Substance use disorders represent a significant social and economic burden globally. While effective interventions exist, the overall treatment coverage remains limited, with lack of an adequately trained workforce as one of the prominent reasons.
World over, recent initiatives have been taken to improve the training in addiction medicine; however, further efforts are required in building curricula that are internationally applicable. Here, we present a recent paper published in the British Journal of Psychiatry – International, https://www.cambridge.org/core/journals/bjpsych-international
Is drug court meeting the need of the most vulnerable people who use drugs? What is the drug court judge’s hardest decision? What is social detox? How voluntary is drug court treatment?
November 8th, The Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) met for 42nd time in San Francisco, CA. These, and other questions, pondered five AMERSA speakers at the Thursday’s Interdisciplinary panel session.
Meeting the Need: Collaborative Justice and Treatment.
(Interdisciplinary panel, Thursday, November 8th, 2018, 10:15 – 11:45 am)
The panel was presented by:
Judge Eric Fleming, JD – San Francisco Collaborative Courts
Lisa Lightman, MA – Collaborative Courts, San Francisco Superior Court;
Angelica Almeida, PhD – San Francisco Department of Public Health;
Linda Wu, MSW, LCSW – San Francisco Department of Public Health;
Charles Houston – San Francisco Department of Public Health;
Drug Court Judge’s hardest choice.
Judge Eric Fleming, JD
The court calls people who have addictions participants, not defendants. Among others, the key role is to listen as a judge and to show respect. The hardest decision is to decide who’s going to be terminated; terminating very young people is the hardest. Some people have been fighting addiction for 20 years, but not making enough progress. This raises a question: What is enough progress?
It is one of the most important courts in San Francisco, they devoted a chief to it – not just someone pushing them through the system. The court takes high risk clients, those who haven’t done well in previous programs, facing significant punishment.
They understand that there are layers to the individuals, case can be dismissed if it’s the first case, but not the fourth case. If anything happens the system can send them to jail, but it doesn’t; instead, they talk to them and they listen – give them numerous chances. Relapse is considered as part of the process – if judge understands that, it’s good for the client.
The graduation is pretty awesome, it wasn’t easy for anyone. The judge oversees the ceremony, starts with positive remarks, and then problems. I’m proud of you as a judge, I hope you learned from me, because I learned from you. The judge concluded with a story about a young female user, 22-year old, that he had to terminate, before the termination, he made a couple of phonecalls to make sure that she had a place to go when he terminated her.
Where does transitional youth belong?
Angelica Almeida, PhD – San Francisco Department of Public Health
Some of the core functions of the drug court system are: (1) Making sure that the services were coordinated, mental health and addiction behavioral health. (2) Trying to keep people in the least restrictive settings by intervening early.
Sometimes, it is a challenge of being a harm reduction city but working in a court that is historically abstinence based. The drug court is offering outpatient and intensive outpatient services. Also, low threshold services – medication assisted treatment.
Harm reduction principles are really what brings people to treatment; not judging them also makes a big difference. Thinking about how they work with transitional age youth, which don’t quite fit to children or adult services, is still evolving. System made to work with adults, really older adults. The transitional age youth drops out of services too much. Next step after residential treatment is always the hard piece.
Sobriety doesn’t take a certain number of days.
Linda Wu, MSW, LCSW.
Drug court treatment center has now become a civil service organisation. It is Co-located with community justice and violence intervention programs. It utilizes onsite urinalysis testing, all observed. Four levels of treatment graduation, graduation rate is 20% but 6 months of sobriety required, also housing and income or training – “you can’t be sober if that’s all you’re working on.” After graduation the case manager can help them even after the case is over, because they are part of dept of public health. Clients making significance progress towards recovery despite ongoing use, finding housing or using less harmful drugs such as cannabis. To be able to offer some choices (voluntary program) is really important and confidence-building.
Challenges of drug courts are many. Clients look at the treatment in terms of their sentence – sometimes, they ask how many days I have to serve? Sobriety doesn’t take a certain number of days.
