Mental Health Matters 2018 Spring

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SPRING 2018

Medication-Assisted Treatment: A lifeline in the opioid epidemic

BY RHONDA DOTSON, LCSW, LSATP

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ore than 1,400 Virginians were among the 42,000 Americans who lost their lives to opioid overdoses in 2016. Now a crisis that some contend is worse than the AIDS epidemic at its peak, the hike in opioid deaths is staggering. The Centers for Disease Control and Prevention (CDC) report increases of 34.7 percent in Virginia and 28 percent nationwide.

Substance use disorder specialists believe, and the CDC acknowledges, these statistics may not even tell the full story. In 2013, 249 million prescriptions for opioid pain medication were written by healthcare providers — enough for every American adult to have a bottle of pills. The CDC adds that at least 4.3 million Americans engaged in nonmedical use of prescription opioids in the last month.

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Communities are working together to fight the epidemic, and mental health professionals are taking a hard look at opioid use and substance abuse disorders. They believe part of the solution is to treat opioid use as a chronic illness similar to diabetes, heart disease, or arthritis. Their goal is to remove its stigma so that people will seek help and seek treatment. Substance use disorders do not discriminate. As we read or hear in the news every day from the rich and famous to our friends and neighbors, people are dying. continued on page 2 Rhonda Dotson is a licensed clinical social worker and licensed substance abuse treatment practitioner with Centra Mental Health Services. For more information, visit CentraHealth.com or call 434.200.4447.

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May is Mental Health Awareness Month

Medication-Assisted Treatment

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One of the most effective treatments for opioid use disorders is medication-assisted treatment (MAT), which combines the use of medication (methadone, naltrexone, and buprenorphine) with counseling and evidence-based therapies. MAT is primarily used for the treatment of addiction to prescription pain relievers that contain opiates and opioids such as heroin.

opioids lose their spouses, jobs, transportation, and homes.

Patients are provided education on the safe storage of their medication and “begin changing old people, places, and things” associated with a drug-using lifestyle. MAT counselors help people connect with community services, such as housing, financial resources, and other forms of necessary healthcare.

Approved by the U.S. Food and Drug Administration in 2002, one of the more commonly prescribed medications is Suboxone®, a combination of buprenorphine and naloxone (a medication that blocks the effects of opioid medication).

Counseling includes individual and group therapy, motivational interviewing, relapse prevention, and psychoeducation. Counseling helps patients understand the biochemical effects of opioids and helps patients examine the consequences of their behavior. The objective is not to be punitive, but to keep patients engaged in treatment.

The more engaged patients are in their medication and counseling, the better the outcomes. “Healing is in the relationship.” Patients must feel and believe healthcare providers are offering an environment of trust and safety for patients to share their stories so that the best possible outcome can be achieved.

Although it is not a cure for opioid use disorder, Suboxone normalizes brain chemistry, suppresses cravings for opioids and normalizes body processes without the negative withdrawal effects. The use of Suboxone can make addiction recovery possible as long as it is used in accordance with a comprehensive treatment program.

Scientific data shows that medication-assisted treatment plus evidence-based therapies can lead to positive outcomes, including less potential for overdose and death, improved changes in lifestyle, and a reduction in crime.

Unlike methadone, which can only be dispensed from specialized clinics, Suboxone can be prescribed in a physician’s office. Patients can pick up prescriptions at a local pharmacy, and with the necessary counseling, can begin getting their lives back on track. Also unlike methadone, which is often abused, Suboxone squelches the craving for opioids and enables patients to feel “normal” again. Studies show that patients taking Suboxone tend to be more motivated to stop taking opioids. Prescriptions are closely monitored by psychiatrists and other physicians who have been specifically trained in prescribing Suboxone.

The counseling aspect of MAT enables therapists to look at the big picture of the patient’s life. Opioid abuse is crippling, and many people who become addicted to 2 | CENTRA

Treatment also needs to be individualized so that patients get the help they need when they need it. Someone who has abused opioids may first go to an outpatient clinic, but may need a higher level of care. Upon release from inpatient or residential treatment, MAT can be available through an outpatient clinic. Some, but not all, patients may remain on medication-assisted treatment for the rest of their lives.

Medication-assisted treatment is a true lifeline to those with opioid use disorders. The importance of removing the stigma connected to opioid abuse and all substance abuse cannot be overstated as communities, counselors, and physicians work toward recovery of patients, a reduction in the number of lives lost, and an end to today’s opioid epidemic and substance use disorders.

