Amidst the Opioid Crisis

Amidst the Opioid Crisis:

Best Practices for

SMVF Resilience, Treatment, and Recovery

Donna Aligata, R.N.C. | SAMHSA’s Service Members, Veterans, and their Families

Technical Assistance Center, Policy Research Associates, Inc.

Kimberly A. Johnson, Ph.D. |Center for Substance Abuse Treatment, SAMHSA

Karen Drexler, M.D. | U.S. Department of Veterans Affairs

Michael Flaherty, Ph.D. | Clinical Psychologist

February 22, 2017

Disclaimer: The views, opinions, and content expressed in this

presentation do not necessarily reflect the views, opinions, or policies

of the Center for Mental Health Services (CMHS), the Substance

Abuse and Mental Health Services Administration (SAMHSA), or the

U.S. Department of Health and Human Services (HHS).

3

Welcome

Donna Aligata, R.N.C.

Project Director

Substance Abuse and Mental Health Services Administration (SAMHSA)

Service Members, Veterans, and their Families (SMVF)

Technical Assistance Center

Policy Research Associates, Inc.

4

SMVF TA Center – Policy Academy States49 States, 4 territories, and the District of Columbia

5

SAMHSA’s SMVF TA Center

• Facilitates military and civilian interagency strategic planning

• Strengthens the coordination of military and civilian behavioral

health systems serving SMVF

• Implements SMVF best practices

• Builds workforce capacity

6

Webinar Objectives

• Explain the characteristics and risk factors among SMVF for opioid

misuse and addiction, including chronic pain, post-traumatic stress

disorder, and other co-occurring conditions

• Describe SAMHSA’s new and emerging national initiatives designed

to help states and communities better address the opioid crisis

among SMVF

• Identify the steps the VA has taken to address the opioid crisis

• Discover solutions for integrating military culture and recovery-

oriented approaches with medication-assisted treatment and

recovery

• Implement prevention strategies to reduce opioid-related SMVF

deaths

7

Kimberly A. Johnson, Ph.D.

Director

Center for Substance Abuse Treatment (CSAT)

SAMHSA

8

SMVF and Opioids:

Public Health Solutions

SMVF and SUDs:

The Surgeon General’s Report

https://addiction.surgeongeneral.gov/

9

Snapshot of Opioid Use/

Opioid Use Disorders in the U.S.

10

Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder

Note: Estimated numbers of people refer to people aged 12 or older in the civilian, noninstitutionalized population in the United States.

The numbers do not sum to the total population of the United States because the population for NSDUH does not include people aged

11 years old or younger, people with no fixed household address (e.g., homeless or transient people not in shelters), active-duty

military personnel, and residents of institutional group quarters, such as correctional facilities, nursing homes, mental institutions, and

long-term care hospitals.

Note: The estimated numbers of people with substance use disorders are not mutually exclusive because people could have use

disorders for more than one substance.

2015 NSDUH11

Trends in Pain Reliever Use and Disorders in

People Aged 12 and Older

PAIN RELIEVER USE DISORDER

IN THE PAST YEAR PAST MONTH NONMEDICAL USE

OF PAIN RELIEVERS

(+):  Difference between this estimate and the 2014 estimate is statistically significant at the .05

level.

NSDUH 2014 data 12

HEROIN USE DISORDER IN THE PAST YEAR

(+): Difference between this estimate and the 2015 estimate is statistically significant at the .05

level.

Trends in Heroin Use and Disorders in

People Aged 12 or Older

PAST MONTH HEROIN USE

NSDUH 2015 data 13

National Opioid Deaths, 1999-2015

https://www.washingtonpost.com

CDC data

14

Illicit Drug Use In the Past Year Among Persons

Aged 18 or Older, by Veteran Status and Year

Veteran Status 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Veteran 8.2 8.4 8.3 7.5 8.6 8.5 8.7 9.6 8.5 7.7 8.7

Non-veteran (adjusted) 9.4b 8.2b 8.9b 10.4b 9.1b 11.1b 9.3b 10.6b 10.7b 11.4a 13.5

a Difference between estimate and 2012 estimate is statistically significant at the 0.05 level.b Difference between estimate and 2012 estimate is statistically significant at the 0.01 level.