There is a continuous discussion between harm reduction versus abstinence; it’s challenging at times to find the balance between client centered treatment and also making recommendations to the court. One of the ways they make recommendations to the court is through the UA (commitment, process).
Staff is sometimes feeling pressured to become enforcers because they need to write the court notes for court. It’s very different than writing clinical reports. Clinical note is very different from court note. That takes away the awareness from the what am I (staff) doing – to what are you (client) doing. Lack of community resources in a resource-rich city because lack of space (beds) and big stigma of working in drug services.
When change came over him
Charles Houston – public health.
Mr Houston, once a drug court participant – now working for the city and county, as a family liaison – spoke about how important drug court is. He was running (there was a warrant), but then change came over him. He called the court himself. They asked him, do you want to try it – drug court? Judge reviewed monthly progress, fostered accountability. They showed him a different way, the strengths that he had, the ability to make change.
While drug courts benefit certain groups of persons who use drugs, the jury is still out there when judging their overall effectiveness and organisation. Yes, treatment is voluntary but court mandated – the other option is jail.
AMERSA – what’s in the name?
AMERSA, formerly known as the association for medical education and research in substance abuse was recently renamed. Now it is The Association for Multidisciplinary Education and Research in Substance use and Addiction. The association’s mission is to improve health and well-being through interdisciplinary leadership in substance use education, research, clinical care and policy. Text taken from www.amersa.org
If you enjoyed reading about this year’s conference, you may like to read my notes from the previous years:
39th meeting in Washington, DC, November 5th, 2015
38th meeting in San Francisco, CA, November 4th, 2014
Celebrating 30 years of CSAM-SMCA in Vancouver, BC, the conference focused on: Crisis, Controversy & Change. What is the role of education in tackling the overdose crisis?
Three speakers at the education session on Friday offered several potential solutions.
Friday, October 26th: Medical Education in Addictions (CSAM-SMCA Education Committee)
(1:30) Who Learns the Most about Addictions in Hospitals? A Mixed Methods Study.
Jan Klimas (representing a co-author team: Gorfinkel, L., Ahamad, K., Mead, A., McLean, M., Fairgrieve, C., Nolan, S., Small, W., Cullen, W., Wood, E., and Nadia Fairbairn), summarised the results of a 2-year evaluation of the addiction medicine consult team in the St Paul’s hospital, Vancouver, British Columbia. Learners, such as medical students, completed web surveys before and after their clinical placements with the team. A purposeful sample participated in post-elective interviews. Results of this research study will soon appear in a paper accepted for publication in the Substance Abuse journal.
(1:45) Addiction Medicine Mentorship: Capacity Building Through Relationship Building.
Kate Hardy (Manager) and Sarah Clarke (Sarah Clarke) from the Metaphi mentoring project spoke about the role of primary care providers in the treatment of substance use disorders. The length of the treatment is more important than the intensity. Patients prefer to be treated in primary care. Integrating mental health with physical health services creates better outcomes. Primary care has greater capacity for treatment. But many providers are not willing to take over the care of persons with SUD. Medical mentoring of primary care providers by specialists. There’s no wrong door to access the addictions treatment. Mentorship, such the one provided via Hardy’s and Clarke’s project – metaphi – must be easy and convenient, sufficiently incentivized. Check out the project website www.metaphi.ca.
(2:00) The ABC’s of Addiction Fellowship Programs in Canada.
Melanie Willows (introducing her co-author team: Anees Bahji, Annabel Mead, Nikki Bozinoff, Ron Lim, Lydia Vezina, Ronald Fraser & Kim Corace) and a group of fellowship directors facilitated a session, which was sponsored by the CSAM education committee, about the Canadian fellowships in addiction medicine and offered recommendations for the future of the training programmes in Canada. In addition to the fellowship directors, the talk started with a lived experience of someone who has been accepted to the fellowship but who has not started the fellowship. A recent fellowship alumna concluded the group presentation.
