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Macomb County Office of Substance Abuse (MCOSA) Strategies to Address Opioid Misuse in Macomb County: Recommendations June 2011 BACKGROUND The Macomb County Office of Substance Abuse has been concerned with the number of heroin deaths, hospitalizations and growing treatment admissions trends over the past several years related to opioid use. With input from the Strategic Prevention Framework - Strategic Planning Team and support of the MCOSA Advisory Council, an epidemiological study was commissioned to explore the actual data and trends surrounding this issue, resulting in a compiled “burden document”. The document confirmed that opioid prescription drug use among teenagers and heroin addiction among young adults is rapidly becoming a major problem in Macomb County, with dire consequences for the users, their families and local communities. Subsequent to dissemination of the document and related information to key stakeholders, three focus groups were held to solicit input regarding potential strategies for addressing the opioid problem in Macomb County. Separate focus groups were facilitated in the areas of prevention, treatment and recovery and explored possible causes for rise in use, public perceptions, system impact, service gaps, and potential strategies to combat the issue. Many common themes and strategies emerged from the focus groups; the details of which are included as attachments. Major concerns included: the overuse and misuse of prescription opioids; the lack of perceived risk of opioid drugs: the ease of availability of both prescription and illicit opioids; the younger onset of problematic use and the unique challenges in treating them; the rapid progression from opioid prescription drug use to heroin use and addiction; and the devastating effects from their use, especially the rise in opioid related deaths. RECOMMENDATIONS The following recommendations were derived in part from information gained from the focus groups. Other sources included staff research and participation in state level meetings focusing on opioid problems, input from MCOSA Advisory Council members and years of collective experience in managing a substance abuse treatment and prevention system of care. While developing recommendations, MCOSA considered the current substance use delivery system, which continues to be racked by dwindling resources and increased service demand. This circumstance makes it difficult to add new services, without adversely affecting existing services. Thus, many of the 1 recommendations may actually be system enhancements as opposed to major shifts in service delivery. It should be noted that MCOSA has already taken action to reduce its waiting time for treatment, by A) requiring outpatient treatment agencies to utilize group treatment as a cost effective and clinically appropriate strategy to serve more clients, and B) by offering pre-treatment group services to individuals waiting for funding so as to enhance their readiness for change before entering intensive services. The current peer support pilot project is also designed to assist clients with a history of recurrent treatment admissions to overcome obstacles to recovery and reduce the need for future residential treatment. Although not exclusive to the opioid problem, these measures do allow for greater recovery opportunities for opioid users and all others in need of MCOSA funded treatment. Another factor incorporated into these recommendations is the Bureau of Substance Abuse and Addiction Services and the Substance Abuse and Mental Health Services Administration’s initiative to transform the state’s substance use disorder system to a Recovery Oriented System of Care (ROSC). ROSC will promote greater participation of individuals in the recovery community in MCOSA’s treatment and prevention service continuum, in an effort to increase the number of individuals in Macomb County with Substance Use Disorders (SUD) who will be able to achieve long term recovery. Further detailed discussion pertaining to ROSC occurs in segment on Recovery; it should be noted, however that many of the recommendations are made with this shift in mind. Prevention The area of Prevention plays a major role with regards to the recommendations being made. The increasing use of opioids by high school aged individuals is problematic, but it is also an age group that is reachable to receive modified programming that addresses specific information so they will be more receptive to hear the messages. Many of the recommendations below can be readily incorporated into existing prevention services. Core strategies to be addressed through Prevention Services include: increasing information and awareness related to opioid issues; increasing awareness of consequences to users; identifying support systems; increasing risk perception associated with opioid misuse; and reducing inappropriate access to addictive prescriptions. Each of these areas will consist of multiple-tier approaches. Increase Information and Awareness Increase presentations