Understanding Opioids and Other Drugs How Usage Impacts SOAR Applications – Part I

Understanding Opioids and Other Drugs How Usage Impacts SOAR Applications – Part I


– [Pam] Good afternoon and
welcome to our webinar. Today’s topic is on the
opiod crisis in America and what it means to
individuals experiencing homelessness and SOAR
applicants which we serve, and those who provide treatments
and supportive services to SOAR applicants. My name is Pam Heine,
Senior Project Associate with the SOAR TA center
and I will be moderating today’s event. Providing today’s welcome is Robert Grace, SOAR Project Officer
with the Homeless branch with the Center for Mental Health Services in Rockville, Maryland. Bobby? We’re just unmuting Bobby so he can provide the welcome today. – [Booby] Thanks very much. I appreciate it. And thank you all for joining us today. I’m Bobby Grace. And on behalf of the (mumbles)
and Mental Health Services Administration and the Center
for Mental Health Services Homeless Programs Branch,
I would like to welcome you to this SSI-SSDI Outreach
Access and Recovery SOAR webinar called Understanding
Opioids and Other Drugs How Usage Impacts SOAR Applications. SOAR helps states and communities increase access to self security
disability benefits for eligible adults who are experiencing or
at risk of homelessness and have a serious
illness medical impairment and/or cocaine substance use disorder. Today’s webinar will
focus on the opioid crisis in the United States. In the context of people
with disabilities who are experiencing or at risk of homelessness we know that opioid crisis
have significantly impacted this vulnerable population. To further address this crisis,
the US Department of Health (mumbles) has awarded
an additional funding of $144.1 million in grants to prevent and treat opioid addiction, which are administered by SAMHSA. I’d like to welcome and thank
our presenters for today Dr. Tyler Gray, who is
Medical Director with Healthcare for the Homeless
in West Baltimore, Maryland. Next we have with us Jacqueline Long, who is a Director of Housing and Grants with Mountain Comprehensive Care Center in Prestonsburg, Kentucky. And to round out our presentation we have Mr. Steven Samra, Deputy Director with BRSS TACS in Massachusetts. Thank you for your willingness to share your expertise with us. So without further delay
I will turn it back to Pam Heine who’ll be
moderating today’s webinar. Pam? – [Pam] Thanks so much,
Bobby, for your support of this webinar. So just a few housekeeping
items before we begin, a disclaimer. This training is supported
by SAMHSA and DHHS. The contents of this
presentation do not necessarily reflect the views or
policies of SAMHSA or DHHS. The training should not
be considered substitutes for individualized care
and treatment decisions. And a few more webinar
instructions which will help you enjoy this event. Your mic will be needed
throughout the webinar and this webinar is being
recorded and will be available for download on the SOAR
website in about a week. You may download now the
presentation fliers and handouts by going to the top left of your screen, clicking on the icon Style
then Save and then Document. Just download the materials or you can go to the SOAR websites, which
you saw in our title slide. You will also be connected
to a brief evaluation at the conclusion of the webinar, which we ask that you complete. And finally we will save
all questions and comments until the end of the
presentations at which time we will review instructions
for asking questions via our chat functions. So just a few of learning objectives. So the (mumbles) intention
that by the end of this webinar you will have a better
understanding of the opioid crisis both nationally and in the
Kentucky and Maryland areas. And have a better idea about
is it abused and misused amongst people experiencing homelessness and some of those national
trends and you’ll have a better understanding of
the clinical consequences of addiction to opioids
and know the differences between (mumbles) treatment and addiction. You’ll learn about the
importance of peer support with engaging and providing
services to individuals with opioid use and misuse, and also improve your
knowledge over all of the signs of opioid addiction and related treatments and supportive services to
better serve SOAR applicants. So as Bobby mentioned,
for the agenda today you’ll first be hearing from
Dr. Gray who’ll provide us clinical perspective. (mumbles) hear from Jacky Long
who is in Eastern Kentucky and talk a little bit
about opioid crisis there and the housing supports
and treatment available in Eastern Kentucky. And then we’ll round things
off with hearing from Steve Samra who is, again,
is again with BRSS TACS, who will provide a pure perspective on medication-assisted treatment. And then, again, we will
go back to you for some questions and comments. So without further ado,
I’d like to turn it over to Dr. Tyler Gray to
begin his presentation. Dr. Gray? – [Tyler] Good afternoon everyone. So yeah, my name is Dr. Gray. I’m the Medical Director with
Healthcare for the Homeless. We have a few different clinics, and I work in West Baltimore. So let’s get started. So my disclaimer is that
I am a family physician. I work in primary care. I do have a strong interest in addiction but I do not have any specialty training. I’m not an addiction
psychiatrist but I do have fair amount of experience with this. And I have no financial disclosures. So brief outline of what
I’m gonna go through. I’m gonna start out with a
case study just to kind of frame this discussion. A brief review of some
of the statistics of our current epidemic. We’ll go through some definitions. We’ll talk about Medication
Assisted Treatment and kind of review treatment
strategies in general. and Steven is gonna
talk us more about these strategies later as well. So I’m just gonna read
this slide to get us on the same page. So this is a patient of mine. FJ, she’s a 42-year-old woman. She has AIDS, hepatitis
C, and major depression. She comes in and asked
for help with her heroin and cocaine problem. She asked for and decides
to start on Suboxone which is buprenorphine treatment. She asked to come on
every one or two weeks, which she does for a period of time. She says that during these
times she goes to NA meetings a few times each week. She’s living here and there and
is kind of vague about that. Sometimes stays with her parents. She frequently misses
appointments and then will come in a few days later. (mumbles) she ran out of
medication and relapsed. Her urine drug screens are
always positive for heroine and cocaine, and she also
is not consistent with taking her HIV medication. So our team had tried to get
her into a more structured drug treatment program. And she did get to a
couple of these escorted by our outreach team, but each
time she left those programs within a couple of
weeks, largely kicked out for not following the
rules of either the housing or was kicked out for relapse
so then she comes back to us. So there’s a lot we could
talk about with this case but I suspect that many of us on the call has seen someone with at least
some of these challenges. So a few statistics in Maryland. And I used the Maryland
statistics over the national ones because I could find
more up-to-date numbers. Because really the numbers
had changed quite a bit in the last couple of years. So don’t worry quite so
much about the numbers ’cause, again, this is
just unique to our state but there’s gonna be three graphs here, and take a look at the
difference and the trends. So this first one is the
number of prescription opioid related deaths. So this is medications like
oxycodone, Percocet, morphine. So those have increased. If we look at heroin-related
deaths in Maryland over this time you can
see that the numbers have gone up quite a bit more
and has more than doubled since 2014. One of the big players that
has driven the crisis recently has been fentanyl, which we’re
gonna talk about in a second. So this graph you can see
fentanyl’s always been around causing overdoses in a minority of folks. And recently it’s really exploded. And I believe this is a
trend not just in Maryland but throughout the country. So I’d like to spend a moment on fentanyl because many of you may have heard of it and wonder what it is. So this picture, I think
it’s a bit dramatic but it does get the point
across that fentanyl does essentially the same thing
as heroin does in the body and is quite a bit more potent. So it’s top to 10 all these numbers down but one way to think about it is that, so morphine is a opiate
that we use to compare a lot of things to. So heroin is about four
to five times stronger than morphine, and fentanyl’s
about 20 times stronger than heroin. So you might hear (mumbles)
like fentanyl’s a hundred times stronger than morphine which is true. And you might have heard of
a thing called carfentanyl which is a derivative of fentanyl, and that’s about a hundred
to a thousand times stronger than fentanyl itself. So the challenge is that it just takes very, very, very small amounts
of fentanyl or carfentanyl to potentially cause an overdose. So I don’t have great
