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By Guida Brown, Co-Chair, Kenosha County Substance Abuse Coalition

The Kenosha County Substance Abuse Coalition has spent a considerable amount of time working to reduce stigma around substance use disorders. Still, day in and day out I see reminders that we have a lot of work to do. Most recently I read about a truly kind woman who bought a meal for a woman who was homeless. The post ended this way: “So next time u judge a homeless person think twice…not all of them are homeless because of a drug addiction or because they are lazy.”

I really try not to be a social media troll, but I couldn’t stop myself from commenting: “I love the kindness shown toward the woman, but I think we’d all be hard-pressed to find a person who’s homeless due to laziness. Further, drug addiction is a DISEASE that NO ONE chooses. Let’s be kind to EVERYONE, even those we don’t understand.”

I realize that I’m not going to win everyone to my side, but I am going to give it my all trying!

Stigma is defined as an association of disgrace or public disapproval with something, such as an action or condition. By itself, that’s probably not a bad thing. We often disapprove of people who don’t follow rules, mores, or laws, right? Stigma around substance use disorders (SUDs), however, goes beyond that. Stigma regarding SUDs means that people disapprove of people with a DISEASE – a disease they had no choice in getting. That’s why we have to change how we think about those with SUDs and change our language to reflect our support of them.

I often hear that addiction is a choice, but no one would ever choose to have a substance use disorder. What we don’t know is why one person gets one and the other doesn’t, but here’s what we do know:

• There’s an inherited biological disposition – meaning, it runs in families. If a parent has a substance use disorder, the child is about 40% more likely to have a substance use disorder than the general population.
• A parent’s use – EITHER parent’s use – preconception may also play a role in a child developing a SUD. Give it a Google; it’s a FASCINATING new field of study!
• Early exposure also plays a significant role in SUDs. That is, the younger a person starts using substances, the more likely that person is to develop an addiction. Think about that for a moment: a young person whose brain isn’t fully formed starts making bad choices by using mood-altering substances. Can we really blame that child for then developing an addiction?
• Using a lot leads to a SUD, but, as I like to say, no one wakes up in the morning and says “I think I’ll inject heroin today.” No one PLANS to use a lot in order to develop an addiction in his life.

Which brings me to the next point: addiction is a chronic, progressive, lethal disease, and part of the problem with stigma is that people think it’s only “hard drugs” that cause problems. Until their lives or the lives of their loved ones spin out of control because of alcohol. Or marijuana…. cocaine…benzos. Or opioids. Because when someone is finally using meth or heroin, we all know that person has a significant substance use disorder, and that’s when we say “It’s his fault. If he hadn’t picked up, he wouldn’t be addicted.” Do you see how ridiculous that is? Again, no one wakes up in the morning to get ready for his job and says, “Today is the day I’ll try meth.”

The trajectory is much more unsteady because addiction is not a choice. I once worked with an outstanding Recovery Coach who told about how she bargained with herself to determine if her addiction was, indeed, a problem. She’d say to herself, “As long as I’m not using cocaine, I’m OK.” Until she used cocaine. Then she’d say to herself, “As long as I’m not using heroin, I’m OK.” Until she used heroin. Then she said to herself, “As long as I’m not shooting up, I’m OK.” Until she shot up.

No one wants to have any disease, and the disease of addiction is no different. Let’s be kind to EVERYONE, even those we don’t understand.

By Guida Brown, Co-Chair of the Kenosha County Substance Abuse Coalition

Addiction is considered a family disease because of its wholly negative impact on the family and other loved ones.

Consider how, when a person receives a diagnosis of a different chronic, progressive, lethal disease…one that ISN’T the disease of addiction, the typical societal response is to offer support – bring over food, offer rides, provide child care – you support the entire family while they wrap their arms and minds around the new diagnosis.

Now, take a moment to contrast that response to the one when a loved one gets diagnosed with an addiction. If, and it’s a BIG IF, but IF the family is even willing to discuss the disease with others, the typical response is too often blaming, shaming, and stigma. And so this chronic, progressive, lethal disease that the entire family suffers from continues to wreak havoc.