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

02 03 04 05 06 07 08 09 10 11 12

Veteran Non-Veteran (adjusted)

Perc

ent

15

Past-Year Substance Use Measures among Persons

Aged 18 or Older, by Veteran Status and Gender:

NSDUH 2002 to 2012

16

a Difference between nonveteran (adjusted) estimate and veteran estimate is statistically significant at the .05 level.b Difference between nonveteran (adjusted) estimate and veteran estimate is statistically significant at the .01 level.

8.4 8.3

10.6

6.3 6.2

7.1

2.4 2.3

4.0

10.5b 10.5b 10.5

7.8b 7.8b

6.9

3.0b 3.0b3.5

0

2

4

6

8

10

12

Total Males Females Total Males Females Total Males Females

Perc

ent

Veteran Nonveteran (adjusted)

Illicit Drugs Marijuana Nonmedical Use of Pain Relievers

Past-Year Substance Use Measures among Persons

Aged >18 by Veteran Status and Age Group: NSDUH

2002 to 2012

36.3

16.6

3.4

29.9

12.6

2.3

14.8

4.9

0.8

38.0

18.2b

5.6b

32.6a

13.7b

3.9b

12.9a

5.4

1.5b

0

5

10

15

20

25

30

35

40

18-25 26-54 55+ 18-25 26-54 55+ 18-25 26-54 55+

Perc

ent

Veteran Nonveteran (adjusted)

a Difference between nonveteran (adjusted) estimate and veteran estimate is statistically

significant at the .05 level.b Difference between nonveteran (adjusted) estimate and veteran estimate is statistically

significant at the .01 level.

Illicit Drugs Marijuana Nonmedical Use of Pain Relievers

17

• 32 percent of individuals with chronic

pain (CP) estimated to have SUDs

• 29-60 percent of people with OUD report

CP

• CP and addiction are dynamic conditions

that can fluctuate in intensity over time

• Both require multimodal interventions,

and treatment for one may impede or

conflict with treatment for the other

• Both have serious consequences if left

untreated

Chronic Pain and SUDs

18

SMVF and Opioids

• Trauma, pain, depression, and other risk factors associated

with opioid use disorders (OUDs) are often experienced at

elevated levels by SMVF

• Data indicate that over 50 percent of VA patients seen in

primary care settings report chronic pain

• Prescription drug misuse among service members and

veterans has more than doubled since 2002

• In veterans aged 18–25 the risk for prescription drug misuse

is at an all time high

• Opioid use in the military is twice that of use in the general

population

19

SMVF, Opioids, and Overdose Risk

• Veterans are twice as likely to die from accidental overdose

compared to the non-veteran population

• Assessment of risk factors is important in our veteran

population especially in returning combat veterans

• Often they present to primary care seeking relief from both

physical and psychological pain

• Psychological distress may lead to inappropriate use of opioid

medications in patients with mental health disorders. Caution

should be used in this high risk population

https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Toolkit_Pain_Educational_Guide.pdf

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SMVF, Opioids, and Overdose Risk

https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Toolkit_Pain_Educational_Guide.pdf

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• Approximately 20 veterans per day die of suicide

• Alcohol and drug misuse are often contributing

factors

• Highest risk age group is 30-64 years of age

• Higher prevalence in men than women

• Higher rate of women veterans than women in

general population

Addiction and Suicide

22

Past Year Illicit Drug Use among Wives of Military Personnel and All Married Women (18-49):

Percentages, 2015 NSDUH

23

+Difference between this estimate and the estimate for All Married Women Aged 18

to 49 is statistically significant at the .05 level.

Past Year Illicit Drug Use among Children of Military Personnel and All Youths (12-17):

Percentages, 2015 NSDUH

24

SMVF and Opioids: SAMHSA’S Public Health Approach

25

Public Health Solutions:

Multidimensional and Complementary

Prevention, Risk Reduction

Treatment Recovery

Overdose Intervention

26

Select SAMHSA Initiatives that Serve

SMVF and their Communities

• Block Grants

• Discretionary Grants

• Technology Transfer &

Technical Assistance

• Workforce Development

• Health Information

Technology

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SMV Served by SAMHSA/CSAT

Discretionary Grants FY 2012- FY 2016

All CSAT SAIS Grantees

Number Military

Number Currently on Active Duty

Number Ever

Deployed to Combat

Zone

Number ofClients Served

1,678,044 62,023 17,127 21,008

2017 SAMHSA CSAT Data

28

SMV Served by SAMHSA/CSAT

Discretionary Grants FY 2012- FY 2016

47.98%

51.88%

0.13% 0.01%0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Male Female Transgender Other

