Continuing the Conversation: Considering Best Practices for Whole People

1. Continuing the Conversation: Considering Best Practices for Whole People February 7, 2018

2. Overview Introductions Addictions and Primary Care Addictions and Schools Q&A

3. Your Presenters Cheryl S. Sharp, MSW, ALWF Exclusive Consultant National Council for Behavioral Health Reba Smith, M.S. National Council for Behavioral Health Exclusive External Consultant

4. Your Presenters Pamela Black, MEd Exclusive External Consultant National Council for Behavioral Health

5. Addiction & Trauma in Primary Care Chronic Pain

6. Why Chronic Pain? • Reality of providers • The highest percentage of all medical visits are from pain • Institutes of medicine called chronic pain the largest public health issue today • Opioid overdoes is the number one cause of death—outpacing car accidents • Legacy patients with high doses of opioids prescriptions often with benzodiazepines • Patients seen as drug seeking • Patients do not ‘fit’ the usual image of a ‘drug addict’

7. Predictors of Addiction Relapse • Psychiatric co-morbidity • Low family support • Poverty “The frequency of all types of abuse and neglect were higher in the addicted group. While 70.3% of the study group reported at least one type of childhood maltreatment, this figure was as low as 33.8% in the control group (P < 0.001). After adjusting the two groups for differing background characteristics and the GHQ-12 score, emotional abuse, physical neglect, and sexual abuse were proved to have significant relationships with addiction to opiates.” –National Center for Health Statistics

8. The prevalence of trauma among chronic pain patients is twice as high as in the general population. (Goldgerg, 2000)

9. The Co-morbidity of Chronic Pain and PTSD The prevalence of pain has been estimated to be between 45 to 87% in patients referred for the treatment of PTSD.

10. ADVERSE SELECTION Highest Risk Patients* Receive Highest Opioid Dose *Co-occurring psychiatric and addiction disorders Odds ratiosadjusted for pain severity and patient characteristics 2.6 2.1 1.4 1.0 Merrill et al. 2011 Sullivan 2012

11. The Interaction between Chronic Pain and PTSD • Patients with co-morbid pain and PTSD experience more intense pain, more emotional distress, higher levels of life interference, and greater disability than pain patients without PTSD. • Due to the interaction of these conditions, these patients can also be more complex and challenging to treat.

12. Current State of Addiction Treatment • Different funding streams, different cultures of care • Patients get punted between providers—becomes no one’s problem and everyone’s problem • Complexity due to influence of trauma • “Given the high rates of comorbidity between chronic pain and PTSD, and evidence suggesting that these two disorders may interact in some way, efforts to develop more effective treatments for this population are greatly needed.”

13. Whole Person Approach • Primary care integrates mental health and addiction approaches • Universal understanding of the effect of trauma (dysregulation) on addiction • Universal understanding of interactions that promote patient resilience • Intentional partnering with competent providers

14. Dr. Peter Levine:

15. Primary Care Can Partner with Addictions Professionals

16. KEY CHRONIC PAIN NARRATIVE HISTORYAdverse Childhood Events (ACE) Significant Events: Robust Correlation: Depressed affect, suicide attempts Multiple sexual partners, sexually transmitted diseases Smoking & alcoholism Social, emotional, cognitive impairment Disease, disability & social problems • Recurrent physical/emotional abuse • Contact sexual abuse • An alcohol and/or drug abuser in the household • An incarcerated household member • Someone who is chronically depressed, mentally ill, institutionalized, or suicidal • Mother is treated violently • Emotional or physical neglect Anda R., www.acestudy.org • Chronic Pain

17. OPIOID RISK TOOL Administration • On initial visit • Prior to Opioid Therapy Scoring • 0-3: low risk (6%) • 4-7: moderate risk (28%) • > 8: high risk (> 90%)