What if we regarded this disease the same way we regard other diseases? From the family member’s/loved one’s perspective, what if we all stopped pretending the disease didn’t exist? When we saw the continued negative consequences of addiction in our loved ones’ lives, what if we actually started pointing it out to them as we would with any other disease? “Hey, I see you have a great big new discolored mole with irregular edges on your back. You may want to have that looked at” works reasonably well for suspected skin cancer. What if we said to loved ones we suspect suffer from addiction, “Hey, I see you have a great number of negative consequences from your substance use, including loss of income and loss of friendships. You may want to have that looked at.” Sure, someone may get mad, but as with every chronic, progressive, lethal disease, the lethal part is a given without intervention. Without intervention, death or incarceration – or incarceration (then death) – is the result. It doesn’t matter if the disease is cancer or addiction or something else. The inevitable outcome of a chronic, progressive, lethal disease that is ignored is death.

But, people who suffer from other diseases actually want to get better, and with addictions it’s different, right? Well, no, it’s really not, but it certainly does seem that way. The truth is that the “relapse” rate for chronic diseases is all about the same, but what’s different is the level of frustration we feel with the person who actually has the disease. Loving a person with an addiction is hard, and knowing where our responsibility for that person ends is hard to recognize. That’s why loved ones have to understand – and then mitigate – their role in helping the addiction to continue.

“Codependency” is said to be the idea that I will work harder on your problem and your life than you do. “Enabling” is doing for someone what that person can and should be doing. It’s helping avoid the natural consequences of behavior, and it’s one of the factors that allows people with addictions to ruin lives…their own lives and those of the people who love them.

The bottom line is that the loved ones of those with addictions are also victims of the disease. They need to learn to detach…to let the people with the addictions experience their own consequences rather than taking responsibility for them. Doing so is hard, but it can be done.

This is the one disease where we seem to believe that we can force someone to get better…where we seem to think that we can provide them all the information that they need, and then they’ll simply accept it and miraculously stop using with no future concerns. But, let’s compare this to heart disease. Heart disease is caused by diet and lack of exercise among other factors. So, when a loved one has heart disease, do we go to the doctor’s office for that person to find out how to “cure” it, then take the information back to the sufferer? Of course not! We expect THAT person to go to the doctor and then make the changes to put him- or herself on a healthy path. And, if that doesn’t happen, what do we do? Threaten? Cry? Curse? Maybe. But we don’t run out to find a new doctor to start the process all over because that first doctor “just didn’t know what he was talking about and that treatment just didn’t work.”

Addiction is a disease: a chronic, progressive, lethal disease. It is no better or worse than any other chronic, progressive, lethal diseases, but our reaction to it – societal, familial, fraternal, or sororal – has to change because our loved ones are dying.

By Gillian Greene, Public Health Nurse, Kenosha County Division of Health

From 2016 to 2017, more than 66,000 deaths across the US involved opioid overdoses. In Wisconsin, Kenosha ranked first among the state’s 72 counties for overdose deaths. Community leaders and health experts united rapidly in the fight against the opioid epidemic. Conversations then and now continue to focus on raising the community’s awareness about opioid overdoses.

“Opiates” are psychotropic substances derived purely from the opium poppy plant (heroin, morphine) or their synthetic analogues, which are generally referred to as “opioids” (fentanyl, dilaudid, Oxycontin, codeine, Vicodin, Norco). However, “opioids” is now used as the umbrella term for all opiates and opioids.

According to the United State’s Surgeon General’s advisory, two major factors have contributed to the epidemic of overdose deaths: 1) the rapid production of illicitly made fentanyl and other highly potent synthetic opioids; and 2) the increased number of prescribed opioids for long-term pain management.

Fentanyl is a synthetic version of heroin but much stronger and more potent. Fentanyl and other powerful, illicit synthetic opioids are being mixed with heroin; other drugs, such as cocaine; and even pressed into tablets to resemble the appearance of misused prescription pills. This unpredictability in illegal drugs has led to numerous overdose deaths.