Gender

All CSAT Clients CSAT SMV Clients

Black21%

Asian1%

Native Hawaiian or Other Pacific

Islander1%

Alaska Native1%

White64%

American Indian5%

None of the above

7%

Multi-Racial1%

Race

16.9% of

clients

reported as

Hispanic/Latin

o

7.4% of clients

reported as

Hispanic/Latin

o

86.63%

13.26%

0.10% 0.01%0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Male Female Transgender Other

Gender

2017 SAMHSA CSAT Data29

SMV Served by SAMHSA/CSAT

Discretionary Grants FY 2012-FY 2016

All CSAT Clients CSAT SMV Clients

Top 5 Substances % Used

Alcohol: Any Use 38.7

Marijuana/Hashish 24.6

Cocaine/Crack 7.3

Heroin 4.8

Methamphetamine 4.2

0.11%1.91%

15.61%

22.86%

17.83%18.31%

13.02%

10.35%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

10-12 13-17 18-24 25-34 35-44 45-54 55-64 65+

Age

0.06%

12.86%

20.09%

14.80%

21.79%

17.02%

13.38%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

13-17 18-24 25-34 35-44 45-54 55-64 65+

Age

Top 5 Substances % Used

Alcohol: Any Use 41.3

Marijuana/Hashish 14.7

Cocaine/Crack 7.0

Methamphetamine 2.9

Heroin 2.8

2017 SAMHSA CSAT Data30

SAMHSA Serves SMVF:

Veterans Helping Veterans

The primary goal of the Jobs2Vets program is to help

homeless veterans with substance use disorders and

co-occurring disorders achieve and maintain

employment, while preventing relapse and promoting

improvement in overall mental health functioning.

Jobs2Vets is a collaborative effort between MTI IBD,

SAMHSA, VANJ, and the Rutgers-Bloustein Center

for Survey Research.

The Jobs2Vets peer mentorship and recovery

support model is increasing employment

opportunities, promoting workforce development, and

helping Veterans break the cycle of mental illness,

substance misuse and chronic homelessness.

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SAMHSA Serves SMVF:

Veterans Helping Veterans

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SAMHSA Serves SMVF VIA Technology Transfer

and Technical Assistance

33

SAMHSA Serves SMVF Through Workforce

Development

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SAMHSA Serves SMVF Through Workforce

Development

35

SAMHSA Serves SMVF Through HIT

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SAMHSA Serves SMVF Through HIT

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SAMHSA’S Commitment

Serving America’s SMVF and

their communities through

leadership, partnership, &

funding to ensure that high

quality, trauma-informed,

culturally appropriate health

care and related services are

readily accessible, affordable,

and effective.

https://www.samhsa.gov/veterans-military-families38

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Serving Those Who Serve Our Nation

Thank [email protected]

Karen Drexler, M.D.

National Mental Health Program Director, Substance Use Disorders

U.S. Department of Veterans Affairs

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VA Response to the Opioid Crisis

Karen Drexler, M.D.

National Program Director- Substance Use Disorders

Department of Veterans Affairs

February 22, 201741

VA’s Mission

42

“To care for him who shall have borne the battle and for his widow, and his orphan.”

- Abraham Lincoln, 1865

The Pain Challenge in VHA

43

In Veterans, chronic pain is common.

