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Something for the Pain

Something for the Pain - ECHO Idaho Podcast artwork

Listen to recorded lectures from ECHO Idaho’s substance use disorder education series archives and interviews with Valley County subject matter experts to find out the latest trends, best-practices and existing resources for opioid and substance use disorder prevention, treatment and recovery in Idaho.

Whether you work in healthcare and want to claim continuing education credit or live in Idaho and want to educate yourself about opioid and substance use disorder treatment, Something for the Pain has a little something for everybody.

Claim Continuing Education (CE)

Something for the Pain is considered an enduring material jointly by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC).

ECHO Idaho uses eeds software to manage our continuing education (CE). To claim CE for listening to an episode of Something for the Pain, please navigate to the eeds website.

Questions? Email us at wwami-ce@uidaho.edu, or call 208-364-4072.

Episode 12 – Partial Hospitalization Programs | Coding and Billing for Substance Use Disorders

Featuring: Jason Coombs, MPC and Deborah Seltzer, certified professional and risk adjustment coder

Claim CE for this Episode

Featuring: Jason Coombs, MPC, CEO and founder of Brick House Recovery and Deborah Seltzer, CPC, CRAC, certified professional and risk adjustment coder at Kootenai Care Network

Didactic Presentation Details

  • Didactic Presenter: Jason Coombs, MPC, CEO and founder of Brick House Recovery in Idaho Falls and Boise
  • Didactic Presentation Title: “Partial Hospitalization Programs”
  • Didactic Presentation Date: Oct. 7, 2021 
  • ECHO Idaho Series: Counseling Techniques for Substance Use Disorders
  • Didactic Presentation Video: video for this session is unavailable. 
  • Didactic Presentation Slides: slides for this session are unavailable.

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Jason Coombs, MPC, CEO and founder, Brick House Recovery, Boise and Idaho Falls
  • Speaker: Deborah Seltzer, CPC, CRAC, certified professional and risk-adjustment coder at Kootenai Care Network
  • Speaker: Nari Hsiu, DO, Addiction Medicine Fellow, University of Washington, Boise Addiction Medicine Fellowship 
  • Speaker: Karley Kline, former ECHO Idaho program manager

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • “VCORP Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

SOMETHING FOR THE PAIN
EPISODE 12_Partial Hospitalization Programs | Coding and Billing for Substance Use Disorders 

(0:00)
[Music]
[Jason Coombs]
…the biggest issue in Idaho is that even the influencers and the powers that be don’t utilize partial hospitalization

[Nari Hsiu]
…as a psychiatrist, we often think about rehabilitating folks once they’re in PHP and making sure that we’re integrating whatever’s going on in their own lives in terms of employment and their housing situation…

[Deborah Seltzer]
…Medicaid and Medicare loses its memory every January 1, even right down to if you’ve had a leg amputated, they consider it grown back unless it’s been recoded…

[Jason Coombs]
…We involve and offer resources for all members of the family because the most influential individuals in one’s life are the people that are closest to them…

[Sam Steffen]
Welcome back! This is Something for the Pain, a podcast produced by project ECHO Idaho made for Idaho’s healthcare professionals working to prevent, treat and facilitate recovery from opioid and substance use disorders in Valley County and throughout the Gem State.  I’m your host, Sam Steffen.  

[theme song plays]
E stands for extensions, looking where we aim to be
CH is for community healthcare the welfare of you and me
O is for the outcomes, that’s the story we can tell
ECHO altogether, you know what that spells… 

[fade music]

[Sam Steffen]
On today’s episode—Episode 12—we’re going to be talking about Medicaid and insurance for patients with substance use disorder. We’re going to hear about Partial Hospitalization Programs, what they are and how they help individuals recovering from opioid and substance use disorder, and their current status in the state of Idaho. Jason Coombs, founder and CEO of Brick House Recovery in Idaho Falls and Boise will be sharing a didactic presentation that was featured as a part of ECHO Idaho’s Counseling Techniques for Substance Use Disorders series. Following that presentation, I’m talking with certified professional coder and certified risk-adjustment coder, Deborah Seltzer, of the Kootenai Care network in northern Idaho to get a bit more insight into what’s involved in the coding and billing for patients with substance use disorder. All of that is coming up in today’s episode of Something for the Pain.

[cue music]
ECHO Idaho—sign up for our free sessions, there’s a handful every month
ECHO Idaho—you can earn CE credit while you sit and eat your lunch

[Fade music]
[Sam Steffen] 
Prior to Medicaid expansion in 2020, many low-income Idahoans with specialty mental health diagnoses and substance use disorders were denied funding for treatment at the level of medically managed intensive inpatient services. Since Medicaid expansion in 2020, Medicaid and private insurances now cover partial hospitalization programs. Jason Coombs joined us to talk about the benefits of these programs for individuals with a substance use disorder and what this service looks like at his organization. 
Jason Coombs is a person in long-term recovery and the Founder and CEO of nationally accredited Brick House Recovery, with locations in Boise and Idaho Falls. He holds a Masters degree in Professional Communications and is the author of the award-winning book, Unhooked: How to Help an Addicted Loved One Recover. This presentation, titled, “Partial Hospitalization Programs” was recorded live on October 7, 2021 as a part of ECHO Idaho’s Counseling Techniques for Substance Use Disorders series. 

[Jason Coombs]
So what I'm ultimately here to do, from a didactic standpoint is to highlight the landscape of Idaho right now from a substance use disorder approach to healthcare. And historically, we have seen gaps in the process, gaps in the ASAM continuum of care. 

[Sam Steffen]
The ASAM continuum is a spectrum of care for individuals in need of treatment for a substance use disorder, determined by the American Society of Addiction Medicine. If you’re unfamiliar with those levels of care and want to learn more about them, check out Episode 6 of Something for the Pain: LaDessa Foster Talks Levels of Care in Addiction Treatment. 

[Jason Coombs]
A couple of these levels of care, I want to point out. The medically managed intensive inpatient services 4 and level 3.7, with Medicaid expansion, they now they cover those levels. The challenge that we have in Idaho, is that there are only three facilities that offer that level of service.  

[Sam Steffen]
The three facilities that Jason is talking about here are Intermountain Mental Health Clinic and Cottonwood Creek Behavioral Hospital, in the Treasure Valley, and Kootenai Health system, in northern Idaho. 

[Jason Coombs]
So there's a gap here. Historically, anytime someone has needed help, they will end up in the IOP or intensive outpatient services, because prior to Medicaid expansion, level 2.5 was not covered by state funds, Medicaid, still not covered by BPA, yet. And then of course, you have your outpatient services that are covered. 
So now Medicaid actually covers partial hospitalization services. The challenge there is that it's not a detox level, and some people need detox and some people need residential treatment. 
So I've been in many conversations working with the powers that be to expand this continuum of care and levels of services for the Medicaid population. The private population can get most of these levels of care, as long as they're meeting medical necessity and that the authorization is, is approved. So partial hospitalization serves people who are transitioning, but it's a medically supervised transition. So that's the key is partial hospitalization, they're not living in a hospital, there's not a bed that they're staying in. They're still living at home or sober living or wherever, and then they come in between 20 and 30 hours per week. So it's either four hours a day, or it's six hours a day, depending on the program, and it serves to prevent relapse, prevent hospitalization or prevent incarceration. Furthermore, it's an alternative to residential treatment, or a transition from residential treatment. If we had options for residential treatment, I think they would be full of Medicaid clients but it's not an option at this point. 

