Understanding the language of addiction and Understanding the language of addiction and Understanding the language of addiction and Understanding the language of addiction and lessons learned from community stakeholder lessons learned from community stakeholder lessons learned from community stakeholder lessons learned from community stakeholder groups and beyond. groups and beyond. groups and beyond. groups and beyond. Dr. Angela Colistra, Ph.d, LPC, CAADC, CCS [email protected][email protected]Drexel University College of Nursing and Health Professions, Department of Counseling and Family Therapy Assistant Clinical Professor, Online Program Director in Behavioral Health and Addiction Counseling Addiction and Behavioral Health Faculty Consultant with: Project ECHO New Mexico Hub and Fundamentals of Addiction Medicine with American Society of Addiction Medicine (ASAM)
Transcript
Understanding the language of addiction and Understanding the language of addiction and Understanding the language of addiction and Understanding the language of addiction and lessons learned from community stakeholder lessons learned from community stakeholder lessons learned from community stakeholder lessons learned from community stakeholder
groups and beyond.groups and beyond.groups and beyond.groups and beyond.
College of Nursing and Health Professions, Department of Counseling and Family Therapy
Assistant Clinical Professor, Online Program Director in Behavioral Health and Addiction Counseling
Addiction and Behavioral Health Faculty Consultant with:
Project ECHO New Mexico Hub and
Fundamentals of Addiction Medicine with American Society of Addiction Medicine (ASAM)
At the end of this training participants will be able to:
• Review and discuss national and local data on the opioid crisis.
• Define interprofessional community efforts aimed to tackle the opioid crisis.
• Outline national efforts focused on opioid overdose intervention and prevention across different stakeholder groups prevention across different stakeholder groups
• Explore how to transform opioid overdose intervention and prevention work across communities by sharing interdisciplinary projects that set the stage for change.
• Apply data to what we know about the language of addiction, why our beliefs about substance use disorders matter, and recommendations to reduce stigma across systems.
Interdisciplinary Scavenger Hunt: Locate the following individuals. Get to
know this person i.e. where does s/he work and what are her/his primary responsibilities? Exchange business cards if available.
1. Find a social worker.
2. Find someone involved in the criminal justice
3. Find a medical professional
4. Find a researcher
5. Find a first responder
6. Find a psychologist 6. Find a psychologist
7. Find a nurse
8. Find a family member or loved one of someone who is struggling with addiction
9. Find a faith leader
10. Find a pharmacist or pharmacist tech
11. Find a human resource worker
12. Find a clinical supervisor or manager
13. Find an educator
14. Find someone that works for a Health Plan
15. Find a policy maker
Key Terms: • Inter/multiprofessional: Teams consisting exclusively of professionals from
different professional disciplines in order to redefine problems outside of normal boundaries and reach solutions based on a new understanding of complex situations.
• Inter/multidisciplinary include all members of healthcare teams, professional and nonprofessional. and nonprofessional.
• Research: A careful consideration of study regarding a particular concern or a problem using scientific methods. Quan, Qual, or Mixed Methods with IRB approval.
• Treatment: Any treatment available and being provided for patients with alcohol and drug use disorders or high risk substance using behaviors. This will include harm reduction and user engagement education.
any opioid
Progression of the US opioid epidemic 2000-2009
natural & semi-synthetic
opioid analgesics
heroin
methadone
other synthetic opioids
CDC Wonder 2016 Copyright ECHO Institute 2017
Overdose Deaths Involving Opioids, by type of Opioid, United States, 2000-2017
Copyright ECHO Institute 2017
National Center for
Health Statistics
Issue Brief
#329, November
2018
How bad is this epidemic?
https://wonder.cdc.gov/mcd-icd10.html
NCHS Issue brief #329, 2018
Latest data: In 2017, the age-adjusted rate of drug
overdose deaths in the United States was 70,237;
9.6% higher than the rate in 2016.