– Veterans: more than 50% of older Veterans experience chronic pain

• 60% of Veterans from Middle East conflicts

• Up to 75% of female Veterans have chronic pain

– More than 2 Mil Veterans with ≥ one pain diagnosis in VA (2012, 1/3 on opioids)

– National Health Interview Survey (NHIS) (2016)

66% of Veterans vs. 56% of non-veterans with pain in prior 3 month

joint pain (43.6%), back pain (32.8% - axial 20.5%, sciatica 12.2%), neck pain (15.9%), migraine (10.0%) and jaw pain (3.6%)

In Veterans, chronic pain is often severe and complex

– Posttraumatic Stress Disorder (PTSD) and Opioid Use Disorder (OUD)

NHIS: interview of 67,696 US adults in 2010-14. Nahin RL, J. Pain 2016

Substance Use Disorder (SUD): Prevalence

• Veterans receiving VA health care in FY 2015

• 560,922, or 9.7%, were diagnosed with a SUD*

* Compares to 8.4% of U.S. adults

44

VA Trends in SUD

45

0

50,000

100,000

150,000

200,000

250,000

300,000

FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13

Nu

mb

er

of

Pati

en

ts

SUD Diagnosis

Alcohol Only DX Drug Only DX Both Alc and Drug DX

VA-Drug Use Disorder Diagnoses

46

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13

Nu

mb

er

of

Pa

tie

nts

Cocaine Opioids Cannabis Amphetamines

VA’s Efforts to Improve Opioid Safety

2007 Launched the Buprenorphine in VA (BIV) Initiative

2008 Policy required access to medication for opioid use disorder

2009 Established National Office for Pain Management Practices

2011 Created standardized metrics for pain management therapies

2013 Launched the Opioid and Psychotropic Drug Safety Initiatives

2014 Began targeted interventions for opioid reduction and opioid

overdose education and naloxone distribution

2017 Published VA-DoD Clinical Practice Guideline for Opioid

Therapy for Chronic Pain

47

Impact of Efforts: 2012-2016

• 170,000 fewer Veterans were prescribed opioids (25% reduction)

• 51,000 fewer (42% reduction) concomitant use of opioids and benzodiazepines

• 19,000 less (32% reduction) in dosage of those on chronic opioids

48

Approaches to Opioid Use and SUD

49

• Guidelines and best practice implementation

• Stepped pain care

• VA/DoD guidelines

• Informatics tools: leveraging big data

• Stratification Tool for Opioid Risk Mitigation (predictive analytics for opioid misuse)

• Opioid Safety Initiative dashboard

• Psychotropic Drug Safety Initiative

• Pain management, complementary care, and National Formulary

• Pharmacologic and non-pharmacologic therapies

• National Formulary includes all recommended medications

• Provider and patient education

• National community of practice (i.e., consultation, webinars, e-mail groups)

• Buprenorphine in VA initiative

• Mini-residencies in pain management

• Academic Detailing using 285pharmacists

• Medication Take Back Program

• Informed consent process for patients

50

Evidence Hierarchy

51

Meta-analyses of RCTs

Randomized Controlled Trials

Observational Studies

Non-Analytical Studies

Expert Opinion

VA-DoD SUD Guideline Key Recommendations

52

• Screening and brief alcohol intervention

• Treatment (pharmacotherapy and psychosocial interventions)

• Alcohol use disorder

• Opioid use disorder

• Cannabis use disorder

• Stimulant use disorder

• Promoting group mutual help (e.g. AA, NA, Smart Recovery)

• Address co-occurring mental health conditions and psychosocial problems

• Continuing care guided by ongoing assessment

• Stabilization and withdrawal

SUD Medications Psychosocial Intervention

Alcohol AcamprosateDisulfiramNaltrexoneTopiramateGabapentin*

Behavioral Couples TherapyCognitive Behavioral therapy (CBT)Community Reinforcement Approach (CRA)Motivation Enhancement Therapy (MET)Twelve Step Facilitation

Opioid BuprenorphineMethadoneER-InjectableNaltrexone*

Medical Management**Contingency Management (CM)/Individual Drug Counseling (IDC)**

Cannabis CBT/MET

Stimulant CBT/CRA/IDC +/- CM

http://www.healthquality.va.gov/guidelines/MH/sud/

*suggested **recommended only with medication

Patient-Centered Care and Shared Decision Making

53

• Patient is the expert on his/her life and experience

• Elicit preferences and goals

• Clinicians are experts on risks-benefits of the full menu of treatment options

• Provide easily understandable information for patient to make an informed decision

• Collaborate to develop treatment goals/objectives/interventions

Access to Medication Assisted Treatment (MAT)for Opioid Use Disorder (OUD)

