Tri-County Oregon Substance Use Disorder Best Practice Guidelines

Transcription

1 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Advancing high quality care fr substance use disrders in Clackamas, Multnmah, and Washingtn cunties Octber 1, 2018 Health Share f Oregn 2121 SW Bradway, Prtland, OR 97201

2 TABLE OF CONTENTS I. INTRODUCTION... 1 A. Purpse f The Best Practice Guidelines... 1 B. Emerging Research... 2 C. Health Share s Pririties... 2 D. Language Thrughut the Guidelines... 3 II. PRINCIPLES OF SUBSTANCE USE DISORDER CARE... 3 A. Cre Principles B. Principles f Treatment III. ESSENTIAL CHARACTERISTICS OF THE SYSTEM OF CARE... 9 IV. COMMITMENT TO POPULATIONS WITH HIGHEST RISK... 14

3 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines ACKNOWLEDGEMENTS Thank yu t the fllwing rganizatins that cntributed t these guidelines: Cascadia Behaviral Healthcare Clackamas Behaviral Health Divisin CODA, Inc. De Paul Treatment Centers Lifewrks NW Mental Health Assciatin f Oregn Multnmah Cunty Mental Health and Addictins Divisin Multnmah Cunty Public Health Native American Rehabilitatin Assciatin (NARA) Washingtn Cunty Health and Human Services Yuth Cntact INTRODUCTION Purpse f the Best Practice Guidelines The purpse f these Best Practice Guidelines is t advance standards f care and prmte best practice fr substance use disrder prviders wrking in the Tri-Cunty regin f Oregn. This regin includes Clackamas, Multnmah, and Washingtn cunties. Health Share f Oregn is a Crdinated Care Organizatin, r CCO, that is tasked with crdinating physical, mental health, substance use treatment, and ral health benefits fr Medicaid enrllees, as well as wrking with cmmunities t imprve their health, reduce preventable health disparities, and help individuals manage chrnic health cnditins, including substance use disrders. The Natinal Survey n Drug Use and Health (NSDUH) reprts that between 2005 and 2010, 20.7% f persns in the Prtland-Vancuver-Hillsbr area used any illicit drug in the past year, higher than the natinal rate, as is this area s rate f nn-medical prescriptin drug use. The rate f substance use disrders diagnsis was 11.2%, als higher than the natin as a whle. There is recgnitin that there are many pathways t recvery and many individuals access recvery supprts f all kinds thrugh their cmmunities. All recvery effrts in ur cmmunity are valued; hwever the purview f this dcument is substance use disrder treatment that is prvided by Health Share cntracted prviders. Health Share aims t wrk cllabratively with behaviral health prviders t advance a cmprehensive System f Care t prevent, reduce, and treat substance use disrders and that substance use disrders are a chrnic medical cnditin. The System is built n recgnitin that substance use disrders undermine all aspects f the health and well-being f individuals, families and cmmunities, including ecnmic well-being, educatinal achievement, physical and mental health, and safety. T be effective, 1

4 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines the System must be capable f prmting the health and well-being f individuals, families, and cmmunities, as well as address the effects f harmful substance use and substance use disrders. These Guidelines describe best practices fr substance use disrder prviders. Health Share s intentin is fr prviders t adpt these Guidelines and wrk twards implementatin f evidence-based best practice. Emerging Research Health Share recgnizes that research int substance use disrders, as well as research n preventin and treatment, cntinues t prduce new understanding and that the capacity t define and apply best practices evlves as evidence is tested and disseminated. Health Share is cmmitted t wrking with prviders and partners t imprve the capacity f the System f Care t identify and implement best practices, by wrking clsely with cmmunities, prviders and prvider grups, and by ffering training and technical assistance aimed at imprving best practice. Health Share is cmmitted t increasing inter-agency cllabratin and clsely mnitrs the activities f federal agencies such as the Substance Abuse and Mental Health Services Administratin (SAMHSA), Center fr Substance Abuse Preventin (CSAP), Center fr Substance Abuse Treatment (CSAT), the Office f Natinal Drug Cntrl Plicy (ONDCP), the Administratin fr Children and Families and the Department f Justice, amng thers. Health Share s Pririties Health Share hlds the design and implementatin f best practices in this system as a primary gal and has priritized imprving the Substance Use Disrder System f Care, including preventin, screening, treatment, and recvery. This apprach fcuses n: maximizing inter-agency and inter-system cllabratin, identifying and addressing disparities, increasing preventin and linkages t services, imprving transitins in levels f care, imprving screening and access t services, strengthening the array f recvery-riented services, wrkfrce develpment, and imprving perfrmance thrughut the System. The Guidelines are drawn frm CCO System values and principles, frm study f cmparable natinal principles, such as Massachusetts Department f Public Health Bureau f Substance Abuse Services, Natinal Institute n Drug Abuse (NIDA) Principles f Drug Addictin Treatment Principles f Preventin Guidelines f Care Guidelines fr Treatment Institute f Medicine, Natinal Quality Frum recmmendatins. Tgether, these highlight equity, cllabratin, quality imprvement, recvery supprt, preventin and recgnitin that addictin is a chrnic cnditin requiring a cntinuum f services. Health Share values cllabratin with health care prviders, with individuals served and their families, fr example, thrugh the cunty Cnsumer Advisry Bards and meetings with prviders in a variety f venues. Internally, the CCO highlights pririties such as equity, preventin, early life health, wrkfrce develpment, integratin, etc. This, cmbined with brad cllabratin allws the CCO t effectively crdinate and plan substance-related disrders preventin and treatment prgramming, plicy and practice guidelines and funding. 2