Age-adjusted drug overdose death rates, by state: United States, 2017
National Center for Health Statistics Issue Brief #329, November 2018
The pipeline to overdose…
CDC. 2011
1 Overdose
Death
10 people in
treatment 32 ED visits 130 addicted 825 using opioid non-medically
All-cause mortality, ages 45–54 for US White non-Hispanics (USW), US Hispanics (USH), and six comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada
(CAN), Australia (AUS), and Sweden (SWE).
Anne Case, and Angus Deaton PNAS 2015;112:15078-15083
impact of loss of manufacturing jobs for white men
with low educational attainment in Americawith low educational attainment in America
From 1996 to 2001, American drug
giant Purdue Pharma, maker of
OxyContin, held more than 40
national “pain management
Doctors and pharmaceutical companies launched the opioid epidemic
Int Narcotics Control Board
national “pain management
symposia” at picturesque
locations, hosting thousands of
American doctors, nurses and
pharmacists.
Guardian.com 10/25/17
“From 1996 to
2002, Purdue more than
doubled its sales force
and distributed coupons
so doctors could let
patients try a 30-day free
Shah, 2017, MMWR
patients try a 30-day free
supply of these highly
addictive drugs.”
https://www.theguardian.com/us-
news/2017/oct/25/americas-opioid-
crisis-how-prescription-drugs-sparked-
a-national-trauma
The US, in recent years, still consumes more opiates
In 2016, there were 1,505 opioid-related overdose deaths--- in North Carolina—a rate of 15.4 deaths per 100,000 compared to the national rate of 13.3 deaths per 100,000 persons. Since 2010, when the rate was 8.1 deaths per 100,000 persons, the rate has almost doubled. From 2010 to 2016, the number of heroin-related deaths increased from 39 to 544 deaths and the number of deaths related to synthetic opioids rose from 170 to 601 deaths.
Number of Opioid Related Overdose Deaths in NC.
https://www.statnews.com/feature/opioid-
epidemic/obituaries/
The opioid epidemic:
Opioid Overdoses/Poisoning Opioid Overdoses/Poisoning Opioid Overdoses/Poisoning Opioid Overdoses/Poisoning can occur by:-therapeutic misadventures -therapeutic misadventures -adverse effects from the licit use of medications for pain -management or opioid maintenance-nonmedical use of prescription opioids or illicit use of heroin
[Osterwalder, 1996; Shah et al. 2007; Warner et al. 2011; Rosen et
al. 2013]
How do we conceptualize our problems and solutions as an addiction treatment field?
The silo of addiction treatment The silo of addiction treatment The silo of addiction treatment The silo of addiction treatment
Disagreements within our field Disagreements within our field Disagreements within our field Disagreements within our field
The impact of a silo model of care The impact of a silo model of care The impact of a silo model of care The impact of a silo model of care
• Other professionals feeling like it is not their job to help those who struggle with addiction.
• Other professions may make assumptions about our profession (what are some of these).
• Challenges to train and educate across professions so other professions can serve those with SUDs. Educational models often have left out addiction education. those with SUDs. Educational models often have left out addiction education.
• Due to the lack of understanding about the disease, our clients often experience stigma when seeking services outside of our care settings
• We cannot do it alone across urban and rural communities: challenges with improved policy and structures to support the aging population with alcohol and drug use problems
• The changing face of addiction and the rise and fall of different epidemics helps us recognize our own limits and define our own solutions
What does it take to have a successful What does it take to have a successful What does it take to have a successful What does it take to have a successful interdisciplinary team ?interdisciplinary team ?interdisciplinary team ?interdisciplinary team ?
• We must learn to work with, from, and about each other if we are ever going to work along side each other and expand the addiction treatment and recovery impact.