With Medicaid expansion, not only is PHP covered by Medicaid, but they are working on covering level 3.5. And standing up level 3.5. Another win, and I love the direction we're going in terms of Medicated Assisted Treatment, if you have heard of Sublocade, which is the extended injection that patients can get once a month. Medicaid now covers that in full. 
But back to PHP. So this this is, this is a transitional care here in lieu of the continued hospitalization. And it's for people who aren't at crisis risk or immediate risk to themselves. The severity of their symptoms need to be appropriate for partial hospitalization, because in a less acute level of care, which is IOP, they would struggle, they would fumble, maybe they got co-occurring stuff, maybe it's their ADHD that's not dialed and maybe it's their anxiety disorder that’s not dialed in yet. They haven't seen a psych provider. So PHP serves as the front door to get into successful intensive outpatient treatment. The kicker to that is how long is PHP? Well, Medicaid will typically authorize one month right out of the gate with trusted providers. 

This level of care also serves for people that are coming out, but people that are in IOP, that are struggling. And oftentimes, and we have someone in IOP, and the stressors hit him or they go through a med change, and they're starting to get squirrely…instead of sending them to a residential treatment, which is a hard sell by the way, even if they do have funding to encourage them to go to 30 days away from home, family, work, all that—partial hospitalization is the next level of care in the continuum that would help this individual while they're still engaged in their daily life to a degree. So anytime there's increased in symptomology, anytime that there's disturbances of behavior or their mental health and behavioral health aren't working well in a lesser level of care, this is what partial hospitalization does. And then they go through the psych provider, get dialed in the medications, there is medication management through that. We have community partners that we work with that monitor that as well throughout the whole program, but specifically, having one provider or a group of providers that are aware of substance use disorder and the risks of medications with a substance use disorder patient is really helpful plus, it, I don't have to have 100 releases of information with 100 different providers throughout the Treasure Valley and in Idaho Falls. 

So the experience of partial hospitalization includes everything from the beginning clinical and psych assessments, to then be medically cleared and clinically cleared, and diagnosed appropriately for this level of care. With the medication management, they get a weekly follow up while they're in PHP. So they're not just put on meds, and then, you know, see you next month, because every single day is risky for someone in this level of care. So daily monitoring of their behaviors in groups. Continued guardrails with the drug testing and accountability. Although Medicaid has limited drug testing, those of us that are in this level of care and in outpatient, we know that it's a cost of doing business. So we typically will cover that, at least at Brickhouse. 
So this is the flow of someone's experience in the levels of care from PHP down from an intensive partial hospitalization experience for about a month. And I just want to make it clear, these timelines are not firm. So just cause it says one month they go to IOP, that should be a very blurry line. This is very person centered. The same with IOP: It's not a mandatory 90 days, but you kind of get the idea that we tried to treat them for a full six months. We want them to invest in the whole thing. And what we have seen through this process is if they're able to get dialed in mentally, and through their pause and their cravings and get stable in PHP, then in IOP, that's really where they can transcend the self-hatred and do that inner cleanse, that “soul work” while connecting with a higher power. And if they're not ready for a higher power, as long as they're not inappropriately dismissing someone else's experience, we bring them in and let the sunlight kind of melt that ice cube and soften them up. 

So the biggest issue in Idaho is that even the influencers and the powers that be don't utilize partial hospitalization, you get so much more juice for the squeeze in PHP, than trying to have five providers accomplish the same thing that can be done in a partial hospitalization setting. And it's one month or two weeks, depending on the person—if someone's like, I can't do PHP, I have a job I work and then all these pressures, we will try to do at least one week so that they can meet with the psych provider, have it covered, get dialed in on medications and have one follow up and stabilize at least in one week. And then help them get to IOP. 

[Karley Kline] 
Thank you so much Jason for all your insights and experiences with Idaho Medicaid, community resources, and of course your lived experience. 

[Sam Steffen]
Speaking here is former ECHO Idaho program manager, Karley Kline.

[Karley Kline]
I want to open it up to any questions.

[Nari Hsiu]
Thank you so much, Jason. I thought that was really helpful to learn more about. 

[Sam Steffen]
This is Nari Hsiu, psychiatrist, and Addiction Medicine Fellow at the University of Washington-Boise Addiction Medicine Fellowship. Nari is also a panelist on ECHO Idaho’s Counseling Techniques for Substance Use Disorders series.

[Nari Hsiu]
So you know, as a psychiatrist, we often think about kind of rehabilitating folks once they're in PHP and making sure they're integrating whatever is going on in their own lives in terms of employment and their housing situation. So I'm just kind of curious and interested to hear what it is that you guys also do to help rehabilitate people to get them gainfully employed—because that can be a really big risk for relapse or return to use, for a lot of folks. So that was one question. And then I also was wondering about MAT. You mentioned Sublocade and if that's something that folks are starting when they're in PHP, or you initiate that later on during the course of their treatments?

[Jason Coombs]
Yeah, let me start with the MAT answer, cause I think that can be quicker, and then I'll talk about the case management, job stuff. The MAT piece, there are nuances and complexities that come with MAT, and there are a lot of variety types of MAT. And so I'm encouraged that there's more funding for it. And that more resources and centers brick and mortar and mobile, MAT services and incorporating MAT services within institutions, and the stigma is sort of melting away is an encouraging direction. 

What we try to do with MAT is just be cautious from a provider standpoint, so that there's not a black market, where people are saying I need this and that and that and this because their peers are on it. That's why I've been abstinence-based through my own treatment, through the genesis of Brickhouse, but I've had a couple of shifts to open it up with guardrails and one of those reasons is because I had my my cousin detox on my couch who was five months pregnant, who was an IV heroin user and her medicated assisted treatment experience not only saved the baby, and that baby's healthy and happy, she's pregnant with their second and she's been almost four years sober. But doing MAT and I'm like, that works! But I've had I've had a huge shift and just like there's a way to do this right with the right accountability. 

To your question about work and getting a job, paying fines, functioning. So this is my belief to my core. Substance use disorder as a disease needs to be treated as if someone is coming out of the ICU as a cancer patient that just that just had chemotherapy and there is a convalescence window. And convalescence is: don't run out there and work full-time. Don't run out there and add stress to your life. Like, pump the brakes! Breathe! Take walks around the block! All of your finance stuff, they will wait for you I promise they will hound you but let's help you convalesce, right now. And that's the beauty of residential treatment. That's the beauty of going to a North Point and going to a Walker Center and an Intermountain Hospital and to just be serene to connect again to come out of the fog and then at PHP that's still happening. And so we encourage them to begin that process of learning the skills and learning how to apply for a job. Some don't even have a resume. Some have been dependent on the state forever. And so it's a hand-holding experience. And that is our primary focus, is to help them pump the brakes and put first things first. We need providers in this industry. So my focus is every single patient and client are the future providers. And so how do we help them go through this properly so that when they graduate, they're becoming peer support specialists, they're becoming students that want to get their CADCs, they're becoming students that want to go get their masters degrees, and they want to rise up and help us because we need more help here in Idaho. 