explanation about why this is ending up in a drug supply. Certainly it makes the
high stronger and faster. And somewhere along the production chain this is getting put in
there, but obviously no one’s doing it with the precision needed so some batches come out heavy on the heroin, I’m sorry, on the fentanyl and those lead to these hotspot overdoses that many of us had seen. So a few definitions. Actually I was thinking about this. I think the good analogy
when we talk about these kind of medical definitions
is to think about caffeine. So I, like many from us on the call, and dependent on caffeine. So as you can see the third
bullet point dependence is being a bit of circular
argument but being dependent on a substance. So really what that means
is that tolerance develops so you get used to a
certain dose of a substance. So with caffeine maybe you
found that if you’d never had coffee before, you
drink a cup of coffee and you feel a bit wired, you
have a hard time sleeping. But if you have that cup
every day for a while, all of a sudden that one cup
doesn’t do so much for you and to get that same effect,
you’d need multiple cups. So that’s a description of tolerance. Withdrawal are symptoms
caused when habitually used suddenly ends. So I get caffeine withdrawal headaches, and many of us probably do. Every substance that can
produce tolerance and withdrawal has a different set of
symptoms associated with it. And it’s really key to
think about the difference between dependence and addiction. I did put on here that these
terms are actually not used in a DSM V. That stands for the diagnostic
and statistical manual version five, which is
the kind of the bible of psychiatric and psychologic diagnosis. And they no longer use those terms. I’ll get to what we
currently use in a moment. But these are terms that are
used colloquially quite a bit. And the main difference is
that dependence just signifies a state where someone gets
tolerance and withdrawal symptoms from a substance whereas
addiction implies a lot of maladaptive features such
as some of the features on the slide. So the current term we
use for any substance is substance use disorder. And as you can see down the
bottom right of this slide we then label that or
modify that as being mild, moderate, or severe, and we like to specify which substance. So these 11 criteria, if
you’d apologize my short hand, each of them are a little bit long. This is my short hand to
kind of get a sense for, for some of the criteria
that you need to meet in order to get diagnosed to
the substance use disorder. The few I wanna point out
are numbers five and six which really suggest that
not just that someone is using something and
getting withdrawal symptoms but that they’re having
problems in their lives and their work life and their social life, or in number eight and nine
using in hazardous situations or using despite medical problems. And those are really
the hallmarks of when a substance use disorder
really becomes problematic. And so I would say that
for most of us who may be dependent on caffeine we probably are not, perhaps, (mumbles) your obligations
or using it in hazardous situations and therefore would
not meet the criteria for a substance use disorder or addiction. A brief note about co-occurring disorders. Definition of a co-occurring disorder is really describing someone
who has both a serious mental illness and a
substance use disorder. And the quote here is
from the SAMHSA website. The link there in the bottom. There’s lot more
information on the website for those who are interested. But in many cases people
receive treatment for one disorder while the other
disorder remains untreated. And really what this
gets to is the fact that while there are some
similarities in terms of the brain chemistry that can be
involved in substance use disorders and mental health disorders, they’re unique diseases. And to really get at
properly treating someone, we have to take all of these into account. So for me as a family doctor
and primary care doctor, I need to take into account
the medical conditions, the mental health conditions, and the substance use conditions. And if we ignore any of those, we find that we don’t
make a lot of progress. So this is just a list of some
of the signs or symptoms of opioid use disorder. So left kind of
descriptions of intoxication and on the right are
symptoms of withdrawal, which patients often describe
as feeling dope sick. I was gonna find some
pictures but the pictures were all a bit gruesome for these. I’m not gonna read through all these but happy to answer questions
about them more later. But intoxication
obviously is what leads to overdose and death. And that happens through someone’s
breathing is slowing down so much that they don’t
get enough oxygen in. So one thing that’s really
changed in terms of our understanding of addiction
over the last decade or so is really how we have
come to view addiction as a chronic brain disease as opposed to a problem of will power. So the first bullet point dopamine. Dopamine is a chemical
that’s in all of our brains. And it’s very important in
the brain for reward pathway. So that means anytime any
us experience something which is rewarding, our brains
get flooded with dopamine and this produces a, in some
cases, a state of euphoria but other cases just it
can produce happiness. And that’s what our
brain uses to tell us oh, that made me feel good, I
should do that again some time. And with the drug it
really hijacks the system and the levels of dopamine are quite high. And the brain never forgets that. So what happens is, this is
a generalization of course, but with ongoing use, with many
of the substances of abuse, tolerance and withdrawal develops. So at first the dopamine
produces the positive effects and then someone finds
that hey, when I don’t use now I’m starting to feel sick. And man, before when I used
to for the amount of drugs I would get for $10 I would
be good for a day or two, now it’s only lasting me
hours and I need to spend more and more money. So those are all signs of tolerance and withdrawal developing. And then people’s social lives start revolving around the drugs. People can develop habits
and, you know, compulsive uses and find themselves in a situation where they’re using simply to avoid withdrawal and to try to get that dopamine level back somewhere near normal. Most of us who have talked
to people who have had a long term substance
use disorder find that they’re not using to even try to get high, they’re just trying to feel normal. And that’s oftentimes what happens. My point at the bottom is that
stress, compulsive behaviors, and the social context of
initial use such as being in the neighborhood where
you were using in the past can lead to relapse after
years without opioids. And again, I just go back
to this dopamine rush and the imprint that leads on your brain, that even if it’s out of
your mind that it’s kind of back in the primitive part of our brain and those memories can come
back and lead to relapse. So these are a list of some consequences of opioid use disorder. The main ones that I think
about, HIV, hepatitis B and C, and then infections. All of you are I’m sure quite familiar with the social consequences. Incarceration, unemployment,
loss of family support, and obviously overdose. This is kind of a menu
of treatment options. You’ll probably get a
lot of different opinions if you ask different doctors
or addiction counselors about what treatment
entails, but one of the ways that I think about it is
there’s a lot of possibilities. And we mix and match our interventions to meet the patient’s needs. So that can involve self-help groups like NA or AA, LifeRing. Can involve one-on-one
psychological interventions, can involve group interventions or community level interventions. From medical side it can
involve a detox which is just using medications to
get someone through the withdrawal period so
that they’re no longer dependent on a medication or drug. It can involve
medication-assisted treatment which we’ll talk about more in a moment. It can involve intensive
outpatient treatment or inpatient residential. So we’re gonna hear more about these. I like to think about a
behavioral component of treatment and a medication component of treatment. And you know, some patients
only get one or the other and some patients get
both, most of the the time that is determined by the
specific treatment program but as doctor not necessarily necessarily a facility with a treatment program. I’d like to look (mumbles)
individually and see what their needs are. So on the left here I listed
four medications that we, I think about a lot when
I think about opioid addiction and treatment. So methadone, buprenorphine,
naloxone, and naltrexone. So I just wanted to spend
a minute talking about how these medications are all different and briefly about how we utilize them. So the top one methadone. I’m sure everyone has heard of it before. The medical term is it’s
a full opioid agonist. This means that the higher
that the dose of methadone that gets in someone’s body, the more it has a agonistic effect or additive effect in the
same parts of the brain where morphine or
Percocet or heroin would. And it’s used clinically in
