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
Systematic reviews are the cream of the research crop. Those who understand their value thrive at an opportunity to meet the review authors at scientific conferences. This year, the annual meeting of the College on Problems of Drug Dependence (CPDD) in San Diego featured several important reviews. Here’s a listing of all the posters presenting reviews from the session on Wednesday, June 13th, 2018.
Non-fatal overdose prevalence among people who inject drugs Samantha Colledge (June 11, 2018);
Prescription drug monitoring programs on nonfatal and fatal drug overdoses David Fink;
Limited inclusion of women in functional neuroimaging studies of opioid-use disorder Hestia Moningka;
Women’s prescription drug misuse Bridgette Peteet;
Gender differences in HIV, anti-HCV and HBsAg prevalence among people who inject Janni Leung;
Case for hospital teams in treatment of opioid use disorders Kelsey Priest;
Addiction-related characteristics of substances users in harm reduction settings Charlotte Kervran;
STDs and injecting
Extremely low HIV incidence among PWID: Terminology, high/middle income settings, methodology, and addressing new outbreaks Don Des Jarlais;
Use of opioids and stimulants by people who inject drugs Amy Peacock;
Factors associated with uptake or willingness to use pre-exposure prophylaxis (PrEP) among people who inject drugs Yohansa Fernández;
Pre-exposure prophylaxis (PrEP) for people who inject drugs? Angela Bazzi;
Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions Emily Stockings;
Medical marijuana laws and adolescent marijuana use in the US Aaron Sarvet;
Does liberalization of cannabis policy influence adolescents’ levels of use? Maria Melchior;
Clinical and toxicological profile of NBOMESs Nino Marchi;
Sensation-seeking personality trait and its association to drug seeking behavior in adolescents Thiago Fidalgo.
Systematic reviews cream of the crop from Brazil through Egypt
NIDA International poster session on Monday, June 11, 2018
Three Australians, two North Americans; an Egyptian, African and Brazilian had one poster on systematic review each. Five were meta-analyses.
The Australian reviews dealt with overdose, STDs and injecting:
Nonfatal overdose prevalence among people who inject drugs S. Colledge, (UK, Australia);
Gender differences in HIV, anti-hepatitis C virus, and hepatitis B virus surface antigen prevalence among people who inject drugs J. Leung, (Australia, UK, Portugal);
Use of opioids and stimulants by people who inject drugs: A. Peacock, (Australia);
The North-Americans reviewed drug monitoring programmes:
Global review of drug-checking services 2017 L.J. Maier, (California);
Urinalysis frequency and health outcomes for persons on opioid agonist therapy: J. McEachern, (Canada);
Anger, brain stimulation and antipsychotics were reviewed too:
Anger in users of psychoactive substances H.V. Laitano, (Brazil);
Noninvasive brain stimulation in addiction medicine A. Elaghoury.(Egypt);
Atypical versus typical antipsychotics for the treatment of addiction: S. Hanu. (Ghana).
With the increasing demands on scientists’ workloads, systematic reviews are an effective way of staying up to date with the most recent developments in the field. See also my previous blog posts about CPDD from the previous years:
What is the state of the art in addiction research? How do we measure recovery? These, and other questions dominated presentations on systematic reviews of literature at the 2nd European conference on addictive behaviours and dependencies on October 24-26th, 2017, in Lisbon.
This post outlines the many presentations.
Systematic reviews at Lisbon 2017:
– Which individual, social and environmental influences shape different pathways of amphetamine type stimulant use over the life course? A systematic review and thematic synthesis of the qualitative literature. Amy O´Donnell and Michelle Addison, United Kingdom
– Determining the efficacy of an intervention to reduce IPV perpetration by men who misuse substances: a systematic review and meta-analysis. Gail Gilchrist, United Kingdom
– Drug use and infectious diseases: reviewing the evidence; Sarah Larney, Australia
Paper session 16
− Injecting and sexual risk-taking amongst people who inject drugs: a global review. Amy Peacock, Australia
− Needle syringe programmes and opioid substitution therapy for prevention HCV transmission among people who inject drugs: Cochrane systematic review. Matthew Hickman, United Kingdom
− Recent incarceration and risk of hepatitis C and HIV transmission amongst people who inject drugs: a systematic review and meta-analysis. Jack Stone, United Kingdom
− A systematic review and meta-analysis of psychosocial interventions to reduce drug and sexual blood borne virus risk behaviours among people who inject drugs. Gail Gilchrist, United Kingdom
− HIV prevention, treatment and care for people who inject drugs: a systematic review of coverage of interventions. Sarah Larney, Australia
– Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. Marica Ferri, EMCDDA
– What is the base for evidence-based treatment of opioid dependence? A systematic review of outcomes from longitudinal observational studies. Lucas Wiessing, EMCDDA
– Health outcomes for clients of needle and syringe programs in prisons: a systematic review. Heino Stöver, Germany
− Worldwide drug use decriminalization practices: a scoping review. Marta Pinto, Portugal
− Review of the effectiveness of treatment alternatives to incarceration for drug-involved persons. Roger Peters, United States
− Factors related to binge drinking in adolescence: integrative literature review. Tereza Barroso, Portugal
Systematic reviews posters at Lisbon 2017:
October 24th: 13:15 – 14:15 POSTER SESSIONS:
– Alcohol use disorders identification test (audit) and mortality risk in US Veterans and international population: a systematic review and meta-analysis. Sören Kuitunen-Paul, Germany
– Contingency management for drug use in treatment for opiate addiction: a systematic review and meta-analysis. Tom Ainscogh, United Kingdom
24th: 14:30 – 16:00 POSTER SESSIONS:
– A systematic review of internet addiction prevention interventions. Roman Gabrhelík, Czech Republic
October 25th: 11:00 – 12:30 POSTER SESSIONS:
– Prevalence and psychosocial predictors of performance enhancing substances use in physical activity settings: a systematic review. Ana Tavares, Portugal
October 25th: 14:30 – 16:00 POSTER SESSIONS:
– What works in the treatment of women with alcohol-use problems? Systematic review of evidence-based studies. Eva Hoch, Germany
Thank you all presenters for your reviews and conference presentations.
Should all medical doctors receive the same training in addiction medicine? Here’s what international experts think about core skills of and addiction specialist.
In a new article published by the Substance Abuse journal, we report on interviews with members of the International Society of Addiction Medicine who identified progression for the core skills and addiction medicine competencies at three educational levels: (i) undergraduate (ii), postgraduate and (iii) continued medical education (CME). The experts described broad ideas, such as knowledge/skills/attitudes towards addiction, for the undergraduate level. At the graduate level, they recommended knowledge of addiction treatment. Next, the experts also described specific recommendations, including the need to tailor the curriculum to national settings and different specialties. We still don’t know whether a global curriculum is needed. But a consensus on a core set of principles for progression of knowledge, attitude, and skills in addiction medicine to be developed at each educational level among medical graduates would likely have substantial value.
Why are the core skills important?
Our findings provide a consensus opinion on core skills for progression of knowledge, attitude, and competencies in addiction medicine. A panel of international scholars recommended that medical students and physicians should learn these skills throughout medical education. This is particularly important for the development of new addiction medicine curricula and enhancement of available courses. If applied, our findings would have profound effects on the quality of medical education. Better education can improve subsequent clinical care provided to people with substance use disorders worldwide.