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Soc Work 453 Final

Terms in this set (63)

Primary Prevention
· Prevent use before it starts
· Aimed primarily at younger people
· Well population
Health promotion and addressing risk factors, social and genetic factors
Secondary Prevention
· Curtail further problematic or risky use
· Prevent addiction and disorder
· Aimed at persons who have used substances
· People at risk of a health problem
Screening of at risk individual, control of risk factors and early intervention
Tertiary Prevention
· Intervention, treatment, recovery
· Aimed at people who have developed substance use disorders
· People with a health problem
Rehabilitation, preventing complications and improving quality of life
The 4 A's
Availability
· How easy is it to access?
Affordability
Acceptability
· Social perception of use
Attractiveness
For both the product and associating attractiveness of the self when using the product
Disparate Policies
Consistent drinking age
· 21 for bars and restaurants
· Parents can purchase alcohol for their child under 21 to consume at bars and restaurants
· Only Wisconsin and three other states (MT, TX, OH) allow this

Taxation
· Increasing alcohol taxes
□ Lowers binge and underage drinking rates
□ Reduces alcohol-related injuries
□ Could generate prevention and treatment funds
□ Federal and state alcohol taxes have not kept up with inflation
□ Wisconsin's beer tax of 6.4 cents/gal has not changed since 1969.

Sobriety check points
· Sobriety checkpoints allow law enforcement to stop traffic to check drivers
· Wisconsin law prohibits using checkpoints
· Statistically proven to decrease the number of alcohol-related crashes and fatalities, typically by 20%
· Public support often increases after implementation
· 38 States and D.C. do this
Outlet density ordinance
· Number of establishments to obtain a substance within a defined area
· A significant link between total outlet density and rates of binge-drinking and drinking related problems
Decreasing outlet density associated with reduction in rates of alcohol related youth violence
Social Host Ordinances
Making it unlawful to provide an environment where underage drinking takes place, regardless of who provided the alcohol
Deemed Approved Ordinances
· Sets performance standards for all off-sale alcoholic beverage premises
Gives cities the power to revoke a business' right to exist if they were grandfathered in if new laws were passed
Conditional Use Ordinances
Allows the city to consider uses which may be essential or desirable, but which are not allowed as a matter of right within a zoning district, through a public hearing process
· Criminal Justice
o Disparities, how they affect SUD, and how they're perpetuated
o School to prison pipeline (be able to have a conversation about it)
Prison industrial complex, how this intersects with SUD, and how this has changed over time
How knowing this does (or should) impact policy
- Children funneled out of schools and into the juvenile & criminal justice system
- High intense security to even get into school
- Zero tolerance ideology: step out of bounds & sent to jail
- # of crimes has decreased but prison population increased because we have criminalized more stuff
- Have bodies from younger age
- Profit off of people who are incarcerated
- Schools reinforce society
- Lack of funding and direct action
- Minorities treated more severely on all aspects
Recovery Oriented Systems of Care (ROSC)
A coordinated network of community-based services and supports that is person-centered and builds on the strengths and resiliencies of individuals, families, and communities to achieve abstinence and improved health, wellness, and quality of life
A transformation of the entire system
· Responsive to meet the needs of individuals and families seeking services
· Change needs to be consistent system-wide
· A continuum of services rather than crisis-oriented care
Care that is appropriate for the individual's needs
What Health Care Should be according to the Institute of Medicine
Safe
· Avoiding injuries to patients
Effective
· Providing services based on science
Patient-centered
· Providing respectful and responsive care
Timely
· Reducing waiting and delays
Efficient
· Avoiding waste
Equitable
10 Guiding Principles of ROSC
1. Hope
2. Person driven
3. Many pathways
4. Holistic
5. Peer support
6. Relational
7. Culture (values, traditions, beliefs)
8. Addresses trauma
9. Strength and Responsibility
10. Respect
Elements of an Effective ROSC
Person centered

Family and other ally involvement

Individualized and comprehensive services across the lifespan

Systems anchored in the community

Continuity of care

Partnership-consultant relationship
· Focus more on collaboration, less on hierarchy

Strengths-based
· Emphasis on individual strengths, assets, resilience

Culturally responsive

Responsive to personal belief systems

Commitment to peer recovery support services

Inclusion of the voices recovering individuals and their families

Integrated services

System-wide education and training

Ongoing monitoring and outreach

Outcomes-driven
Barriers/Difficulties
Moving from deficit-focused thinking to strengths-based