a methadone clinic setting to replace opioids. And we’re gonna get more
into that in a moment. Buprenorphine goes at a
lot of different names. It goes by Suboxone, Bunavail, ZUBSOLV. That’s when it’s
co-formulated with naloxone which is the medication right below there. But buprenorphine does
exist on its own and it is a partial agonist. Really what that comes
down to is that it’s seen as a safer medication than methadone. Methadone, of the doses get high enough, someone can overdose on it
just like off of heroin. It’s much harder to
overdose of buprenorphine because that partial effect
means that with higher and higher doses at some
point the effect actually levels off. And again, that gives it
a better safety profile which means that we are more
comfortable giving people a supply of this to take
home as opposed to methadone where it’s very tightly controlled. Naloxone is those by
the brand name Narcan. This is what you’ve heard
about the news as our opioid reversible drug, our
overdose reversible drug. So this is a thing that EMTs carry about. I would encourage anyone
who might be in a situation where you come across
someone who’s overdosed to have this with you. And it can be administered in
a variety of different ways most commonly as a nasal
spray or it can be in a intramuscular injection. And it quickly reverses
overdoses but it doesn’t last very long. The challenge with naloxone
now is that it doesn’t work quite as well against the drugs
like fentanyl or carfentanyl so people are finding
(mumbles) in the past one dose or two doses
might revive someone. Now it’s oftentimes taking more than that and sometimes the Narcan
actually isn’t working which is a little bit scary. Naltrexone is used to treat,
it’s used as a chronic treatment, it’s not used
in reversal of overdoses and it comes in a shot
called Vivitrol which is once a month or in a daily pill. And we use it to treat
actually alcohol dependence and we use it to treat opioid use disorder for people who do not
want to be on a medication such as methadone or buprenorphine. So the idea of treating
an opioid use disorder with an opiate such as
buprenorphine or methadone sounds kind of intuitive
and even some of my patients I’ve been counseling about
this say, wait a minute, I didn’t think Suboxone was an opiate. I thought it was something different. At the end of the day it is an opiate just like (mumbles) morphine,
Percocet, or heroin. But that’s actually
precisely why it works. Really what we’re trying
to do is reduce the harm of the illicit use. So if someone’s injecting
we wanna make sure they have clean injection
equipment so they don’t get infections. We wanna prevent overdoses
so that someone can live to get to a point where
they can work on the rest of their lives and hopefully
move on from the drug use. So thinking about how do we
minimize the harms of the drug use, I’m not gonna
get into the evidence or science that has kinda backed this up but for post-buprenorphrine and methadone there are many, many studies
showing that a lot of outcomes such as health
outcomes such as overdose, HIV, and others are significantly improved when someone is on the treatment. But importantly,
continuing a medicine like methadone or Suboxone
actually is continuing the body’s dependence on opioid. So one way to think about
this is is if there’s, if that dependence is this
daily need for something rather than trying to
get rid of that need, which we haven’t really found a good way to do at this point, we
kind of substitute that with something that’s safe. So rather than someone
having to inject heroin multiple times a day and risking overdose, they take methadone or
Suboxone once a day. And that need for opiates
of the day is satisfied. And many people find that at
that point they can go to work, they can feel normal and
carry on with their lives. Over time the brain can kind
of return to the pre-addiction stage in terms of not
needing any opiate but for (mumbles) that takes quite some time. One thing I hear a lot
from patients is that well, I’m just trading
one addiction for another. This is always a tough one to
hear because it’s really not how I think about things. So again, if you think back
to when we talked about what differentiates
dependence and addiction, addiction means that you’re
putting yourself in dangerous situations, you’re not meeting
your family or job needs, requires really a situation
where someone’s not functioning well in society. And that’s because of that drug use. And I would argue that for
people that are on methadone or Suboxone treatment and
abiding by the treatment expectations that none
of those things exist and it ends purely a dependence. So I would say that is
not treating one addition for another. So I wanna end with a
couple of quotes from some treatment guidelines
which I found is very helpful to me. This first one is from NIDA. A document called Principles
of Drug Addiction Treatment. I’ll just read this one. Detoxification alone does not
address the psychological, social, and behavioral problems
associated with addiction, and therefore; does not
typically produce lasting behavioral changes necessary for recovery, assessment and referral to drug treatment, drug addiction treatment. So I’ve put this in just a
point that while detoxification does or detox has a role
for a number of people in their treatment in
terms of getting in started on treatment, it should
not be seen as a treatment for any substance use disorder. It’s the detox then leads
into a longer term treatment which can involve medications,
can involve behavioral treatments or anything else. It’s a great start but in
alone is not sufficient and is not considered treatment. These last three quotes are from the Healthcare for the
Homeless Clinicians Network adapted guidelines, and
I have links of these in the slide. Most of you can read these,
but the few that I wanna point out though that
balancing the overall benefits of continuing medication as a
treatment and potential harm. So sometimes we think
well, such as my case and my patient example,
well she’s not really abiding by the rules, shouldn’t
we stop the prescription? We just need to always
weigh the potential risk for someone to stopping
the prescriptions such as increasing risk for
overdose with trying to see what are the harms of continuing. And that’s a challenging
situation to address for everyone. And the last one I put in
bold that housing should be a component as any
treatment strategy to manage opioid use disorder, that
there’s well-established evidence that when people
have a civil place to live, their drug use actually
tends to improve and trying to treat addiction on the
absences somewhat of a stable housing situation is near impossible. I think we’ll hear more
about that in a moment. And that concludes my, these
are the references that I used. Thank you. – [Pam] Great. Thank you so much, Dr. Gray. Your presentation will be
a really great foundation for the second part of our webinar series which will be next week when we will have the Social Security
Administration on the line. And folks, we’ll better
understand what the signs are and some of the symptoms
and treatment for opiod use. So again, thank you so much
for your great presentation. And again, the links that, Dr. Gray provided some great
links on his last slide to encourage you to take a look and take a little bit deeper. So next we’re gonna hear from Jacky Long from Eastern Kentucky who
will share how housing and treatment is really
critical to providing supportive services to
the folks in her area. So I’m gonna hand it over now to Jacky, who will share what’s going
on in Eastern Kentucky. Thank you so much, Jacky. – [Jacky] Thank you. My name is Jacky Long and I am the Director of Housing and Grants for Mountain Comprehensive
Care Center which is in Prestonsburg, Kentucky,
which is in Floyd County in the Big Sandy Region. The net role I manage
are grant portfolio which is about 10 to $15 million in grant, and also I developed and
managed all of our housing. And I developed any
project construction that involved the grant. (indistinct talking) So a little bit about
Mountain Comprehensive Care. We are a Community Mental Health Center. We provide a whole multitude of behavioral services, mental health services. We’re located in the Big
Sandy Region which is the counties that are
highlighted in yellow, but we also have been a huge expansion over the last couple of years. So every county in Kentucky
that has a red dot on it is (mumbles) where we have an
actual physical presence now. So in our region we have
had a very well-publicized substance use problem for many years. And right now prescription
opioids are the overwhelming drug of choice in our region. That actually contrasts with
some other regions in the state where heroin is in a huge
problem as well as fentanyl. But for whatever reasons, in our area, it is prescription drugs. And well, some credit that
with the Medicaid expansion and everyone has insurance and the prescriptions are more available, what we really see is
that overprescription is the biggest problem that
is associated with it. Our problem started well
before the Medicaid expansion, but overprescription is