to medical professionals (nurses, physicians, pharmacists, etc) specific to signs and symptoms of opioid use/misuse 2 Work with local coalitions and Macomb Prevention Network (MPN) to provide technical assistance and data on this issue (painkillers/narcotics and amphetamines) Offer parenting classes to the community with an enhanced focus on prescription misuse (signs, symptoms and the linkage to heroin addiction) Augment “Parent Nights” with information that focuses on narcotic and amphetamine addiction Explore ways to educate coalitions on the Michigan Automated Prescription System (MAPS) and promote the use of this data for their local community Work toward encouraging regular use of MAPS by pharmacies and physician offices Continue to collect data to drive decisions on this topic as it becomes available Increase Awareness of Consequences to Users Educate communities and coalitions on legal issues regarding sharing prescription medication, prescription misuse and heroin abuse Expand working with the Chippewa Valley Coalition to include outreach to the medical community, hospice, and home health care on this issue Supplement the Jail Prevention Service program with information related to the consequences, both physical and legal, regarding narcotic and heroin/opioid drug use Explore ways to partner with the prosecutor’s office, police departments, and judges to determine the consistency of opioid related legal consequences Develop methods to increase community based strategies to youth on legal issues related to consequence for sharing/selling prescription medication Identify Support Systems Work with student assistance programs and coalitions to identify teen self help groups in the county and make this information more accessible Share identified teen resources with the Youth Council and teen service organizations (YMCA, Boys and Girls Clubs, parks and recreation, etc.) Add teen support groups to MCOSA “help cards” that are distributed at prevention activities Identify sections in the “Right Connection” that can be enhanced regarding teen support groups Contact 211 system to ensure they have teen support groups identified Increase Risk Perception Associated With Addiction Enhance knowledge of physical consequences associated with narcotics and amphetamines during educational classes to increase perception of risk 3 associated with prescription drug misuse (Lifeskills, Project Alert, Beyond Trauma) Work with Project Vox to spread message of risk associated with prescription drug abuse and the correlation to opioid use Identify ways to work with parent groups and coalitions to spread message on the link between prescription misuse and heroin use Increase awareness of the relationship between prescription misuse and progression to heroin for classroom presentations Work with student assistance programs and Macomb Intermediate School District to increase perception of risk with students utilizing “Above the Influence”, or other social media campaigns Reduce Inappropriate Access to Addictive Prescriptions Increase the number of coalitions working with local police departments to install “drop boxes” to reduce the access to unused medications Work with community organizers to increase the number of coalitions that will host “Drug Take Back Days” Inform nursing students about procedures and location of “drop boxes” Develop opportunities to encourage physician offices to use MAPS system to help identify ‘doctor shopping’ patients Work with the Bureau of Substance Abuse and Addiction Services to access Macomb data from the MAPS system Consider methods encouraging hospices to spread information on proper disposal of medications Supplement older adult programs with signs and symptoms of narcotic abuse and information on why proper disposal of unused medication is an important community issue Treatment Recommendations related to treatment needs of individuals experiencing opioid abuse and dependency focus on the following needs: improving engagement in treatment, addressing issues related to waiting lists for services (due to lack of funding), expanding the current array of treatment services and addressing issues related to treating the younger population of clients presenting for opioid treatment. Many of these identified needs overlap, as do the recommended approaches to address the issues. Improve Engagement in Treatment Ensure timely access to treatment services. Implement NIATx strategies to reduce wait time to enter treatment where needed 4 Increase retention of clients in treatment. Implement NIATx strategies to increase engagement where needed Provide timely access to alternative services when there is a wait for funded services Explore options to include Peer Support Services, Case Management, Readiness or supportive group treatment if funds for a higher level of care are not available Provide priority admissions to clients actively participating in alternative services while waiting residential or methadone treatment openings over those not active in services Eliminate Wait Time to Treatment Review the length of stay