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

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Addressing Substance Use within a Trauma- Informed Primary Care Framework

UCSF Women’s HIV Program Yvette Cuca, PhD Katy Davis, PhD, LCSW Rosalind de Lisser, MS, FNP, PMHNP Edward Machtinger, MD December 2017

Outline

— Introduction — Background — Trauma-Informed Primary Care (TIPC) Model — Health Empowerment and Recovery Services (HERS)

WHP (Study Population)

— 51 years old (range 20-76) — 49% African American / Black — 20% White — 61% food insecure in the past year — 87% currently on ART — 64% undetectable viral load — 65% on prescribed opiates (~40% chronic)

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Trauma

— Adverse Childhood Experiences (10 items)

— Mean 4.2, 58% had 4+ ACES

— Trauma History Screen (14 items)

— Mean 6.2, 73% had 4+ THSs

— Current Trauma (past 30 days)

— 4% coerced to have sex — 16% abused, threatened, or victim of violence

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Substance Use

— 44% smoke cigarettes — 41% used illicit substances in the past 3 months

— 17% cocaine, 9% amphetamines, 9% opioids

— 23% at moderate/substantial/severe risk on the

DAST-10

— 22% positive AUD screen

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Qualitative Data

— Degree of trust in the clinic — Impact of patient trauma, illicit substance

use, and prescription medication use in clinic

— “When you [clinic staff] ask us about substance use

we think you will call the police and report us”

— “All of us in this group were diagnosed when we were

locked up”

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

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Response

Phases of Trauma Recovery

• 1. Safety and stabilization
• 2. Remembrance and mourning
• 3. Reconnection and integration

Herman, J. L. (1997). Trauma and recovery. New York: BasicBooks.

Healing from Lifelong Trauma: Improving Damaged Connections

Improving Connections with Others

• 1. Trauma-informed and trauma-specific individual and group therapies
• 2. Peer-led empowerment, support and leadership training.

Improving Physiological Connections

• 3. Trauma specific psychiatry and physiologic techniques

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.

— Clinical/peer interventions (STAIR, TILI) effective for a

narrow portion of patient population.

— Substance use not specifically targeted or addressed

by current interventions.

— Some patients triggered by trauma-focused content. — Substance using patients were less likely to engage

and more likely to drop out.

Challenges

— Need for lower threshold interventions—less

commitment, less trauma-specific (initially)

— Need treatments that specifically address substance

use in a trauma-informed way

Challenges (cont.)

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Trauma Informed Care & Addressing substance use: HERS

Health Empowerment & Recovery Services

Health Empowerment Recovery Services: HERS

Stages of change Phases of trauma treatment

Precontemplation

• Engagement (pre-phase 1)

Contemplation

• Clinic based behavioral health

treatment (phase 1) Preparation

• Clinic based behavioral health

treatment (phase 2) Action

• Intensive trauma processing and

behavioral health support (phase 2) Recovery

• Reintegration, empowerment,

post-traumatic growth (phase 3)

HERS Clinic-Based Behavioral Health Services & Trauma Recovery Matrix

Stages of Change Phases of Trauma Treatment Intervention Elements

Precontemplation Contemplation Preparation

Pre-Phase 1 Engagement

Ongoing Screening and Assessment / Treatment Promotion / Social Support 1. Case Management and Linkage Services 2. Motivational Interviewing & Harm-Reduction Counseling 3. Drop-In Support and WRAP Groups Action

Phase 1 Clinic-Based Behavioral Health Treatment

Enrollment / Engagement in Behavioral Health Services (100% of Enrolled Clients) 1. Psychiatric Evaluation with Medication Assisted Treatment 2. Motivational Enhancement Therapy 3. Seeking Safety Groups (12 weeks per group / closed) 4. Drop-in WRAP Groups and Linkage to Residential, Detox, or Intensive Outpatient Treatment

Phase 2 Intensive Trauma Processing and Behavioral Health Support

Intensive Trauma Intervention (Approx. 50% of Enrolled Clients) 1. Skills Training in Affective and Interpersonal Regulation (STAIR) (12 weeks per group / closed or individual sessions) 2. Individual Trauma-Focused Therapy 3. Medea Project &Butterfly Rising (peer led) Maintenance (Recovery)

Phase 3 Reintegration / Empowerment / Post-Traumatic Growth

Ongoing Optional Recovery / Maintenance Support Programs 1. Drop-In WRAP Group 2. Drop-In One-On-One Individual Therapy 3. Drop-In Support and Mindfulness Groups 4. Ongoing Medication Monitoring 5. Follow-up Re-Screening and Treatment Monitoring

Next steps

— Funding Models: Ryan White — Address social drivers

together with the medical model – bridging the medical clinic with the community

— Holistic approach that

addresses SU and MH issues in the context of chronic disease management

Photo by Lynnly Labovitz; used with artist and patient permission

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Questions????

Contact Information: Yvette.cuca@ucsf.edu Katy.davis@ucsf.edu Rosalind.delisser@ucsf.edu Edward.machtinger@ucsf.edu