5 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines The Best Practice Guidelines establish expectatins fr Health Share s substance use disrder prviders. Substance use disrder treatment prgrams licensed by Oregn Health Authrity are als gverned by requirements f Oregn Administrative Rules Guidelines fr apprval/licensure f alchl and ther drug abuse prgrams thrugh The Guidelines may be updated and revised peridically. Prviders may check Health Share s website at fr the mst updated versin. Thrughut these Guidelines, specific cntractual requirements are in bld-face type and marked with a checkmark. Beginning n page 20 there is an appendix with all cntractual requirements. Language thrughut the Guidelines Thrughut this dcument, we intentinally use persn-first language that prmtes recvery and aims t reduce the stigma assciated with substance use disrders. We refer t peple with substance use disrders as individuals, peple, and parents, and clients. We refer t the peple clse t individuals with substance use disrders as family r children and yuth. The term substance use disrders, is meant t be inclusive and aligned with the Diagnstic and Statistical Manual f Mental Disrders (DSM-5) substance-related disrders, which includes ten separate classes f drugs: alchl, caffeine; cannabis; hallucingens; inhalants; piids; sedatives, hypntics, and anxilytics; stimulants; tbacc; and ther r unknwn substances. Gambling Disrders and are utside the purview f these Guidelines. PRINCIPLES OF SUBSTANCE USE DISORDER CARE Cre Beliefs We believe substance use disrders can be prevented and must be treated as a chrnic health cnditin. We believe in strengthening individuals lives thrugh substance use detectin, assessment, preventin, treatment, and recvery. We believe individuals seeking treatment fr substance use disrders must be treated with dignity and respect. We believe treatment must address the scial determinants f recvery, which are the cnditins where peple are brn, grw, live, wrk and age. We believe individuals with substance use disrders must have access t quality, n-ging care that is persn centered, individualized, and readily available. We believe eliminating the stigma assciated with substance use disrders is integral t ur preventin and treatment effrts. We believe recvery is prbable given the right treatment, supprt, and necessary skills fr selfmanagement. 3

6 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines We believe peple with lived experience add value t the System f Care and supprt their emplyment at all levels within treatment rganizatins, including leadership. Principles f Treatment Recvery frm addictin is prbable Treatment must be funded in the hpe fr every individual s ptential f cntributing t sciety and living ut their wn self-identified purpse. Treatment and interventins are supprtive f the individual living a meaningful and prductive life, defined by that individual. Individuals are resilient and have a right t live a life f self-determined purpse and meaning. Recvery happens thrugh the creatin f healing envirnments that are culturally apprpriate, inclusive, supprtive, address hlistic health needs, and have shared decisin-making. Recvery happens in cmmunities where individuals can develp reciprcal and meaningful relatinships. Treatment is persn-centered There are many pathways t recvery. N single treatment is apprpriate fr all individuals. Matching treatment settings, interventins, and services t each individual s particular needs is critical t success. Effective treatment is culturally-specific, cmpetent, and respnsive; beliefs and custms are diverse and impact recvery utcmes. Treatment des nt vary in quality because f persnal characteristics, such as gender, ethnicity, gegraphic lcatin, and sciecnmic status. Treatment must address substance use and any assciated medical, ral health, psychlgical, scial, vcatinal, and legal prblems. Treatment prgrams must prvide pprtunities fr client feedback that refines prgramming and treatment services t be inclusive f client vice. Treatment is readily available and accessible There is n such thing as a mtivated client. There are mments f mtivatin. Treatment prvides utreach and respnds t these mments thrugh assertive utreach and engagement. Treatment adjusts and adapts t where and when the individual is able r wants t engage in treatment withut judgment r cnsequence. 4

7 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Treatment des nt need t be vluntary t prmte recvery. Sanctins r enticements frm the family, emplyment setting, r criminal justice system can increase treatment entry and retentin rates. Treatment, utreach, and engagement shuld be trauma-infrmed and include harm-reductin appraches, including ptins fr individuals wh d nt abstain frm substance use. Treatment prgrams must be respnsive when prgrammatic barriers affect a prtin f individuals within r trying t access the prgram, including lcatin t public transprtatin and ther barriers. Treatment must be mdified t meet changing needs An individual may require varying cmbinatins f services and treatment cmpnents during the curse f treatment and recvery. In additin t cunseling r therapy, an individual may want r require medicatin, medical services, family therapy, parenting supprt, vcatinal rehabilitatin, scial, r legal services. Treatment appraches must be apprpriate t the individual s age, gender, language, ethnicity, and culture. Certified Recvery Mentrs with lived experience in recvery are a vital part f the service array and System f Care. Treatment is trauma infrmed Treatment recgnizes the high likelihd f expsure t trauma and prvides a safe envirnment fr wrkers and the peple they serve. Treatment avids injuries t peple frm the care that is intended t help them. Treatment addresses adverse life events with a trauma-infrmed framewrk. Treatment is based n scientific knwledge, evidenced-based practices, and cultural best practices. Recvery frequently requires multiple interventins and episdes f treatment As with ther chrnic health cnditins, relapse t substance use can ccur during r after successful treatment episdes. Individuals with substance use disrders may require prlnged treatment and multiple episdes f treatment t achieve lng-term recvery. Transitins between treatment, levels f care, and mdalities are a heightened time fr relapse. Treatment prgrams must plan and prvide additinal resurces during transitin perids. 5