[Sam Steffen]
That again was a didactic presentation delivered by Jason Coombs titled “Partial Hospitalization Programs.” That lecture was delivered live on October 7, 2021 as a part of ECHO Idaho’s Counseling Techniques for Substance Use Disorders series. Information about how to contact some of the organizations and services mentioned in that talk are available in our podcast shownotes on our website: www.uidaho.edu/echo-podcast. 

[Banjo strum]

Jason’s mention of Medicaid expansion, substance use disorder treatment and patient economic status gives us a launching point for the next portion of today’s program, which investigates the role coding and billing play in the healthcare landscape. For individuals who receive the diagnosis of a substance use disorder from a healthcare provider, the way that diagnosis is coded can affect not only how the patient is billed by Medicaid or their private insurance—it can also have an impact on future treatment options for that patient. 
I sat down with Deborah Seltzer, certified professional coder and certified risk adjustment coder at Kootenai Care network to talk about this very thing.

[Sam Steffen]
Welcome to the program, Deborah! I was just wondering if we could just start with you saying your full name and then saying where you work, and what it is that you do.

[Deborah Seltzer]
Yes, hi. My name is Deborah Seltzer, I work for Kootenai Care Network up in northern Idaho. I am a certified professional coder and a certified risk adjustment coder. And my title here is risk adjustment clinical coding reviewer.

[Sam Steffen]
Can you tell us a little bit about what brought you to this line of work?

[Deborah Seltzer]
Well, I’ve kind of specialized in risk-adjustment coding since I became certified as a coder. And I kind of came to the medical coding field as a second phase of my professional life which is really common in this field. I started first as a licensed practical nurse, worked in acute care nursing in various hospitals in Southern Puget Sound, and later as a clinical outpatient nurse. But after I had children we moved around a lot. Really a lot. I kind of hung up my stethoscope and settled in to become a full-time mom. But once my kids were grown it was time to find some new work again and I decided to just use my healthcare knowledge and get back to work in a different role.

[Sam Steffen]
And for folks who may not be familiar, your job title is certified professional coder, and certified risk-adjustment coder. Can you just talk a little bit about what’s involved in becoming certified?

[Deborah Seltzer]
Sure. It’s something that there’s not mandatory…you have to have a degree of some sort from a college to be certified as a professional coder. It is something that a lot of people who have been in the role for a long time learned as they went along. But I think that with the change that came from ICD-9 to ICD-10 where there was a lot more specificity involved in the coding of the diagnoses, it became more and more apparent that people really needed to be certified in the role that they had so that everybody had the same education. 

So there are a lot of different places out there that offer different billing certification programs, but your most highly-sought-after certifications come from AAPC and from AHIMA, and my certifications are through AAPC. Their CPC certification is based mostly on out-patient clinical coding and AHIMA’s CCS program is based more on inpatient coding because there is kind of a large difference between the two.

[Sam Steffen]
You mentioned a few acronyms there. The AAPC stands for the American Academy of Professional Coders and AHIMA is the American Health Information Management Association. You also mentioned the ICD-10. This is like the main coding manual, is that right?

[Deborah Seltzer]
Yes, it’s the diagnostic bible, basically. There’s ICD-10 CM, which is for outpatient, and then there’s the ICD-10 PCS which is for in-patient. And just because some of the inpatient diagnoses and procedures have different kinds of codes, so they use slightly different books. But these are still books that are used from the World Health Organization, the same books that are used around the world. 

There are different manuals of codes that you use depending on the kind of care has been provided. The ICD-10 is the book that contains your diagnoses codes, so for whatever their diagnosis is, or their symptom, if they haven’t got an actual diagnosis yet, then you use a code for what their symptom is until the diagnosis is found. 

And then there’s CPT codes which describe the procedures that are performed, and some of the…which would include your lab and pathology and all of those things, and some medications…your HCPC codes, deal a lot with your Medicare codes, what the government wants to see, what they have different codes for like their annual well visits and for a Medicare Advantage patient versus you know somebody who’s 20 years old. So there’s different codes for…different codes for different folks for different things, all the time, but they all work together and make it…it’s just a shorthand, so that instead of everybody trying to decipher the messy notes that a doctor may have written or going through the electronic medical record, we can just go to the claims data for the codes that were submitted and they’ll all tell a similar story in the same language and make it a little more concise.

[Sam Steffen]
So coding is a global…these are the same codes in every country, every state?

[Deborah Seltzer]
Yes. Every country. Every state. Even in the United States, unfortunately, some people outsource their medical records and so they can be coded in India and the Philippines because they all use the same codes, too. And so they may be looking at our medical information, but it’s still the same code, just as if it were a patient in their own country, the same code would apply. 

[Sam Steffen]
Okay. And for the people who may not be familiar with the roles of a coder or a biller… can you just kind of walk us through the process from when a patient comes in to see their care provider, to what kind of happens to those notes as they get passed through to the coder then to the biller and so on?

[Deborah Seltzer]
Sure. Let me describe the two separate roles of coder and biller. They’re combined in a very small office  sometimes, but they are usually two distinct roles. And the generalized kind of description is that the coders and billers together, we translate the medical documentation between what the provider has written in his medical notes for what they’re diagnoses are and what procedures have been performed, and then those are then translated into these codes that can be submitted to the insurance companies or your federal government, which is Medicaid and Medicare, for payment. 
Generally, the notes from the providers go to the coders first. They are the first ones to receive the chart-note, and they make that translation from the notes to the codes, the ICD-10 CM codes or the CPT codes or HCPC codes that describe the procedures, diagnoses, injections and supplies that were used—all those things are all written down in these codes and then that information is given to the biller so that they can put that on the claim form and get that sent out to the payer or the insurance company or the federal government, whoever it is that’s going to be paying the bill.
Once the biller receives that information they are responsible for sending that claim out and then tracking that claim so that they can record any payments that come back or any denials or questions that come from the insurance companies, or changes in modifier codes that were used to make sure that everything’s lined up the way the insurance company wants it to look. Because a code that you can submit to one insurance company, it’s the very same code but if you submit it to different insurance companies they’re going to want a different modifier before they’re willing to pay it. So it comes down to the experience of “these people want this and this person wants that,” and most coders just have kind of a little log book of, “okay, I’m sending this over to…Blue Cross” or whoever so they need to have it this way and then this other company over here needs to have it billed a different way.