allocated for each level of care for any needed improvements Improve identification of Readiness to Change to better match services to stage of change Explore and develop as appropriate, alternative treatment levels that address the safe housing needs for clients requiring intensive services by offering an expanded array of residential treatment levels and by partnering with recovery homes to bring services to the clients needing less intensive treatment Expand Service Array Expand the current service array to incorporate the Recovery Oriented System of Care (ROSC) within the MCOSA system, including more early intervention, assistance with transitions between levels of care and expand recovery services beyond traditional treatment services Explore the feasibility of expanding the use of Suboxone to outpatient detoxification from opioids and early recovery maintenance, particularly with the younger opioid user who has a shorter history of dependency Seek potential alternative detoxification options which can reduce the expenditure on sub-acute services and provide more access to this needed service Promote the expansion of alternative recovery housing to provide for safe living environments for clients in recovery Increase the number of peer support specialists and case managers in the treatment system to better link clients with community resources and supports Explore the possibility of having people in recovery come to treatment sites to connect clients to self help and recovery community Encourage more treatment programs to offer alumni groups Encourage more treatment providers to offer self help support groups at the treatment site 5 Address Needs of Younger Clients Explore ways to provide more contemporary modes of treatment and revise practices to engage and retain younger clients in treatment Consider utilizing more technology in services (ex: computers, tablets, use of cell phones) Recruit/retain therapists and staff who are successful at engaging the younger population in treatment Promote the formation of young person’s recovery groups to better engage them in treatment and self help Recovery As previously indicated, MCOSA will be working in collaboration with many stakeholders, including representatives of the recovery community, substance use disorder providers, Board and Advisory Council members, prevention coalitions and other relevant partner agencies to develop a Recovery Oriented System of Care (ROSC). The purpose of this endeavor is to promote greater participation and integration by individuals in the recovery community in MCOSA’s Treatment and Prevention service continuum, to increase the number of individuals in Macomb County with substance use disorders who will be able to achieve long term recovery. Efforts toward achieving this goal, along with other recovery focused interventions are outlined as follows: Initiate a planning forum with key stakeholders to begin development of a ROSC for Macomb County (Scheduled June 23, 2011) Evaluate of the existing Peer Support Services pilot study in place at Sacred Heart, with an eye toward expanding peer supports in other areas of the continuum of care Work more closely with the recovery community and 12-step organizations to increase the number of support groups for teenagers and young adults Explore the feasibility of establishing support groups in schools, community colleges, or other areas where young people gather Encourage establishment of 12-step orientation groups specifically directed toward younger users Continue to support Project Vox, a local recovery advocacy group, to help promote recovery and anti-stigma focused messages. It also is believed Project Vox will helps to create a more supportive environment for individuals in and seeking treatment for SUD. Explore the efficacy of establishing a recovery home to fill an existing gap in intensive services 6 CONCLUSION MCOSA, along with committed stakeholders, will continue to explore ways to implement these recommendations in a timely and effective manner. New concepts and services that are created over time from the ROSC transformation will also be developed with these goals in mind. Working together with our community partners, we can reduce the negative impact of opioid and other substance use issues in our community. By simultaneously addressing the problems from prevention, treatment and recovery approaches, we can have a greater impact in improving the sustained recovery of individuals and healthy communities for all Macomb County residents. 7 ATTACHMENTS PREVENTION FOCUS GROUP NOTES January 21, 2011 1. What are you seeing or hearing in the community regarding prescription abuse? 2. How much does the general public understand about the risks of prescription abuse? 