An NASW Online Webinar Series Presented by: Dr. Joseph Hunter, - - PowerPoint PPT Presentation

An NASW Online Webinar Series Presented by:

• Dr. Joseph Hunter, LCSW, Ph.D.

• 1. Introduction and Problem Overview
• 2. Etiology: Genetics, Neurobiology and

Psychosocial Factors

• 3. Co-Occurring Disorders
• 4. Levels of Care, Addiction

Medicines and Therapies

1.

Participants will learn the macro interventions and practices currently underway to prevent opiate addiction and stop opiate-caused deaths, including new initiatives that are providing funding to treat opiate use disorder.

2.

Participants will learn the admission criteria for the various levels of care utilized to treat opiate dependency.

3.

Participants will learn about the evidence-based treatment approaches to opiate use disorder treatment, including addiction medicine treatments.

4.

Participants will learn specific strategies that can be used to successfully treat individuals with opiate use disorders.

• What do you hope to gain from this

webinar today?

• Please write this on your

worksheet and post it in the chat (if you wish)

• Although I am an employee of both Veterans Affairs (VA) and The

University of Southern California (USC), this presentation is done independently of those positions.

• The views expressed in this presentation are those of the author

and do not necessarily reflect the opinion, position or policy of the VA, the US Government or USC.

• In addition, although I am recognized by the New York State

Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers (#324), this training is offered under NASW’s approved provider number.

• I will describe the process for administering Narcan today;

however, I am not a medical professiona,l and it is recommended that you access DOH materials for step-by-step guidance.

• 61.8 million smoked cigarettes
• 175.8 million people drank alcohol
• 36.0 million people used marijuana
• 4.8 million people used cocaine
• 828,000 people used heroin
• 1.5 million people used lysergic acid diethylamide

(LSD)

• 2.6 million people used Ecstasy
• 1.8 million people used inhalants
• 1.7 million people used methamphetamine

[compare to 12.5 million misusers of prescription pain killers]

AGAIN

• Drug overdose is the leading cause of

accidental death in the US

• 52,404 lethal drug overdoses in 2015
• Opioid addiction is driving this epidemic
• 20,101 overdose deaths on prescription

pain relievers

• 12,990 overdose deaths on heroin in 2015

• Builds tolerance: more of the drug is needed to

achieve the same intensity of effect.

• Fosters dependency: the need to continue use of

the drug to avoid withdrawal symptoms.

• Deteriorates the brain’s white matter
• Impairs decision-making abilities
• Impairs the ability to regulate behavior
• Affects responses to stressful situations.
• Opioid overdose is now the second leading cause
• f accidental death in the United States

Increases risk of the following:

• Fatal overdose
• Spontaneous abortion
• Infectious diseases like hepatitis and

HIV

• Chronic users may develop collapsed veins,

infection of the heart lining and valves, abscesses, constipation and gastrointestinal cramping, and liver or kidney disease.

• Pulmonary complications, including

various types of pneumonia, may result from the poor health of the user as well as from heroin’s effects on breathing.

• Street heroin often contains toxic

contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs.

Increases risk of the following:

• Fatal overdose
• Spontaneous abortion
• Infectious diseases like hepatitis and

HIV

• Chronic users may develop collapsed veins,

infection of the heart lining and valves, abscesses, constipation and gastrointestinal cramping, and liver or kidney disease.

Jeremy is a 19 year old African-American youth who graduated from high school in the top 10 percent of his class academically. He was also a talented athlete, setting state HS records in the 200 and 400 meter track events. Toward the end of his senior year, after having received a full scholarship to a prestigious college, he was severely injured. He slipped off a trail, while running cross-country, and injured his back. He was started on Hydrocodone in the emergency room with a 30 day supply. After 30 days, his primary care doctor continued the treatment, while admitting surgery was not going to help.

• Strengthen public health surveillance
• Advance the practice of pain management
• Improve access to treatment and recovery

services

• Target availability and distribution of
• verdose-reversing drugs
• Support cutting-edge research

• First responders provided with Narcan
• Education for middle and high school curriculums

and college orientation

• Increased penalties for practitioners and

pharmacists who abuse their position by selling controlled substances to patients illegally

• Requirements for insurance companies to

improve access to coverage

• Public awareness campaigns
• Extensive training on the use of intranasal

naloxone

• Eliminate prior authorization requirements to make

substance use disorder treatment available to all

• Add fentanyl analogs to the New York controlled substances

schedule to subject emerging synthetic drugs to criminal drug penalties

• Increase access to life-saving buprenorphine treatment by

recruiting health care providers to become prescribers

• Establish 24/7 crisis treatment centers to ensure access to

critical support services

• Require emergency department prescribers to consult the

Prescription Monitoring Program registry to combat “doctor shopping“

• Create New York's first recovery high schools to help young

people in recovery finish school.