In 2012, opioid prescriptions exceeded 250 million in the US alone. The proliferation of prescribed opioids increases both the risk of chemical addiction as well as accidental overdoses amongst individuals, even when taken as prescribed for pain. Anyone taking or using any form of an opioid is at risk of an opioid overdose; however, elevated risk factors for an overdose include: taking larger than usual dosage; using alone; injecting; long-term use; and using after a period of abstinence (recent incarceration or drug rehabilitation program).

Opioids affect various parts of the brain that control functions such as breathing, heartbeat, and emotions. Excessive and prolonged use increases a user’s tolerance. As the tolerance increases, so does the need and the amount of the drug in order to achieve continued effects (“the high”). Because the body is unable to manage this quantity over time, a threshold is breached, and an overdose occurs.

It is important to recognize the signs of an opioid overdose. Kenosha County educates its citizens by the B.L.U.E. acronym:

B: Breathing during an overdose is shallow, gurgling, erratic, or completely absent.

L: Lips and fingertips are blue. This is because of the decrease of oxygen throughout the body.

U: Unresponsive. The victim will not respond to verbal or physical stimulation because the high dose of opioids causes the brain to slow down.

E: Eyes (pupils) are pinpoint. The opioids constrict pupils to an unusually small size.

During an overdose, a pulse may still be present despite an ongoing depletion of oxygen. Therefore, immediate assessment, identification, and action can help save a life. If you encounter someone with a suspected overdose, assess the individual, administer Narcan, dial 9-1-1, and perform rescue breathing if able and needed.

For more information contact:

The Kenosha County Division of Health (262) 605-6741 or,

The AIDS Resource Center of Wisconsin (262) 657-6644

By Guida Brown, Executive Director at Hope Council on Alcohol & Other Drug Abuse

A recent survey indicates all of 53% of Americans believe that addiction is a disease. (https://www.usnews.com/news/news/articles/2018-04-05/ap-norc-poll-most-americans-see-drug-addiction-as-a-disease) Granted, this is an improvement, but the battle isn’t over, and it’s a wonder such a survey was done in the first place.

“Disease” is defined as “An abnormal condition of a part, organ, or system of an organism resulting from various causes, such as infection, inflammation, environmental factors, or genetic defect, and characterized by an identifiable group of signs, symptoms, or both”; therefore, regardless whether or not one “agrees,” addiction is, in fact, a disease. No survey is needed.

So why the question?

Likely because of the stigma associated with addiction. If we recognize that addiction is the chronic, progressive, lethal disease it is, we – incorrectly – assume that we can’t hold those who suffer from the disease accountable for their recover. Oh, but we can…and should. We would hold accountable a smoker with lung cancer, a person with diabetes who eats carbs with abandon, a person with heart disease who eats fried foods at every meal. So, of course we should hold accountable a person with a substance use disorder who continues to use substances in a way that they aren’t prescribed!

What we shouldn’t do is stigmatize people because of the disease they have.

First, we should always put the person first. Always. Language that labels people takes away their humanness. Therefore, there are no “junkies,” “druggies,” “alcoholics,” “addicts,” or the like. There are only people with substance use disorders or people with addictions, as in “My son who has a substance use disorder…,” or “My daughter who has alcoholism….” And even in reference to one’s self, “I’m a person in long-term recovery” or “I’m a person with a substance use disorder” beats “I’m an addict” any time. Language that labels is appropriate in some circles, but it is never appropriate in the general community because, sadly, when the general community sees “addicts,” we still see something very negative, at least today. That’s why we need your help to change it.

Think about the last test your doctor ran on you. Did the office call with results and say, “Hello, Mr. Smith…your test results are in, and you failed”? Of course not.

So why do we still – and many professionals in the field are guilty of this – insist on saying people “failed” drug tests? This type of test, as with all tests for health care, either has a positive or negative result. There is no “pass” or “fail.” They are also not “clean” or “dirty.” The results are simply the results…positive or negative.