The other thing that you have to be careful of is, a lot of procedures that are done, are “bundled” meaning there’ll be various steps to a procedure, and all those codes wind up being bundled into one bulk fee. And you have to be careful that you don’t separate those bundled codes and try to bill them separately, because that can be considered unbundling and it’s against the rules. Because you could have a higher amount paid to you than if you billed it as a bundled code, I guess. And so… that’s just one of the things that you have to look at. 

Generally one of the reasons that people try to discourage providers from doing a lot of their own coding and billing—in very small practices you do see that—Providers are great for being providers and having received that medical training in school, but nobody really taught them how to code. And it’s just not part of the curriculum. And so, I have seen providers that just Google what they think might be a good code, and then they usually end up with the short end of the stick on that one.  

[Sam Steffen]
Yeah, can you talk at little bit about some of the additional functions that coding has to the medical process?

[Deborah Seltzer]
Sure. The codes that we use not only allow the provider to get paid for what the work is that they’re doing, but they also become part of the patient record, which is like a description of the patient’s medical condition and their medical history. But they also tell a story of not just the patient illnesses or what kind of medical procedures or health screenings that they’re having done, but also if they’re experiencing any things like unstable housing, limited access to safe drinking water or food, financial difficulties that can affect their ability to obtain their medications, domestic violence, other life events like that. And so these codes might indicate that they could use some further assistance, and may be eligible for a case manager or chronic care management, depending on what their diagnoses are and what their insurance coverage provides. And if they don’t have that benefit through their insurance there may be some other locally or federally funded program that could help fill that gap for them. 

These codes also…after they’re kind of stripped of their personal identifiers, become really important data for the state and federal governments, where they can use that information to help determine where and how much funding may be needed for social safety-net programs. 
And then they can also be used to help determine where resources maybe should be allocated to investigate the prevalence of certain diseases and study them and hopefully find potential treatments. This data is also how local and federal officials have determined that there has been an increase in substance use disorders and death which has resulted in the national efforts that we have now to turn around the opioid crisis in the country.

[Sam Steffen]
Yeah, I do want to kind of get into talking about specifically how coding and billing works for patients who may be receiving treatment for a substance use disorder. I kinda just want to hear you talk about what that process is like?

[Deborah Seltzer]
Well, I can kind of skate around some of that a little bit… in my role as a risk adjustment coder is to make sure that the usually chronic diseases, some acute diseases, are recaptured each year so that Medicare/ Medicaid understands how sick a person is. And so if I code for a patient who’s seeing the doctor this year and they have diabetes or they have a substance use disorder, and then they’re seen again January 1 of 2022, and through all of 2022 nobody codes that they have diabetes or a substance use disorder, then Medicare would be like, “oh, they don’t have these anymore!” And so they’ve been presumed to be healthy in those two areas. And that affects the amount of funding that Medicare/ Medicaid will pay to…whether it’s another third-party payer insurance or just like a Medicare Advantage plan or just what they plan to have available to care for that patient. So that’s my role…not in just the daily—making sure all those bills get paid and sent out correctly so that the providers get paid. My role is to make sure that the payers know this is the disease acuity of this patient, this is what they look like like on a report card every year for their disease burden, how sick are they. So that it can be planned for. And that comes down to also including like a substance use disorder, whether they’re dealing with an opioid addiction or any of the other substances that it could be. If we are not capturing those on a yearly basis, then the payer does not know because Medicaid and Medicare loses its memory every January first, even right down to if you’ve had a leg amputated, they consider it grown back unless it’s been recoded. 

Now, on the flip side of that, they are also—the payers are also looking at the claims that are coming in to them. So if they are seeing treatment for a substance use disorder, or if they are seeing a lot of opioid prescriptions coming through that they are paying for, they are going to send out a report to us that says, “Maybe this patient needs to be diagnosed with a substance use disorder.” The Payor’s role is to be prepared to meet the financial responsibilities of providing care to their beneficiary. In an attempt to make sure that all possible diagnoses are covered and planned for, they can make assumptions about information they receive, that may increase a patient’s risk score. But it is the provider’s responsibility to make sure that a diagnosis is appropriate for a patient and they make that decision. And unfortunately how ill they are also means how much money will the payor get to provide the care to that patient. So it is a careful balance of what a payor may expect versus what a provider feels is a true representation of their patient’s diagnosis. And then if the payor can provide that care at a lower price, making sure that patient’s having quality care, but have money left over, then that ends up as like shared savings for the payer and sometimes for the providers that are contracted with them. And so that’s a good way for them to reinforce, you’re doing a good job of taking care of this patient. 

[Sam Steffen]
So the diagnosis of a substance use disorder potentially means the patient is at a higher risk level…

[Deborah Seltzer]
But at the same time you have to be really careful to make sure you’re not saying, “Well, I guess we can say this patient has a substance use disorder,” when actually they’re being treated long-term with an opioid-prescription, but they’re on a pain-contract, they’re taking their drug-screens, they’re not coming up short on their medications, they’re not—they’re having no problems functioning in their daily life, it’s not creating problems in their personal relationships, there’s nothing there that says that they are misusing their medications, that they are using them just to deal with whatever it is that’s causing them this chronic pain and based on that they are in line and doing what they are supposed to do. But if a payer comes along and says, “Well, hey, they are on these chronic medications, we think that they should be considered as having a substance use disorder…” and if the provider, who’s under a lot of pressure as it is when it comes to prescribing opioids and the regulations that they must meet, and, you know, the constant scrutiny about the quantity of opioids that are being prescribed and the age of the patient, potential interactions—all those things that are watched—now they have to make the decision about whether their patient has a substance use disorder or if they are using them carefully as directed for a legitimate diagnosis. Unfortunately, the clinical language that a provider may use in documentation to say that a patient is dependent on opioids to manage their pain and maintain their activities of daily living is interpreted differently in ICD-10. Opioid dependence in ICD-10 which is usually code F11.10 or F11.20 represents a patient that has a substance use disorder, which is considered a behavioral health diagnosis. If a provider wants to indicate that the patient is on long-term, current opiate analgesic, that they are not abusing or psychologically dependent on the medication, then they should be coding it as Z79.891 which is long term current use of an opioid analgesic. Whichever code the provider selects needs to be backed up by the documentation that they record in the chart.

So if we have a code come in on the bottom of the doctor’s note that says that the patient has an opioid use disorder, they are dependent on opioids, there’s nothing in the chart notes that backs up that  statement, I can’t code that. I need the documentation. If the provider is like, “Oh, yeah I totally meant to write down the stuff that would support that and he does an addendum and does give you the legitimate stuff that you need to be able to code that, then that’s great, send it in and do it.

[Sam Steffen]
So it sounds like coding for a substance use disorder is dependent upon the doctors’ ability to document their assessments. It seems like this could also have lasting implications on the patient…

[Deborah Seltzer]
These kinds of diagnoses come with a lot of social stigma still and they do come with an added responsibility in assigning the diagnosis correctly to a patient. A substance use disorder can impact future decision in your healthcare, may impact life insurance premiums, or even cause problems with employment, depending on the type of job you have. Just like maybe having prior heart attacks might make somebody think twice about whether or not they want to offer you life insurance, somebody who has a substance use disorder, it may make them think twice about whether they want to give you life insurance, too. You’re at a higher risk. And if that label has been put on you falsely, that’s a big burden to carry through your life. 