In April, it was announced that New York State will be awarded over 25,000,000 to address opiate addiction that aims to:

• Increase access to treatment, reducing unmet

treatment need, and reducing opioid overdose related deaths through the provision of prevention, treatment and recovery activities for OUD (including prescription opioids as well as illicit drugs such as heroin)

• Supplement current opioid activities undertaken by

the state agency

• Support a comprehensive response to the opioid

epidemic using a strategic planning process to conduct needs and capacity assessments

• Develop Centers of Treatment Innovation in

high need areas which will include developing Telehealth capacity

• Increase the number of prescribing

practitioners for medication assisted treatment via training and mentoring

• Have care managers to bridge the gap

between behavioral health and primary care

• Use locally placed Peer Recovery Support

Staff to improve treatment engagement and retention;

• Enhanced clinical staff
• Providing reentry support for individuals

being released from jails/ correctional facilities.

• Utilize multi-level prevention approaches
• Delivery of evidence-based prevention services

to underserved, hard-to-reach youth and other at risks populations, foster care settings and permanent supportive housing

• Provide training and distribution of Naloxone

kits

• Targeted media campaign

• OASAS will develop a youth and young adult

statewide recovery network and local community networks.

• Establish a social media campaign that

promotes health, recovery and wellness, establish peer supports and to provide technical assistance and support to local communities and networks of young people across New York State.

• Require that issuers and their

utilization review agents use evidence- based and peer reviewed clinical review tools designated by OASAS that are appropriate to the age of the patient and consistent with the treatment service levels within the OASAS system.

• It require every large group policy or contract

that provides medical, major medical or similar comprehensive-type coverage to provide coverage for medication approved by the U.S. Food and Drug Administration (“FDA”) for the detoxification or maintenance treatment of a substance use disorder.

• Require every policy or contract that provides medical,

major medical or similar comprehensive-type coverage and provides coverage for prescription drugs for the treatment of a substance use disorder to include immediate access, to a five-day emergency supply of prescribed medications

• therwise covered under the policy (without prior

authorization)

• … Or contract for the treatment of a substance use

disorder where an emergency condition exists, including a prescribed drug or medication associated with the management of opioid withdrawal or stabilization, except where otherwise prohibited by law (which includes medication for opioid overdose reversal)

• Chapter 71 amended those sections to

clarify that inpatient coverage includes unlimited medically necessary treatment for substance use disorder treatment services provided in a residential setting as required by the federal Mental Health Parity and Addiction Equity Act of 2008

• These new provisions prohibit issuers

from requiring preauthorization.

• These provisions further prohibit issuers

from performing concurrent utilization review during the first 14 days of the inpatient admission provided the facility notifies the issuer of both the admission and the initial treatment plan within 48 hours of the admission.

• An issuer’s utilization review of the inpatient

treatment may commence after the 14th day of the inpatient admission and may include a review of all services provided during the first 14 days of the inpatient treatment.

• However, an issuer may deny coverage for any

portion of the initial 14-day inpatient treatment on the basis that the treatment was not medically necessary only if the inpatient treatment was contrary to the evidence-based and peer-reviewed clinical review tool utilized by the issuer and designated by OASAS.

• A new Public Health Law prohibits a practitioner

from prescribing more than a seven-day supply of any schedule II, III, or IV opioid to an ultimate user upon the initial consultation or treatment of the user for “acute pain”

• Chapter 71 amended Insurance Law to include a

reference to parity for utilization review requirements

• Other changes address co-payment

• Medicaid Managed Care plans are required, by

contract, to use LOCADTR 3.0. Commercial insurers may only use LOCADTR 3.0 or another OASAS designated tool.

• New York State law does not provide for the

inclusion of prior treatment history in coverage decisions for substance use disorder services. Coverage is determined based on medical necessity. Medical necessity is based upon the use of an OASAS designated tool.