I take medicine daily to stave off migraines, yet no one accuses me of being “addicted” to my medication. I have gone periods of time without taking the medications, and I end up with more migraines – a relapse, if you will. This would lead one to believe I’m dependent on my migraine meds, which I probably am. And no one cares. But we love to accuse those who use Medication-Assisted Recovery as prescribed by the doctor as trading one addiction for another. That’s not true! Treatment works. Medication-Assisted Recovery works. Recovery happens. But it happens differently for folks, and our “One time at band camp” stories, as in, “One time at band camp I knew a guy who was on methadone and he was using it to get high…” are not helpful to ANYONE.

Recovery can happen, and when it doesn’t, it’s not because “treatment didn’t work.” It’s likely because someone wasn’t working the treatment. There’s always next time…until there isn’t. Be supportive; be corrective; and be accurate. Our children are dying because of stigma, and they need your help to recover.

 

 

 

by David Galbis- Reig, MD, DFASAM, Medical Director of Addiction Services at Ascension Wisconsin All Saints, Racine, and President-Elect of Wisconsin Society of Addiction Medicine (WISAM)

There is a lot of confusion in the lay press and among the general public (and even some healthcare professionals) about the various levels of care and treatment options. People mistakenly assume that all individuals with addiction need inpatient detoxification services. The American Society of Addiction Medicine (ASAM) has a well validated tool, known as the ASAM Criteria, to determine the appropriate level of care for individuals seeking treatment for addiction.

At what level of care should a person be receiving addiction treatment?

David Mee-Lee, MD, was instrumental in developing the ASAM Criteria tool and has an educational program at the ASAM website (asam.org) that provides great insight toward understanding the ASAM Criteria. ASAM Criteria were initially developed in the 1980s but are not static and have changed quite a bit. For example, ASAM Criteria now include a level of care for medications to treat opioid addiction, which was not initially recognized as a separate level. Medications include buprenorphine, methadone, and injectable naltrexone.

ASAM Criteria is both an assessment tool and a tool to determine what treatment is appropriate. It is important to realize that an individual’s treatment needs change throughout the course of the disease, and the treatment may require similar adjustment. Therefore, continually reassessment of patients is important.

What is the ASAM Criteria? Generic Overview

ASAM Criteria involves six dimensions for a multidimensional assessment.

DIMENSION 1 considers the severity of withdrawal from a substance or intoxication with a substance. It is important to note that withdrawal management can be accomplished at various levels of care, from outpatient to acute medical inpatient hospitalization, depending on the substance involved and the risk associated with the withdrawal syndrome.

The MOST INTENSIVE level of treatment for withdrawal management (Level 4) is Acute Inpatient Medically Managed Withdrawal that occurs in a full-fledged hospital that can provide multispecialty care and has access to emergency services (e.g., Ascension Wisconsin’s Inpatient Behavioral Health and Addiction Unit at All Saints in Racine). Level 4 withdrawal management is reserved for those with significant psychiatric or medical co-morbidities or for substance withdrawal syndromes that carry a high risk of death (alcohol withdrawal, sedative/hypnotic withdrawal, or any substance withdrawal with a severe complicating co-occurring medical [Dimension 2 of the ASAM Criteria] or psychiatric condition [Dimension 3 of the ASAM Criteria]).

The LEAST INTENSIVE level of treatment for withdrawal management would be outpatient, office-based, withdrawal management for uncomplicated opioid withdrawal, cocaine, amphetamines, hallucinogens, and cannabis.

Level 3 (Residential Withdrawal Services) includes residential facilities like Roger’s Memorial Hospital, the Dewey Center of Aurora Healthcare, NOVA, or the Gateway Foundation in Illinois, as well as therapeutic community facilities such as the Salvation Army, Teen Challenge, or Mount Zion House. Residential withdrawal management would be appropriate for those individuals who do not meet criteria for acute inpatient hospital withdrawal management but who require a controlled living environment, lack appropriate social support, or require removal from their usual living environment because it hampers their recovery. It is important to note that Wisconsin Medicaid DOES NOT currently pay for the room and board fees of residential treatment programs due to a federal restriction that requires a waiver from the federal government. Wisconsin is in the process of requesting that waiver.