really what we see that is putting drugs on the street and making them really available. Just an example, my friend
just had hip surgery in April and she left the hospital
with a narcotic pain killer that they gave her I think 60 pills and another refill of that and she didn’t even nearly use
her first prescription of it and then she just had to have
another surgery on her hip, and she left with 120
this time with a refill. So when it’s overprescribed like that, it’s very easy for those extra
pills that don’t get used to end up on the streets because they have a great catch value. And when you look at
that in conjunction with the economic depression
that we have in Kentucky, especially in Eastern Kentucky
where our, an employment rate are double the national average, then you can see how that
creates a huge problem. And although the state
has tried to correct that somewhat with legislation,
what happens is the prescribers sometimes are overprescribing
now because the paperwork is intensive that they
give another prescription. So it’s easier to give a
prescription and tack on a refill than it is to do the paperwork for the original prescription. So the 2016 Kentucky Department of Drug Control Policy
Overdose Fatality Report says that Kentucky resident
drug overdose deaths for Floyd County alone for 2012 to 2016 was 46.67 deaths per 100,000 that’s death, not overdose incidents. In Eastern Kentucky we
see in some counties death rates that are three
times the national average. Now, more than interesting
is I just recently did some research in
Paducah in McCracken County which is down here way
in the western corner, that county has now crept
up into the top five. And the kind of (mumbles)
done why that has happened since it’s usually Eastern
Kentucky is associated with all those deaths
that it’s thought that Missouri has a lot lacks or the regulations and laws
on prescriptions (mumbles) and that it’s coming across
the border from Missouri and into Paducah because
it’s just across the river. So as I said heroin is not a real issue in the Big Sandy Region as illustrated by the zero heroin death for Floyd County. Heroin and Fentanyl are serious problem in other parts of the state. I personally live in Lexington
which is west of Prestonsburg and it’s about an hour
45-minute drive away that it’s situated right on us 75. So Lexington gets the
benefit, if you will, of the drugs that move north to south between Michigan and Florida
and a lot of stuff out here and we think that’s what
creates the heroin problem here. So in the Big Sandy Region, we
don’t have that in our state, we have the mountain parkway that runs between Lexington and
Prestonsburg, but it’s not, it’s not a route for
trafficking of drugs like that and so access is limited to the heroin just because of geographic reasons. And then Gabapentin has become one of the most abused
substances in Kentucky. I have seen that recently in our housing of how the complaints in our apartment of someone selling Gabapentin and again, that was probably this person’s personal prescription of
Gabapentin that they are selling. And the effects that you
see in the Big Sandy region aren’t always as evident as you think. This picture shows downtown Prestonsburg which is a cute little town. It’s clean. You don’t see people
sitting on the park benches and sleeping on park benches. In fact our homeless
population where there is quite a number of homeless there is
of invisible for the most part and as is in Prestonsburg
the effects of drug use. In Prestonsburg, it’s just
that the economy is as bad as in other areas of Eastern
Kentucky that it’s just not, not expected outwardly the town as much. It doesn’t affect our
economic development though and we still have high
rates of unemployment. That contrast though with Wheelwright which is also in Floyd County. This is what Floyd,
Wheelwright used to look like. The town as you can see
has the secluded nature. It’s in a valley between the mountains, there is a holler, if you will, and it was a town that’s
created by a coal company and it used to be a really booming town, but then the coal boom-bust in. And now Wheelwright is just
a shadow of its former self and it is severely
affected by the epidemic of substances abuse. And it’s tied directly
to economic reasons here. They have just given out economic
opportunity in Wheelwright and you can walk down the
street at any given time there. And if you’re not approached by someone, you will encounter someone
who is under the influence of a substance, usually a prescription drug
that was not prescribed to them. I have just finished up
the project in Wheelwright and I’ve traveled this road a lot and I’ve seen on any given day
a risk of drug-related arrest all up and down that road
that’s pictured here. And in the big building on the left side was formerly a dance
halling, halling alley and was part of the booming
towns of Wheelwright and that house should
be recently taken down because there were so many
juveniles going in the building. The city was afraid and the juveniles was part of
the substance abuse problem in the community in juvenile usage and they were going in
there to buy and sell drugs and so the city isn’t
having to take down this big beautifully historic building that they couldn’t get restored. So overall, the impacts in our area are similar to other areas. There’s an increase in petty crime. It used to be a place where you can move your purse in your car and leave your keys in the
ignition and go into the store and come out it would still be there, that’s not the case anymore. Everything has to be locked. The jails are overcrowded. Families have been greatly impacted. There’s hardly anyone
in the area who hasn’t somehow been touched by
the substance use epidemic. There is increases in domestic violence. There is increases in homelessness. You have children who
are removed from homes. And then in other
situation, you have children who are basically the parents, acting as the parent in the home. It is a severe strain
on economic development in the area of, region wide. I’m focusing mostly in Floyd County today but in the entire region
it’s all a similar story. The lack of a sober workforce
has really made it hard to attract new economies and it’s hard to develop an economy. I personally have had
people who I’ve interviewed that I couldn’t hire because
they couldn’t pass a drug test. I’ve also had people that in
the middle of the interview literally fell asleep
with like chin to chest falling asleep in the interview. So it is a huge issue and it’s hard to attract
companies to come there. We have first the problem of terrain that it’s very hard to find
a place to build a factory or something like that
and then coupled with the lack of a sober workforce. It really dampens the effects. The problem is so severe that the Big Sandy Area Development District in their strategic plan
over the last several years has said that the need for treatment that has to be addressed in order for economic
growth in the region. Now, of course we know, if
there is no economic growth and there is no job for
people, it kind of becomes a vicious cycle of dependency on drugs and not being able to break that cycle. So Mountain Comprehensive Care
is doing everything it can to address the problem in our region. We are providing residential treatment. We have the Mountain Center
for Recovery and Hope that’s recently opened in the last year and it has 60 beds for men and women. So 30 of each. We recently opened the Serenity House which has 10 beds for treatment
for women who are pregnant. They can also bring their children back to the Serenity House with them after they have had the child so that they can start parenting classes and learn to take care of the child before they go out on their own and finish their substance
use disorder treatment. We have the Homeless Veterans
Transitional Housing Center which is also licensed
as a treatment center. So when our homeless veterans come there, if they have a substance abuse disorder they can also receive treatment. They are rather in transitional housing. And we are developing a new
Women’s Treatment Center in Paducah which will be a 16-bed center. Also, I forgot to say on on the slide, we just opened in the
last couple of months another Women’s Treatment
Center in Western Kentucky in Owensboro. It’s also 16 beds. We also offer outpatient treatment through all of our clinics statewide, we collaborate with the
drug courts in our region, in our home region, and we offer school-based
programming statewide. In fact, school-based
programming is where we started with our expansion. You can get funding for programs for substance abuse disorders
through many state resources which of course they vary nationwide. For housing, you can
access PATH resources. In Kentucky, you have to
access that through the state and I think that that
is pretty much uniform across the nation. Grant programs that we currently have just for substance abuse are the ACF Responsible Fatherhood Grant and that focuses on incarcerated men and we also have the
SAMHSA where we did have, that we’ve completed it now, the SAMHSA Adult Offender Reentry program. We have the SAMHSA Residential Treatment for Pregnant and Post-partum Women program which is funding for out Serenity House. We have the HRSA Substance Abuse and Mental Health Services