Addiction professionals' pride and power

Lack of protocols and financing for support services

Absence of ethical codes for peer services

Weak infrastructure of addiction treatment organizations and turnover

Fidelity monitoring

Record keeping

Reliable evaluation data
Prevention
o Universal
For an entire population
· Example: community, school
o Selective
For high-risk groups within a population
· Example: students doing poorly in school
o Indicated
For individuals who show signs of developing problems
Example: adult arrested for first offense OWI
Public Health: The prevention Paradox
The large number of people at small risk contribute more harm/costs than the smaller number of people who are individually at greater risk
Social Influence Model
Training in refusal skills
- through films, discussion, and practice
- assertiveness; ways to refuse without being negative

countering advertising
- analyze and discover hidden messages in ads and how messages differ from the actual effects

normative education
- teach students they may overestimate the number of their peers who use

use of peer leaders
- to talk to others about use, own experiences, and to teach skills
Alcoholics Anonymous
- reported success rate of 5-10%
- AA is never wrong according to AA, so if you fail AA, you fail.
- Pseudo-scientific organization: difficult to track actual progress
- AA is religiously affiliated
Knowledge-Attitudes-Behavior Model
• Typically involve presentations by police and former users
• Often include traditional scare tactics and/or pharmacological information
• Approach assumes increasing student knowledge about drugs will change their attitudes
• Assume these changed attitudes will be reflected in decreased use
• Model questioned by research findings
• Students with more knowledge about drugs tend to have more positive attitudes about drug use
• All early prevention approaches
• Effective in increasing knowledge about drugs
• Ineffective in altering attitudes or behavior
• Research on early drug prevention education efforts
• Students more likely to experiment with drugs
Less likely to develop abuse problems
Affective Education
• Focuses on emotions and attitudes
• Use as a pursuit of excitement, relaxation, power, control, or response to peer pressure
• Use may be reduced by early intervention
• To know and express their feelings
• To achieve altered emotional states without drugs
• To feel valued and accepted
• Values clarification
• Assumes students have factual information about drugs
• What they lack is ability to make appropriate decisions based on the information they have
• What is taught:
• Recognizing and expressing feelings and beliefs
• Decision making skills
• How to analyze and clarify their own values
• Parents may not understand this approach as it may run contrary to the set of values they want their kids to learn
• Alternatives to drugs
• Assumes one reason young people take drugs is for the experience of altered states of consciousness
• Teaches other ways of obtaining a high
• Relaxation, meditation, exercise, sports
• Alternatives need to be realistic and tailored to the individual
• Personal and social skills
• Assumes personal and social skills are causes of drug use
• Teaches students communication skills and provides opportunities for successful interpersonal interaction
• Examples
• A group of students operates a school store
• Older students tutor younger students
Anti-Drug Norms
• 1984 review of drug prevention programs
• Most don't contain an appropriate evaluation component
• Few studies demonstrated success in terms of actual substance use prevention
• Increased knowledge about drugs has virtually no impact on substance use
• Affective education approaches appear too experiential and place too little emphasis on skills necessary to resist pressure to use
• Anti-drug norm programs were developed in part in response to these findings
• Refusal skills and pressure resistance strategies
• Focus on teaching students to recognize and respond to peer pressure
• Presented within the broader context of self-assertion and social skills training
• Typical program
• Film that demonstrates effective ways of responding
• Follow up student discussion
• Practice with techniques presented in the film
• Approach shown to be effective in reducing cigarette smoking among adolescents
• Adapted for other drugs and behaviors
Social Influence Model
• Many approaches to drug-abuse prevention have been tried with smoking behavior
• Key lessons can be learned from research findings about these approaches
• It is possible to design effective smoking prevention programs
• Presenting information about the delayed consequences is ineffective
• Presenting information on immediate effects is more effective
• Five key elements

1. Training in refusal skills
• Through films, discussion, and practice
• Students taught ways to refuse without being negative
• Ways to be assertive and insist on the right to refuse

2. Public commitment
3. Countering advertising by inoculating children against it
• Students taught to analyze and discover the hidden messages in ads and how these messages differ from the actual effects of smoking
• Example: ads associating cigarette use with healthy young athletes

4. Normative education
• Teach students they may overestimate the number of their peers who smoke

5. Use of teen leaders
• Talk to younger students about use
• Older students can explain that neither they nor their friends smoke, and how they have dealt with others' attempts to get them to smoke
• Peer, lived experience