•Know your role as a professional
•Know your expertise
•Know your team members roles
Kailee Venzin April 3, 2018
A Successful Interdisciplinary Team A Successful Interdisciplinary Team A Successful Interdisciplinary Team A Successful Interdisciplinary Team
Share and PairShare and PairShare and PairShare and Pair
• What interprofessional/disciplinary projects have you worked on that has been effective for the alcohol and drug use field
• What do you think we do well as a profession related to interprofessional work?
• Where do you think the field can make some progress?• Where do you think the field can make some progress?
• What are the within and between group differences that make this interdisciplinary work exciting?
Developing an Opioid Overdose Prevention and Intervention Training. Interdisciplinary Focus
PI: Angela Colistra, PhD (Counselor and Addiction Researcher)
Funding: Community Driven Research Day Funding Grant.
This project aimed to identify and inform an opioid overdose prevention and intervention training based on the
responses from those providing and receiving the current opioid overdose prevention and intervention
training, or being a recipient of or impacted by the current opioid overdose intervention.
Why did we do the study?
• At the site of an opioid overdose naloxone is administered to reverse the respiratory depression that causes opioid overdose deaths.
• It is hypothesized that communities are responding to the opioid training needs of their community but the effectiveness of these trainings is unclear
• This study focuses on the continued development of a multi-level opioid overdose prevention and intervention training protocol which is delivered to the community and anyone who would be responding to an opiate overdose to prevent additional opioid overdoses and to increase moving the client along a continuum of care (medicated assisted treatment, detox, in-patient treatment, out-patient treatment, etc.).
Recruitment of Participants and Location of focus groups
Recruitment Efforts
• Email
• Twitter
Focus group Location
• Holcomb Behavioral Health
• Recovery HousesTwitter
• Direct Community Contacts via community partner
• Recovery Houses
• Conferences
Recovery Houses
• Zoom Platform (audio and video)
Qualitative Research: 5 Homogeneous Focus Groups
• Opioid Overdose Victims are our focus
• All the other groups impact and increase survival and recovery Opioid
National Naloxone Trainers
increase survival and recovery rates
• What focus group would you add to this research? Who impacts the trajectory of overdose victims?
Opioid Overdose
Victims
Behavioral Health
Specialists
Family Members and Loved
Ones
First Responders
Qualitative Focus Groups Interviews From November 2016-2018
21%17%
5 Homogenous Focus Groups n=92
Behavioral Health Specialist
Overdose Victims. 21%
25%
20%
17%
17% Overdose Victims.
First Responders
Family Members & Loved ones
Nat. Naloxone Trainers
Aims of Community Based Research
� Aims 1: Define the attitudes and beliefs about opioid intervention protocols needs for first responders (paramedics, emergency room responders, substance use disorder professionals, residence hall supervisor, school nurse, and recipients of services (recent overdose clients) during and after the opiate overdose intervention.
� Aim 2: Define professional behaviors that have increased clients’ motivation to change opiate using behaviors after a recent overdose and move along a continuum of care (Assessment, Intake, Medicated Assisted Treatment, Medical Detox, In-Patient or Intensive Outpatient care). (Assessment, Intake, Medicated Assisted Treatment, Medical Detox, In-Patient or Intensive Outpatient care).
� Aim 3: Identify what trained participants in naloxone community training found helpful and what information could be added to benefit an intervention at the start of the overdose and following the intervention.
� Aim 4: Identify what recipients of naloxone intervention reported as factors that motivated their likelihood to change substance using behaviors and how emergency responders and medical and behavioral staff improve their intervention.
� Aim 5: Identify national resources of organizations that are implementing naloxone training, what information their training consists of, how is it delivered, what informed their information in their training, and how do they report it helping the community in response to the opioid epidemic.
National Naloxone Trainers:
• Recognizing the signs and symptoms of an overdose, rescue breathing if CPR is known, call 911, training on the naloxone administration (multiple forms depending on what the local pharmacies are carrying), what is addiction, impacts of opioid on the reward pathway, different types of opioids, time for frequently asked questions, how to support family and loved ones,
• What is working: multiple methods of data dissemination-online training, in person training (45-90 minutes), pop-up trainings at bus stops, outside of medication assisted treatment facilities, or any areas where individuals are congregating, community training days with multiple training seminars related to the epidemic, onsite discipline specific training,epidemic, onsite discipline specific training,
• Who is delivering the training-pharmacists, doctors, behavioral health specialist, public health department workers, educators, recovery workers, harm reduction workers, But there are reports that it is helpful to have audience trainer matching for part of the training.
• What is needed: reduce stigma related to Naloxone, getting the training to the individuals that need the trainings (people using opiates and family and loved ones),
• Steering committees that represent key stake holders to address what is working and what is not with the main objective to close gaps and identify who they failed.
• Multiple forms of information dissemination: Training (with PP, discussions, role-play, and videos), folders with treatment brochures and frequently asked questions and answers, scoring rubrics related to Shout, shake, call 9-11 and administration of naloxone.
FAMILY MEMBERS AND LOVED ONES of someone with opioid addiction or someone who has overdosed and/or died
Stigma:
“I still think because of the stigma, a lot of family members, there really isn't a lot for us in how to deal with this. When you
have any other disease, the family is brought in and taught how to change diets or things like that. With this disease, there
really isn't anything that even as family members can do unless the individual wants the help”
Lack of professionals that have expertise in this care: “I found transparent communication in helping the family members
to help their loved ones, you really need to bring in those that are really concerned for them, and take an approach out of
love and concern and not hate and anger. It helps to have a professionals”love and concern and not hate and anger. It helps to have a professionals”
What is needed to help family members: “providing shelter or food or financial support, you do have a voice in all of that.
And then helping families understand that you need to take it down to a decision, right, so either they're going to help their
loved ones in recovery, or they're going to help their loved ones in addiction, and that there really is no gray area in
between.”
Collaboration: “And to be able to define what has worked and continue to build upon that and really look at what hasn't
worked and throw those things aside. I think that's my experience with being able to come up with a comprehensive plan
with family members to help them make a plan that makes sense to them”
Behavioral Health specialists
Warm handoff.” But it's not just a warm handoff because part of it is-- it is a service in terms of the ideas that the certified recovery specialist is someone who's had lived experience. So they're not delivering therapy. However, they are giving support and they're being present in a moment of crisis for an individual. And there can be some empathy that takes place, and there can be, once again, some support. And then, the more administrative aspect of it is helping the person navigate their treatment options, and locate treatment placements for the person, and helping them with their insurance issues or helping them with maybe ID or logistics of gathering everything they need and notifying the right person. Just offering that support and sometimes, in some cases, transportation.”
Staff training on how to access treatment: and they had stopped doing that to the point where it seemed like some of the newer staff were-- they had no idea how to “navigate or access drug and alcohol treatment whatsoever. They had no idea how to do it. And they didn't want toAnd they didn't want to
Help Post Naloxone: They're technically in withdrawal so they're having-- they're technically a danger to themselves or others, the fact that they're in withdrawal. So having them be released out against their will or whatever, I feel like something needs to be done with that. If someone was, I don't know, had a-- their sugar levels were through the roof, they wouldn't get released untilthey were stabilized. And I feel like that's not being done with drug abuse. They're either in withdrawal and-- like we said, you're more likely to go out and use them after having Narcan or not being clean for so long. I feel like there needs to be some kind of standard
More training for other professions on how to provide care“if somebody has diabetes or heart disease or whatever and they want to walk out, the hospital is not keeping them. But they have a lot of interventions that we don't-- that haven't been applied to this substance abuse patient. So there's interventions that we can use. And the one thing with drug and alcohol is there's a taboo about using any medications”
First responders • How do we help the family? “During an overdose or administering the Narcan, but there's a lot of family around
who just don't know what to do, whether it's the first time, what have you. But we asked, "We don't even need you to say anything, just give them our brochure." We'll step up from there and do what we're supposed to do, providing resources for family members and try to get them support as well.
• Access to treatment “I do also think that we have a lot of access issues, and so we don't have enough available treatment for the number of people who need to go to treatment today. And substance abuse treatment is that really unique type of treatment that it needs to be available today because today is the day you're asking for help, and you might not ask for help tomorrow. Hence, in a perfect world, we would have enough treatment beds for everyone who wanted to go to treatment today to be able to go to treatment today. I think, also, a barrier is that we don't have enough providers who can do medication-assisted treatment, so they might not meet the criteria for going inpatient. But the only place where you could start inductions for medication-assisted treatment is by going going inpatient. But the only place where you could start inductions for medication-assisted treatment is by going inpatient. And then we don't have an inpatient bed, so now you have to go through withdrawal without any kind of medication-assisted treatment, even if you wanted it. And so I just think that we have lots of room for improvement.”
• Hospitals readiness to respond: “ There is a problem at the ER, So they're going to give you fluids, and they're going to make sure that you are not going to overdose again, but then they're sending you out the door. And on your discharge paperwork, it tells you to contact AA/NA, and that's about it because there were no treatment providers”
•
Overdose Victims
• Never give up on me! “So an overdose to an addict is nothing, literally. To a normal individual, it would be like, Whoa. I need to stop doing this." Addicts' brains are wired differently. So I share my life experience. And by doing that, the nurses, I could see some of their expressions on their faces, they are shocked. And I was like, "It took 12 times for me. 12 times I entered treatment." They didn't give up. Someone did not give up on me, and that's why I'm here today.”
• “I woke up every day praying it all would stop and then I continued to put a needle in my arm. It was crazy and a crazy existence, but I could not stop. “
• “I did drugs before I did anything. “
• Access to care: “Treatment was not available. I had four kids. I knew something bad was going to happen so I went out that morning with the goal to get arrested because I knew that is how I would get help. “
Where is treatment readily available: “I received treatment for the first time in jail. I am thankful for my incarceration”“The only family I have is through the recovery house. When I overdosed they showed up at the hospital and
they continue to believe in me. “
Paths towards addiction: “I have done everything imaginable for drugs, this all started from a dental appointment, doctors office, at a friends house, after labor and delivery.
How the work has impacted and began to shape new systems:
• Translational: Improving community trainings for the five stake holder groups
• Tackling stigma that prevents others from receiving care and systems from opening their doors in communities that need them (i.e. from opening their doors in communities that need them (i.e. Recovery houses, syringe exchange programs, education about MAT).
• Training more professionals about Medicated Assisted Treatment, How to work with patients with addiction,
Advancing Education in Addiction and Behavioral Health: Interdisciplinary Education: We launched two pathways to advance education: Certificate and a MS in Addiction Counseling with an interdisciplinary focus.
Our goals:
• Individuals who wish to advance their career options and have a greater impact on the development of workforce competencies and treatment policy and resources will benefit from these programs of study. Due to the opioid epidemic, community members and professionals are seeking educational advancement opportunities in addiction counseling and education. The online master's degree in addiction counseling and educational advancement opportunities in addiction counseling and education. The online master's degree in addiction counseling and certificate in substance use disorder treatment will provide individuals in professions such as probation and parole, criminal justice, nursing, physician assistants, and public health to receive supplemental education to improve their effectiveness in responding to the clinical problems associated with the opioid epidemic and substance use disorders. In addition, this degree will provide a pathway to eligibility for a student’s State addiction counseling certifications.
What we need more of in the Addiction Treatment Field?:
• Innovative Leaders and fearless followers
Efforts to break down stigma that we as a profession face (professionals, clients, family members)
Unpacking the Associated Stigma with the opioid epidemic
What is stigma
• Stigma refers to attitudes and beliefs that lead people to reject, avoid, or fear those they perceive as being different. ... “Public Stigma” refers to the attitudes and beliefs of the general public towards persons with mental health or addiction challenges or their family members.
• In Goffman's theory of social stigma, a stigma is an attribute, behavior, or • In Goffman's theory of social stigma, a stigma is an attribute, behavior, or reputation which is socially discrediting in a particular way: it causes an individual to be mentally classified by others in an undesirable, rejected stereotype rather than in an accepted, normal one.
What is Stigma?
• Stigma has many different characteristics and target variants according to Pescosolido and Martin and it can be
• provider-based –telling patients that MAT is a replacement drug and recommending detox or residential treatmentrecommending detox or residential treatment
• policy-related-lack of insurance coverage for EB Treatment, taking children away from mother’s on MAT
• public practice-not providing medical providers with the education to screen and treat for addiction
• self-induced-internalizing and defining self as an “addict” who is “dirty” and not worth help.
Stigma: What role has stigma played in receiving, providing, and/or accessing treatment for patients with
opioid use disorder within your system of care or for your loved one and what is being done within your systems to decrease this stigma?
Did you know?
350,000 die due to other illicit drugs worldwide (WHO, 2014), 115 Americans die daily of an opioid overdose (CDC, 2016).
Alcohol and other drug related conditions are the number one public health concern in the US and Alcohol and other drug related conditions are the number one public health concern in the US and unintentional overdoses is the leading cause of accidental death (Warner, Chen, Makuc, Anderson, & Minino, 2011).
Despite the high prevalence of substance use conditions and about 14,000 treatment facilities and 100,000 recovery mutual-aid support chapters meeting weekly across the US, only about 10% affected individuals receive some form of help for their substance use disorder in any given year.
A main barrier to seeking and receiving help is stigma
(Kelly et al, 2016)
Why does what we believe about addiction matter?
There are approximately 23 million individuals who meet the criteria for SUD in the US and annually we spend approximately $600 billion dollars on the economic impacts from substance use mainly loss of productivity, health care expenses, and criminal justice involvement. Despite the high prevalence of substance use conditions and about 14,000 Despite the high prevalence of substance use conditions and about 14,000 treatment facilities and 100,000 recovery mutual-aid support chapters meeting weekly across the US, only about 10% affected individuals receive
some form of help for their substance use disorder in any given year. A main barrier to seeking and receiving help is stigma. (Kelly et al, 2016. para 3)
Evidence of this My personal beliefs about causes and treatment of addiction?
• Evidence of this
treatment of addiction?
My agency/institutions beliefs about causes and treatment addiction?
Stigma and Language
• Person first vs. Problem first (addict, alcoholic, substance abuser)
• Substance use disorders replace “abuse” and “dependence”
• Medicated Assisted Treatment Vs. Replacement or substitution treatment. (Collogquialisms)(Collogquialisms)
• Clean vs. dirty
• Conflating substance use disorder?
• Drug related moral panic?
• Understanding the difference between dependence and addiction
Language Matters
• The language used to describe health conditions reflects and influences our attitudes and approaches to addressing them even to the extent of suggesting that a health condition is a moral, social, or criminal issuesuggesting that a health condition is a moral, social, or criminal issue
Confronting Inadvertent Stigma and Pejorative Language in
Addiction Scholarship
A language Audit: Words that should be avoided
• Addict (Language that we use to self refer and professional language)
• Junkie
• Clean
• Dirty• Dirty
• Substitution Therapy
• Replacement Therapy
• User
• Habit
• Enabler
• Co-dependence
Words that work• Addiction
• Addiction free
• Addiction survivor
• Remission
• Medicated Assisted Treatment
• A person with
• Patient/Client
• Misuse
What I ask of you: • We must all self-reflect as individuals, treatment centers, agencies, and
as policy makers.
• How can we evolve?
• Recognize your power to create change
• Recognize opportunities to challenge the status quo• Recognize opportunities to challenge the status quo
• Educate yourself on Medicated Assisted Treatment; we all have the ethical responsibility to know best practices for all SUDs.
• Power is about impact and the ability to affect change, the ability to make things better for people (Arianna Huffington)
• I ask us all to think radically different about what we do, how we do it, and where change is needed.
Activity:
• Everyone has a white piece of paper
• Make four boxes:
• Label these: potential interdisciplinary collaborations, ways to combat stigma, educational changes that can be made, how can I get out of my silo (way of thinking, way of working, way of practicing)
• Separate each box in a half (one side is at your agency and the other is for your • Separate each box in a half (one side is at your agency and the other is for your community)
Think Big!!! Brainstorm within each section
Once done:
Consider adding an idea to one of the four papers in the room.
• interdisciplinary efforts that you can get involved in
• Ways you can innovate change in your organization
• Remember the interdisciplinary connections that we made today! Get business cards.
References
• Atwal A, Caldwell K. Do multidisciplinary integrated care pathways improve interprofessional collaboration? Scand J Caring Sci. 2002;164:360–367. [PubMed]
• Borgsteede SD, Deliens L, van der WG, Francke AL, Stalman WA, van Eijk JT. Interdisciplinary cooperation of GPs in palliative care at home: a nationwide survey in the Netherlands. Scand J Prim Health Care. 2007;25:226–231. doi: 10.1080/02813430701706501. [PMC free article] [PubMed][CrossRef]
• Cook G, Gerrish K, Clarke C. Decision-making in teams: issues arising from two UK evaluations. J Interprof Care. 2001;15:141–151. doi: 10.1080/13561820120039874. [PubMed] [CrossRef]
• Kailee Venzin (2018). Five things to know when working with an interdisciplinary health care team. Retreived from https://covalentcareers.com/blog/5-tips-interdisciplinary-healthcare-team/
• McCallin A. Interdisciplinary team leadership: a revisionist approach for an old problem? J Nurs Manag. 2003;11:364–370. doi: 10.1046/j.1365-2834.2003.00425.x. [PubMed] [CrossRef]
References
• Fornili K, Alemi F. Medicaid reimbursement for screening and brief intervention: amending the Medicaid state plan and approving state appropriations for the Medicaid state match. J Addict Nurs 2007;18(4):225–32.
• Gilson, A. M. and Kreis, P. G. (2009), The Burden of the Nonmedical Use of Prescription Opioid Analgesics. Pain Medicine, 10: S89–S100. doi: 10.1111/j.1526-4637.2009.00668.x
• John F. Kelly PhD, Richard Saitz MD & Sarah Wakeman MD (2016) Language, Substance Use Disorders, and Policy: The Need to Reach Consensus on an “Addiction-ary”, Alcoholism Treatment Quarterly, 34:1, 116-123, DOI: 10.1080/07347324.2016.1113103
• McLellan, A.T., Lewis, D.C., O’Brien, C.P., & Kleber, H.D. (2000). Drug dependence, a chronic medical illness: Implications for • McLellan, A.T., Lewis, D.C., O’Brien, C.P., & Kleber, H.D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13), 1689-1695.
• Miller, W.R., & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change Addictive Behavior. London:
• Ng, J., Sutherland, C., & Kolber, M. R. (2017). Does evidence support supervised injection sites? Canadian Family Physician, 63(11), 866.
• Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63, Executive Summary. HHS Publication No. (SMA) 18-5063EXSUMM. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
• SAMHSA (2016). SBIRT. Retrieved from www.samhsa.gov/sbirt.
• Warner, M., Chen, L.H. & Makuc, D.M. (2008). Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. US Department of Health and Human Services. Atlanta, Ga. Center for Disease Control and Prevention (CDC).
• Wermeling, D. P. (2015). Review of Naloxone safety for opioid overdose: Practical considerations for new technology and expanded public access. Ther Adv Drug Saf. 6(1): 20–31.doi: 10.1177/2042098614564776