and Treatment Grant which is located in our Healthcare
for the Homeless clinics. And the SAMHSA Primary and
Behavioral Health Integration, a program which is a new
grant we just thought that also have at our Healthcare
for the Homeless Clinic. So addressing the housing problem because that is really, as we
said, essential to recovery. In our area, we have a
max of housing problems and many of our people who come out of our residential treatment
have nowhere to go. They’re either homeless when they come in or they don’t have a
sober place to go back to. And of course if you can’t go
back into a sober situation, it’s really hard to
maintain your recovery. We are trying to be innovative
about transitional housing because the permanent housing situation is not great in our area. So we’re trying to develop
transitional housing that we can have people come
out of the Mountain Center and go into housing where they can become or they can live until they
can get a voucher for housing and for permanent housing and continue their treatment
while they are there, be reunited with their children and prepare on jobs and prepare themselves to go
back into permanent housing because sometimes really
when you’re released from treatment, you’re
really not ready to make that jump back into the real world and having a transition is better. The problem of course is always resources to produce something like this. Construction resources are limited, but everyone can access
Federal Home Loan Banks. Wherever you’re at, there is a regional Federal Home Loan Bank somewhere in the two
or three states of you. And although their rules
for their affordable housing programs are
different in every region for the Federal Home Loan Bank, they all have programs
that would be accessible and you could use for transitional housing or permanent housing for people who have a
substance abuse issue. In the Cincinnati region, we can actually be awarded a grant of up to
million dollars per project and we have accessed those
funds many times over. And in fact there are some in our Mountain Center
for Recovery and Hope, but that is a major player
in the affordable housing industry for construction resources. Your state housing agencies
will usually have some funding. It’s different from state to state. We’re lucky in Kentucky that we have an affordable
housing trust fund. Our state housing agency also
administers the home funds and also the low income
housing tax credits. So those are all resources
that you can tip in to reduce the amount of debt and occasionally having no debt project which is wonderful if you
can get a no debt project that allows you so much more flexibility in the programming that you do. And also you have the continuum of care permanent housing bonus, especially if you have
chronic, a large population, a chronically homeless
people that you’re serving. Private foundation is a great
place to look for funding. It varies usually regionally and it’s really good to
access local corporations because they will usually
have some kind of foundation that caters to only, to
regions where they do business. So that sometimes is you
can locate those people, make a relationship with them, and you can many times
get fundings from them that you can use for your
housing and construction. Rental assistance is a
huge issue in our area. I think it’s an issue nationwide actually. We don’t have enough
available rental assistance. Our housing authorities
have very long wait list. One housing authority recently
closed their waiting list because it’s three years long and that’s for a housing choice vouchers and that doesn’t even count
their public housing units. So again, having choice vouchers are something that you can
use if you can access them. We prefer rental assistance because of the lack of housing vouchers. So a lot of the resources like the tenant-based rental assistance, emergency solutions grant, rental assistance, sources
like that can help you to get into your, get
your people into temporary situations where they can
have their housing paid for until a voucher can be available. Housing first is really important when you’re talking about
people coming out of treatment because they have barriers
with the housing authorities and probably the best thing
to do is have a dialog with them to tear down
some of the barriers. But most importantly you need to increase your people’s income
while they’re in housing so that they can get a better setup on trying
to maintain their housing. And I’ve listed some
things here that you can do to help people increase their income through their case management so that they can maintain their housing and remain in recovery. And I’m going to turn
it that back over now. – [Pam] Great. Thank you so much, Jackie, for sharing not only what’s going
on in Eastern Kentucky, but also about your comment
on Medicaid expansion that it may be more of a coincidence that there’s an increase
in the opioid crisis in the correlation with
Medicaid expansion. So I think that will be helpful for folks in other areas of the country and also the tremendous
amount of resources that you’re sharing with everybody. So I’m gonna now hand it
over to our last presenter who is Steven Gray, I’m sorry, who is Steven Samra
with SAMHSA’s BRSS TACS. He’s gonna give a pure perspective and talk a little bit about
Medication Assisted Treatment, so I’m gonna hand it over to Steven. – [Steven] Fantastic, Pam, and thank you. And I would always be
happy to take on that Dr. Gray’s title as well, so thank you much. And folks (audio trails off) today, a big thanks to SAMHSA, to government project ops, to Bobby Grace, and of course Policy Research Associates for their timeliness on a
really important webinar. And a huge thanks again to both Dr. Gray and Jackie Long for excellent
presentations today. There is some really important information that’s been disseminated so I hope that you found
some value in that. As we move to this presentation, I wanna provide an overview of
the various treatment options that are available to us around
substance use and misuse, but before we dive into that,
I think it really behooves us to understand the critical
issue facing us as we wrestle particularly now in the middle
of the worst drug crisis that this country may have ever seen with the challenges in how to
provide effective treatment to those suffering from
substance use disorders. As you can see from this slide, what drives this substance use disorder is a complex set of variables
both nature and nurture that makes each person
experiencing it unique. As such, its really clear
that a cookie-cutter approach, this sort of one size fits all
approach simply will not work and I think that’s been
proven over and over again over the last 20 or 30 years now. So if we’re really
serious about truly having a substantial impact on
supporting in treating individuals experiencing substance use disorders, we really need to approach
this challenge holistically. And we need to do that by recognizing it’s not just the addiction
that is creating the challenge, we need to understand that in many cases these other factors may in fact be driving the compulsion to use. And if we ignore them, we
ignore critical factors in their potential recovery journey. And we also need to be
mindful and attentive to what’s happening in their
lives regarding medical needs, social service needs,
behavioral health needs, and importantly potential
pharmacologic treatments that may be beneficial for them. Obviously, for those without
an income or health insurance, access to these areas is
essentially nonexistent. And no matter how many times
we send someone to rehab or help them achieve sobriety, if the rest of their life is in shambles or in need of serious
attention and support, the risk that they return
to addictive patterns and behaviors remains very high. So in focusing in on
what we have to work with in providing treatment
and recovery support to individuals with
substance use disorders, we currently have five models
really available to us. 12-step programs, Medication
Assisted Treatment or MAT, recovery residences, the harm reduction approach
to addiction and drug use and peer support. So let’s all just take a moment and we’ll take a look
at each one of these. Now the 12-step program originated
from Alcoholics Anonymous and outlines a set of
guidelines to help individuals recover from their addiction. Bill Wilson, one of the original
founders of the AA program recognized the need for the
effective treatment program for individuals who are struggling. And in 1939 after battling with
his own alcoholism for years and finally in recovery, he wrote the Big Book
for Alcoholics Anonymous which became the foundation
for the 12-step program. Now 12-step programs are open to anyone and today there are number
of ways to participate from in-person meetings to online groups. They are primarily abstinence-based, but are also becoming
increasingly accepting of the idea of multiple pathways to recovery including the use of
Medication Assisted Treatment. One of the challenges
that has helped shift the 12-step perspective to accept multiple