8 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Substance Use Disrder System f Care Overview Cmpnents f the System f Care Preventin Health Share wrks with partners t develp a system that supprts preventin strategies in tw categries: Universal preventin, which targets all residents in a cmmunity; and selective preventin, which fcuses n individuals wh are at particularly high risk. Health Share cntracted prviders are required t be knwledgeable abut cmmunity preventin effrts and t wrk with the CCO and its partners t assess need, implement, and sustain preventin effrts. Screening, Brief Interventin, and Referral t Treatment Universal Screening, Brief Interventins, and Referral t Treatment (SBIRT), as part f rutine healthcare practice has been shwn t be a cst effective apprach t reducing unhealthy substance use, and t save lives and mney. Early identificatin thrugh screening and brief interventins can identify risky use, reduce harm caused by high risk alchl and substance use, frestall develpment f disrders, and reduce need fr intensive and/r multiple interventins. Health Share, their partners, and prviders have wrked t establish SBIRT in a variety f healthcare settings. Brief clinician advice is a pwerful tl, especially fr wmen f child-bearing age, r wmen wh are pregnant. Adlescence is als a perid f cnsiderable risk, and there is an SBIRT guide fr pediatricians t screen and cunsel pre-teens and teens, as recmmended by the American Academy f Pediatrics. Treatment within the Specialty Behaviral Health System The treatment system encmpasses several levels f care as described in the American Sciety f Addictin Medicine (ASAM) Criteria, including withdrawal management services, residential services fr yuth, adults, and adults with families, and intensive utpatient and utpatient services. Medicatin assisted treatment (MAT) is nt a distinct level f care, but rather an evidence-based treatment mdality that can be integrated int any level f care, but is generally prvided n an utpatient basis. Each level f care is tailred t respnd t specific treatment needs. In determining need, develping treatment plans, and mnitring utcmes, Health Share requires all substance use disrder prviders t apply criteria established by the American Sciety f Addictin Medicine. All substance use disrder prviders are required: T be knwledgeable abut the full range f services in the System f Care, and have wellestablished, well-utilized cllabratins and relatinships with ther treatment prviders and cmmunity prviders such as ther levels f SUD treatment, primary care, dental care, culturally-specific services, and mental health services, as evidenced by established referral pathways. 6

9 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Prvide treatment that is based n a full assessment including the individual s histry f substance use, medical, dental and psychiatric care needs, and scial histry. T have established the capacity t facilitate transitins frm ne level f care t anther r ne prvider t anther, as needed. T address health disparities based n scial histry; which includes addressing risks assciated with sex wrk and intravenus drug use, including but nt limited t, sexually transmitted infectin and pregnancy testing, as well as family planning r effective cntraceptin use. T mnitr pssible substance use fr individuals in treatment, which can prvide early evidence f substance use and allw the prvider and client t adjust treatment, as needed. Treatment shuld nt be terminated due t relapse. The decisin t transitin t a different level f care based n drug screening results must fllw a prcedure and evaluate harm t ther individuals in the prgram. The transitin t a different level f care r prgram shuld include care crdinatin during the transitin. As key surces f recvery supprt in the cmmunity, utpatient service prviders are required t supprt relevant r pertinent cmmunity preventin effrts and be aware f cmmunity grups prmting recvery. Health Share requires that prviders f withdrawal management prgrams establish referral and transitin systems which ensure smth and timely transfers t the next apprpriate level f care, including develping plans fr uninterrupted medicatin assisted treatment. Medicatin Supprted Recvery Opiid use and abuse, and piid verdse are the fcus f natinal, state and lcal calitins, which target multiple lcal systems using an eclgical apprach. These prgrams aim t implement lcal plicy, practice, systems, and envirnmental change(s) t prevent the use and abuse f piids, prevent and reduce fatal and nn-fatal piid verdses, and increase bth the number and capacity f entities addressing these issues. Health Share supprts the prvisin f Nalxne and is cmmitted t increasing its availability and use t prevent verdses. Health Share encurages the c-prescribing f Nalxne with Opiids that carry risk fr respiratry failure. Research and experience prvide an increasingly cmprehensive understanding f the physilgical changes that accmpany r result frm substance use. Fr example, we understand a great deal abut substance-related changes in metablism and brain activities, such as increased r decreased neurtransmitter prductin. This expanding field f knwledge is accmpanied by increased availability f effective treatments using medicatins which target thse physilgical effects, fr example by disrupting metablism f the substances r mdifying substance-related brain activity. The effectiveness f medicatin assisted treatment in stabilizing individuals and enabling them t build a recvery-based lifestyle is well dcumented. 7

10 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Health Share is cmmitted t nging prgram evaluatins with particular attentin t specific ppulatins that are underrepresented in evidence-based research. Health Share supprts the use f prven, effective medicatin assisted treatment in a variety f settings: Opiid Treatment Prgram (OTP): Medicatin assisted treatment in an Opiid Treatment Prgram prvides a cmprehensive, effective treatment, primarily using Opiid agnist therapies such as methadne, in cmbinatin with individual and grup cunseling, and ther services. Office-based Opiid Treatment (OBOT): Medicatin assisted treatment in OBOT settings ften includes the use f Buprenrphine/ Nalxne, Buprenrphine, r Naltrexne. OBOT services can ccur in primary care settings r in specialty behaviral health treatment settings. Within the specialty behaviral health system, there has been an initiative called Wheelhuse: Expanding Recvery Optins. Wheelhuse aims t increase the capacity f specialty behaviral health prviders t integrate high-quality medicatin supprted recvery int their existing prgrams, which already ffer individual and grup cunseling, and ther services. Other Medicatins: Research cntinues t prvide insight int hw medicatins can imprve utcmes in the treatment f substance use disrders, and a number f medicatins are currently used in behaviral health and primary care settings. Medicatin assisted treatment can supprt recvery and reduce risk f relapse, verdse, and ther harms related t substance use. Examples f additinal FDA apprved medicatins used in the treatment f substance use disrders include: Disulfiram: a medicatin that disrupts metablism f alchl, causing severe reactins if alchl is ingested; Acamprsate: a medicatin that mdulates and nrmalizes alchl-related changes in brain activity; As well as ther medicatins with an evidence base such as Tpirimate and Gabapentin. All substance use disrder prviders are required t: Be knwledgeable abut effectiveness f medicatin assisted treatment as a primary treatment in cnjunctin with ther levels f care, and t prvide accurate and up-t-date infrmatin abut medicatin assisted treatment t individuals served. Be aware f and facilitate access t a variety f medicatin assisted treatment ptins whether in cnjunctin with existing treatment, with referral t r supprt frm anther prvider wh ffers MAT, r as a transitin frm ne level f care r prvider t anther. Substance Use Disrder prviders must nt discriminate r deny prgram admissin based n an individual engaged in medicatin supprted recvery. Prviders must nt cmpel the discntinuatin f medicatin assisted treatment, unless there is a medical ratinale frm the licensed medical prvider recmmending discntinuatin. Recvery Supprt frm Peple with Lived Experience Health Share supprts prgrams and services aimed at supprting individuals, families, and cmmunities in maintaining recvery. Recvery supprt can be prvided by Certified Recvery Mentrs wh are 8

11 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines emplyed by peer-run rganizatins, culturally-specific prviders, r ther substance use disrder prviders. In additin, recvery supprt may be ffered by cmmunity-based self-help grups such as Alchlics Annymus (AA), Narctics Annymus (NA), Ratinal Recvery (RA), faith-based rganizatins, r ther cmmunity-based rganizatins that supprt thse in recvery. There are many rads t recvery. All recvery effrts in ur cmmunity are valued. Essential Characteristics f the System f Care This sectin describes the fundatins f the System f care. These essential characteristics shuld be evident thrughut the system, varying accrding t the cmpnents. These characteristics are described in detail belw: Recvery-Oriented System f Care Health Share is cmmitted t ensuring that its System f Care is recvery riented. That is, the system recgnizes that there are many paths t recvery: sme individuals recver n their wn, r with the help f their family and friends; sme achieve recvery thrugh frmal treatment. Fr sme recvery means cmplete abstinence frm substance use. Fr thers, reductin f the harm arising frm use is a meaningful gal. Similarly, the nature f effective treatment may vary widely: frm a single episde t a series f treatment experiences, cmprising different levels and numbers f episdes. An increasing range f medicatins are prving effective in the treatment f substance use disrders, in cmbinatin with ther appraches, as well as thrugh primary care. Chices in treatment and in the path t recvery vary accrding t experiences with substances, age, culture, c-ccurring cnditins, availability f family and cmmunity supprts, and a range f ther factrs. Health Share is cmmitted t supprting a Culture f Recvery that fcuses n building and sustaining an individual s physical, mental, and dental health, engagement in supprtive relatinships, and prductive participatin in their cmmunity. It recgnizes the multiple and varied effrts individuals and their families make t achieve recvery. Prviders are required t demnstrate characteristics f Recvery Oriented Systems f Care and t establish and maintain a Culture f Recvery. Early Identificatin and Supprting Engagement in Recvery Individuals, and their families, may apprach treatment and recvery in many ways. Health Share is cmmitted t ensuring that the System f Care is capable f respnding t any apprach r inquiry s that thse wh need help are effectively and efficiently identified and engaged. This requires that cmpnents f the System are welcming, respnsive and skilled, and that cmpnents f the system actively crdinate t ensure the System prmtes engagement in Recvery. Health Share requires that prviders: 9

12 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Ensure that individual needs are accurately assessed and individuals are referred t the apprpriate level f care; Develp screening and assessment plicies, prcedures and tls that: Ensure accurate cllectin f infrmatin; Ensure screening fr c-ccurring physical, ral, and mental health needs; Ensure screening fr trauma, husing, criminal justice, emplyment, family, and ther scial supprt needs; Are apprpriate t the age and develpmental capacity f the individual; Are inclusive f cultures and ethnicities Respnsive t linguistic needs; Respnsive t literacy needs; Wrk with each ther, and ther System cmpnents, t ensure that referrals and transfers are carried ut in planned, crdinated way, based n established, agreed upn prcedures and cdified relatinships; Ensure that planning fr discharge frm treatment begins at assessment; Ensure that regardless f the circumstances f discharge, individuals are supprted in cntinuing in recvery, and reducing harm frm substance use; Establish mechanisms t prmte peer relatinships and resurces by: Prviding infrmatin and peer resurces including peer rganizatins, recvery caches and mentrs, and self-help grups. Prviding infrmatin and referral fr family supprt services and supprt grups. Targeting Harm and Risk Reductin The American Sciety f Addictin Medicine describes harm reductin as: A treatment and preventin apprach that encmpasses individual and public health needs, aiming t decrease the health and sciecnmic csts and cnsequences f addictin-related prblems, especially medical cmplicatins and transmissin f infectius diseases, withut necessarily requiring abstinence. A range f recvery activities may be included in every harm reductin strategy. Health Share supprts this definitin and add Risk Reductin as a characteristic f the System f Care, aiming t assist individuals, families, and cmmunities t identify risk behavirs in relatin t treatment gals and defining strategies related t thse gals that decrease health risks. This apprach incrprates principles f harm reductin as described by the Harm Reductin Calitin (see belw), 1 which fcuses n strategies that reduce negative cnsequences assciated with substance use. These strategies represent a cntinuum frm safer use, t managed use, t abstinence. Cmbined, harm and risk reductin pen a range f ptins which individuals can define as attainable gals