54

OAT (buprenorphine & methadone):• ~12,000 patients (27% of

OUD pts.) in FY 2010 • >20,000 patients (30% of

OUD pts.) in FY 2015

MAT (OAT + extended release injectable naltrexone):• 34% of OUD patients

received MAT in FY2016

Number of VA Patients Receiving Opioid Agonist Treatment (OAT)

Buprenorphine Prescribing Trends

55

Naloxone Kit Prescription Fills by State

56

Veterans Health Administration

• The nation’s largest integrated healthcare system

– Serving over 8.76 million Veterans

– Over 1700 sites of care

• Basic Medical Benefits Package includes:

– Preventive Care

– Hospital (Inpatient) Services

– Ancillary Services

– Mental Health

– Home Health Care

– Geriatrics and Extended Care

– Medical Equipment

57

https://www.va.gov/healthbenefits

/

Mental Health Services

• Outpatient care including counseling, medication and care coordination:

• Brief counseling & medication in Primary Care

• General Mental Health Clinics (including telehealth)

• Specialty Mental Health Clinics (e.g. PTSD, Substance Use Disorder-SUD)

• Intensive outpatient care (e.g. Intensive Outpatient SUD care);

• Residential Treatment Programs- Domiciliaries

• Short-term inpatient (hospital) care

• Supported work settings.

58

http://www.mentalhealth.va.gov/VAMentalHealthGroup.asp

Apply for Health BenefitsOnline or by phone at 855-574-7286

59

https://www.vets.gov/

60

AboutFace

Peer Support Specialists in VA

Program Number of Peers

Homeless Program 246

Outpatient Mental Health (MH) 204

Psychosocial Rehabilitation and Recovery Center 133

MH Residential Rehabilitation Treatment Program 81

Substance Use Disorder 80

MH Intensive Care Manage 63Posttraumatic Stress Disorder

(PTSD) 52

61

About the Consultants

Experienced senior psychologists, psychiatrists, social workers, pharmacists, and other

health professionals who treat Veterans with PTSD

Available to consult on everything from your toughest cases to general PTSD questions

Ask about:

Evidence-based treatment

Medications

Clinical management

Resources

Assessment

Referrals

Collaborating with VA on Veterans’ care

Developing a PTSD treatment program

Available Resources - www.ptsd.va.gov/consult

Free continuing education

Videos, educational

handouts, and manuals

PTSD-related publications

PTSD and trauma assessment and screening tools

Mobile apps, and more

WWW.PTSD.VA.GOV

62

http://www.mentalhealth.va.gov/communityproviders/ 63

Providing Key Information and

Tools for Providers Serving

Veterans:

• Military service screening

• Military culture

• Behavioral health treatment

services and resources

ListenMore than 600 videos of real stories from Veterans experiencing mental health challenges and how they found support

LearnInformation about life events, signs and symptoms, and conditions

LocateFind VA, SAMHSA and National Resource Directory resources near you

64

Video GalleryFilter customizes video

results in real time,

providing user with stories of

Veterans with similar

experiences.

Choose from several filter

identifiers including a list of

signs and symptoms and

conditions

Expansive library of more

than 600 videos

65

Facebook Community

One of the largest and most engaged Facebook communities in the U.S. Government.

Robust dialogue from Veterans encouraging each other, sharing their experiences.

Posts designed to engage Veterans and family members with stories and videos from the website.

66

Conclusions

• Pain can be managed safely and more effectively with comprehensive strategies.

• SUD and PTSD are brain diseases that respond to recommended treatment

• VA performance-improvement efforts are increasing access to evidence-based treatments for PTSD & SUD

• Veterans and their families and those who care for them are encouraged to access VA services and to partner to with VA (e.g. Choice Program)

67

Michael T. Flaherty, Ph.D.Clinical/Consulting Psychologist

Founder – Institute for Research, Education and Training in the Addictions (IRETA)

Captain, USNR (Ret)

68

Amidst an Opioid Crisis: Best Practices for

SMVF Resilience, Treatment, and Recovery

Serving Service Members, Veterans, their and Families (SMVF)

69

System Challenges

SMVF navigate 4 systems:

• Active duty care or hospital

• Veterans Center

• Veterans clinic or hospital

• Civilian care or hospital

70

Mission

To serve those who have served

by implementing and integrating substance use

disorder (SUD) best practices across systems for

SMVF

71

Today’s SMVF

“Members of the armed forces are not immune to the

substance use problems that affect the rest of society.