Other Levels of Care for Outpatient Addiction Treatment (Level 2 Programs)

Partial hospitalization programs require intensive programming, generally about six hours per day, five to six days per week. Locally available programs include the Dual Partial Programs at Roger’s Memorial Hospital in Kenosha and Ascension Wisconsin All Saints in Racine.

Intensive Outpatient Programs (IOPs) represent the most widely available level 2 outpatient treatment programs. Many IOPs have success rates as high as partial hospitalization or residential programs. Racine Behavioral Health, Ascension Wisconsin All Saints, Aurora Healthcare, and Roger’s Memorial Hospital in Kenosha all have IOPs. IOPs involve a combination of group therapy, psychoeducation, and individual therapy; some individuals do well while others require a higher level of care.

Lowest Level of Care for Outpatient Addiction Treatment (Level 1 Programs)

Outpatient Treatment may be individual or group therapy, but it’s generally only one or two times per week. ASAM Criteria calls for the least restrictive effective setting for treatment, so, unless there’s physical medical evidence to the contrary, if a person hasn’t had previous failed attempts in treatment, the lowest level of care – outpatient treatment – will be indicated.

Regardless of where the traditional treatment is provided, we need to overcome our stigma towards medications for addiction. While it is true that methadone and Suboxone are opioids, their use is linked with recovery from opioid use disorders (OUD). One model for us to consider is that of France, which experienced its opioid epidemic in the ’90s. The French government deregulated use of Suboxone to treat opioid use disorders, reducing mortality from opioid overdose 85% in five years. Medications are not a miracle, but they can be life-saving and life-changing for many individuals.

Further, there is no evidence that medication should be stopped at some predetermined time. In the past, providers would treat with medications for six months or one year, then begin tapering, especially with Suboxone, because data was not available to support long-term use. However, more recent studies suggest that discontinuation of medication assisted treatment (MAT) leads to relapse in 80% of individuals within two years of discontinuation. As is the goal of any treatment, care should be taken to use the lowest effective dose. In other words, MAT should be tapered to the lowest dose that controls the disease of addiction.

The above said, some patients have a better profile to consider a taper. For some individuals early in the course of addiction who have not developed significant permanent changes to the brain and who are able and willing to make the lifestyle changes that are needed to control the disease (similar to patients with diabetes who must change their lifestyles), taper after a shorter time may be feasible and appropriate. Such tapers must be individualized and discussed with the patients. Additionally, there are times when MAT must be discontinued; those decisions, too, must be discussed with the affected individuals.

DIMENSION 2 takes into account the individual’s medical problems such as hypertension, diabetes, pancreatitis, liver function problems, heart problems, or any other condition that could cause complications during the withdrawal process or otherwise hamper recovery. Pregnancy is one criterion that qualifies for acute INPATIENT withdrawal management. Typically, however, uncomplicated opiate withdrawal is either accomplished as outpatient or residential withdrawal.

It is important to remember that “detox” is not treatment and without additional treatment can actually increase the risk of overdose for an individual with an opioid use disorder. Evidence-based treatment strongly encourages medication assisted treatment (MAT) such that insurance companies are starting to deny funding if MAT is not being offered.

DIMENSION 3 takes into account co-occurring psychiatric conditions such as psychosis, suicidal ideation, bipolar disorder, and schizophrenia.

DIMENSIONS 4, 5, AND 6 all involve assessment of the patient’s social and environmental support structures and the patient’s own motivation for change.

Treatment should be seen as a continuum of care, meaning that individuals can move up and down the continuum. Transitions of care should be seamless but can be hampered by fragmentation of the health care system, which is why partnerships between different organizations is critical – to allow for seamless transition across the continuum. In order for the treatment system to work, different healthcare entities need to stop seeing each other as competition and start working together to provide seamless care for the patient. It is important to realize that different health systems may provide complimentary, but not identical, healthcare services.

Such cooperation between healthcare systems is crucial given that there is a significant workforce issue in Wisconsin; we currently lack ample psychiatry, addiction medicine, primary care, and psychotherapy services. A model similar to the wheel-and-spoke one from Vermont could work well here, provided we start working together to build stronger systems of care for those affected by the disease of addiction.