If you enjoyed reading about this year’s CSAM 2018 conference, you can read about the CSAM 2015 here
Diagnosing opioid addiction in people with chronic pain requires a fully validated alternative to DSM-5.
Over the past two decades, a steep rise in the number of opioids dispensed for pain treatment has been accompanied by a dramatic rise in overdose deaths in the United States. In 2016, up to 32 000 deaths reportedly involved prescription opioids. Besides that, the economic burden of prescription opioid overdose exceeds $78bn (£59bn; €67bn) annually.
Despite all the evidence of harm, it remains unclear exactly how to determine if a patient with chronic pain has opioid addiction. What criteria should serve as a gold standard in making a diagnosis of opioid use disorder (OUD) in this context? This is an important gap in the literature. It hinders both evidence based care and research on the links between prescription opioids and OUD. Therefore, we discuss the limitations of diagnosing OUD in people with chronic pain, and make several recommendations for further research.
Diagnosing opioid addiction in people with chronic pain
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides a widely used set of diagnostic criteria for OUD. But these criteria do not always apply to patients who are prescribed opioids for chronic pain. According to DSM-5, if a patient presents with 2 out of 9 specific symptoms, it may indicate …
Diagnosing opioid addiction in people with chronic pain
Will an increasing pressure on prescribers curb the rising opioid overdose rates?
With only 0.5% of patients prescribed opioids reportedly developing addictions, there must be something else going on that’s making people overdose. A mismatch. Research on this topic is messy and patchy–– simply put, the large correlational research and incidence studies of addiction do not match up. In a recent commentary, we outline how prescription opioids might indirectly influence the rising overdose and addiction rates.
Mismatch: Why Correlation and Incidence Might Not Match Up
First, diversion gets medically prescribed opioids (MPOs) to those who are not prescribed the medication. Diverted MPOs can be sold, gifted (mostly to family members or friends), stolen, or sometimes obtained through “doctor shopping”, where patients get the same prescription from multiple physicians. But we don’t know how much diversion is due to sold, gifted or stolen medicines. How much do the different diversion types contribute to addiction and overdose? And for that matter, how much is diversion occurring, and to what extent is it contributing to national opioid crises?
Second, because overdose is often preceded by addiction, many researchers have focused on the persons who develop an addiction when prescribed opioids. However, if addiction doesn’t come before overdose, some high-risk patients go unstudied, and thus unreported. This has been shown in some states, such as West Virginia, where prescription opioids contributed to 93% of overdose deaths and very few of the deceased had iatrogenic addiction. So, some people might be at risk of sudden overdose but are missed in research studies that focus on medical diagnoses of addiction. This gap in the research is likely due the difficulty of studying overdose risk without the presence of addiction.
Polydrug use and overdose
Third, polydrug use may lead to overdose in people who use prescription opioids but do not specifically have addiction to their MPO. Here benzodiazepines are a big issue. It is important to note that many studies of addiction to MPOs do account for polydrug use by incorporating urine drug screens; however, positive results are often lumped together with other “aberrant” behaviours such as failed pill counts or requesting opioids from multiple doctors. Ultimately, we can’t tell how much polydrug use is really leading to addiction or overdose in this context.
Finally, it is possible that incidence studies to date could be misrepresenting the true risk of addiction to MPOs. Studies of OUD incidence in pain care use definitions of addiction that range from very broad to highly specific, mixing up terms like “dependence”, “abuse”, “misuse”, or “problematic use”. This could make it so our guesses about the risk of addiction to MPOs are muddled, leading to skewed results.
We need to understand better if reduced opioid prescriptions can reduce the opioid crisis. Then we can make the change happen.
To read the whole commentary, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:
Gorfinkel, L., Wood, E., Klimas, J. (In Press) Prescription opioids, opioid use disorder, and Overdose Crisis: Current Dilemmas and Remaining Questions. (Published ahead of Print, June 4th) Canadian Journal on Addiction
I thank Lauren Gorfinkel for feedback on this post.
If you enjoyed reading this post, you may also like my poem about pain. See link below: