PreventionThe Big Picture

Going Up Stream

Prevention

• The central thought process in prevention is “going up stream”• It’s asking “sure, something is happening, but why is it

happening, and why here?”

• Identifying the core influences of an issue, and addressing those influences to impact the root of the issue

• Because of this it is important to examine not just the individuals, but also the environment, and its impact on individuals

What is the Environment

• The environment is often thought of as “the outside,” but we know it’s much more than that

• In addition to green space, it is also the downtown area, it is neighborhoods, it is our churches, and community organizations. It is the buildings, roads, businesses, and parking lots. It is the playgrounds, abandoned factories, gas stations, and schools.

• It’s also the community itself • It’s us, how we behave, act, and communicate with each

other

The Ecological Model

• From a public health perspective, it’s important that we view ourselves as one part of a system

• In one way, our actions, behaviors, and beliefs directly impact that system

• At the same time, the system directly impacts us; and in ways we might not always see or expect

Risk Factors

• In this context: factors that can increase the risk of initiation, continuation, escalation, or otherwise mode of substance use.

• Examples can be:• Positive attitudes toward youth substance use• Peer groups advocating risky behaviors• Lack of parental supervision and/or lack of boundaries

and expectations• Lack of effective package store ID practices• Lack of enforcement of social hosting• High alcohol outlet density

The Need for an Environmental Approach

• Focus on addressing the root cause of the issue, rather than triaging and treating those impacted• Look at macro level, environmental factors• When a pipe bursts in your house, do you start by

grabbing a bucket to scoop out the rising water, or do you stop the flow first?

• Focus on population level changes – changes that impact the whole community, rather than individuals

• Sometimes also called the public health approach

Examples of Environmental Approaches in Public Health

• Automobile accidents• Mandating

seat belts included in all vehicles

• Implementing speed limits on roadways

• Road signage and markers

• Reflective paint

How Can We Apply an Environmental Approach to Substance Use?

• Focus on changing the environment that youth are living in, rather than changing the youth directly• Programs like Dare, and Wellness Fairs are popular, but

have limited impacts on the community

• Look at interventions that address the “denominator”• The greater the number of people within the community

are impacted by the intervention, the greater the effect will be

• Ensure that interventions are appropriate to the communities that you are addressing• Local solutions to local problems

Emerging Trends

Higher 30-day use rates.• Self-reported mental health indicators

• Students who reported feeling sad or depressed, who had seriously considered suicide or hurt themselves on purpose report higher substance use rates across all four core substances.

• Trusted adult• Students who reported that they did not

have an adult in their life that they would go to for help report higher substance use rates across all four core substances.

• Risky behaviors• Students who reported stealing, cheating,

bullying and gambling in the past 12 months report higher substance use rates across all four core substances.

Perceive Parents

DISAPPROVE

of alcohol use

(n=1009)

Perceive Parents

LITTLE TO NO DISAPPROVAL

of alcohol use

(n=106)

30-Day Alcohol Use6% 24%

Perceive Parents

DISAPPROVE

of marijuana use

(n=970)

Perceive Parents

LITTLE TO NO DISAPPROVAL

of marijuana use

(n=140)

30-Day Marijuana Use6% 32%

Perceive Parents

DISAPPROVE

of E-Cig use

(n=942)

Perceive Parents

LITTLE TO NO DISAPPROVAL

of E-Cig use

(n=170)

30-Day E-cig Use2% 29%

Get Involved as a Member of the Community

• You do not need to be an “expert” to make a difference!

• Volunteer • Local groups/coalitions addressing the root causes leading to

youth substance use need all the community help they can get

• Change the community conversation• Community norms inform behaviors

• Advocate for effective policies• ID policies, purchasing age, social host, enforcement

• Role model healthy behaviors• Change can start with you

Vaping

Vaping

• Even “nicotine free” vape juice often contains detectable levels of nicotine

• Vape products are made from tobacco

• Popcorn lung

• Pneumonia

• There is still a lot we don’t know about

• FDA notice

• Increased rates of vaping at progressively younger ages has profound implications on the developing brain

Beneath the Surface:The Opioid Epidemic in Northwest

Connecticut

“Loving an addicted child is like grieving his death

and fighting for his life at the same time…”

- Sandy Swenson

Map

By the Numbers

• On average, 3 to 4 people die of an opioid overdose every day in Connecticut

• Since 2013, Connecticut has surpassed the national death rate for drug and opioid overdoses

2014 - Oct. 2016 121 referrals

52% connected to detox or other treatment

2017 156 referrals - 64 detox requests

66% connected to detox

2018 YTD 40 referrals - 16 detox requests

86% connected to detox

NEW! Connecticut Community for Addiction Recovery

Recovery Coach in

Charlotte Hungerford ED and Sharon Hospital ED

Community Case Manageran initiative of the Litchfield County

Opiate Task Force

• Insurers spend an average of $3,435 per year on an individual patient

• Those with an opioid dependence or abuse diagnosis cost insurers an average of $19,333 per year

Insurance Payments

• From 2003 through 2015, arrests for Drug Abuse Violations in CT declined 50%per Crime in Connecticut annual reports (state data)

• From 2007 to 2010, arrests for Drug Abuse Violations in CT declined by 3.3%per Crime in Connecticut Uniform Crime Reports (town data)

o Arrests for Drug/Narcotic Violations and Drug Equipment Violations in Northwest CT increased by 23.5%

Arrest Reports

Opioid-Related Treatment AdmissionsDMHAS programs only

Primary Drug at Admission = Opioid

• In the past two years, autopsies have increased more than 50% in CT, due to accidental drug overdoses.