13 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines The Harm Reductin Calitin cnsiders the fllwing principles central t harm reductin practice: Accepts, fr better and r wrse, that substance use is part f ur wrld and chses t wrk t minimize its harmful effects rather than simply ignre r cndemn them. Understands drug use as a cmplex, multi-faceted phenmenn that encmpasses a cntinuum f behavirs frm severe abuse t ttal abstinence, and acknwledges that sme ways f using substances are clearly safer than thers. Establishes quality f individual and cmmunity life and well-being nt necessarily cessatin f all substance use as the criteria fr successful interventins and plicies. Calls fr the nn-judgmental, nn-cercive prvisin f services and resurces t peple wh use substances and the cmmunities in which they live, in rder t assist them in reducing harm. Ensures that peple with, and with a histry f, substance use disrders rutinely have a real vice in the creatin f prgrams and plicies designed t serve them. Affirms individuals wh use substances themselves as the primary agents f reducing the harms f their substance use, and seeks t empwer peple wh use substances t share infrmatin and supprt each ther in strategies which meet their actual cnditins f use. Recgnizes that the realities f pverty, class, racism, scial islatin, past trauma, sex-based discriminatin, and ther scial inequalities affect bth peple s vulnerability t and capacity fr effectively dealing with substance-related harm. Des nt attempt t minimize r ignre the real and tragic harm and danger assciated with drug use. Health Share requires prviders t demnstrate a Harm Reductin apprach by wrking with individuals served t develp gals and strategies that decrease health risks and negative cnsequences f substance use. Evidence-Based Practice and t Quality Imprvement Health Share is cmmitted t imprving practice thrughut the System f Care. Our apprach fcuses n imprvement thrugh enhanced availability and use f data; quality assurance; disseminatin f evidence-based and best practices; and increasing respnsiveness t needs f cmmunities, families, and individuals served. Our Principles f Care call fr design and perating decisins t be based n evidence f effectiveness, and SAMHSA underscres the imprtance f using evidence in making funding decisins, and highlights the imprtance f assessing the effect f plicies and prgrams n health disparities. T supprt these effrts, Health Share is wrking t refine data cllectin and analysis s that data are available t treatment prviders t supprt assessments f effectiveness and prgramming decisins. These data are used t supprt prgram assessment, design, and decisin making. Cmmitted t Persn-Centered Care Health Share s Principles underscre the imprtance f respnding t the whle persn. Substance use disrders affect all life dmains: develpment, brain functin, and behavir, acquisitin f life skills, 11

14 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines relatinships, emplyment, educatin, and husing. Individual characteristics, family and friends, cmmunity and envirnmental factrs can hinder r prmte preventin and recvery. Health Share requires prviders: T demnstrate understanding f individuals varying strengths and vulnerabilities in relatin t develpmental status. T recgnize the imprtance f family and significant relatinships. T engage individuals and families in their varius life circumstances, (e.g., thse parenting r building a family; thse with husing instability r experiencing hmelessness; r thse invlved with mandated systems, such as the criminal justice system r child welfare system.) T demnstrate understanding and affirmatin f sexual rientatin and gender identity. T recgnize and respnd effectively t c-ccurring mental health disrders and trauma. T recgnize and respnd effectively t c-ccurring cnditins such as: HIV/AIDS, Viral Hepatitis and Tuberculsis; piid verdse; tbacc use and nictine addictin, and gambling disrders. Prviding Trauma Infrmed Care Trauma infrmed care is an apprach t the delivery f behaviral health services. The first Natinal Cmrbidity Study fund that in the general ppulatin, 61% f men and 51% f wmen had at least ne traumatic experience. Mre recently, the Natinal Epidemilgic Survey n Alchl and Related Cnditins fund that as many f 71% f persns with substance use disrders had experienced traumatic events, including dmestic vilence, cmbat-related trauma, and childhd abuse. By nw, the prevalence f expsure t trauma amng persns served in the behaviral health system is widely acknwledged. SAMHSA advcates fr trauma-infrmed service systems, the benefits f which t individuals, families, agencies and prgrams are increasingly evident. SAMHSA describes benefits including a greater sense f safety, imprved screening, assessment and treatment planning, and decreased risk f re-traumatizatin. Benefits can apply t staff as well as t individuals served. Traumainfrmed care can reduce the impact f trauma and vilence. Given the prevalence f trauma amng peple with substance use disrders and the benefits f trauma-infrmed appraches, Health Share requires prviders t ensure trauma infrmed care, as evidenced by: Health Share requires prviders t prvide a stated cmmitment t trauma-infrmed care, with emphasis n individual chice and decisin making; Cllabrative partnerships which prvide fr access t trauma specific services; Inclusin f trauma screening in all assessments, and peridic reassessments; Prhibitin f cercin r frce in treatment; Recgnitin that children f individuals served have experienced trauma, and that they and their families may require supprt and assistance in btaining effective treatment t address trauma. 12

