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1 This product was supported by the Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding.

2 You may be participating in this course because you are required to do so, or, you may be seeking to enhance your knowledge, skills and abilities helping families whose substance use contributes to the maltreatment of their children. Perhaps both reasons are relevant to your situation. Either way, we hope this course assists you in working with these families. Thank you for the important role you play every day and for your commitment to ongoing learning and skill development. Our families are fortunate to have you and they deserve nothing less! 2

3 Prac%cal Content This module is part of a larger course that addresses substance abuse as one of the most significant contributing factors to child maltreatment. A significant amount of subject matter was reviewed and distilled to result in the selection of streamlined practical content most useful to child welfare professionals in safety decision making and behavioral health professionals and others working with child welfare-involved families. 3

4 } Your mastery of the knowledge and skills associated with this course can contribute to effective identification, screening and treatment of substance use disorders (SUDs) resulting in increased family safety, more timely reunifications, reduced repeat maltreatment and better child and family outcomes all the way around! 4

5 After completing this module, participants will demonstrate their understanding of the following: 1. The variety of settings and forms in which SUD treatment occurs; 2. Your role in facilitating effective treatment; and 3. Qualities of and resources about effective treatment, including trauma informed care (TIC). 5

6 } Part of understanding substance abuse and its contribution to child maltreatment is being familiar with the common terms used in the substance abuse field and being able to use them in communication with others. } Key terms from this module that you may want to learn or refresh your memory about have been identified. 6

7 Behavioral therapies Cognitive-behavioral therapy Contingency management Medication therapies Each term will be defined when it is first used to provide context. Also note that the word substance as used throughout this module refers to alcohol and/or mood altering drugs including prescription drugs that are misused. 7

8 } Some of the content in this module is from the most current version of the National Institute of Drug Abuse (NIDA) Principles on Drug Addiction Treatment: A Research-Based Guide Third Edition (12/2012) in which individuals are referred to as patients. For purposes of this course, the term patients will used interchangeably with parent(s) (involved in the child welfare system). 8

9 } Florida s General Appropriations Act established a child welfare performance outcome measure, Increase the number and percent of individuals (adults) in protective supervision who have case plans requiring substance abuse treatment who are receiving treatment. The state target is 55%. 1 9

10 There are many variations in the availability, type, and effectiveness of substance abuse treatment throughout DCF s service regions. While it may not be possible for you to significantly influence these factors, understanding what you should expect from a treatment provider as well as the role you can play in facilitating recovery for the families with whom you work, can increase their chances of a positive treatment experience. 10

11 } As outlined in Module 2, research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences, including an inability to exert control over the impulse to use drugs despite adverse consequences the defining characteristic of addiction. 2 11

12 } Understanding that addiction has such a fundamental biological component is important to your understanding of the difficulty of achieving and maintaining abstinence without treatment. Research indicates that active participation in treatment is an essential component for good outcomes and can benefit even the most severely addicted individuals. 3 12

13 No matter how much partners, family members and human service professionals want to believe that the threat of a parent losing custody of their children is a compelling enough reason to influence an addicted parent to stop using drugs, it is not enough to counter the affects of such a complex brain disease. Drug testing, 12- step groups and detoxification, while important components, are not the same as treatment. 13

14 } Moreover, because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment is usually not sufficient. For many, treatment is a long-term process that involves multiple interventions and regular monitoring. 4 14

15 Drug treatment is intended to help addicted individuals stop compulsive drug seeking and use. Treatment can: Occur in a variety of settings; Take many different forms; and Last for different lengths of time. 5 15

16 Commonly accepted treatment continuum marked by five basic levels of care (consistent with the American Society for Addiction Medicine- ASAM): 6 Level Early Intervention: Professional services for early intervention constitutes a service for specific individuals who, for a known reason, are at risk of developing substancerelated problems or for those for whom there is not yet sufficient information to document a substance use disorder. 16

