Drug court and Addiction, AMERSA conference

golden gate bridge

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.

 

youth opioid addictionWhere 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.

alcohol drink, methadose

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.

lisbon

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

Canadian Society of Addiction Medicine, CSAM conference

conference meeting

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.

csam logo

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

2018 CSAM October 25-26, 2018

Diagnosing opioid addiction in people with chronic pain

Diagnosing opioid addiction

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 …

Source:

Gorfinkel LaurenVoon PaulineWood EvanKlimas JanDiagnosing opioid addiction in people with chronic pain 

Will this patient go into severe alcohol withdrawal?

bottle in bag

New research from the BC Centre on Substance Use (BCCSU) suggests applying easy and effective tool to identify patients at high risk of going into withdrawal, in efforts to modernize alcohol detox. In a study published in the August issue of the peer-reviewed Journal of American Medical Association, BCCSU researchers used data from approximately 71,295 persons taking part in 14 scientific studies to predict which patient will develop serious complications, including seizures and delirium.

Which patient will go into severe alcohol withdrawal?

From the press release by British Columbia Centre on Substance Use (Aug 28, 2018):

Research sheds light on how to improve diagnosis and treatment of severe alcohol withdrawal syndrome
The treatment of alcohol withdrawal urgently needs to be modernized in order to improve patient outcomes and safety and reduce health care cost, according to new research from the BC Centre on Substance Use (BCCSU).
The study, published today in the Journal of the American Medical Association, involved a multi-year systematic review involving more than 71,000 patients and sought to determine how best to identify the risks of developing severe, complicated alcohol withdrawal – a potentially life-threatening emergency. Those who consume alcohol in quantities above low-risk recommendations may develop this syndrome when they abruptly stop or substantially reduce their alcohol consumption.
Researchers found that patients are commonly over-admitted into inpatient alcohol withdrawal management care, resulting in a poor patient experience and unnecessary health care resource consumption. The review identified highly valid and easily administered screening tools to properly assess symptoms and risks before recommending acute treatment such as withdrawal management, and to look at outpatient care to improve patient outcomes and reduce the burden on the health system.
“Alcohol addiction is not only the most common substance use disorder, it’s among the most devastating in terms of both health impacts and the costs to our health system,” said Dr. Evan Wood, executive director of the BCCSU and lead author of the study. “This study demonstrates that there are more sophisticated tools that the health system should be employing to provide more appropriate care for patients, which will result not only in better outcomes but also free-up resources for high-priority needs.”
According to a study released by the University of Victoria’s Canadian Institute for Substance Use Research (CISUR) and the Canadian Centre on Substance Use and Addiction (CCSA), alcohol use costs Canadians $14.6 billion per year in health care, lost production, criminal justice, and other direct costs – higher than all other substances combined.
B.C. has the highest rate in the country of hospitalizations entirely caused by alcohol, and consumption is rising faster in the province than elsewhere in Canada. Research from the Canadian Institute for Health Information published last year found that British Columbians who use alcohol consume, on average, 9.4 litres of pure alcohol each year —  the equivalent of roughly 14 bottles of beer or two-and-half bottles of wine each week.
“Hospital wards are often filled with individuals suffering the consequences alcohol addiction,” said Dr. Keith Ahamad, a co-author on the study and Medical Director at Vancouver Coastal Health’s Regional Addiction Program. “This study helps identify those who truly need admission and demonstrates that many patients can be better treated as outpatients, even in primary care.”
The BCCSU is funded by the provincial government and is currently developing provincial guidelines for treating alcohol use disorder, expected to be released later this. They will be the first evidence-based guidelines of their kind for the province.

(Text taken from http://www.bccsu.ca/news-releases/)

From: Will This Hospitalized Patient develop Severe Alcohol Withdrawal Syndrome?: The Rational Clinical Examination Systematic Review. JAMA (In Press) JAMA Network: jama.jamanetwork.com

If you’re interested in alcohol, read more about my alcohol research here.

For more information about the study or to schedule an interview, please contact:
Kevin Hollett, BC Centre on Substance Use
778-918-1537
khollett[at]cfenet.ubc.ca

Addiction social work fellowship launched

man and boy

Addiction social work fellowship launched!

Substance use disorders disproportionately contribute to the global social and economic burden of disease.

Sadly, their treatment has been inadequate in large part due to an enduring research to practice gap. Here, the competencies for treating and preventing substance use disorders are often lacking from social work education curricula.

Addiction social work fellowship launched in Canada

Recently, the British Columbia Centre on Substance Use started a new interdisciplinary fellowship in addiction social work, nursing and medicine in Vancouver, Canada. We describe the new fellowship program and outline initial impact of the training on knowledge and skills in addiction social work from our qualitative evaluation of the fellowship.

“The Addiction Social Work Fellowship program accepts two positions in Social Work annually. The program strives for excellence in clinical training, scholarship, research, and advocacy and includes specialty training in inpatient and outpatient addiction services, as well as related concurrent disorders training. The program prepares Fellows to work clinically in the field of addictions and take leadership roles in academic and/or research settings.” (www.bccsu.ca)

 

To read the whole story, please visit the journal website https://www.tandfonline.com/loi/wswp20 or lookup the paper using the following citation:

Callon, C., Reel, B., Bosma, H., Durante, E., Johnson, C., Wood, E., Klimas, J.  (In Press) Addiction Social Work Fellowship in Addiction Medicine: A Novel Programme in a Canadian setting. (Early Online July 30th) Journal of Social Work Practice in the Addictions 

If you enjoyed reading this post, you may also enjoy reading about the fellowship here.