15 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Health Share requires prviders t cnduct peridic assessments f the degree t which plicies and prcedures: Ensure that the envirnment is safe and clearly prvides a sense f safety, e.g., interactins are predictable; staff are aware f ptential triggers in the envirnment; service prvisin is transparent; Review questinnaires and assessment questins t ensure they are respnsive t the trauma experiences f thse served. Recgnize that sme behavirs may be attempts t cpe with trauma-related symptms and respnd accrdingly. Health Share requires prviders t ensure that prgram design and wrkfrce develpment reflect understanding f: Pervasive effects f trauma, fr example, n relatinships, families and cmmunities; The cmplex links between trauma and addictin; Trauma-infrmed services d nt depend n staff knwledge f an individual s trauma experiences, nr n an individual s disclsure f trauma experiences; Sensitive and effective methds f explring trauma, making referrals and supprting individuals; and Ptential fr staff t experience secndary trauma (r their wn trauma) thus requiring rganizatinal and supervisry supprts. Addressing Tbacc Use Disrder Tbacc-related health cnditins are the leading cause f death amng persns treated fr substance use disrders. Smking and tbacc use are knwn t cntribute t relapse. Secnd hand smke is knwn t causes a brad range f health prblems including asthma and ear infectins in children, pregnancy cmplicatins, and crnary diseases in adults. Research has fund that simultaneus treatment f ther substance use and tbacc use can be mre effective than treatment that des nt address tbacc use. There are an array f prgrams and resurces t help peple discntinue tbacc use. Health Share has supprted integratin f tbacc plicy, educatin, and treatment int services, in partnership with the Public Health Department. Heath Share requires behaviral health prviders t treat tbacc use disrders and supprt tbacc cessatin, including assessments, treatment planning, educatin, services, and access t medicatin fr smking cessatin. 13

16 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Zer Suicide and Suicide Preventin Individuals with Substance Use Disrder are at high risk fr cmpleting suicide and suicide is the leading cause f death amng peple with Substance Use Disrders. Cmrbidity- r c-ccurring mental illness and substance use disrders increases the risk even further. 2 Heath Share requires behaviral health prviders t implement available suicide preventin tls, including: suicide risk assessment, lethal means cunseling, and safety planning. Cmmitment t Ppulatins with Highest Risk Cmmitment t Respnding t Develpmental Status The cmpnents f the System f Care are attuned t risks and abilities assciated with develpmental status, and individual variatins in develpment. Examples include: Preventin prgrams targeting yuth, aiming t reduce age f first use; and SBIRT prgrams fcusing n yuth and wmen f childbearing age; specialized treatment prgrams designed t respnd t specific develpmental needs, fr example, prgrams fr yuth and yung adults, adults with develpmental disabilities, r fr adults with children. Being attuned t develpmental status is understanding that, while it is cnvenient t refer t ages as delineatrs f develpment, human develpment des nt adhere t set timetables. Attunement depends n understanding majr dmains f human grwth, which in additin t physical develpment include relatinal capacities, family and scial rles and abilities, language, cgnitin, sexuality, gender identity, health, and persnal surces f meaning. Individual variatins in develpment can arise frm disabilities, injuries, trauma, physical health challenges, scial determinants, and substance use. Using this apprach, an inability t anticipate cnsequences may be viewed as evidence f a cgnitive develpmental lag r lss, rather than risk-taking; and difficulty in understanding hw thers might feel may be viewed as evidence f trauma in early life, rather than indifference r nt being ready fr recvery. Health Share requires prviders t be cmpetent t address develpmental status in planning and implementing prgrams and services, as well as in assessing service needs f individuals. Health Share requires prviders t refer, cnsult and crdinate with prgrams t that supprt recvery fr develpmental status when the scpe is utside f their expertise. Yuth with Substance Use Disrders 2 Center fr Substance Abuse Treatment. (2008). Substance Abuse and Suicide Preventin: Evidence and Implicatins A White Paper. DHHS Pub. N. SMA Rckville, MD: Substance Abuse and Mental Health Services Administratin. 14