18. CHRONIC PAIN TREATMENTS: Average Expected Reduction in Pain Intensity • Opioids: 30% • Tricyclics: 30% • Antiepileptics: 30% • Acupuncture: adds 10% • Cannabis: 10-30% • CBT/Mindfulness: 30-50% • Physical fitness: 60% • Sleep restoration: 40% • Hypnosis, Manipulations, Yoga: “some effect”

19. Oregon Law: Lay People Have Narcan • Online training (not required) • Ask a pharmacist • Also available at local syringe exchange locations • All local law enforcement

21. In the Chat Box Please tell us how your organization is partnering with primary care.

22. Schools and Districts: Community Responses to the Danger of Alcohol and Drugs

23. Educate/Inform/Consequence • Educate and Inform • “Just Say No” • Health Curriculum-Dangers • Alcohol & Drug Forums • and Summits • Consequence • Required class for offenders • One of the “Big Three” • violations

24. Trauma Informed Approach • Teach about ACEs • Student led presentations • Skills to feel better-mindfulness, connection, resilience • Create trauma-informed interventions for substance abusers • Involve community partners

25. Talking with Parents Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.

26. Family Checkup Questions: Are you able to communicate calmly and clearly with your teenager regarding relationship problems? Do you encourage positive behaviors in your teenager on a daily basis? Are you able to negotiate emotional conflicts with your teenager and work toward a solution? Are you able to calmly set limits when your teenager is defiant or disrespectful? Are you able to set limits on more serious problem behavior such as drug use, if or when it occurs? Do you monitor your teenager to assure that he or she does not spend too much unsupervised time with peers? https://www.drugabuse.gov/family-checkup

27. Resources ASCD, Districts Vow to Not “Lose One More Kid to Opioids” Education Update .November, 2017. Retrieved on 2/3/2017 at http://www.ascd.org/publications/newsletters/education-update/nov17/vol59/num11/Districts-Vow-to-Not-%C2%A3Lose-One-More-Kid%C2%A3-to-Opioids.aspx ACEs Connection. ConVal High School's Story: Becoming Trauma-Informed for Substance Abuse Prevention. April 19, 2017 retrieved on 2/3/2017 at http://www.acesconnection.com/blog/conval-s-story-becoming-trauma-informed-for-substance-abuse-prevention

28. Baltimore City Public School-Based behavioral Health Services Prevention, Early Intervention and Treatment In a Trauma Informed System Ashley Collins, MPH Rehabilitation & Treatment Coordinator Heather Dewey, LCSW-C Associate Director of Child and Family Services

29. Objectives • Provide an overview of BHSB’s school-based behavioral health services provided in partnership with Baltimore City Public Schools and Baltimore City Health Department • Provide an overview of BHSB’s work towards improvement in outcomes evaluation • Provide a system overview of trauma-informed care integration efforts connected with BHSB and BCPS

30. Overview of Behavioral Health system Baltimore (BHSB) Understanding Who We Are

31. Behavioral health system Baltimore • Ensures access to a full range of quality behavioral health services • Advocates for policies to advance prevention, early intervention, treatment and recovery • Collaborates with system partners improve access to care • Strengthens communities by supporting behavioral health and wellness

32. Impact of the Work

33. notes Expenditures for mental health and substance use services System is largely funded by Medicaid BHSB also funds services for uninsured and services not reimbursable by Medicaid/Medicare Source: ASO (Beacon Health Options) * Total expenditures for services only

34. Overview of BHSB’s School-Based Behavioral Health Disorder Services Understanding the Value of Partnerships

35. Who Do we partner with? BHSB partners with Baltimore City Public Schools and the Baltimore City Health Department to ensure that youth have access to high-quality behavioral health care that promotes social-emotional health and academic success.

36. How Do we Partner? ensure consistency with the purpose for the funding determination of deliverables Overall System collaboration/development evaluate provider performance

37. School-Based Substance Use Disorder Services (SUD) Overview • FY2018 School-Based SUD Program facilitates access to school-based outpatient services in 16 schools Includes • Prevention • Early Intervention • Ongoing Care How to Access • Crisis, Information and Referral (CI&R) Line. 410-433-5175 • ESBH Directory via BHSB website • Contact BHSB Program Lead Services are funded by a combination of grants and fee-for-service billing.