Now, the Affordable Care Act made it possible that the health insurances that are available on that marketplace have to offer you insurance without considering your preexisting conditions. But that does not necessarily apply to whether someone will let you buy life insurance without a higher premium, if at all. So you need to be careful what you’re agreeing to about a patient, and if you’re going to say that that’s what they have, then we need to make sure that the documentation is there in the chart that backs that up. 

[Sam Steffen]
That’s really helpful. Thanks for explaining that. 
You mentioned some of the criteria that would go along with diagnosing somebody with a substance use disorder. If it’s not too much, would you mind kind of just walking us through that?

[Deborah Seltzer]
According to the American Psychiatric Association, these are the following diagnostic criteria for an opioid use disorder—and that would be a problematic pattern of opioid use leading to clinically significant impairment or distress as manifested by at least two of the following for a diagnosis level of mild, and 4-6 of the criteria for a moderate to severe level, of the following,  occurring within a 12-month period. 

[Sam Steffen]
Okay so the following is a list of 11 different criteria.

[Deborah Seltzer]
And the list of the things are:
1. Opioids are often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid or recover from its effects.
4. A craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use despite having a persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the opioids.
6. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations which is physically hazardous.
9. Continued opioid use despite knowledge of having a persistent or recurrent psychological problem that is likely to have been caused or exasperated (exacerbated) by the substance.
10.Tolerance, as defined by either of the following: a need for markedly increased amounts of opioids to achieve intoxication or desired effect, or a markedly diminished effect with continued use of the same amount of an opioid.  And on this one that there is a notation here that the criterion is not considered to be met for that clause there if they are taking opioids solely under appropriate medical supervision. So the patient that is experiencing chronic pain may eventually experience it, the dose of medication they’ve been on is not relieving their pain as well anymore, that does not necessarily qualify them for a substance use disorder, that just means it’s not being as effective anymore because of long-term use. One of the other criteria is:
11. Withdrawal, as manifested by either of the following: Which is, characteristic opioid withdrawal syndrome or if opioids or a closely-related substance are taken to relieve or avoid withdrawal symptoms. And again for this withdrawal criteria, it is also not considered to be met for individuals who are taking opioids solely under medical supervision. Anybody who has been put on them long-term for a chronic pain disorder will experience withdrawal symptoms if that medication is withheld from them. That does not mean that they have a substance use disorder, that just means that their body was used to the medication and now it’s not.

[Sam Steffen]
Okay.

[Deborah Seltzer]
So those are the main criterion.

[Sam Steffen]
And again, you said, out of that list you just read, you could have any two of those?

[Deborah Seltzer]
Any two of them for a mild substance use disorder, four to six for a moderate to severe substance use disorder, occurring within a 12-month period.

[Sam Steffen]
Okay. You also mentioned in the notes you sent the nuances of coding for a substance use disorder as opposed to like diagnosing for it, and I thought those were kind of interesting as well. Would you mind just kind of going through those examples also?

[Deborah Seltzer]
No I don’t mind at all. I’m just looking real quick through my notes here because I wanted to read them correctly to you as well. Even when I code for it, I still look at the guidance because you just gotta make sure you’re getting it right. So when you’re coding for a substance use disorder or an opioid use disorder there are rules which guide which code you choose. And according to the guidelines in the ICD-10 book, it says when the provider’s documentation refers to use, abuse, and dependence of the same substance, whether that’s alcohol, opioids, cannabis, whatever the substance is, only one code should be assigned to identify the pattern of use based on the following hierarchy: 
- So if both use and abuse are documented, you only assign the code for abuse.
- If both abuse and dependence are documented, you assign only the code for dependence.
- If use, abuse and dependence are all documented, you only code for dependence, kind of like that’s the trump card.
- And if both use and dependence are documented, then you still only assign for dependence.
So if dependence is in there, that’s the one you would code. It just wouldn’t make sense to code all three—if they’re dependent of course they’re using and abusing. 

[Sam Steffen]
Right. And so that also makes me wonder about the distinctions between use and abuse and dependence… or those things that are being determined by the physician? Or are those…? 

[Deborah Seltzer]
Those are things that should be determined by that physician, by that provider. And based on those criterion that we just went over, that would be the difference between a patient using it carefully as directed and a patient abusing it.

[Sam Steffen]
Gotcha.

[Deborah Seltzer]
And then there will be some medical dependence if they’re legitimately using them in the safe way that the doctor has prescribed them; it’s still a physiological process where their body is going to become dependent on them, but that doesn’t mean that they’re psychologically dependent on them and they can’t wait to score their next fix. They’re just trying to seek some release for their chronic pain condition.

[Sam Steffen]
Sure. Okay. Thank you. That’s really helpful. Well, Deborah, is there anything else you want to share or anything that you think I should have asked that I didn’t?

[Deborah Seltzer]
I just want to make it clear that no coder, including myself, wants to second-guess the provider. That’s not our job. So when I say, “your documentation isn’t supporting this,” I’m not saying “you’re not doing your job correctly, this is not what this patient has,” what I’m saying is: “if this is what you’ve filled in as the diagnosis for the patient, I just need you to put it in the chart.” Cause a lot of providers they chart in their head, and we try to get them to chart in ink, you know. They know what’s going on with their patient but they fail to put it down on paper or in the electronic medical record. And so that’s where you run into that kind of translation problems, like, “I know you’re probably thinking something, but it’s not here in the charts to support it.” And we can’t—we can query a provider to get that information from them, but we can’t lead them with a leading query to say, you know, “if this is the diagnosis that you want to put, this is what you need to say.” It’s very regulated. So we just have to say, “this is what the chart indicates, this is what you wrote, these are some choices, do any of these apply?” And then they can figure out on their own, “Oh, wow, look at that, I didn’t quite get the documentation down that I need to,” and then they can cover their bases …but again, we’re not out to say “oh, I know how to serve your patient better and you didn’t do that right!” I just want to be really clear that we’re only out to make sure that that record reflects what the doctor is trying to say.

[Sam Steffen]
Yeah, that’s great. Just one other question that that made me think of: in Idaho, which is defined as a largely frontier state, where there’s a lot of rural communities, rural health clinics, you mentioned a situation where a lot of times it may be a provider who is actually doing their own coding. Do you think that’s pretty typical of Idaho’s healthcare? 