3. There have been 6 deaths in our school district from heroin Concerned drug use is going underground Youth say drugs are easy to get Coalition members have been asked to talk to their doctors about prescription abuse School data is incomplete, because they are not reporting what type of drug a student was suspended for Students confirmed that abuse of prescription drug is growing, especially Adderal and Vicodin Baby formula is starting to be locked up in stores because people are stealing it and selling it to party stores for drug money. A lot of property crimes lead back to drugs The public knows very little Parents don’t believe kids are stealing their prescriptions Drug addicts are making false reports so they can get free refill/get another prescription Parents will give their kids pills for pain and they don’t understand they shouldn’t be giving them drugs that belong to another (sharing drugs) There is a lot of misuse of Adderal in schools A lot of prescription drug abuse comes from “social norming” -ads on TV from drug companies, kids see parents take medication for problems so think use is ok Need to look at a way to target prescription abuse in schools- high risk period for kids is between 8th & 9th grades Need to be more specific about prescription message-say no Kids are well networked –cell phones, face book – know how to get drugs, talk about using We need to use social media to get the antidrug message out as well as the drug companies do Why do you think prescription drug abuse is on the rise? Kids take drugs from medicine cabinets at home and sell it in school. To t hem, it’s no big deal 8 4. What strategies do you think are needed to change these risk factors? 5. Kids are very well “networked” with cell phones and texting. The problem with cell phones in schools is that parents won’t allow the schools to take the phones away You can’t tell if kids are using drugs like you can with smelling pot or alcohol School of choice causing problems as some kids come in from other areas just to set up their selling network with other kids The schools are so large, it’s hard to see everything going on You can be still “functioning” on Vicodin, that the kids think it’s no big deal, they don’t realize it’s hard to get off it and they find out they need to take it just to function; “if I’m functioning, I’m not an addict.” No support groups for kids after they shared their story Multi-tier marketing Kids need to hear different messages than parents Have recovery people tell their story, focusing on the consequences of use (don’t glorify use)– what it was like to lose control; this makes it more real with people Use small focus groups for young people in recovery to tell their story and have follow up services available Teach people healthier ways to deal with stress and problems Get people connected to recovery groups early on We need more NA and AA meetings for young people. This helps them to understand they are not the only one. We need to link NA & AA with the schools and community Need to teach brain chemistry to students and keep repeating the message There needs to be more consequences, more consistency especially when an officer stops kids Health care professionals need to be aware of the problem (learn about MAPS) How would you go about informing people that inappropriate prescription and over-the-counter drugs use is an issue and is not safer than illegal street drugs? What is the best way to communicate these messages to students? To parents? To general community? Parents need to learn more. Kids need to hear message Health care community needs to get the message. They are not trained in substance abuse Use movie ads and posters like the one FAN did Drug companies should be required to provide warning/messages, maybe mandated by the federal government Need to let people know legal consequences of sharing/selling/giving prescription drugs to others– it’s not as clear as heroin use 9 6. Use Take Back Drug Projects, make it easier and more known how to get rid of or protect drugs Create awareness of the abuse problem because we are not going to be successful in decreasing pain medication be prescribed. We also need to have awareness about locking up your medications What strategies or approaches do you think would work for heroin issues? Talk about the link between prescription drug abuse and heroin use, use personal stories Kids need to hear it from their peers in a non-threatening environment. Need to hear that drug dealers just want your money – they don’t care if you die. Talk about the lack of control that you have when you do drugs Educate parents about the paraphernalia associated with drug abuse Work with DEA to urge all police departments to have take back programs Put together a program for coalitions to buy to give to their communities. Approach local clubs (Rotary, VFW) to provide funding for programs/projects 10 ATTACHMENTS TREATMENT FOCUS GROUP January 25, 2011 1. How does the Macomb County Opioid Report relate to what you are seeing at your agency? Any issues, changes to treatment strategies? 