pathways approaches is that while completely unintended
by 12-step practitioners, the abstinence-based
philosophy may inadvertently have promoted additional discrimination and stigma for those
unsuccessful in the model. This moral failing mentality
is slowly being replaced with the understanding that
addiction is a brain disease as Dr. Gray has pointed out, and as such like any disease, medication may be
required to help treat it. Now, I wanna be really clear here that my intent is not to
disparage a 12-step program or even minimize their
efficacy or viability. The bottom line here for me
is that if just one person was to find recovery
through a 12-step program, well, then that is a
viable pathway to recovery and it should be honored and embraced. 12-step programs are an
incredibly important resource both for our communities and
for individual struggling with addiction challenges. Now, I’m not gonna spend a lot of time here on Medication Assisted Treatment as Dr. Gray’s presentation
was comprehensive. But as a treatment model we know, especially in today’s opioid epidemic, that this treatment is a
critical evidence-based approach to addressing opioid use disorders. We also know that through
MAT, absolute rates, abstinence rates, excuse me, exceeds 60% in long-term follow ups. Something that would make
any 12-step advocates cheer. And as Dr. Gray also pointed out earlier, there are three medications available for those who are using MAT. As you can see, these are the same medications
Dr. Gray discussed, but I’ve added a screenshot
of a very important tool developed by the SAMHSA BRSS TACS team in highlighting the three
medications available for MAT. And this way, you don’t
have to commit it all to your memory. This is the decisions in recovery shared decision making tool. It’s available online right now. It’s free of charge. And as we developed it,
we knew a few things based on a lot of research. The tool needed to be practical. It had to be accessible
for a wide audience. It needed to include
information and help people begin to think about making
a change in their lives. It needed to be available
to a broad range of learners with language accessibility
at around the eighth grade. And finally, it needed to
have a very simple framework. The tool, are multimedia
user directed website, helps clients with opioid use disorder answer three principal questions: whether MAT is right for
them in their recovery, if MAT is something they’re
interested in pursuing, and then which of the three
licensed MAT medications best meets their needs? And finally, how do you
get started with MAT in collaboration with
their medical provider? Using a shared decision making model to engage clients and providers, the tool incorporates real-world video testimonial from people in recovery. One thing we thought
be critically important was truly thinking
through how peers fit into the opioid use disorder epidemic. We think this tool is a natural roadmap for utilizing peer
support recovery services. The decisions in recovery tool incorporates a number of recovery tools including a set of worksheets
that people can download, print or e-mail to their
peer specialist or provider. The recovery tool offers
a level of introspection and deep consideration about defining a personal recovery path and you can access this
tool at the web link at the bottom of this to your slide. And I really strongly
encourage you to take a look and share this tool with your colleagues and any key stakeholders. Recovery residences provide
safe and healthy housing with an eye towards either initiating or sustaining the
individual’s recovery journey. In 2011, the National Alliance
for Recovery Residences or NARR established a national standard for recovery residences. The standard defined the spectrum of recovery oriented housing and services and distinguishes four different types which are known as levels
or levels of support. The standard was developed
through a strength-based and collaborative approach
that solicited input from all major regional and national recovery
housing organizations. Guidance for the standard
was also received from recovery residence
providers from across the nation. And you may have noticed it from the slide that recovery residences
are absence-based models, but I wanna point out
a very important caveat they share about this. It is abstinence from alcohol and other non-prescribed drug use. This is a critical distinction
that has opened the doors for individuals using
Medication Assisted Treatment to access recovery residences. Now, not all recovery residences
are doing this currently, but if we do believe in multiple pathways and no wrong doors for
the recovery journey, we must continue to promote
NARR’s approach here as a viable recovery vehicle for anyone interested in pursuing their recovery. The harm reduction coalition
defines harm reduction as a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. And Dr. Gray talked a
little bit about this. Harm reduction is also a
movement for social justice built on a belief in and respect for the rights of people who use drugs. Harm reduction incorporates
a spectrum of strategies from safer use to
managed use to abstinence to meet drug users where they’re at addressing conditions of use
along with the use itself. Because harm reduction
demands with interventions and policies designed to serve drug users reflect specific individual
and community needs, there is no universal
definition or formula for implementing harm reduction. Now in implementing this approach, the harm reduction
coalition considers a number of principles essential to
harm reduction practice. I won’t cover them all at this point, but there is a downloadable document that will address every one of those. Now harm reduction
strategies are shown here in a really simple and concise way. For individuals, clean syringes and opioid overdose prevention with naloxone trainings
are very good examples. For the environment, methadone clinics and buprenorphine prescribers
are good examples. And for policy, Good
Samaritan laws mandates for a methadone clinic in
every county in the country, licensing buprenorphine physicians, these are all examples of
harm reduction policies. There are a number of
studies that demonstrate the effectiveness and
efficacy of peer support. For example, researchers that
demonstrated that peer support helps improve the mental
health of veterans, makes people reduce hospital visits for those who have critical disorders and increases coping skills of families with a family member who
has a serious mental illness or a substance use disorder. Because of studies like these, SAMHSA, the Department of Veteran Affairs and over 40 states consider
peer and family support an evidence-based practice. Peer support services usually
operate in conjunction with clinical services which amplify
the benefit of treatment by engaging peers in services. Individuals might otherwise not accept offering ongoing support and
psychosocial rehabilitation and encouraging peers to stay in treatment and services by sharing
their stories of recovery. Many peer support services require that they’d be part of a treatment plan authorized by a licensed
practitioner of the healing arts such as a psychiatrist to
psychologist work position in order to be reimbursed by Medicaid under the centers for
Medicaid services rules. Peer support services
are a valuable adjunct to traditional care that
are known to contribute to improved outcomes and
employment, education, housing stability,
satisfaction, self-esteem, medication adherence, and
a decrease in the need for more costly services
such hospitalizations. Peer-provided services
help to foster recovery, increase treatment and service engagement, reduce acute care costs and use, and improve the overall quality of life. So why should SOAR providers
care about any of this? Well, this information helps
us look beyond the deficit. Sort of the what’s wrong with you approach and recognizes the importance of income, insurance, and peers in
supporting the whole person. It also helps identify both
the issues for SOAR filing and it provides a framework
for ancillary recovery support for the individual upon
receipt of the new benefits. Now we know that access
to insurance allows access of treatment for a
host of challenges and issues related and unrelated to drug use. But all are related to a
satisfying and productive life in the community. And the income provides
funding for housing, recovery residences,
and critical resources like transportation, food, medications, health needs, dental care, and other things like that. Peers help support wellness and recovery via their own lived experience and modeling a powerful recovery force for those who are still
struggling in active addiction and they also act as a gateway between the clinician and the client. Before I close today, let me tell you all why this information is important to me. It’s because it is personal and I am a person in a long-term recovery as a result to most of
these treatment approaches. I was a poly-drug user
and I have a long history of long-term heroin and
cocaine use, almost 30 years. I’ve then spent 15 years in a Medication Assisted Treatment program and I detoxed out of that