• Possible improvements by using cognitive development approach
• Don't automatically assume all students need training in social skills or refusal skills
• Students make active, conscious decisions in preparation for trying smoking and becoming an occasional or regular user
• Prevention programs might be different at each stage of cognitive development
• NOTE risk and protective factors have more influence on drug behavior than information or education
Screening
• Determines the likelihood that a client has co-occurring substance use and mental disorders or that their presenting signs, symptoms, or behaviors may be influence by co-occurring issues
• The purpose is not to establish the presence or specific type of such a disorder, but to establish the need for an in-depth assessment
• Screening is a formal process that typically is brief and occurs soon after the client presents for services
• Screening at the beginning (cast wide net, get as many people as you can)
• Screening is not diagnosis
Assessment
• Gathers information and engages in a process with the client that enables the provider to establish (or rule out) the presence or absence of a co-occurring disorders
• Determines the client's readiness for change
• Identifies client strengths or problem areas that may affect the processes of treatment and recovery
• Engages the client in the development of an appropriate treatment relationship
The Assessment Process
1. Engage the client
2. With consent, identify and contact collaterals to gather information
3. Screen for and detect COD
4. Determine severity of mental and substance use disorders
5. Determine appropriate care setting
6. Determine diagnosis
7. Determine disability and functional impairment
8. Identify strengths and supports
9. Identify cultural and linguistic needs and supports
10. Identify additional problem areas to address (physical health, housing, vocational, etc.)
11. Determine readiness for change
Plan treatment
Maslow's Hierarchy of Needs
• Self-actualization: morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
• Esteem: self-esteem, confidence, achievement, respect of others, respect by others
• Love/belonging: Friendship, family, sexual intimacy
• Safety: security of: body, employment, resources, morality, the family, health, property
Physiological: breathing, food, water, sex, sleep, homeostasis, excretion
Old Way Treatment
• "One-size fits all" treatment plan
• Driven by
• What is offered by the program
• Program philosophy
• Structure
• Pre-scheduled meetings and groups
• Pre-packaged, available services
• Variation
Most treatment plans within a treatment program look the same
New Way Treatment
• Individualized treatment plan
• Driven by
• What someone needs
• Individual's desire, "person-centered"
• Structure
• Meetings and groups as a tool to meet specific needs
• A range of needed services, within the clinic and/or community
• Variation
Most treatment plans within a treatment program look different
Confusing Language in Wisconsin
• The Functional Screen
• Used as an assessment for state-funded programs (12 page document)
ASAM Criteria is the recommended assessment tool of the State of Wisconsin
• Dimension I: Acute Intoxication and/or Withdrawal Potential
• This life area explores your past and current experiences of substance use and withdrawal

• Dimension 2: Biomedical Conditions/Complications
• In this life area, think about your physical health, medical problems and physical activity and nutrition

• Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications
• This life area helps explore your thoughts, emotions and mental health issues

• Dimension 4: Readiness to Change
• This life area identifies what you are motivated for and your readiness and interest in changing

• Dimension 5: Relapse/Continued Use/Continued Problem Potential
• This life area addresses concerns you might have about your continued substance use, mental health or a relapse