2. Providers are struggling to catch up with the “immediate response” and “quick fix” mentality from the opioid population Challenge is with the media and the “no pain” mentality Younger generation has no concept of recovery and treatment- they want an immediate fix Suboxone is being utilized as the wonder drug for opioid treatment Clients are only staying a few days in Detoxification services and leave before transferring to Residential treatment Current delivery of treatment is not working for this generationsuggestions entailed deliver treatment electronically, provide video games, change sleeping patterns etc. Accessibility of narcotic prescriptions is the leading cause to opioid dependence Narcotic prescriptions are over-prescribed and cheap How is the growing demand for opioid use services affecting your program? Length of stay is down – clients leaving treatment early Clients need detoxification services, but there is always a wait list Clients do not want to experience pain they just wants a quick fix- difficult to deliver effective treatment; very sensitive to pain/discomfort due to effects of opioid use Younger clients are coming to treatment only because they ran out of money, haven’t experienced other losses/pain The younger opioid users lack motivation to get and stay clean- just looking for a place to stay Field of Addictions is not turning out younger therapists - Population demands the need for professionals who are younger to provide treatment. Challenges with retaining younger professionals due to the credentialing requirements Some younger professionals who are working in the field do not see a problem with using narcotic prescriptions drugs Challenges with getting therapists to provide new therapy strategies when they want to stay “old school” in their therapeutic interventions Critical to connect the right therapist with the right client Younger clients’ attitude/behavior ticking older clients off 11 3. What needs to be done to more effectively treat this problem? Service Gaps? Change Treatment approach by not allowing clients to be on the wait list Engage clients in services immediately, while on waiting list- adjust level of care later Contemporary mode of treatment needs to be implemented- i.e. computers, tablets, revise treatment programming etc. Technology needs to be a prominent resource- i.e. allow cell phones in treatment Review the Length of Stays allocated for each level of care Main concerns for our system – how to address the problem? Getting through to medical community that prescription drug use is a huge problem- differences in pain management philosophy Re-evaluate pain management- older adults even ones in recovery can become addicted to pain medications (due to injury, etc.), and even heroin Lack of transportation and housing Non-priority clients are wait-listed and access is limited for detoxification and residential treatment services Need for alternative treatment options- defining ROSC within our system of care Lack of motivation for treatment o Require all clients to be put into a group while on the waiting list for residential treatment. o Link the client with a peer support specialist at the initial screening appointment to assess motivation for treatment. o Need to provide wraparound services at the treatment centers 4. Are there harm reduction strategies that the system could support? What are they? Suboxone - utilized as a detox medication and is also an abused drug on the streets o County does not cover the cost o Medicaid will cover the cost under formulary drugs o Need for alternative detoxification methods Need for alternative recovery housing- client’s home environments are not safe 5. How could our system utilize the recovery community to assist in treating individuals with opioid dependency? Need to provide support groups at the treatment agencies- recovery individuals can be a key to their engagement. Form young people’s recovery group Use Project Vox for support/outreach 12 Have recovery person come to treatment to make connection to community meetings State is moving forward with ROSC for a more integrated system between those in treatment and the recovery community. ROSC looks like a cost cutting “tactic” more than a good system of care. Partnering with medical facilities and doctors. Current Service Gaps Housing – limited transitional housing available; need more supportive housing options Residential treatment - need to develop an effective alternative that is connected to housing General Comments Overall System - focus on the different levels Treatment to adapt to the needs of the population served – substance use trends will continue to change over time Focused and driven by local group needs, not State level needs Show legislators numbers & charts to advocate for an increase in funding Show that secondary diagnoses increase due to substance use. Invest in substance use services and they would save in other areas (jail services, welfare, etc.) Approach health care cost saving –the cost of treating one overdose vs. providing substance use disorder treatment services; save money by providing SUD treatment due to cost of secondary issues Suggestions for Providers to obtain survey information from individuals who have relapsed vs. first time treatment clients o Find out the reasons of why individuals are more prone to relapse o Set up focus groups within your organization if the need is identified 13 ATTACHMENTS RECOVERY FOCUS GROUP February 4, 2011 1. How does the MCOSA Prescription/Opioid Report fit with what you know about recent/current drug patterns in Macomb County? 