program under medical supervision on February 13, 2014. I’ve been living sober
the past three years now for the first time since I was a teenager. For my colleagues who are recovery coaches in 12-step proponents,
I need you to understand that the discrimination I experienced from 12-step program stigma because I could not achieve
abstinence back in the 1990s, it actually delayed my entry into Medication Assisted
Treatment by three years. And in those three years,
I overdosed three times all three of those were
reversed by Narcan. What I also want folks
to understand is that this wasn’t a malicious
effort, but instead it was my brothers and
sisters in the program who were trying to save my life the only way they knew how at that time. Now through education and awareness, 12-step programs had begun to understand that MAT is a viable pathway to recovery. Harm reduction provided clean syringes, info on drug interactions
like benzos and opioids, speedballs, all things I was doing in the MAT program in my community and thisnformation protected
me from serious diseases and it also provided me with
another recovery pathway through Medication Assisted Treatment. A recovery-oriented
system of care approach focused on my whole health wellness when I was still focused
on my substance misuse. And it helped me think about my life in terms of the impact of trauma as well as the critical importance
of stability and support in the areas of health, home,
community, and my own purpose. Peer support was the critical
component that made detox from Medication Assisted
Treatment possible and then supported me through
two years of pretty intense post-acute withdrawal syndrome or PAWS. I could not have done
this without that support. And by the way, while I
was doing the MAT program I achieved a Bachelor’s,
a Master’s, a degree in all while practicing
holistic wellness approaches. Now today, I’m proud to say that this is the longest
job I’d ever held. I’m in the longest relationship of my life with a supporting, loving,
and healthy partner. I’ve reunified with the
family that was fractured and scattered as a result of my drug use and my incarceration. I own my own home, I don’t ever have to worry
about homelessness again. I’m healthy, and I pay
attention now to primary care, behavioral health, and dental health. Finally, after what seems
like a lifetime struggle, today at 58 years old, I have a satisfying life in my community and I’m a productive member
of that community as well. So here is my bottom line as
I close this presentation. I realized how challenging
it is for many of you to see difficult clients day after day and not feel somehow that some
of us are never gonna change. Please, I am imploring you,
never give up on any of us. Many people gave up on me. And for those who did
not, I owed them my life and everything I have today. Recovery should not just
be something we talk about, it should be expected and SOAR
can be a major stepping stone along the recovery pathway. SOAR can provide the keys
literally and figuratively in setting up the opportunity
to pursue many other options leading to and supporting a full recovery and ultimately, that satisfying and productive life in our communities. Isn’t that what we want
for every single person we’re working with today? So thank you so much for your time today. Thanks again to SAMHSA and
to Policy Research Associates for the opportunity to share and I hope you’ll have
a terrific afternoon. Pam? – [Pam] Thank you, Steven, so much for your very powerful presentation and sharing your personal story. And again, congratulations
on your recovery, your continued recovery. You provide so much hope
and inspiration to others. So now it’s time to open it
up to questions and answers. To be able to ask a
question or make a comment, you can type your question
into the Q and A panel which is located underneath
the participant tab on the right hand side of your screen. So you can, again, use that
to type in some questions. We do have some questions
that came in already and again, I’m gonna
start with this question. And, Steve, you may have just answered it. But again, I think it’s so important for you to kinda hit this home again. I think that, you know,
we wanna make sure that folks really understand your message here. Let me just pull it up for you. It had to do with an individual
who’s been on methadone for a little over 20 years, but really I guess the case manager or
the individual has not seen any semblance of recovery
with the individual. And you might need more
information more to this question, but, Steve, would you want to kind of talk a little bit about that an individual who’s been
on methadone for 20 years, but yet not seeing that this
is somebody that is recovered or seeing it as a recovery tool? – [Steven] Sure, Pam,
and thank you for that. And you know, there’s
additional information that I certainly would
ask about, but, you know, if I was to dig deeper into this, but I think off the top of my
head what I can say is this. You know, the drug
methadone or buprenorphine, I always think of that
as treatment, right? That is the treatment that we receive for opioid use disorder. Recovery is the information
that we collect and gather. The support, the social capital, the things that we pull into our lives that are supportive of
our recovery journey. Now when I first started
the methadone program for about five years, I thought
of methadone as treatment and I also thought of it as recovery and I hadn’t really been
exposed to recovery language and principles. I think that piece often is lacking in a lot of the treatment
modalities or treatment protocols that particularly through clinics, we get them from counselors within the methadone clinic
itself, but I think where the real strength of that
recovery message comes isn’t from a counselor
at a methadone clinic. It is from a person like Steven Samra who has been in a methadone
program, has recovered, and who walks alongside another individual on their recovery journey
sharing our recovery, key points of our recovery
story exposing them to recovery literature
and recovery principles. And in order for us to get there, our counselors need to
have at least a base in understanding what peer
recovery principles are. – [Pam] Thanks, Steven. Now do you think this is
an individual who may not have been connected to a
peer support specialist someone like yourself then? – [Steven] You know, it’s highly likely. It’s hard to guess, but it
wouldn’t surprise me to hear that they’ve been working
through the clinic, attending meetings at the clinic, meeting with their
counselor and, you know, the various meetings that are required as for participation in a MAT program, but even in that environment
that the understanding of particularly peer recovery
principles is pretty limited and this is not their fault, but there is an onus on
the peer recovery world to collaborate and work
alongside clinicians to really strengthen that knowledge and to model our own recovery both to individuals who
may still be in a program and to the clinicians themselves. The other thing I’ll add about
this really quickly is that 20 years in the program,
I spent 15 years in. I never had, you know, really
an indication for myself that I wanted to come off until I felt like I had reached the point particularly in my work that
I thought I could do more. And after spending four decades
under the influence of some, I’ve really wanted to know
what life was like sober. I just wanted that really bad. And so I shared that because not everybody is going to come off of this program. Some people maybe, you know,
spend a lifetime on it. But the bottom line is
when you think about this in terms of harm reduction,
I’d much rather see somebody in the program for their
lifetime rather than exiting out with the potential to relapse and all the harm that can come from that. – [Pam] Thanks, Steven. Maybe, oh, yeah Tyler. Dr. Gray, yup. – [Gray] Yeah, this is Dr. Gray. I just wanted to chime in as well ’cause this is a situation
that I hear about sometimes as well. And I think the couple
things I wanted to add were one, when you think about
one of the principles of a harm reduction approach is to meet the patient where they are or meet the client where they are. And the other thing is
that we, well, Steven has really incredible story and obviously what recovery has meant for
you is really wonderful. Recovery is gonna mean
something different to everyone so I think sometimes our job
can just be to say to someone, you can just point out
and say hey, you know, it seems like you’re a bit stuck or you’re not reaching your goals, then you can just say,
tell me what your goals are with your life, with
your work, with something and let the patient drive what they want to happen with their lives. And then if it turns out
that treatment is getting in the way, great, we deal with that. And if it, and otherwise
they continue the treatment so I think that’s a good place to start just letting the patient define
kind of where they wanna go and what their recovery
looks like to them. – [Pam] Yeah. Thanks Dr. Gray. And next week, one of our
panelist will be talking about some motivational interviewing techniques on certainly how to help