[Deborah Seltzer]
I think it’s for some of the very rural areas you may find practices that are that small, I know a lot of the providers are joining a lot of the larger health systems or Accountable Care organizations, which gives them more resources, but yeah, you may find your lone functioning out there who’s trying to do it all, and I just think it’s really important if they are going to take on that additional responsibility—because it is a legal responsibility on top of the medical care that they’re providing—that they’re billing properly and following the regulations and so if they’re going to do that, they probably should make sure that if they’re not going to pay someone, then they should spend the money to get certified themselves, because they are getting not only submitting the bills legally and lawfully the way they should be, but they’re also getting them done correctly so that they’re getting the reimbursement for the work that they’re doing. If they’re not filing them correctly, they could be leaving a lot of the care that they do on the table, not getting paid for, so…it’s a benefit to them to do that, and it’s not a huge investment. So, if they don’t want to hire somebody, they should probably get certified.  

[Sam Steffen]
Well, great. Well, Deborah, I really want to thank you so much for taking the time to talk with me today. This has been a really great conversation. 

[Deborah Seltzer]
No problem. Thank you for having some interest in what we do. 

[Transition music]
[Sam Steffen]
That again was an interview with Deborah Seltzer, certified professional coder and certified risk-adjustment coder at Kootenai Care Network. More information about the diagnostic manuals and the organizations and services that Deborah mentioned are available in our podcast show notes on our website: www.uidaho.edu/echo-podcast.

[Banjo music]

If you’re interested in joining our free, live ECHO sessions to receive Continuing Education credit, learn best practices, ask a question or grow your community—please visit our website at www.uidaho.edu/ECHO where you can register to attend, sign-up to receive announcements, donate, and find out more information about our programs. 
[Fade out banjo music]
Something for the Pain is brought to you by ECHO Idaho, supported by the WWAMI Medical Education Program and the University of Idaho, and is made possible by VCORP, the Valley County Opioid Response Project. 

There’s an epidemic going round called o-p-i-o-i-d
In the gem state the overdose rate is on the r-i-s-e
To change it will take community-wide e-f-f-o-r-t
That’s why they started VCORP, the v-c-o-r-p
I’m glad to know in Idaho, there’s the v-c-o-r-p
A valley county i-n-i-t-i-a-t-i-v-e
A community-wide effort to reduce opioid O-D
Through prevention education, treatment and recovery!

[cue guitar strum and guitar theme w/ lyrics in background]

We here at ECHO also want to hear your feedback.  We welcome your questions, comments and suggestions and invite you to email us at echoidaho@uidaho.edu.  And don’t forget to subscribe to Something for the Pain using your podcast app.  And if you have a moment, write us a review!

[theme music]

Something for the Pain is made possible by grant number GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDH or HRSA.

The voices you heard at the beginning of the episode were those of [Jason Coombs, Nari Hsiu and Deborah Seltzer] respectively. 
We’d also like to thank the other contributing voice on today’s episode: [Karley Kline].  We’d also like to thank the other members of our Counseling Techniques for Substance Use Disorders Panel [Sara Bennett, Lindsay Brown, Drew Holliday and Natalia Samudovsky]. We’d also like to thank all of our listeners, without whom none of this would be possible.  Without you, we’d just be talking to ourselves.

Lachelle Smith is the ECHO Idaho Program Director; Katy Palmer is our Assistant Director; our Marketing Manager is Lindsay Lodis; our Program Manager is Lynsey Winters Juel; Kayla Blades is our Grants Services Manager; Jessica Whitlock is our Continuing Education Coordinator; our Program Coordinators are Jocelyn Elvira, Laura Jackson, and Sam Steffen. 

Episode 11 – Talking Telehealth in SUD Care | McCall Mobile Medicine

Featuring: Drew Holliday, BS, Case Management Team Coordinator, Trivium Life Services, Boise and Courtney Hill, PA-C, Cascade Medical Center, Cascade and McCall Mobile Medicine, Valley County

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Featuring: Drew Holliday, BS, Case Management Team Coordinator, Trivium Life Services, Boise and Courtney Hill, PA-C, Cascade Medical Center, Cascade and McCall Mobile Medicine in Valley County

Didactic Presentation Details

  • Didactic Presenter: Drew Holliday, BS, Case Management Team Coordinator, Trivium Life Services, Boise
  • Didactic Presentation Title: “Telehealth’s Role in Accessing SUD Care”
  • Didactic Presentation Date: Jan. 6, 2022
  • ECHO Idaho Series: Counseling Techniques for Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Lynsey Winters Juel, MPA, Program Manager, ECHO Idaho, Boise
  • Speaker: Drew Holliday, BS, Case Management Team Coordinator, Trivium Life Services, Boise
  • Speaker: Courtney Hill, PA-C, Cascade Medical Center, Cascade, and McCall Mobile Medicine, Valley County
  • Speaker: Sara Bennett, LCPC, CADC, Executive Director, Owner, Riverside Recovery, Lewiston
  • Speaker: Charles Pohl, LCSW, Clinical Social Worker at Cottonwood Creek Behavioral Health Hospital, Boise
  • Speaker: Jerry Wilmes, ECHO participant
  • Speaker: Debra Mueller, ECHO participant
     

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • “VCORP Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 10 – Lindsay Brown Talks Peer Recovery Supports

Featuring: Lindsay Brown, Certified Peer Recovery Coach Supervisor, Certified Peer Recovery Support Specialist, Center for Behavioral Health, Boise

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Featuring: Lindsay Brown, CPRC-Supervisor, CPRSS, Center for Behavioral Health, Boise

Didactic Presentation Details

  • Didactic Presenter: Lindsay Brown, CPRC-Supervisor, CPRSS, Center for Behavioral Health, Boise and Scott Jones, CPT, RC, The Phoenix, Boise
  • Didactic Presentation Title: “The Role of Peer Recovery Specialists”
  • Didactic Presentation Date: July 15, 2021
  • ECHO Idaho Series: Counseling Techniques for Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Edits/ Commentary/ Errata/ Redactions

  • Throughout the recording, Lindsay Brown is referred to as the certified peer recovery coach supervisor and lead recovery coach at Center for Behavioral Health in Boise. She has since left that organization.

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Lindsay Brown, CPRC-Supervisor, CPRSS, Center for Behavioral Health, Boise
  • Speaker: Scott Jones, CPT, RC, The Phoenix, Boise
  • Speaker: Sara Bennett, LCPC, CADC, Executive Director, Owner, Riverside Recovery, Lewiston
  • Speaker: Katy Palmer, Assistant Director, ECHO Idaho, Boise, ID
  • Speaker: Colleen Turk, ECHO participant

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • “VCORP Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 9 – LaDessa Foster Talks Managing Clinical Services for Patients and Providers

Featuring: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise

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Featuring: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise

Didactic Presentation Details

  • N/A

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Cathy Oliphant, PharmD, College of Pharmacy Chair, Idaho State University, Pocatello
  • Speaker: Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC
  • Speaker: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project, Boise
  • Speaker: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 8 – Marjorie Wilson Talks Idaho's Syringe Exchange Programs

Featuring: Marjorie Wilson, LMSW, MPH, Executive Director of the Idaho Harm Reduction Project and Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier

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Featuring: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project