38. prevention in schools • Botvin Life Skills Training (LST) • Targeted Prevention Services for 6th graders embedded within the Expanded School Behavioral Health (ESBH) Program • Substance Use Disorder Prevention Program • Promotes healthy alternatives to “risky” behaviors • Provided in 35 schools

39. Naloxone/Narcan All Baltimore City Public Schools carry a supply of Naloxone/Narcan During FY2017 BHSB: Provided overdose education to 4,272 individuals Distributed 3,999 naloxone kits BHSB makes overdose education, as well as an overview of treatment resources, available to all Baltimore city public school employees upon request

40. School-based Mental HealthServices Overview • FY2018 School-based Mental Health program facilitates access to school based outpatient services in 127 public schools Includes • Prevention • Early Intervention • Ongoing Care How to Access • Crisis, Information and Referral (CI&R) Line • ESBH Directory via BHSB website • Contact BHSB Program Lead Services are funded by a combination of grants and fee-for-service billing. .

41. Overview of BHSB’s Outcome Evaluation Understanding the Value of Data

42. Outcomes focused Evidence Based Assessment (EBA) Initiative • Data collection at regular intervals throughout treatment • Informs diagnosis, treatment planning, and outcomes • Ongoing progress monitoring to inform changes in treatment • Supports data-informed decision making in schools • Associated with greater treatment success • Increases school behavioral health quality and accountability

43. Overview of Trauma Informed Care Integration Understanding the Value of Knowledge

44. Trauma Informed Partnerships Promoting Student Resilience (PSR) Seeking Safety Led by BHSB Trauma informed care model Evidence based Addresses trauma and addiction Approved for adolescents age 13 and up • Funded by SAMHSA grant • Led by BCPS • 13 Focus Schools • Goal to increase trauma informed systems in City Schools • Training and coaching for school staff • BHSB’s ESBH providers in Focus Schools received specific training in assessment and treatment of trauma

45. BHSB Youth & Family contacts • Heather Dewey Associate Director, Child & Family Services 443-615-7814; Heather.Dewey@BHSBaltimore.org • Ashely Collins Rehabilitation and Treatment Coordinator, Child & Family Services 410-735-8552; Ashley.Collins@BHSBaltimore.org • Jen Baskette Rehabilitation and Treatment Coordinator, Child & Family Services 443-615-7836; Jennifer.Baskette@BHSBaltimore.org • Denise Wheatley-Rowe Director, Child & Family Strategic Initiatives 443-615-7834; Denise.Wheatley-Rowe@BHSBaltimore.org • Emily Heinlein Director, Public Health Initiatives 410-735-8522; Emily.Heinlein@BHSBaltimore.org

46. Learn more about bhsb • BHSB Youth and Families Website: http://www.bhsbaltimore.org/for-individuals-and-families/youth-and-families/ • BHSB Newsletter; enroll by visiting www.BHSBaltimore.org • BHSB Events for Providers: http://www.bhsbaltimore.org/for-providers/events-for-providers/

47. Contact us 100 S. Charles Street Tower II, 8th Floor Baltimore, MD, 21201 Phone: 410-637-1900 Website: www.BHSBaltimore.org Facebook: www.facebook.com/BHSBaltimore Twitter: @BHSBaltimore Envisioning a city where people live and thrive in communities that promote and support behavioral health

48. In the Chat Box How are you partnering with schools around addiction issues in your community?

49. Q&A Burning desires…

50. Gaylord National Resort & Convention Center 201 Water Street, National Harbor, MD 20745 Save $200 on your registration! Use promo code 18TCPI at check-out! Use promo code NCSTAFF50 for an additional $50 off!