17 Level I - Outpatient: Organized, nonresidential services, which may be delivered in a wide variety of settings. Addiction or mental health treatment personnel provide professionally directed evaluation, treatment and recovery service. Such services are provided in regularly scheduled sessions and follow a defined set of policies and procedures or medical protocols. (Typically 4 hours or less per week). 17

18 Level II - Intensive Outpatient Treatment/Partial Hospitalization: Organized outpatient service that delivers treatment services during the day, before or after work or school, in the evening or on weekends. For appropriately selected patients, such programs provide essential education and treatment components while allowing patients to apply their newly acquired skills within "real world" environments. Programs have the capacity to arrange for medical and psychiatric consultation, psychopharmacological consultation, medication management, and 24- hour crisis services. (Typically 9 or more hours a week) 18

19 Level III Residential/Inpatient: Organized services staffed by designated addiction treatment and mental health personnel who provide a planned regimen of care in a 24 hour live in setting. Such services adhere to defined sets of policies and procedures. They are housed in, or affiliated with, permanent facilities where patients can reside safely. They are staffed 24 hours a day. Mutual and self-help group meetings generally are available on-site. The defining characteristic of all Level III programs is that they serve individuals who need safe and stable living environments in order to develop their recovery skills. 19

20 Level IV Medically Managed Intensive Inpatient: A planned regimen of 24-hour medically directed evaluation, care and treatment of mental and substance-related disorders in an acute care inpatient setting. They are staffed by designated addiction-credentialed physicians, including psychiatrists, as well as other mental health- and addiction-creden tialed clinicians. Such services are delivered under a defined set of policies and procedures and has permanent facilities that include inpatient beds. Level IV programs provide care to patients whose mental and substancerelated problems are so severe that they require primary biomedical, psychiatric and nursing care. 20

21 There are a variety of evidence-based approaches to treating addiction. Drug treatment can include: behavioral therapy, such as cognitive-behavioral therapy, (anticipating likely problems and enhancing patients self-control by helping them develop effective coping strategies) or contingency management (giving patients tangible rewards such as store vouchers to reinforce positive behaviors such as abstinence). 21

22 } Evidence-based approaches to treating addiction also include medications, or a combination of behavioral therapy and medications. The specific type of treatment or combination of treatments will vary depending on the patient s individual needs and, often, on the types of drugs they use. 7 22

23 } MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. Medication assisted treatment (MAT) is clinically driven with a focus on individualized patient care. 8 Module 6 - Dra6 23

24 } These pharmacological treatments counter the effects of the drug on the brain and behavior, and can be used to relieve withdrawal symptoms, help overcome drug cravings, or treat an overdose. Although a behavioral or pharmacological approach alone may be sufficient for treating some patients, research shows that a combined approach may be best. 9 24

25 } While a discussion about the medications associated with substance abuse treatment is beyond the scope of this training module, it is important to know that such medications exist. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies

26 } For example, methadone, buprenorphine, and naltrexone (including a new long-acting formulation) are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Acamprosate, disulfiram, and naltrexone are medications approved for treating alcohol dependence

27 Methadone is taken daily (liquid and a wafer form). It has been used successfully for more than 40 years in the treatment of opioid dependence. MedicaIon is integrated with psychosocial therapy to address the unique needs of each paient. Module 6 - Dra6 27

28 } mat.aspx } topics-in-brief/medication-assistedtreatment-opioid-addiction Module 6 - Dra6 28

29 Behavioral therapies including individual, family, or group counseling are the most commonly used forms of substance abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships

30 } Also, participation in group therapy and other peer support programs (including 12-step groups) during and following treatment can help maintain abstinence

31 } Facts 14 Available 7 days/week, 24 hrs/day Work well with professionals Primary treatment modality is fellowship (identification) Safety and acceptance predominate over confrontation Offer a safe environment to develop intimacy 31

32 Because they work on different aspects of addiction, combinations of behavioral therapies and medications (when available) generally appear to be more effective than either approach used alone. Successful treatment may need to incorporate several components, including detoxification, counseling, and sometimes the use of addiction medications. Multiple courses of treatment may be needed for the patient to make a full recovery

33 Treatment varies depending on the type of drug(s) used and the characteristics of the patients. Matching treatment settings, interventions, and services to an individual s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. 16 Florida has a large network of treatment providers, including a number of faith-based providers. 33

34 } Characteristics of the patients: Some individuals are more vulnerable than others to becoming addicted, depending on the interplay between genetic makeup, age of exposure to drugs, and other environmental influences

35 } For parents with child welfare involvement, family-centered treatment is essential. } Pregnant women and persons who inject drugs receive immediate priority admission to treatment in publically funded treatment programs or must be provided interim services until such placement can be made. 35

36 Module 6 - Dra6 36

37 Women s Treatment With Family Involvement Women s Treatment With Children Present Women s and Children s Services Family Services Family-Centered Treatment Services for women with substance use disorders. Treatment plan includes family issues, family involvement Goal: improved outcomes for women Children accompany women to treatment. Children participate in child care but receive no therapeutic services. Only women have treatment plans Goal: improved outcomes for women Children accompany women to treatment. Women and attending children have treatment plans and receive appropriate services. Goals: improved outcomes for women and children, better parenting Children accompany women to treatment; women and children have treatment plans. Some services provided to other family members Goals: improved outcomes for women and children, better parenting Each family member has a treatment plan and receives individual and family services. Goals: improved outcomes for women, children, and other family members; better parenting and family functioning

38 Treatment needs to be readily available. Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes

39 } The next slide is from work from the National Center on Substance Abuse and Child Welfare and it depicts the all too common drop off that occurs in the process of getting a parent in the child welfare system through the screening, assessment, treatment admission and treatment completion process. 39

40 40

41 To foster a rapid connection to treatment you can: Visit your local substance abuse treatment centers to understand the services they offer (or lack) and develop relationships with key treatment administrators and staff. Explore whether your local treatment centers will prioritize child welfare clients as they must do with pregnant women and those that inject substances (per federal Substance Abuse Prevention and Treatment Block Grant requirements). Offer transportation and warm handoffs until they are surely and safely connected to treatment. 41

42 } Capitalize on the parent s natural motivation for treatment that typically occurs at the point of a maltreatment report (and rapidly wanes thereafter) by making sure assessment and linkage to treatment is immediate. } Identify and utilize any family relationships and friendships that will support treatment and recovery for the parent while minimizing parent exposure to individuals who might sabotage recovery efforts. 42

43 } Utilize recovery support/peer support assistance if available. } Ensure that the treatment program has a safe and welcoming program environment or work collaboratively to assist in its development is needed. 43

44 We now know from research that motivation is not the sole responsibility of the person seeking recovery but rather a responsibility shared with the helping professionals. Motivational interviewing (MI) is a counseling style based on the following assumptions: 20 Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery. Ambivalence can be resolved by working with your client's intrinsic motivations and values. 44

45 The alliance between you and your client is a collaborative partnership to which you each bring important expertise. An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.) 45

46 } For a free archived webinar on Motivational Interviewing (MI), go to } } Then click on the word recording } You will have to register (even though it is an archived training but there is no charge). Module 6 - Dra6 46

47 } Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual s drug abuse and any associated medical, psychological, social, family, vocational, legal problems, safe housing, etc.) It is also important that treatment be appropriate to the individual s age, gender, ethnicity, and culture

48 You may play a role in the process of ensuring the best alignment between the parent and the type of treatment program to which he or she is referred. Sharing everything you know about the parent with the assessment counselor can help to ensure the best match possible. Also, getting to know your local treatment providers and asking about their specific approaches and plans for meeting the multiple and diverse needs of the parents you refer is critical (and subsequently holding them accountable). 48

49 } One of the more common needs of families involved in the child welfare system is for trauma informed care. People who have experienced traumatic events in childhood are at increased risk for a host of other problems, impacting all domains of functioning. Impaired emotional, social, cognitive, and physiological functioning can result from adverse childhood events

50 } Trauma is so prevalent in the lives of parents with SUD that is can almost be assumed that it should be universally addressed in SUD treatment. } In one of the first studies on addicted women and trauma, 74% of the addicted women reported sexual abuse, 52% reported physical abuse, and 72% reported emotional abuse. 23 } Between 44% and 56% of women seeking treatment for a substance use disorder had a lifetime history of Post-traumatic Stress Disorder (PTSD). 50

51 } Tonier Cane, Team Lead for the National Center for Trauma Informed Care (NCTIC) } v=kqmaf_rceuo&feature=related } You will need to advance the YouTube tracking bar to to see the presentation (otherwise you will have to listen to other presentations first) Module 6 - Dra6 51

52 Other multiple areas on which effective treatment should focus include being: Both individualized and family focused Gender specific Culturally relevant Each of these categories could comprise a full training module. Some resources are available at the end of this module for further review. 52

53 It is important parents unique needs are identified and addressed on the service plan and treatment plan as this is the road map for addressing these needs. In most cases the addiction process involved multiple problems and therefore needs multiple solutions. You will need to collaborate regularly with the treatment partner to help address needs that cannot be met by the treatment provider alone. 53

54 } As depicted on the next slide from NIDA, because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual s life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences

55 Source: NIDA Principles of EffecIve AddicIon Treatment 25 55

56 } Also because an individual's needs change over time, the treatment and services plan must be assessed continually and modified as necessary to ensure that it meets these changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery

57 } In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person s changing needs

58 } Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of the patient s problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment

59 Treatment length: } Depends on patient problems/needs; } Less than 90 days is of limited or no effectiveness for residential/outpatient setting; } A minimum of 12 months is required for methadone maintenance; and } Longer treatment is often indicated

60 The Adoption and Safe Families Act (ASFA) requires a permanency plan within 12 months after a child enters foster care and requires states to initiate proceedings to terminate parental rights if a child has been in foster care for 15 of the most recent 22 months. While 12 or 15 months is a long time in the life of a child, it is a relatively short time in the recovery process of a parent with years, or even decades, of alcohol and/or drug abuse

61 } In cases where the ASFA time clock is ticking, it is critical that the 15-month time period be well spent. When substance abuse is an issue, the parent s need to be assessed and appropriate alcohol and drug services accessed without delay. These parents did not get into their addiction overnight and it is not reasonable to expect that they can emerge from it that quickly either

62 } Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment

63 } Because drug abuse and addiction both of which are mental disorders often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate

64 } Detoxification safely manages the physical symptoms of withdrawal } Can pave the way for longer term treatment } Only first stage of addiction treatment } Alone, does little to change long-term drug use 34 High post-detoxification relapse rates 35 64

65 } Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment settings, and/or the child welfare criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions

66 Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual s treatment plan to better meet his or her needs

67 Important monitoring criteria: 38 Number of sessions parent was supposed to attend each month and the actual number of sessions attended. Drug tests administered and the results (including those not taken due to parental admission of use). Number of other meetings recommended (e.g., 12-step) and the actual number attended. 67

68 Important monitoring criteria: The status of other ancillary services/recovery support services recommended and the extent to which the parent has successfully linked to these services and supports. The monitoring status of these important criteria will tell you a lot about the likelihood that the parent is on track for a successful treatment outcome and provides you important advance notice if you need to make adjustments. 68

69 Relapse Like with any complex disease (see next slide), relapse is common. Psychological stress from work, family problems, psychiatric illness, pain associated with medical problems, social cues (such as meeing individuals from one s drug- using past), or environmental cues (such as encountering streets, objects, or even smells associated with drug abuse) can trigger intense cravings without the individual even being consciously aware of the triggering event. Any one of these factors can hinder axainment of sustained absinence and make relapse more likely

70 Addiction and Other Chronic Conditions JAMA, 284: ,

71 Relapse Because relapse is so common, the parent s treatment plan should focus on relapse prevenion. Child welfare staff working with parents in treatment can (with proper prior consent) review the treatment plan to ensure that it does so and ask for this to be added if the plan fails to include specific relapse prevenion strategies. The relapse prevenion strategies should be specific to each client s specific triggers as these differ from one person to another. 71