Didactic Presentation Details

  • Didactic Presenter: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project, Boise
  • Didactic Presentation Title: “Needle Exchange and Harm Reduction in Idaho”
  • Didactic Presentation Date:  10 June 2021
  • ECHO Idaho Series: Opioids, Pain and Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Courtney Boyce, Health Education Specialist Senior and Drug Overdose Prevention Project Coordinator, Central District Health
  • Speaker: Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier / Cache Valley Community Health Center in North Logan, Utah
  • Speaker: Marjorie Wilson, LMSW, MPH, Executive Director, Idaho Harm Reduction Project, Boise
  • Speaker: Amber Peace, Latah Recovery Center, ECHO Participant
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Lachelle Smith, Program Director, ECHO Idaho
  • Speaker: Camille Evans, ECHO Participant
  • Speaker: Randi Pedersen, MPH, Program Manager, Idaho Department of Health and Welfare, ECHO Participant
  • Speaker: Cathy Oliphant, PharmD, Pharmacist, Professor and Co-Chair, ISU College of Pharmacy
  • Speaker: Megan Gomeza, ECHO Participant
  • Speaker: Rachael Bazzett, Idaho Harm Reduction Project, Sexual and Reproductive Health Program Manager
  • Speaker: Amy Jeppesen, LCSW, ACADC, Behavioral Health Director, Trivium Life Services, Boise
  • Speaker: Annie Hawkins, ECHO participant
  • Speaker: Jacob Harris, MD, Psychiatry and Addiction Medicine Specialist, Boise VA

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 7 – Monica Forbes Talks SMART Recovery, Stigma, and Reentering Society Post-Incarceration

Featuring: Monica Forbes, Nationally Certified Peer Recovery Support Specialist / Certified Peer Recovery Coach - Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC

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Featuring Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC

Didactic Presentation Details

  • N/A

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Lindsay Brown, CPRC-Supervisor, CPSS, Lead Recovery Coach, Peer Recovery Supports of Idaho, LLC
  • Speaker: Radha Sadacharan, MD, MPH, Primary Care Physician/ MAT Provider, VA Medical Center, Boise
  • Speaker: Skip Clapp, Director of Valley County Court Services
  • Speaker: Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 6 – LaDessa Foster Talks Levels of Care in Substance Use Disorder Treatment

Featuring: Ladessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health and Craig Lodis, PhD, Psychologist, VA Medical Center, Boise

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Featuring LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise 

Didactic Presentation Details

  • Didactic Presenter: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise
  • Didactic Presentation Title: “Levels of Care in Addiction Treatment, Pt I”
  • Didactic Presentation Date: Feb. 4, 2021
  • ECHO Idaho Series: Counseling Techniques for Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: LaDessa Foster, LCPC, MAC, NCC, Clinical Services Manager, BPA Health, Boise
  • Speaker: Radha Sadacharan, MD, MPH, Primary Care Physician/ MAT Provider, VA Medical Center, Boise
  • Speaker: Monica Forbes, NCPRSS/ CPRC- Supervisor/MA, CEO of Recovery United, founder of PEER Wellness and the ROC
  • Speaker: Katy Palmer, Assistant Director, ECHO Idaho, Boise
  • Speaker: Craig Lodis, PhD, Psychologist, VA Medical Center, Boise

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 5 – Motivational Interviewing and Donnelly's The Change Clinic

Featuring: Debbie Thomas, CADC, LPC, CEO of The Walker Center, Gooding, ID; Barbara Norton, LMSW, Program Director of the Change Clinic, Donnelly, ID 

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Featuring Deborah Thomas, CADC, LPC, CEO of the Walker Center, Gooding, ID & Barbara Norton, LMSW, Program Director at The Change Clinic, Donnelly, ID

Didactic Presentation Details

  • Didactic Presenter: Deborah Thomas, CADC, LPC, CEO of the Walker Center, Gooding, ID
  • Didactic Presentation Title: “Motivational Interviewing”
  • Didactic Presentation Date: June 13, 2019 
  • ECHO Idaho Series: Opioid Addiction and Treatment
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Interview Details

  • Interviewee: Barbara Norton, LMSW, Program Director, The Change Clinic, Donnelly, ID

Edits/ Commentary/ Errata/ Redactions:

  • Sadly, Barbara Norton passed away in October of 2021, several months after this episode was released.

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier
  • Speaker: Skip Clapp, Director of Court Services, Valley County
  • Speaker: Deborah Thomas, CADC, LPC, CEO of the Walker Center, Gooding
  • Speaker: Lachelle Smith, ECHO Idaho Program Director
  • Speaker: Lachelle Smith, Director, ECHO Idaho
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services, Boise
  • Speaker: Patrice Burgess, ECHO participant
  • Speaker: RJ, ECHO participant

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 4 – Harm Reduction and the Valley County Opioid Response Project

Featuring: Brenda Hoyt, APRN; Shelly Hitt and Courtney Boyce

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Featuring Brenda Hoyt, APRN

Didactic Presentation Details

Resources and Publications Mentioned

Interview Details

  • Interviewee: Skip Clapp, Director of Court Services, Valley County

Speaking Credits

  • Narrator / Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Abbey Abbondondalo, Security Director, St. Luke’s Health System, Boise
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services
  • Speaker: Cathy Oliphant, Pharm D, College of Pharmacy Chair, Idaho State University, Pocatello 
  • Speaker: Brenda Hoyt, APRN, NP, Raise the Bottom, Boise
  • Speaker: Skip Clapp, Director of Court Services, Valley County
  • Speaker: Lachelle Smith, Director, ECHO Idaho
  • Speaker: Ian Troesoyer, DNP, APRN, FNP-C, Nurse Practitioner at Bear Lake Community Health Center, Montpelier 
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Shelly Hitt, Valley County Opioid Response Project Coordinator, Central District Health
  • Speaker: Courtney Boyce, Health Education Specialist Senior and Drug Overdose Prevention Project Coordinator, Central District Health

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

SOMETHING FOR THE PAIN
EPISODE 4: Harm Reduction and Valley County’s Opioid Response Project
(47:00 mins)

(0:00)
[Somber Music]

[Abby Abondandalo]
…we need to train ourselves to recognize that non-verbal communication the patient is providing us with…

[Amy Jeppesen]
…depending on their functioning level if they’ve really struggled with an addiction, not only is it a physical addiction, but there’s a lot of psychological pieces that go along with that…

[Cathy Oliphant]
…I do think there is a lack of public knowledge about the good samiratan law and I think that is something that all of us probably need to get out there…

[Brenda Hoyt]
…cause right now, in Idaho, for cash-pay naloxone, for a 2-pack of the nasal is…about $140.00. 

[Theme Song]

[Sam Steffen]
Welcome back!  This is Something For the Pain, a podcast produced by Project ECHO in Idaho, made for Idaho’s healthcare professionals working to learn best practices in the fight to prevent, treat and facilitate recovery from Opioid and Substance Use Disorders in communities across the state of Idaho. I’m your host, Sam Steffen. 

[Theme song]
On our last episode, we went over some de-escalation strategies with the Director of Security at St. Luke’s Hospital System, Abbey Abbondandalo and spoke with Skip Clapp, the director of Court Services in Valley County, who was telling us about some of the complexities facing people who have substance use disorders who become involved in the court system.