2. As noted in the report, Macomb County has seen a dramatic rise in the abuse of prescription and opiate based drugs, especially heroin. This has resulted in numerous dire consequences for young drug users (18-25), including doubling the number of heroin and other opiate drug overdoses in three years. What suggestions could you share which may help in trying to reverse the trend? 3. They’re coming in at a younger age View of heroin now is like marijuana was; may get addicted but it’s not deadly Starting earlier with alcohol & marijuana then moving on to harder drugs Lots of education but not enough Risk and experimentation at young age; missing something in their lives; want to feel a part of something Seeing a graduation from prescription opiate use to heroin for either financial reasons or not bottoming out until at heroin stage; desensitization to heroin Seeing peers use with no adverse reactions, make them think its “ok” Need stronger education in the schools Get school administration on board Heroin is more pure than ever so they’ve lost the perceived risk Prescription drugs, prescribed by a doctor so they can’t be risky Easy access to prescription drugs, highly prescribed because of people aging and achy Heroin costs less than prescription drugs, that’s why they move to heroin Deliver the message of recovery to show the cost of addiction and the needed ongoing work for recovery Are there ways which MCOSA could better utilize the recovery community in treating individuals with Substance Use Disorders (SUDS)? Need to contemporize treatment; have younger people at meeting to help others come back, relate Have young people talk to youth with the right message Ways to get around traditions in meetings Peer supports/recovery coaches 14 4. Can you think of any harm reduction strategies that might prove helpful? 5. Give better understanding of what support groups are to reduce stigma Come up with specifics then can take to their groups Need smaller groups other than 12 Step groups Utilize 12 Steps in a way that it’s not “labeled” a 12 Step group; integrate into a younger age appropriate title Need to approach “wealthier” communities about addiction and use Addiction is a lifelong issue, just as physical health is; need to see it as a public health issues to look at treatment/recovery as harm reduction Bridge gap; reduce stigma If Recovery community is open about their recovery, then others will seek their help Let the recovery community know what MCOSA needs and they will step up to help Provide an introductory program to the self help groups so people know what to expect and ease them into meetings More education of doctors and hospitals; use is not taken seriously Emergency room is not the right place for detox or SA issue; they need to move them out quick, not treat their problem Suboxone is being used for management instead of detox; people are getting addicted and the view is same as methadone Suboxone prescribed for long term use; is only meant for short term use, can cause health issues is used too long Raise awareness that fun can be had without drugs and alcohol Get people to see the painful side of addiction, what they stand to lose, consequences so they take it seriously Get community and police departments involved Reduce stigma of AA and NA and education people on the 12 Steps Make addiction a stronger public health issue Do you think Macomb County would benefit from a recovery home? Yes, could pay a treatment provider to go to these homes to provide therapy, etc. Good idea, but there needs to be regulations. People will use, families would try and help pay for the cost 15 ATTACHMENTS Prevention Focus Group Participants Colleen Burke, L’Anse Creuse Community Action Coalition Gary Burnett, Community Mental Health and MCOSA Advisory Council Melissa DiPirro, CARE Nancy Donahue, Macomb Family Services Judy Hartwell, Congressmen Levin’s Office Gen Klida, Utica Community Area Action Team Patti Kovacs, Fraser Community Action Team Lori Misch, Macomb County Sheriff Gail Peterson, Alcohol Highway Safety Jamie Siefert, CARE Alycia Starr, Northwest Macomb Prevention Coalition Barb Towner, Chippewa Valley Coalition for Youth and Families John Willer, New Baltimore Police Department Randy O’Brien, MCOSA Helen Klingert, MCOSA Dawn Radzioch, MCOSA Nancy Jenuwine, MCOSA Treatment Focus Group Participants Heather Dombrowski, CARE Bill Epling, CPI Andy Konwiak, Eastwood Clinics Phil LaCourse, Sacred Heart Rick MacFarlane, Turning Point Larry McCarrick, Eastwood Clinics Sharon McRae, Bio Med Jeff Oldham, Clinton Counseling Center Sue Owens, Premier Kameshia Rogers, Premier Karen Stetson, Macomb Family Services Grady Wilkinson, Sacred Heart Randy O’Brien, MCOSA Helen Klingert, MCOSA Karen Slattery, MCOSA Recovery Focus Group Participants Joelene Beckett Sean McGraw Shannon Rozell Alycia Starr Justin Randy O’Brien, MCOSA Helen Klingert, MCOSA Lisa Carrizales, MCOSA 16