• Over 14 out of 20 Northwest CT towns now have reported opioid-related deaths:Barkhamsted Morris TorringtonCornwall Bridge New Hartford WarrenHartland North Canaan WashingtonHarwinton Salisbury Winchester/WinstedKent Sharon

Median Age at Death in 2017 = 37

People in their 20s and 30s = 58% People in their 50s = 32%

Men = 65%

• Many deaths involved multiple substances including benzodiazepine, cocaine, ethanol (alcohol), fentanyl, heroin, hydrocodone, methadone, oxycodone, oxymorphone, and tramadol.

• Fentanyl and fentanyl analogs are EVERYWHERE: in marijuana, in cocaine, in counterfeit pills, in benzos, in ketamine, in meth……… NOTHING IS SAFE.

Autopsy Results

“This was not a cartel from Mexico kind of pushing drugs in our community, this was basically, an epidemic generated by the over-

prescribing of prescription medication within our medical community.”Michael Botticelli

White House Director of National Drug Control Policy (2014-2017)

“[This is] about America and Mexico, about addiction and marketing, about wealth and poverty, about happiness and how to achieve it.”

Sam Quinones

Dreamland: The True Tale of America’s Opiate Epidemic

How Did This Start?

94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more

expensive and harder to obtain”

Source: Opioid Addiction 2016 Facts and Figures,

American Society of Addiction Medicine

vs.

• Latest research indicates it can take as few as 5 days to become fully dependent on opioids.

• CT law currently limits prescriptions to 7 days for adults and 5 days for minors.

• However……………

How Addictive Are Opioids?

Recent Real Life Example

Day 1 An accident results in a broken leg which needs to be set, and a torn ligament which requires surgical repair. The EMT administers morphine. The ED sets the bone, schedules surgery and discharges you with a prescription for 20 Percocet (5 day supply – 4-6/day) which you start after leaving the hospital, even though you only need a 2 ½ day supply until surgery takes place.

Day 2 Waiting for surgery, taking Percocet.

Day 3 Waiting for surgery, taking Percocet.

Day 4 Surgery Day. The anesthesiologist uses Fentanyl and a nerve block to manage pain during surgery. You are discharged with a prescription for 56 Oxycodone tablets (7 day supply = 8/day) which are started immediately. Let’s say you take 2 2-tablet doses on this day. 52 tablets left.

Day 5 Post-op: taking Oxycodone, 2 tablets every 4 hours. 44 tablets left.

Day 6 Post-op: taking Oxycodone, 2 tablets every 4 hours. 36 tablets left……………………

Day 7

• Almost 30% of high school students have been offered, given, or sold illegal drugs on school property

90% of addiction takes root in ADOLESCENCE

High School Students

In general, heroin use is decreasing for Connecticut high school students

Age at First Use Risk of Dependence

Source: Hingson RW, Hereen T, Winter MR. Age at drinking onset and alcohol dependence. Arch Pediatr Adolescc Med. 2006;160:739-746.

0

5

10

15

20

25

30

35

40

45

50

<=13 15 17 19 >=21

47

38

28

17

9

17 16

118

4

% w

ith

Dis

ord

er

Age at First Use

Alcohol

Marijuana

“The traffickers…figured out thatwhat white people - especiallymiddle-class white kids - wantmost is service, convenience.They didn’t want to go to skid rowor some seedy dope house to buytheir drugs. The guys…woulddeliver it to them.”Sam Quinones

Dreamland: The True Tale of America’s Opiate Epidemic

The Impact on

Families

• Addiction impacts the entire family, so the entire family often needs treatment. A trained therapist can:

• Provide addiction education “what’s the right thing to do?"

• Help establish appropriate boundaries

• Provide support and aid in the healing process

• Greenwoods can connect anyone in Litchfield County with trained mental health clinicians.

• McCall has a program for loved ones called Recovering Together

• Nar-Anon meetings are widely available

How to HelpWhat You Can Do RIGHT NOW

• Safely discard ALL medication that is not being used to treat a current illness or condition.

• Local Medication Drop Boxes These boxes are located in the lobby of the police department, and are accessible any time the department is open. No questions asked, just drop the unwanted medications in the box and they will be safely and securely destroyed.

State Police Troop B State Police Troop L

463 Ashley Falls Road 452 Bantam Road, #A

North Canaan, CT Litchfield, CT

860-542-5249 860-626-7968

Torrington Police Department Winchester Police Department

576 Main Street 338 Main Street

Torrington, CT Winsted, CT

860- 489-2000 860-379-2721

How to Help –What You Can Do

RIGHT NOW

Lock up medications that must remain in your home. Carefully scrutinize the labels of any over-the-counter medications and safely dispose of those containing an active ingredient that could be abused. Do not keep a supply of over-the-counter medications “just in case.” Use non-narcotic, alcohol-free medications.