Although illicit drug use is lower among U.S. military

personnel than among civilians (3.9 percent versus 17.2

percent) heavy alcohol and tobacco use, and especially

prescription drug misuse, are much more prevalent and are

on the rise.” –National Institute on Drug Abuse

72

Returning Home -

Our Nation’s Opioid Crisis

73

The Facts

• Today 1 in 8 active duty military personnel are current users of

illicit drugs 1.

• Nearly half of active duty service members reported binge

drinking 2.

• 60 percent of the 140,000 veterans in federal and state prisons

struggle with substance use disorders 3.

• Over 50 percent of male and female VA patients seen in

primary care settings report chronic pain 4.

74

The Facts (cont’d)

• In younger veterans, ages 18–25, risk for prescription drug

misuse is at an all time high 5.

• Today 11 percent of service members report misusing

prescription drugs with opioid pain medication being most

frequently misused

• Pain reliever prescriptions written by military physicians

quadrupled between 2001 and 2009 to almost 3.8 million*

(NIDA)

75

What we need to know

Unique risk factors for SMVF:

• Stress of deployment – in wartime or peace; often multiple

deployments

• Zero-tolerance policies1

• Stigma

• Confidentiality

• Pre-existing conditions, e.g., chronic pain, PTSD, or other

psychological or physical wounds2

([email protected] /866-948-7880)

• Suicide*

76

National Opioid Prescribing Practice

77

What We Can Do: Our “Op-Plan”

Understand the world from the perception and need of the service member and his or her family and align services.

Practice emergency, urgent, and general medicine over a continuum of care with a focus on long-term health, wellness, and recovery.

78

What We Can Do

Understand the belief system of the service member

• Army: This We’ll Defend

• Navy: Semper Fortis – Always Courageous

• Marine Corps: Semper Fidelis – Always Faithful

• Air Force: Above All

• Coast Guard: Semper Paratus – Always Ready

79

Know: The Military’s Guiding Rule

“Substance abuse by military personnel is inconsistent with the Department of Defense’s Values, the Warrior Ethos, and

the standards of performance, discipline, and readiness necessary to accomplish the DoD’s mission.” (1)

80

Know

Military Culture … and Civilian Realities

• Emphasizes discipline, hierarchy, and readiness

• Prioritizes the group over an individual

• Expects core values: loyalty, duty, respect, selfless

service, honor, integrity and personal courage

Many service members and their families are

experiencing multiple deployments

81

Know Combat to Home Defenses

Combat-Zone

Cohesion with buddies

Accountability and control

Targeted aggression

Tactical awareness

Lethally armed

Emotional control

Non-defensive driving

Discipline & obeying orders

Home-Zone

Withdrawal from others

Lack of control

Inappropriate aggression

Hypervigilance

Locked & loaded at home

Detached and uncaring

Aggressive driving

Giving orders…conflict

82

([email protected] /866-948-7880)

Know the Warrior’s Perception

By seeking treatment:

• 65 percent fear the perception of being seen as “weak”

• 63 percent fear leadership might treat them differently

• 59 percent fear others would have less confidence in

them

83

Substance Misuse Affects Military Families:

Resilience, Reintegration and Recovery

84

In Sum: What We Can Do

Understand this is a valued and unique population

surrounded by:

• Military culture and warrior mind

• Zero tolerance policies

• High stress, drinking, denial

• Co-occurring mental health/substance use issues

• Family needs

• High rates of PTSD, suicide, homelessness

• A fragmented system

85

What We Can Do to Address Opiate

Dependence

Increase Access to Treatment

• Service members struggling with addiction are being

discharged to local communities and VA Centers where a

capacity for treatment exists for only 20 percent of the existing

total population

• System or treatment access is the greatest barrier to care

• Nearly 2.7 million veterans have enrolled in the VA health

care since 2009

• 54,000 of these veterans will likely need substance use

screening and treatment

86

Build Prevention and Early Intervention

• Increase population resilience with community prevention

and involvement of all services, systems, and communities*

Educate, educate.

• Create a systemic approach to identify drug use earlier so as

to reduce harm and costs, e.g., Screening, Brief Intervention,

Referral to Treatment (SBIRT); Prescription Drug Abuse

Monitoring Program (PDMP); Pain Management Medical

Substance Use Monitoring

87

Build Prevention and Early Intervention

(cont’d)

• Expand addiction treatment services for SMVF in

community health centers; expand access to Medication

Assisted Treatment (MAT)

• Expand access to care

88

Know What is Working

• Naloxone/NARCAN - high risk populations

• Increased access to MAT, with an understanding for military

status and benefits and family

• Offer treatment on demand – 30 percent reduction (CDC)

• 24/7 Crisis Stabilization with MAT and treatment

• Boston Medical Center – Opioid Urgent Care Center

• Zuckerberg San Francisco General Hospital

89

Know What is Working (cont’d)

• Implement an operational PDMP across systems

• Crisis hotline: 1-888-796-8226; Crisis Text Line: text 4HOPE

to 741741 (24/7)

• Build peer supports – warm handoffs; recovery center

• Monitor all overdoses for root cause system improvement,

educate the community and empower it and parents to step

up … and have hope

Build military community resilience and recovery capital!

90

Join With Other Successful Initiatives

• Use veterans or community or family drug courts

• SBIRT in all medical settings; Community Reinforcement

and Family Training (CRAFT) for families

• Peer support – “Battle Buddies” – “No one left behind”

• Sober housing, homeless, and jail outreach

• Education and awareness – e.g., National Guard Beyond

the Yellow Ribbon

91

What We Can Do

• Design cross system care to build person-centered and

person-driven care for a continuity of care for SMVF

• Integrate care* – medically and behaviorally at all levels of

service for each person in the community

92

What We Can Do (cont’d)

• Make identified cross system “barriers” challenges for

refinement*

• Accept a shared responsibility to make seamless care

available; use peers for retention and to strengthen the

opportunity for recovery in all care across a continuum,

whatever the system providing it, i.e., Recovery Oriented

Systems of Care (ROSC)

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We Know What to do

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Resources

• SAMHSA: www.samhsa.gov

• U.S. Department of Veterans Affairs: https://www.va.gov/

• The Surgeon General’s Report on Alcohol, Drugs, and Health:

https://addiction.surgeongeneral.gov/

• National Survey on Drug and Health 2014:

https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-

2014/NSDUH-FRR1-2014.pdf

• Pain Management Opioid Safety Educational Guide:

https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Toolkit_Pain_Ed

ucational_Guide.pdf

• VA/DoD Clinical Practice Guidelines: http://www.healthquality.va.gov/

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Resources (cont’d)

• U.S. Department of Veterans Affairs Health Benefits:

https://www.va.gov/healthbenefits/

• U.S. Department of Veterans Affairs Mental Health:

http://www.mentalhealth.va.gov/VAMentalHealthGroup.asp

• U.S. Department of Veterans Affairs About Face Program:

http://www.ptsd.va.gov/apps/AboutFace/

• U.S. Department of Veterans Affairs - The PTSD Consultation Program:

www.ptsd.va.gov/consult

• U.S. Department of Veterans Affairs Community Provider Toolkit:

http://www.mentalhealth.va.gov/communityproviders/

• National Institute on Drug Abuse – Substance Abuse in the Military,

https://www.drugabuse.gov/publications/drugfacts/substance-abuse-in-

military

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Resources (cont’d)

• Center for Disease Control and Prevention IMS National Prescription Audit

2012: https://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html

• National Institute on Drug Abuse: https://www.drugabuse.gov/related-

topics/trends-statistics/overdose-death-rates

• The Prescription Opioid and Heroin Crisis: A Public Health Approach to an

Epidemic of Addiction: https://www.ncbi.nlm.nih.gov/pubmed/25581144

• Equipping Behavioral Health Systems and Authorities to Promote Peer

Specialists/Peer Recovery Coaching Services:

http://www.naadac.org/assets/1959/samsha_2012_expert_panel_meeting_r

eport_-_equipping_behavioral_health.pdf

• DOJ/ONDCP National Heroin Task Force 2015:

www.justice.gov/file/822231/download

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For Technical Assistance Questions,

Please Contact

345 Delaware Avenue

Delmar, NY 12054

Phone: 518-439-7415, ext. 5270

Email: [email protected]

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