• Dimension 6: Recovery Environment
• This life area explores your living situation and the people, places, and things that are important to you
• Higher scores on dimensions show greater risks
Components of Client-Centered Treatment Plan
• Acute safety needs
• Determines the need for immediate acute stabilization to establish safety prior to routine assessment
• Severity of mental and substance use disorders
• Guides the choice of the most appropriate setting for treatment
• Appropriate care setting
• Determines the client's program assignment (based on ASAM)
• Diagnosis
• Determines the recommended treatment intervention
• Disability
• Determines case management needs and whether an enhanced level of intervention is required
• Strengths and skills
• Determines areas of prior success around which to organize future treatment interventions and determines areas of skill building needed for management of either disorder
• Availability and continuity of recovery support
• Determines whether continuing relationships need to be established and availability of existing relationships to provide contingencies to promote learning
• Cultural context
• Determines most culturally appropriate treatment interventions and settings
• Problem Priorities
• Determines problems to be solved specifically, and opportunities for contingencies to promote treatment participation
• State of recovery/client's readiness to change behaviors relating to each problem
• Determines appropriate treatment interventions and outcomes for a client at a given stage of recovery or readiness for change
• Defining treatment goals
• Use to socialize, self concern about use, weekend binging, use to relieve stress avoid pain or cope, physical withdrawal
• Keeping you in your real world without changing is best (least restrictive is best)
• Cultural context
Stages of Change
• Precontemplation
• Patient does not see the behavior as a problem, no desire to change
• Contemplation
• Patient beginning to see the behavior as a problem, but still wavering
• Preparation
• Patient is considering options for change
• Action
• Patient taking specific steps to change
• Maintenance
Patient preventing relapse
CBT Skill Topics
• Coping with craving
• Understanding and describing craving
• Identifying triggers
• Avoiding cues
• Motivation and commitment to stop
• Prioritizing goals
• Processing ambivalence
• Coping with thoughts
• Assertiveness skills
• Assessing and reducing availability
• Breaking contacts with dealers
• Learning and practicing refusal skills
• Assertiveness education and training
• Seemingly irrelevant decisions
• Understanding the relationship of daily decisions to high-risk situations
• Practicing safe decision making
• All-purpose coping plans
• Anticipating future situations that are high-risk
• Problem solving
• Introducing the basic steps of problem solving and practicing problem solving skills
• Factors that need to be considered regarding coping
• Social, environmental, emotional, and physiological
• Case management
• Reviewing and applying problem solving skills to issues
• Developing support plans
• Monitoring and supporting clients
• Risk reduction
• Assessing risk and high risk behaviors (examples, IV needle use, sexual behavior/STIs)
• Educating about risk
• Building motivation to change high-risk behaviors
• Setting goals related to behavior change
The Spirit of Motivational Interviewing
• Collaboration (Partnership)
• Positive interpersonal atmosphere
• Willingly suspend reflexes to fix everything
• Acceptance
• Acceptance of what the client brings
• Absolute worth, empathy, autonomy, affirmation
• Evocation (vs. education)
• "you have what you need, together we will find it"
Compassion
Principles of MI
Express empathy, develop discrepancy, roll with resistance, support self efficacy, showing warmth and caring, support patient's self-esteem, evoke patient's own reasons for and against change, resistance is a predictor of poor outcomes, and question and reflect to help the patient believe they can change
OARS
• Open-ended questions- exploration
• Affirming- reinforcing strengths and positive features
• Reflections
• Simple
• Restating what was said
• Amplified
• Exaggerating the point to where they have to agree/disagree and explain
• Complex
• Introduce emotion
Summaries
Aspects of Acceptance
• Absolute Worth
• Unconditional positive regard, not met with disapproval
• Empathy
• Communicate an accurate understanding of the person, as if it were your own
• Autonomy
• Human nature is positive; restricting autonomy provokes reactance
Affirmation
Motivational Interviewing- General Principles
• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
Support self-efficacy
Eliciting Change Talk
• Evocative questions- asking directly for change talk
• What concerns you now about your use?
• What changes would you like to see in your use?
• Tell me a little bit about how things would be better if you made those changes?
• Looking back
• Explore how things were before problem use
• Contrast with how things are now
• Exploring goals
• Explore how change might align with personal values and goals
• Eliciting change talk is also called "Evoking". You are evoking their readiness to change. This is just one aspect of motivational interventions. You also seek to engage the person, defining a manageable problem to focus on, and help them plan for making changes. Planning for making changes may include problem solving, help them boost their confidence, troubleshooting barriers to change, and helping them maintain forward momentum even in the face of difficulty.
Decisional Balance
• Decisional balance
• Pros and cons of changing
• Giving feedback
• Direct and personal, not vague and general
• Typical situation
• Client's view of what life is like in relation to issue
• 1st: Pros of no change
• 2nd: Cons of no change
• 3rd: Cons of change
• 4h: Pros of change
Benefits of MAt
• Can be used to:
• Manage withdrawal symptoms
• Prevent relapse
• Treat co-occurring conditions
• Medication can:
• Re-establish normal brain function
Decrease cravings (can help you cognitively understand issues instead of letting it take over)
Harm Reduction
• Basic tenets
• Provides a public health alternative to the moral/criminal and disease models
• Abstinence is an ideal goal, but other definitions of recovery are acceptable
• When we cannot prevent risky behavior, we may be able to reduce the consequences
• Can be applied in both individual practice and in policy
• Habits can be placed along a continuum of potentially harmful consequences
• Any steps toward decreased risk are steps in the right direction
• Individual intervention
• Changing route of drug administration
• Providing alternative and safer substances
• Reducing frequency or intensity of addictive behaviors
Examples of Harm Reduction
• Needle exchange
• Supervised injection facilities
• Pharmacological interventions
• Modified relapse conceptualization
• Relapse as a process and part of change (prolapse)
• the problem behavior is corrected and the desired behavior re-instantiated--an event referred to as prolapse
• Keeps drug use out of public spaces and is safer
• Access to supportive, limited judgment, knowledgeable people willing to provide resources including treatment
What is recovery?
• "A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential"
Doesn't mention abstinence needing to be a part of it

