: Severity as Defined in the DSM 5 1. Mild: 2 -3 symptoms 2. Moderate: 4 -5 symptoms 3. Severe: 6 or more symptoms

‘Substance Use Disorder’: 10 Classes of Drugs as Defined in the DSM 5 1. 2. 3. 4. 5. 6. 7. 8. 9. Alcohol Caffeine Cannabis (marijuana) Hallucinogens Inhalants Opioids Sedatives Hypnotics, or anxiolytics Stimulants (including amphetamine-type substances, cocaine, and other stimulants) 10. Tobacco 11. Other 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 25 Brain has great growth spurt just prior to puberty Teens highly driven by reward and peer influence, at the same time that judgement, self control and problem solving are still developing Exposing a teen brain to substances is different than when an adults’ fully developed brain is exposed to those same substances http: //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 disease For every year a teen delays their first use, it protects the developing brain Risk of later life disorder is reduced 10% for every year first use is delayed Even 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 driving • Weight gain • Sexual activity including assault • Impaired memory and reduced cognition • Poor decision making from clouded judgement • Depression and anxiety • Injuries while drunk/high • Difficulty concentrating • Vomiting or choking • ER Visits • Poor grades and disciplinary action • Arrests • Impaired relationships with friends • Brain damage and family • Liver disease • Loss of job • HIV/Hepatitis • Suspended or kicked off sports teams • Property damage

When Use Turns Into Disorder: Why Don’t People Just STOP if They Know it’s Bad? ? Substance Use Disorders change BRAIN CHEMISTRY. Knowing doesn’t change behavior. “It is like telling a person who has diabetes that exercise and willpower will be enough to help their 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. ” Szubiak http: //www. socialworktoday. com/archive/JA 18 p 10. 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 clinics • Naltrexone – office-based non-addictive opioid antagonist that blocks the effects of other narcotics; daily pill or monthly injection • Buprenorphine – 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 facilities • 38 offer Vivitrol upon re-entry “MAT…can cut mortality in half” Dr. Nora Nolkow, NIH Director

What is Harm Reduction? Discussion

What is Harm Reduction?

Discussion 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/

The Science of Prevention 1. National scope and trends 2. Public health model of substance use and misuse 3. The science of prevention 4. Case studies and the role of public health social workers 5. Where do we go from here?

Activity Domains of Influence Environmental interventions target organizational, community and public policy domains The higher the domain, the bigger the population impact

Big Picture Change: Targeting the 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 misuse • Policies enabling use and misuse • Lack of enforcement of laws designed to prevent use and misuse • Inadequate negative sanctions for use and misuse • Inadequate zoning that does not regulate outlet density or signage

Discussion Prevention Strategies

Substance Use and Misuse Prevention relies on PLANNING The DOING comes later

Public Health Approach to Community Planning: Social Work Plays Critical Role • • • Conduct needs assessment Build capacity Make a plan Implement the plan Evaluate the plan Make it sustainable Make it culturally responsive Discussion Video

Where Do I fit into Prevention Planning? The Role of the Public Health Social Worker Activity • 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, sheparding or 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 change Prevention planning (strategic prevention framework) Community organizing Local, state and federal legislation

Case Studies and the Role of Public Health Social Workers 1. National scope and trends 2. Public health model of substance use and misuse 3. The science of prevention 4. Case studies and the role of public health social workers 5. Where do we go from here?

Case Study: Public Health Social Work in Action Neighborhood Substance Use Prevention Coalition 3 -year opioid overdose state grant Required to conduct SPF Assessment took over a year 3 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? 1. National scope and trends 2. Public health model of substance use and misuse 3. The science of prevention 4. Case studies and the role of public health social workers 5. Where do we go from here?

Moving PHSW and SUDs Forward Education and professional training in prevention & intervention • Introduce and expand training in schools of social work with required and elective courses, specialization and field placements • Trained 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 science • Build community partnerships and coalitions in which public health planning and decision making gives true power and inclusion to the population it intends to target Language • Modernize the language and terminology we use to discuss individuals with substance use disorders • Play 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 criminalization • Overcome policy and practice barriers presented by stigmatization of substance use and misuse presents through research and sound prevention science • Use 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 color • Advocate 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 treatment • Demand 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 Advocacy • Influence policies and practice that perpetuate social norms that encourage use. • Document and advocate against criminalization of substance use in communities of color • Integrate the mission of racial and ethnic health equity for individuals with SUDS into everything PHSW’s do, not as a side issue or task • Call 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.

Deborah Milbauer MPH, MSW Deborah Milbauer, 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 G 05 HP 31425. 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 Initiatives The ALPS Team: Betty J. Ruth, Principal Investigator bjruth@bu. edu Madi Wachman, Co-Principal Investigator madi@bu. edu Alexis Marbach Co-Principal Investigator alexis_marbach@abtassoc. com Nandini Choudhury, Research Assistant nschoud@bu. edu Jamie Wyatt Marshall, Principal Consultant jamiewyatt 1@gmail. com