Outline Substance Use within a Trauma- Introduction Informed - PDF document

12/7/17 Addressing Outline Substance Use within a Trauma- — Introduction Informed Primary — Background Care Framework — Trauma-Informed Primary Care (TIPC) Model UCSF Women’s HIV Program — Health Empowerment and Recovery Services (HERS) Yvette Cuca, PhD Katy Davis, PhD, LCSW Rosalind de Lisser, MS, FNP, PMHNP Edward Machtinger, MD December 2017 WHP (Study Population) Trauma — 51 years old (range 20-76) — Adverse Childhood Experiences (10 items) — Mean 4.2, 58% had 4+ ACES — 49% African American / Black — 20% White — Trauma History Screen (14 items) — 61% food insecure in the past year — Mean 6.2, 73% had 4+ THSs — 87% currently on ART — Current Trauma (past 30 days) — 64% undetectable viral load — 4% coerced to have sex — 65% on prescribed opiates (~40% chronic) — 16% abused, threatened, or victim of violence 3 4 1

12/7/17 Substance Use Qualitative Data — 44% smoke cigarettes — Degree of trust in the clinic — Impact of patient trauma, illicit substance — 41% used illicit substances in the past 3 months use, and prescription medication use in — 17% cocaine, 9% amphetamines, 9% opioids clinic — “When you [clinic staff] ask us about substance use we think you will call the police and report us” — 23% at moderate/substantial/severe risk on the — “All of us in this group were diagnosed when we were DAST-10 locked up” — 22% positive AUD screen 5 Summary Results — High levels of trauma in WLHIV — High levels of substance use, prescribed and illicit — Trauma is associated with drug abuse (DAST) — A lot of energy around these issues in clinic 7 2

12/7/17 Healing from Lifelong Trauma: Improving Damaged Connections Response Improving Connections with Others Phases of Trauma Recovery 1. Trauma-informed and trauma-specific individual and group therapies 2. Peer-led empowerment, support and leadership training. 1. Safety and stabilization Improving Physiological Connections 2. Remembrance and mourning 3. Trauma specific psychiatry and physiologic techniques 3. Reconnection and integration Improving Connections with Our Bodies 4. Body/Mindfulness-Focused Healing The National Center for PTSD. http://www.ptsd.va.gov/. Last accessed February 4, 2016. Van der Kolk, Bessel A. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Penguin group. New York, 2014. Cloitre, M., et al., The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults . 2012. Herman, J. L. (1997). Trauma and recovery. New York: BasicBooks. Challenges Challenges (cont.) — Clinical/peer interventions (STAIR, TILI) effective for a — Need for lower threshold interventions—less narrow portion of patient population. commitment, less trauma-specific (initially) — Substance use not specifically targeted or addressed — Need treatments that specifically address substance by current interventions. use in a trauma-informed way — Some patients triggered by trauma-focused content. — Substance using patients were less likely to engage and more likely to drop out. 3

12/7/17 Health Empowerment Recovery Services: HERS Stages of Phases of trauma treatment Trauma Informed change Care & Precontemplation • Engagement (pre-phase 1) Addressing Contemplation • Clinic based behavioral health substance use: treatment (phase 1) HERS Preparation • Clinic based behavioral health treatment (phase 2) Action • Intensive trauma processing and Health Empowerment behavioral health support & Recovery Services (phase 2) Recovery • Reintegration, empowerment, post-traumatic growth (phase 3) HERS Clinic-Based Behavioral Health Services & Next steps Trauma Recovery Matrix Phases of Stages of Trauma Intervention Elements — Funding Models: Ryan White Change Treatment — Address social drivers Ongoing Screening and Assessment / Treatment Promotion / Social Precontemplation Support Pre-Phase 1 together with the medical Contemplation 1. Case Management and Linkage Services Engagement Preparation 2. Motivational Interviewing & Harm-Reduction Counseling model – bridging the 3. Drop-In Support and WRAP Groups Enrollment / Engagement in Behavioral Health Services (100% of Enrolled medical clinic with the Clients) 1. Psychiatric Evaluation with Medication Assisted Treatment Phase 1 community Clinic-Based Behavioral 2. Motivational Enhancement Therapy Action Health Treatment 3. Seeking Safety Groups (12 weeks per group / closed) 4. Drop-in WRAP Groups and Linkage to Residential, Detox, or Intensive Outpatient Treatment — Holistic approach that Intensive Trauma Intervention (Approx. 50% of Enrolled Clients) Phase 2 addresses SU and MH issues 1. Skills Training in Affective and Interpersonal Regulation (STAIR) (12 Intensive Trauma weeks per group / closed or individual sessions) Processing and in the context of chronic Behavioral Health 2. Individual Trauma-Focused Therapy Support 3. Medea Project &Butterfly Rising (peer led) disease management Ongoing Optional Recovery / Maintenance Support Programs 1. Drop-In WRAP Group Phase 3 2. Drop-In One-On-One Individual Therapy Maintenance Reintegration / 3. Drop-In Support and Mindfulness Groups (Recovery) Empowerment / 4. Ongoing Medication Monitoring Post-Traumatic Growth Photo by Lynnly Labovitz; 5. Follow-up Re-Screening and Treatment Monitoring used with artist and patient permission 4

12/7/17 Questions???? Contact Information: Yvette.cuca@ucsf.edu Katy.davis@ucsf.edu Rosalind.delisser@ucsf.edu Edward.machtinger@ucsf.edu 5