72 Relapse Relapse planning should be part of the child welfare plan. Both substance abuse and child welfare professionals should tell the parent that relapse someimes occurs and must be planned for if this happens. This should not necessarily result in TerminaIon of Parental Rights. 72

73 Relapse Relapse is o6en a sign that the individual needs a higher level of care than the one they may be receiving or in the case of someone who has already le6 treatment that they need to reconnect with treatment and associated recovery support. Family member relapse typically leads to a collaboraive intervenion to re- engage the family member in treatment and to re- assess the children s safety

74 Aftercare/Continuing Care A supporive a6ercare program (also called coninuing care) should be provided to maintain hard- won treatment gains and to enhance the progress made in treatment toward early recovery. A6ercare planning addresses the significant changes for all family members and idenifies appropriate support strategies to help them maintain healthy recovery (these services and supports will vary by family member). 74

75 The right level of care should be made available (service aligns with the level of need) or a back up plan (including recovery support) should be put in place if the right level of care (LOC) is not immediately available. The treatment should also be: Evidence-based (the NREPP website contains hundreds of effective approved models) - Individualized and family-focused treatment (see Family-Centered Treatment resource); Gender specific (see Family-Centered Treatment resource); Traumainformed or trauma-specific (see Family-Centered Treatment resource). 75

76 Future Directions NIDA research has demonstrated that drug abuse cannot be treated in isolaion from associated concerns, such as criminal behavior, mental and physical health status, social funcioning, and HIV/AIDS. A robust and consistent effort to tap into and integrate different sources of knowledge will be needed to design and implement effecive intervenions in the future, 42 paricularly personalized treatment intervenions

77 publications/principles-drugaddiction-treatment/principleseffective-treatment 77

78 78

79 In this module you have accomplished the following: Learned or refreshed your memory about the variety of settings (e.g., Levels 0.5-IV) and forms (e.g., behavioral therapy such as cognitive-behavioral therapy or contingency management and medications) in which SUD treatment occurs. 79

80 Your role in facilitating effective treatment including providing timely information about the parent s substance use problem so the right level of care and type of treatment can be provided as well as helping foster motivation for and engagement in treatment; and Qualities of effective treatment (individualized and family-centered, genderand-culturally- specific and evidence-based) and knowledge of relevant resources. 80

81 Learned about the need to ensure treatment is trauma-informed. 81

82 } Thank you for your participation in this training effort and for learning or enhancing your knowledge about these important topics. 82

83 1. Child Protection Transformation Project Design Session Teamwork with External Partners Advance Reading Updated: November 8, 2011, p Ibid Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Finally, treatment is a good setting for reaching IDUs and their partners with HIV prevention and care messages and interventions. It also can be a bridge to other needed services, such as primary health care, mental health, or other social services Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Module 6 - Dra6 83

84 12. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) 13. Ibid 14. Peter Banys, M.D., Assoc. Clinical Prof. of Psychiatry, University of California at San Francisco, VA Medical Center, San Francisco. 15. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) 16. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) 19. NCSACW: An example of another state s drop off analysis, SAMHSA/CSAT TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment; Chapter Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Module 6 - Dra6 84

85 section-iii/4-components-comprehensive-drug-addiction-treatment 26. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) 27. Ibid 28. Ibid 29. Understanding Drug Abuse and Addiction What Science Says: Developed by NIDA and NIH 30. Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers, p Ibid 32. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) 33. Ibid 34. Ibid 35. Peter Banys, M.D., Assoc. Clinical Prof. of Psychiatry, University of California at San Francisco, VA Medical Center, San Francisco. 36. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Module 6 - Dra6 85

86 37. Ibid 38. These criteria are used by the STARS program in Sacramento CA and recommended by the NCSACW JAMA, 284: , The Collaborative Practice Model for Family Recovery, Safety and Stability, p. 40; NCSACW Module 6 - Dra6 86

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