Explore Other Options for Pain Relief.

Work With Your Doctor.

It’s OK to ask for non-opioid medication. It’s OK to ask for less opioid medication. Understand the difference between physical dependence and addiction. Have your doctor assess your risk for opioid misuse. Develop a Plan of Care with a Patient Prescriber Agreement.

TALK ABOUT IT!

Support your local prevention network, the Litchfield County Opiate Task Force and other local efforts.

Drug overdoses now kill more people than gun homicides and car crashes combined

Opioid overdoses are one reason US life expectancy declined for the first time in decades

In 2016 more people died of overdoses than in the Vietnam war

© H. Payson 2017 - All Rights Reserved

www.vox.com/policy-and-politics/2017/6/6/15743986/opioid-epidemic-overdose-deaths-2016

Opioid-Related Treatment AdmissionsDMHAS programs only

Primary Drug at Admission = Opioid

• Nationally, those who overdose on prescription opioids are generally:o Poor, white men from rural communities between the ages of 20 and 64

o People with mental illness

o People using prescription opioids long-term, usually for chronic pain

o People who do not have a prescription or a medical need

• In Connecticut:o White, male, and suburban

o Greatest number of deaths between ages 22-32 and 40-50

• Typical drug abuser in Litchfield County (2015):o Age 25-54

o White and male

o Largest concentration of arrests at age 25-34

Source: Crime in Connecticut

Who is Affected?

• Lack of treatment capacity and facilities

• Physicians with little to no training in treating substance abuseo Some feel uncomfortable with patients dealing with addiction

o Others would like to treat addiction but can’t afford to specialize in the field full-time due to low insurance reimbursement rates

• Economic, environmental and social factors

• Insufficient law-enforcement presenceo Particularly concerning as Litchfield County is surrounded by areas defined as

High Intensity Drug Trafficking Areas by the U.S. Department of Justice

o Torrington: 76 sworn officers, 40 square miles, 35,774 residents

o 1 officer per 470 residents

o Winsted: 19 sworn officers, 33 square miles, 11,089 residents

o 1 officer per 584 residents

o Troop B: 13 towns, 514 square miles, 78,230 residents

o Troop L: 14 towns, 416 square miles, 160,015 residents

What’s Different About Addiction in a Rural Area?

Talking about the roots of addiction Barkhamsted, CT, initial film shoot for

“Uprooting Addiction” on 6/16/2016

© H. Payson 2017 - All Rights Reserved

Gabor Mate—Canadian MD and Author, who specializes in the treatment of addiction and trauma

ACE Score and Adult Alcoholismthe more childhood trauma, the higher the risk for addiction

500% increase of alcoholism in graded manner to ACE

© H. Payson & K. Becker 2017 - All Rights Reserved

2.5

5.9

10.511.5

16

0

2

4

6

8

10

12

14

16

18

20

% of Self-Reported Adult Alcoholism

Score of 0 1 2 3 4 or more

% of population

Only two cents of every dollar

goes to prevention or treatment; the

rest goes toward hospital care,

jails, and courts.

The U.S. spends nearly $468 billion a

year on addiction

• reduced drug-related crime/thefts

• criminal justice court costs

$1 toward prevention

and treatment = $4 - $32 savings in:

Access to Treatment

• According to the medical establishment, medication coupled with counseling is the most effective form of treatment for opioid addiction

• Standard treatment in the U.S. emphasizes willpower over chemistry

• Abstinence-only treatment may have a higher success rate for alcoholics, but it fails opiate addicts

o “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts. All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” - Dr. Mary Jeanne Kreek

• Medical treatment buys time for people with addictions to fix their lives, seek counseling, and allow their brains to heal. Doctors recommend tapering off the medication only with the greatest of caution. The process can take years, given that addiction is a chronic disease and effective therapy can be a long, grueling affair.

Access to Treatment

“When your kid’s dying from a brain tumor or leukemia, the whole community shows up…They bring casseroles. They pray for you. They send you cards. When your kid’s on heroin, you

don’t hear from anybody, until they die. Then everybody comes and they don’t know what to say.”

Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic

“We see recovery every day, but if we can prevent addiction?All of the heartache and pain and suffering that could be

alleviated, that would never start - who wouldn’t want that?”Maria Coutant Skinner, McCall Center for Behavioral Health

Uprooting Addiction:Healing From the Ground Up

A documentary that explores the connection between trauma and addiction

Mission Statement

Silence, isolation, stigma and unaddressed trauma cultivates the environment for addiction.

Through the use of personal stories and film, we will explore:• The root causes of addiction

• The transformational power of recovery

• How compassionate, understanding and access to evidence-based trauma treatment are more effective interventions than incarceration or exile

Support the movie that will help people who are suffering find their way home

recoveringcommunitymovie.com

© H. Payson & K. Becker 2017 - All Rights Reserved

“Uprooting Addiction”Official Trailer for local documentary in process