• Establish a supportive home environment
• Maintain focus and desire for overall health
• Enrich personal life/sense of purpose
• Make strong connections in the community
Recovery is the context of maintaining wellness following addiction
Halfway Houses
• Structured living environments
• Testing, duties, restrictions and privileges, employment
A place that allows people with physical, mental, and emotional disabilities to learn the social and other skills necessary to integrate or re-integrate into society
Sober Living Houses
• Informal arrangements
• Often with friends who meet in treatment or in 12-step programs
Both houses are led by sober living counselor to help individuals build their daily living tasks
What does one need for recovery/wellness?
Health:
• Overcoming or managing one's disease (s) or symptoms
• Abstinence/harm reduction
• Making informed, healthy choices
• Supporting physical and emotional wellbeing

Sense of Purpose:
• Meaningful daily activities
• Job, school, volunteering, family, creative endeavors
• Independence
• Income and resources to participate in society
• Spirituality
• A sense of hope

Community:
• Relationships, social networks, community connections, support, friendship, love, hope
SMART Goals
SMART Recovery:
• Self Management and Recovery Therapy
• Paraprofessional treatment group
• Based on treatments that work
• Motivational
• Cognitive-behavioral
• Secular
• Reason and scientific knowledge are the final authority
• 4 main points to the program
• Building and maintaining motivation
• Coping with urges
• Managing thoughts, feelings, and behaviors
• Living a balanced life

S= specific (who, what, when, where, which)
M= measurable (from and to)
A=attainable (how)
R=relevant (worthwhile)
T=timely (when)
SAMHSA's definition and things needed for recovery
hope, person-driven, respect, many pathways, holistic, peer support, addresses trauma, strengths/responsibility
Prevention examples
Early screening before onset
Collaborate with other systems (ex. child welfare)
Stigma reduction activities
Refer to intervention treatment services
Intervention examples
screening
early intervention
pre-treatment
recovery support services
outreach servies
Treatment examples
menu of treatment services
recovery support services
alternative services and therapies
prevention for families and siblings of individuals in treatment
Post treatment examples
continuing care
recovery support services
check-ups
Reliability vs. Validity vs. Sensitivity
Reliability= produces same result with the same person under different circumstances

Validity= whether an instrument measure what one wants it to measure e

Sensitivity= the instruments ability to identify correctly someone with a SUD
What are the goals of CBT?
Motivation: enhance awareness of problem, desire/motivation to quit

Skills: deal with cravings, manage triggers and control impulses, improve communication, build support networks

Practical Assistance: employ assistance, case management, medical needs

Psychological and spiritual assistance
What do methadone and buprenophine do? (opioids)
suppress withdrawal symptoms and relieve cravings
What does Naltrexone do? (opioids)
blocks effects of opioids at their receptor sites
only for patients who have already gone through detox
Opioid treatment/prevention
Heroin (full agonist, actives receptor to produce response) --> methadone
Burprenpphonine (part agonist) --> Suboxone
Naltexone (antagonist, blocks response) --> Narcan
Medical Treatment of Tobacco
patch
spray
gum

(2) Prescription Medications
Burproprion
Varenicline
Most effective when combined with behavioral treatments
Medical Treatment of Alcohol
(3) Prescription Medications

Naltrexone (same as opioid)
blocks opioid receptors
limits rewarding effects of drinking
limits cravings
reduces replase

Acomprostate
may reduce symptoms of long lasting withdrawal (insomnia, anxiety, restlessness, dysphoria)
May be more effective in patients with severe addtions

Disulfiram
interferes with breakdown of alcohol
creates a buildup of acetaldehyde (flushing, headache, nausea, irregular heartbeat, low BP)
What is effective/ideal?
ALERT
based on social influence model; substance abuse prevention for middle schoolers

Life Skills training
based on social influence model
teachers resistance skills, normative, education, media influences, an general self-management and social skills

Peer Programs
based on open discussion among groups of children or adolescents
assumption that the opinion of an adolescent peers are significant influences on behavior
often focus on youth in high risk areas
may involved payed community service
Narcan
- reduced death rate by 66%
- Brings someone back to life by spray
- huge risk to overdose if you stop
- opiates jump on receptors -> Narcan takes high away
- Saves lives which is bottom line (overdose part of recovery/addiction)
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