• This law requires insurers to cover in-network

medically necessary inpatient services for the treatment of substance use disorders, including detoxification, rehabilitation and residential treatment.

• There is no prior authorization or certification

necessary and insurers may not conduct concurrent utilization review for the first 14- days of treatment, provided the inpatient or residential facility gives the insurer notice within 48 hours of the patient’s admission and the initial treatment plan.

• Chapter 71 of the laws of 2016 prohibits prior

authorization for medically necessary inpatient or residential services for any substance use disorder.

• It is incumbent upon insurers to include

substance use disorder inpatient and residential facilities within their network, to ensure patients can access all needed levels of

• care. Insurers’ inpatient or residential facility

networks will be closely monitored.

• The new insurance laws apply to all inpatient

admissions for the diagnosis and treatment of substance use disorder, including detoxification and rehabilitation services, as well as treatment in a residential setting.

• While these changes will impact coverage for many

individuals, they do not apply to plans that are not regulated by New York State, i.e. Employer based plans subject to federal ERISA, or issued outside of New York State.

• The new insurance law provisions do not require

coverage, without authorization, for services provided by out of network inpatient or residential facilities.

• Requests for coverage at out of network inpatient or

residential facilities are subject to review upon admission.

• The prohibition against prior authorization or

concurrent review applies to each inpatient or residential admission where the patient is found to be appropriate for that level of care based on a determination using an OASAS designated tool.

• Classic triad seen in overdose
• Miosis (constricted pupil)
• Coma
• Respiratory depression
• Pulmonary edema
• Seizures (Demerol, Darvon, Talwin use)

• Narcan (naloxone) can potentially reverse

the effect of heroin or opioid overdose and prevent the person from dying.

• Due to the tremendous benefits and very

low risks associated with Narcan, OASAS is currently working with the New York State Department of Health to ensure greater access in communities across New York State.

• A life-saving law took effect on April 1, 2006,

making it legal in New York State for non-medical persons to administer naloxone to another individual to prevent an opioid/heroin overdose from becoming fatal.

• New York’s 2011 “911 Good Samaritan” law provides

protections from charge and prosecution for drug and alcohol possession for the victim and those who seek help during an overdose.

Know the signs of overdose

• Person is passed out and you cannot wake them up
• Breathing very slowly or making gurgling sounds
• Lips are blue or grayish color

Check to see if they respond

• Shake them and shout to wake them up
• If no response, grind your knuckles into their chest

bone for 5-10 seconds

• If the person still does not respond, call 911

• Call 911 immediately!
• Say “I think someone may have overdosed. (S)he

isn’t breathing.”

• If the person is not breathing, do rescue breathing

(mouth-to-mouth)

• Give Narcan (the opioid overdose reversal drug) to

the person if you have it

• Lay the person on their side once they resume

breathing

Step 1: Take the yellow caps o the needle-less syringe. Step 2: Grip the clear plastic wings and gently screw the white cone (nasal atomizer) onto the barrel of the syringe. Step 3: Take the colored cap off the Naloxone vial. Step 4: Screw the Naloxone vial into the barrel of the syringe without pressing down hard.

Step 5: Tilt the person’s head back and put the white cone into one nostril. Give a short, firm push on the end of the syringe to spray naloxone into the nose. Spray one half of the dosage into each nostril. Step 6: If the person does not respond in 3-5 minutes, give a second dose of naloxone. Do not wait more than 5 minutes to give a second dose.

If the person is not breathing, do rescue breathing (or CPR if you know it)

• Tilt the head back, lift the chin, and pinch the

nose

• Start with two breaths into the mouth. Continue

with one breath every 5 seconds.

• The person’s chest should rise and fall with each

breath; if not, check to make sure the head is tilted back and the mouth is clear.