17 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Yuth Transitining int adulthd have sme f the highest rates f alchl and substance abuse. Fr instance, rates f binge drinking (drinking five r mre drinks n a single ccasin) in 2014 were 28.5% fr peple ages 18-20; and 43.3% fr peple ages This ppulatin requires appraches that meet them where they are at develpmentally as research currently demnstrated cntinued brain develpment int the early 20 s. Children and yuth are viewed and understd in the cntext f their families, cmmunities, and cultures. Health share wrks t prmte systems f care that invlved yuth and their parents in treatment plan and decisin making. Prviders serving yuth and yung adults (and/r their parents) are required t demnstrate prgrammatic capacity t respnd t develpmental status and needs by: Using harm reductin strategies and best practices; Respnding t relapse in ways which keep the yung persn engaged in treatment and recvery, and fcus n harm reductin; Applying service mdels which reflect accurate assessment f develpmental status, e.g., pprtunities fr physical activities, shrter grup times, help in develping friendships amng peers in recvery; Ensuring prgram capacity and staff skill in addressing sexuality, gender identity and sexual behavir, including addresses risks f sexually transmitted diseases; Establishing capacity, directly r thrugh referral, t respnd t a range f yuth and yung adult vulnerabilities such as emerging mental health disrders; Accessing Recvery Supprt services fr yuth and yung adults drawing n evidence based curricula and prgraming, framing decisin making in the cntext f develpmental status, and building psitive relatinships, including develping a netwrk f peers in recvery; Engaging and supprting family and ther supprtive relatinships in the yung persn s life; Prviding pprtunities fr meaningful participatin by the yuth/yung adult ppulatin pprtunities that highlight yuth and yung adult strengths such as capacity t make intense cmmitments and invest enthusiastic interest and effrt; these may include participating n advisry bards, in prgram planning, and in engaging ther yung peple; and Demnstrating flexibility and inventiveness in utreach and engagement. Prviders are required t have, where apprpriate, well established partnerships with: Early childhd prgrams; DHS Child Welfare and DHS Self-Sufficiency; Child, Yuth, and Family behaviral health prviders;

18 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Mechanisms fr prviding best practices parenting prgram either directly r by referral. Cmmitment t Families Health Share s Eclgical Framewrk underscres the intertwined effects each element has n the thers. Substance use disrders never affect nly the persn with the disrder. Nr did the individual with a substance use disrder develp that chrnic health cnditin in a vacuum. Family members including siblings, children, parents, partners and family-by-chice and friends exert influence n, and are influenced by the individual. These significant relatinships may supprt r undermine treatment and recvery, and they may als be transfrmed by treatment and recvery. Of particular cncern are yuth f parents with substance use disrders and yuth/ yung adults with substance use disrders. SAMHSA highlights the imprtance f care crdinatin fr children, yuth and yung adults given the number f systems these individuals may be invlved with, and the variety f cultural and linguistic needs. Children and Yuth Many treatment admissins, acrss all levels f care, invlve individuals with children, and tw-thirds f pregnant wmen admitted t treatment have children. A parent s substance use disrder des nt unavidably result in harm t children. Yet, children whse parents have a substance-related disrder are nearly three times mre likely t be abused and fur times mre likely t be neglected than children whse parents d nt have an SRD. 4 Between 40% and 80% f children in fster care placement are affected by substance-related disrders. 5 These children are at increased risk f develping substance use related disrders. Therefre, supprt f parents capacity t care fr their children can prtect children frm current harm and prevent future harm. Once in recvery, parents awareness f hw their substance misuse may have undermined their ability t care fr their children can result in guilt and uncertainty abut hw t carry ut their rles and enjy their children. Health Share and their partners seek prgrams that enhance parents ability t care fr their children, and t enjy their rles as parents. All treatment prviders, including thse serving yuth, are required t assess whether men and wmen have children. If the client is a parent, prviders are required t explre the status f the parent-child relatinship, and t assist the individual in setting and reaching gals in relatin t his r her child(ren). Treatment plans shuld include an evaluatin as t whether ther family members have needs that require specific interventins by the prvider r referral t apprpriate services. 4 N Safe Haven: Children f Substance Abusing Parents, Natinal Center n Addictin and Substance Abuse, Research Studies n the Prevalence f Substance Use Disrders in the Child Welfare Ppulatin, Natinal Center n Substance Abuse and Child Welfare, SAMHSA 16

19 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Treatment prviders are required t participate in enhancing capacity t prvide best practices fr families and enhance their capacity t supprt treatment and recvery fr families. Health Share requires prviders t acknwledge the imprtance f family relatinships in prgram design and peratins. Prviders are required t define families in the bradest sense, including family f chice, and are required t engage family members, t the extent desired by individuals served, by: Prviding infrmatin and educatin abut substance use disrders and treatment, and abut supprts and services available t yuth and families; Ensuring family relatinships are explred in assessments, and gals regarding these relatinships are stated in treatment plans; Prviding, either directly r by referral, family therapy and, where indicated, interventins. Cmmitment t Peple wh identify as Lesbian, Gay, Bisexual, Transgender, Tw-Spirit and Queer r Questining (LGBTQ) Health Share is cmmitted t equity in treatment services fr all members. Deliberate and thrugh attentin must be paid t thse whse substance use is exacerbated by discriminatin and hstility, and whse treatment access is hampered by the same frces. These effects are felt particularly by lesbian, gay, bisexual, transgender, and queer r questining yuth, yung adults and adults. SAMHSA identifies LGBTQ individuals as a higher risk and underserved cmmunity. Data cnfirms this, suggesting that substance use and substance use disrder rates amng LGBTQ individuals are greater than rates in the general ppulatin. Lesbian, gay, and bisexual individuals are mre likely t reprt binge drinking and drug use than are peple wh identify as hetersexual. Data n LGBTQ yuth and yung adults cnfirm that these yung peple -- ften living in envirnments where bullying, threats, and rejectin are cmmn -- are mre likely than their hetersexual peers t use substances: 65% f lesbian and gay yuth and 60% f bisexual yuth (vs. 46% f hetersexual yuth) reprted current alchl use; 20% f lesbian r gay yuth (vs. 2% f hetersexual yuth) reprt having used herin. Health Share is cmmitted t ensuring that LGBTQ individuals, and their families, including families f chice, can access and safely participate in the System f Care. 6 Health Share requires prviders t: Prvide envirnments that are welcming t LGBTQ individuals and their families. Demnstrate safety fr LGBTQ individuals by establishing plicy, prcedure, and effective staff training t prevent harassment, discriminatin, and threats. Use data cllectin instruments, such as intake and assessment frms, which are free f assumptins related t gender and sexual rientatin, fr example, assumptins abut the gender f a spuse r partner. 6 A Prvider s Intrductin t Substance Abuse Treatment fr Lesbian, Gay, Bisexual and Transgender Individuals, Substance Abuse and Mental Health Services Administratin, 2001, 17