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Collaborative Problem Solving

BY CHAD STEELE, M.ED., LMHC, AMS-C II

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hen children fail to meet adult expectations, adults need a plan. Collaborative Problem Solving (CPS) offers an innovative approach to respond to children and adolescents with social, behavioral, and emotional challenges. The model, developed by Think:Kids, a program of the Psychiatry Department of Massachusetts General Hospital, is based on the belief that children with challenging behaviors lack the skill, not the will, to solve problems, handle frustrations, and be flexible.

This evidence-based approach puts forward two beliefs: that such challenging behaviors are the result of underdeveloped thinking skills (rather than attention-seeking, manipulative, limit-testing, or poor motivation), and that the best way to meet these challenges is through teaching the necessary skills (instead of the imposition of adult will or reward and punishment approaches). The mindset behind CPS is acknowledgement, rather than confrontation.

CPS lays out three options to respond to behavioral challenges in children: • Plan A: When adults impose their authority/will to make a child meet their expectations (these are “my” rules, “my” orders. For example, an adult orders a child to take out the trash). A reward may be offered or punishment/ consequences may be threatened if the expectation (taking out the trash) is not met. Plan A is based on the idea that basic consequences can teach lessons.

• Plan B: When adults work together with children to solve problems in mutually satisfactory and realistic ways.

(The adult asks why the child hasn’t taken out the trash, and they discuss options for accomplishing the task.)

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• Plan C: When adults drop their expectations, at least temporarily, when Plan A is unsuccessful. (The adult takes the child’s stress into account, recognizes the child has homework, and either takes out the trash or let’s the chore wait.) Plan C reduces challenging actions by the child, but does not focus on the relationship between child and adult.

Plan B is the heart of the Collaborative Problem Solving model. The plan takes into account the child’s reasoning for his or her actions (the trash wasn’t taken out because of homework), addresses the adult’s concerns (the trash needs to go out because the garbage pickup is soon), and helps the child work on problem-solving skills with the adult to assess potential solutions and choose one that is both realistic and mutually satisfactory (arrives at a way in which the trash is out on time and the child completes his/her homework). Plan B gives the child the first opportunity to initiate the mutually beneficial solution. For example, an adult might ask a child, “Do you have an idea that will get both of our needs met?”

Plan B enables children with behavioral issues to become more competent. Unlike Plan A, the child has a vested interest, and unlike Plan C, the child does not have to take action on his or her own. (If a child cannot figure out simple tasks such as how to take out the trash on time and complete homework, how can we expect them to navigate social, school or work situations in the future?) Plan B addresses all of these issues.

However, the adult reserves the right to choose any of the plans when there is an unmet expectation. continued on the back CENTRA | 3

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Collaborative Problem Solving Plan B offers versions for specific situations, but all are collaborative.

• Proactive Plan B (described above) works best with the proper assessment of a child’s lagging skills in problem situations or unmet situations.

• Emergency Plan B is used in a crisis.

• Spontaneous Plan B is when a child catches an adult off guard with a request.

The objective of Collaborative Problem Solving plans A, B, and C is to decide which is going to best help a child at a certain time, in certain circumstances. Behind most challenging behaviors, there are problems to be solved and skills to be learned, and CPS advocates not letting any challenging episodes go to waste. Just like the recognition that children with learning disabilities require a different way of teaching, children with behavioral challenges require a more adaptive approach to improve their behaviors.

Since its introduction a decade ago, Collaborative Problem Solving has been shown to be an effective approach to solving such challenges. In 2015, the national assault rate in a child and psychiatric unit was 5 percent; at Centra it was 3.5 percent, well below average.

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Today, as a result of implementing CPS at Centra, the inpatient unit assault rate is .3 percent. CPS also has reduced the use of restraints and seclusion in units across the country. Where it is used in schools, CPS has led to reductions in detentions, suspensions, injuries, teacher stress, and alternative school placements.

Its success lies in a variety of factors. Instead of seeing children as manipulative or starving for affection, CPS encourages professionals to consider five categories of skills: language and communication, attention and working memory, emotion and self-regulation, cognitive flexibility, and social thinking skills. Through CPS, professionals take into account skills that are lagging and are able to offer a more compassionate approach to a child’s behavioral challenges. With the underlying mantra that kids do well if they can, CPS offers an effective way to solve problems, build relationships, and instill confidence in children with behavioral challenges.

Chad Steele, M.Ed., is a licensed mental health counselor and certified anger management specialist with the Child & Adolescent Psychiatric Program at Centra Virginia Baptist Hospital.

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