• Keep doing rescue breathing until the person

breathes on their own or until medical help arrives

Step 1: Take the orange cap off the vial and stick the needle through the rubber stopper. Draw all the fluid into the needle by pulling back on the plunger. Be sure the syringe fills with liquid — not air. Step 2: Inject the needle straight into muscle in the shoulder (like a flu shot) or into the front of the thigh. Push down on the plunger to empty the syringe. It is OK to inject through clothing. Step 3: If the person does not respond in 3-5 minutes, inject another dose of naloxone. Do not wait more than 5 minutes to give a second dose

• If not breathing, commence rescue breathing (as previously

described)

• Assessment Step 1: Engage the Client
• Assessment Step 2: Identify and Contact Collaterals

(Family, Friends, Other Providers) To Gather Additional Information

• Assessment Step 3: Screen for and Detect Co-

Occurring Disorders

• Assessment Step 4: Determine Quadrant and Locus
• f Responsibility
• Assessment Step 5: Determine Level of Care
• Assessment Step 6: Determine Diagnosis

III IV Less severe mental disorder/more severe substance disorder More severe mental disorder/more severe substance disorder I II Less severe mental disorder/less severe substance disorder More severe mental disorder/More severe substance disorder

• Assessment Step 7: Determine Disability and

Functional Impairment

• Assessment Step 8: Identify Strengths and Supports
• Assessment Step 9: Identify Cultural and Linguistic

Needs and Supports

• Assessment Step 10: Identify Problem Domains
• Assessment Step 11: Determine Stage of Change
• Assessment Step 12: Plan Treatment

• Emergency Room
• Detoxification (outpatient to medically managed)
• Inpatient Psychiatry
• Inpatient Rehab
• Residential Treatment (“half-way house”)
• Partial Hospitalization
• Intensive Outpatient
• Outpatient
• Early intervention (indicated intervention)
• (self help)

OASAS’s LOCADTR: Level of Care for Alcohol and Drug Treatment Referral

• The LOCADTR requires the clinical staff person to complete

an assessment of an individual’s presenting issues, history, medical, mental health, risk and resource information, and to make clinically informed decisions in order to answer the questions.

• Staff who are working in an SUD setting with appropriate

supervision within the scope of their practice can use the LOCADTR to make level of care recommendations.

• Medical staff is required to complete the crisis decision tree

where there is a potential for serious or life threatening withdrawal to occur.

Considerations:

• Acute intoxication and/or withdrawal

concerns

• Biomedical conditions and complications
• Emotional/behavioral/cognitive conditions

and complications

• Readiness to change
• Relapse/Continued use/Continued problem

potential

• Recovery environment

• Inpatient/Residential Medically Supervised

Withdrawal

• Moderate withdrawal
• Lack of support for early abstinence.
• Outpatient Medically Supervised Withdrawal
• Moderate withdrawal
• Lack of support for early abstinence is not a

problem.

• Medically Monitored Withdrawal
• Intoxicated and experiencing a situational crisis, or
• Unable to abstain without admission to a

supervised setting.

• 24-hour, structured, short-term, intensive treatment

services provided in a hospital or free-standing facility.

• Medical coverage and individualized treatment services

are provided to individuals with substance use disorders who are not in need of medical detoxification or acute care and are unable to participate in, or comply with, treatment outside of a 24-hour structured treatment setting.

• Individuals may have mental or physical complications
• r co-morbidities that require medical management or

may have social, emotional or developmental barriers to participation in treatment outside of this setting.

• An OASAS-certified treatment service provided by

a team of clinical staff for individuals who require a time-limited, multi-faceted array of services, structure, and support to achieve and sustain recovery.

• Intensive outpatient treatment programs schedule

a minimum of 9 service hours per week delivered during the day, evening or weekends.

• This service is provided in a certified outpatient

clinic under the direction of a physician medical director.

• OASAS-certified sites where methadone or other approved

medications are administered to treat opioid dependency following one or more medical treatment protocols

• OTPs offer medical and support services including counseling

and educational and vocational rehabilitation.

• A physician serves as medical director and physician and

nursing staff assess each individual and approve the plan of care.

• Clinical staff provide individual, family and group counseling.
• Patients are prescribed and delivered medication assisted

treatment which is expected to be long term medication management of a chronic disorder.

• Utilize multi-disciplinary teams that include medical staff

and a physician who serves as medical director.

• Provide treatment services to individuals who suffer from

substance use disorders and their family members and/or significant others

• Services may be delivered at different levels of intensity

responsive to the severity of the problems presented by the patient.

• In general, persons are engaged in more frequent
• utpatient treatment visits earlier in the treatment process;

visits generally become less frequent as treatment progresses.

• Services available through community service

providers including: recovery centers, recovery coaching, case management and mutual help groups.

• Peer services through outpatient clinics and opioid

treatment programs (OTP)

• Recovery Center as a recovering member of the

community

• Housing Supports through the case management

associated with supportive housing.