20 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Integrate LGBTQ culture int cultural cmpetence effrts. Cmmitment t Peple Using Opiids Health Share is cmmitted t ensuring that individuals, many f whm are yung adults, have access t all apprpriate levels f care within the treatment system. This includes individuals needing and/r receiving medicatin assisted treatment, an evidence-based best practice fr treatment f piid use disrder. Health Share requires that all prviders admit individuals receiving medicatin assisted treatment including but nt limited t Methadne, Buprenrphine, injectable r ral naltrexne and Nalxne wh als meet ther admissin criteria. In additin t ensuring and crdinating residential services fr this ppulatin, Health Share requires Residential Services prviders t ensure their staff are aware f the rle f medicatin assisted treatment in the System f Care and supprt the recvery f individuals receiving medicatin assisted treatment. Patients wishing t taper frm their medicatin shuld seek guidance frm the prescriber f that medicatin. Individuals shuld nly be supprted in tapering ff their medicatin when clinically indicated. Even if nt clinically indicated, individuals may elect t stp their medicatin. In that event, the prvider shuld assist in withdrawal management. Behaviral health prviders serving individuals with Opiid Use Disrders shall cnsult the Oregn Prescriptin Drug Mnitring Prgram (PDMP) t ensure the safe and apprpriate crdinatin f prescriptins used fr medicatin supprted recvery. Health Share requires Residential Services prviders that d nt have capacity t ffer a variety f medicatin assisted treatment ptins t establish and maintain an agreement with a prvider f MAT specifying: A stated cmmitment t prevent and reduce piid verdse; Up-t-date knwledge f verdse preventin and respnse resurces in their cmmunities, including identificatin f pharmacies stcking nalxne and/r having standing rders fr nalxne; Ensuring staff are trained in preventing, recgnizing and respnding t verdse; Including review f verdse histry, including witnessing verdse, in treatment assessments; Educating individuals served abut piid verdse preventin, recgnitin and respnse including the use f nalxne; Including piid verdse risk reductin in treatment and discharge plans; Referring families and friends f individuals wh use piids t verdse preventin resurces, including cmmunity pharmacies which stck nalxne and/r have standing rders fr nalxne s thse likely t witness an verdse have access t nalxne. 18

21 Tri-Cunty Oregn Substance Use Disrder Best Practice Guidelines Cmmitment t Pregnant and Pst-Partum Wmen Health Share is cmmitted t ensuring that pregnant and pst-partum wmen have pririty access t treatment. Pregnant wmen with substance use disrders are expsed t a range f risks. They are less likely t seek timely prenatal care, and are mre likely t experience pregnancy cmplicatins, including pre-term delivery. Smking during pregnancy is linked t pregnancy cmplicatins such as preeclampsia, stillbirth, and sudden infant death syndrme. Pregnant wmen with substance use disrders as a ppulatin are higher risk: nearly ne-third (32.93%) are between 18 and 25 years ld; 76% reprt lifetime herin use, and 57% reprt needle use in the prir year; 28% are hmeless. It is nt unusual fr a wman t learn she is pregnant as a result f detx admissin pregnancy test. In additin, pregnant, substance using wmen are at higher risk fr depressin during pregnancy and in the pst-partum perid, and are at increased risk f experiencing vilence. Infants brn t wmen with substance use disrders are mre likely t be lw birth weight and, depending n the substance used, t experience nenatal withdrawal syndrme. Fr pregnant wmen using alchl, their babies are at risk f fetal alchl spectrum disrders r birth defects. Health Share supprts Screening, Brief Interventin, and Referral t Treatment (SBIRT) initiatives t screen pregnant wmen in all care settings and educate them t the risks f alchl, tbacc, and ther substance use during pregnancy. There are centers f excellence prgrams in the regin fr pregnant wmen with substance use disrders. Health Share requires prviders t: Identify the unique needs and risks f pregnant wmen and make apprpriate referrals; Establish mechanisms t ensure smth transitins frm ne level f care t anther, especially fr pregnant wmen using piids, recgnizing that medicatin assisted treatment, cmbined with prenatal care, is currently the standard f treatment fr piid use disrdered pregnant wmen, Establish cllabrative partnerships with pre-natal and pst-partum care, early interventin and early childhd services; Supprt family planning; including effective cntraceptin use fr future pregnancies Prvide, directly r thrugh referral: Evidence based parenting services; and Family treatment services, including family therapy. Prviders are required t cllabrate with mental health care and dmestic vilence services and resurces. Cmmitment t Peple Invlved with the Criminal Justice System Many individuals receiving substance use disrder treatment are mandated by the Criminal Justice System. Regardless f hw individuals begin treatment, recvery is pssible and criminal justice invlvement and accuntability may assist sme peple with staying in treatment. Substance use disrders and criminal justice invlvement substantially increase recidivism, risks f vilence and 19