a person get unstuck and sharing some of those
principle techniques next week so I think that’s a great idea. Here is another question that we have and this could be for Dr. Gray. Steven, how long does a detox take for say heroin, they said? So how long does a detox take
for a heroin for example? It might be again individual, but Dr. Gray, do you wanna take that? – [Tyler] Sure. It’s a bit tough to answer. So the detox process is gonna differ depending on the substance and a lot of it has to do
with the chemical properties of how long these things
stay in your body. So for heroin, for example. Heroin actually gets out of
the system pretty quickly. So for most people, heroin detox
would average about a week. Some programs would do a two-week detox. You can do detoxing as
quick as two or three days. It really depends on that there’s different medical
strategies for detoxing and that will kinda dictate
how long that process is. Main reason I think about
detox is for alcohol so that sometimes is
days or many days long, but again, it’s quite
specific to the substance, but two weeks or longer would be on the long end of the detox. – [Pam] Okay. Here is a question that came in. Can you talk a little bit about the challenges at prescribing and the overprescribing of opioids and how this may lead over
time to accessing street drugs? – [Tyler] So, I any one
of the theories for why this opioid epidemic is
kind of so rampant now, Jackie touched on this a little bit that there are areas in
the country where there is just such a high rate
of opioid prescriptions. And the way I think
about that is, you know, in a given person or given population, if there’s an increased
exposure to opiates, there’s a greater chance
that some people’s brains are triggered into developing
an addictive response to the drug which would
then lead them down this, down a pathway towards developing
an opioid use disorder. So it’s kind of like just by
the sheer exposure to people, the number of people,
number of pills around you’re just more likely
to have that happen. And a common scenario
that we’re seeing is, especially in the kind of
more recent epidemic, is that people are starting off either whether it’s pills
prescribed to them or a friend. They kinda start out with pain killers, maybe they have then started
crushing and snorting them, maybe injecting them, and at
some point they realized that they’ve spent a lot of
money on these pills and heroin is a heck of a lot cheaper. So that’s a transition that
happens for a lot of people. It’s by no means universal,
but I think that’s one way that I see these two being connected. – [Pam] Okay. And the second part is,
are we addressing this as part of the strategy in
combating opioid use disorder? – [Tyler] That’s a good question. I’m not sure (mumbles) to answer that, but there certainly is action
from a lot of different levels from the, I can’t say that
much to the federal policies, but certainly every state has
their own kind of governance of providers in prescribing in a big part of this information sharing. So here in Maryland like
I’m sure in a lot of states I can login to website and
type in a patient’s information and see any prescriptions they filled for controlled medications, or actually includes our
neighboring states as well. And so we’re working
on information sharing. There are more checks and
balances with pharmacies. It’s been a challenge, but
I’m not sure I’m prepared to speak to kind of all
levels of intervention that have happened, but
it is attempting to be. It’s trying to be addresses. – [Pam] Sure, go ahead. You can say it on.
– Yeah. Just two quick comments. One backing up around the detox piece. You know, Dr. Gray, spot on and one of the things that I
would point out around detox particularly from folks
who suffer from OUD, opioid use disorder,
we’re really used to go in through cycles of well
sick, well sick, and detoxing. That is a pretty normal and
common experience for all of us and it happens a lot. I mean, I never had the fear
around the actual detox itself and I detox off of
heroin a number of times and certainly detoxing off of methadone was more challenging, but
the one point I wanna make and share with the participants
on this event is that it wasn’t the acute detox that was the biggest challenge for me. And what became a big challenge
was the post-acute detox or withdrawal syndrome
or symptoms, excuse me, that I began experiencing about 90 days after I had completed the acute detox. And that’s something that I
think the clinics are missing. And then we as providers
and peer support specialists are also missing and it’s
a really important piece because I would think that
certainly in my own case, I suspect that that reason, that experiencing post-acute withdrawal and not understanding what was going on months after I had detox off
of heroin led me to relapse. So this idea of PAWS I think
is really, really important and it’s something that I think we need to all get up to speed a little better on. The second thing I’ll say is
Dr. Gray again is spot on. I started my opioid sort of excursion with a bottle of Tussionex
cough syrup when I was 14 and I used pills for as
long as I could get them, but when they became too expensive and when I was cut off
from the pill supply is when I ventured into the street. And at the moment I found
heroin, first, I did, the pills didn’t have the
impact that the heroin did and I was freed from the
hassle of trying to do that through a doctor. And all of those things
were really appealing at the height of my addiction. So I just wanted to share that, thank you. – [Pam] Great. Thank you very much. Here is another question that came in. Are the recovery residents that met, are there are recovery
residences that are managed and operated by peer
specialists organizations? How about Steven for that? – [Steven] So there are some PROs, Peer Run Organizations
out there that I think are certainly managing recovery residences. That they’re more on
the recovery coach side versus the mental health
peer support side. It’s just that, you know, kind
of an internal distinction between the two fields. And you can think about that in terms of places like Oxford Houses, there may be some organizations that are supporting the work of Oxford Houses. Even though those are
independent level one recovery residences,
there’re still some PROs or RCOs, Recovery Community
Organizations out there and that’s the more appropriate term that they’re handling at. And one of the greatest
pieces of information that NARR provides is information around the National Recovery Residence scope and what’s going on within
recovery community organizations and their support to those residents. – [Pam] Great. Thank you. There’s another question. What can we do for someone who refuses to get the help they need,
admits they have a problem and has overdosed twice
and still seek to use? I know from experience this
person used immediately after being released from the
hospital after an overdose. And I know there’s a lot
in that question to unpack so I’m gonna throw that to
really any of the panelist who has seen this and can
provide some brief advice. – [Steven] So this is Steven
and I’ll just say this. Don’t give up. You don’t know what word, what phrase, the time of day when you
approach that individual, you may catch them at
a point where finally they’re like, I can’t do this anymore. I just can’t. It took me seven years from
the point that I first began to be contemplative of my recovery before I actually entered recovery. And in those seven years,
I overdosed three times. I’m certainly lucky to be here today, but my bottom line, you can
never give up on anybody. You just have to keep
putting the information in front of them. You wanna do that in a strengths based positive supportive way, but respecting the
dignity of the individual, of the human being in front
of you, and recognizing that they have a serious
health condition, right? I mean, they’ve got a brain disease. They’re suffering from
the disease of addiction. Please, never give up. – [Pam] Never give up. Thank you so much for those
really departing words today. We are out of time and we
will then thank our presenters for sharing such excellent
and helpful information. And again, if we didn’t
get to your question and we know we had many, we’ll post them to the panelists for follow
up after the webinar. And we did have some questions related to the Social Security Administration and filing SOAR applications. And again, we’ll make
sure that those questions are presented to our SOAR security folks who will be on the webinar next week. So again, as a reminder,
our second webinar is next Wednesday, October
25th at the same time and we’ll be continuing
the conversation on opioids and other drug usage, treatment, and again, SSA Policy on this area. And again, when you log out, you’ll be taken right to an evaluation. We really ask that you complete that because it informs our
future webinar topics. Again, thank you again
and look for the slides and the other handouts to
be available on the website, the recording next week. So again, thanks so much and enjoy the rest of your afternoon.

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