[Skip Clapp]
…the treatment providers, when we send someone there, they tell us if somebody tests positive for drugs or alcohol, they have to tell us if someone’s attending class, they have to tell us about their participation in class…and that requirement can inadvertently cause a wedge between the treatment provider and the client.

[Sam Steffen]
Skip told us about the court’s diversion program, which aims to get people who are facing minor offenses, who may also be in need of substance use disorder treatment and support, into treatment and recovery programs rather than jail or prison. 

[Skip Clapp]
And that requirement can inadvertently cause a wedge between the provider and the client…

[Sam Steffen]
He also talked to us about peer recovery and mentioned the ROC—a community center in McCall that stands for “Recovery-Oriented-Community” that offers peer support recovery services to returning citizens and people in recovery.

On today’s episode, Episode 4, we’re going to be hearing from Brenda Hoyt, nurse practitioner at Raise the Bottom, about Harm Reduction practices and strategies that we can employ when talking with and treating those who may be in the midst of drug use and dependence.  Following that, we’ve got some special guests on the program today.  We’ll be speaking with Courtney Boyce and Shelly Hitt from Central District Health, an organization serving Idaho’s Ada, Boise, Elmore and Valley Counties, and hearing about some education programs they’ve got in place to help connect existing prevention, treatment and recovery resources.  All of that is coming up in the next 45 minutes, so stick around!

[Theme song]

[Sam Steffen]
Let’s get to today’s lecture.  We’re going to be hearing a lecture on “Harm Reduction” delivered by Brenda Hoyt, nurse Practitioner at Raise the Bottom in Boise.  The presentation we’re going to be hearing was recorded live during an ECHO Idaho session on May 23, 2019.  This was a part of ECHO Idaho’s series on Opioid Addiction and Treatment.  Without further ado, let’s turn it over to Brenda.

[Brenda Hoyt]
So harm reduction incorporates a spectrum of strategies from safer use to manage use to abstinence to meeting drug users where they're at, addressing conditions of use along with the use itself. Because harm reduction demands the intervention of policies designed to serve drug users it reflects specific individual and community needs. There's no universal definition or a formula for implementing harm reduction. So the primary principles central to harm reduction is: accepting illicit or illicit drug use as part of the world of that person, and just minimizing the harmful effects rather than ignoring or condemning them; understanding drug use is a complex multifaceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence; and acknowledging that some ways of using drugs are clearly safer than others, giving patients the voice or the drug user a voice in the creation of programs and policies designed to serve them. Giving them some affirmation, not attempting to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use. And then, of course, just recognizing that poverty, class, racism, social isolation and past trauma, sex-based discrimination and other social inequalities affect people's vulnerability to capacity for effectively dealing with drug-related harm.

[Sam Steffen]
Just to reiterate what Brenda’s already said, because harm reduction refers to a wide variety of practices that can be employed in all different walks of life, reducing harm for people who use drugs is a community-wide effort.  Next, Brenda’s going to take us through three different strategies for utilizing what she calls opportunities for overdose risk reduction.  The first of these is through primary prevention, looking at strategies that can be employed as an individual community member, as a prescriber, and at the level of local, state and federal government.

[Brenda Hoyt]
Opportunities for overdose risk reduction through primary prevention: Primary prevention is targeted education for individuals, educating family and friends on the warning signs of abuse, keeping medications locked up, safe disposal of unused medications and education about not sharing meds which seems to be more popular now. Doing the medication take-back drives, intervention in family and friends, encouraging treatment and engagement in treatment, and prescribers utilizing PMP, paying contracts, risk-assessments prior to prescribing and then utilizing evidence-based prescribing for opiates.

[Sam Steffen]
PMP stands for Prescription Monitoring Programs; these are state-run programs that collect and distribute data about the prescription and dispensation of federally controlled substances and other potentially addictive prescription drugs. PMPs help to prevent adverse drug-related events through opioid overdoses, drug diversion and substance abuse by decreasing the amount or the frequency of opioid prescribing.

[Brenda Hoyt]
And then on a state government level, optimizing the PMP, identifying and closing those pill mills and increasing access to pain experts. And then on a federal government level, the CDC, epidemiology research, and targeted research funding.

[Sam Steffen]
The second opportunity for overdose risk reduction is through increasing treatment engagement.  These strategies can also be employed as an individual community member, as a prescriber, and at the level of local, state and federal government.

[Brenda Hoyt]
Giving individuals access to treatment, which I feel like tends to be one of the biggest barriers for people seeking treatment because there's just not a lot of treatment available. Utilizing, in the community, case management at strategic locations, access to multiple treatment modalities, and decreasing the stigma for medication assisted treatment. 
For prescribers, diagnosed non-medical use and dependence, utilizing buprenorphine or suboxone in office-based settings and recommending treatment. State and government: establishing adequate and mighty facilities for treatment, ensure Medicaid coverage for substance use disorder treatment. I know there's some states that Medicaid covers all of treatment, Oregon is one of them. And then just the lack of facilities that are available for treatment is one of the biggest issues I think. And then on a federal level, mental health parity laws, funding for research on innovative treatment models and campaign to reduce MAT stigma.

[Sam Steffen]
And finally, the third opportunity for overdose risk reduction is through the utilization of harm-reduction strategies, which can also be employed at the levels of individual, community, prescriber, and state and federal government.

[Brenda Hoyt]
Opportunities for overdose risk harm reduction strategies: providing naloxone and overdose education to individuals, access to naloxone and overdose education for family friends. In the community, having first responders with naloxone available, giving them overdose education, the distribution of naloxone. I know back east, they have programs where the state provides naloxone. Their health department in Baltimore actually goes to high-risk areas with boxes of naloxone. And then of course for prescribers, utilization of the PMP, evidence-based opioid prescribing and doing the overdose risk assessments with patients. On the state government level, optimizing the PMP, Good Samaritan laws, third party prescribing laws and criminal and civil liability. Right now I know in Idaho, most pharmacies, for cash pay naloxone, for a two pack of the nasal is about $140. So that's pretty expensive. And then a lot of the insurances require prior authorization to prescribe for their insurance to cover it. And a lot of them don't necessarily ask their primary care provider, or because of the stigma or concern of what their provider may think.

[Lachelle Smith]
So let’s say hypothetically I wanted to get naloxone for myself or others in my circle…

[Sam Steffen]
This is ECHO Idaho’s program Director speaking, Lachelle Smith.

[Lachelle Smith]
Would I need prior authorization from my insurance perhaps?

[Brenda Hoyt]
Possibly, so…

[Cathy Oliphant]
Well part of it is not being able to bill or put it to your insurance if it’s not for you.

[Sam Steffen]
This is the Chair of the College of Pharmacy at Idaho State University, Cathy Oliphant, speaking.

[Cathy Oliphant]
You know, so if you didn't pick up an opioid prescription, if you want to use it, say for a friend, you know, or potentially, you know, some will not run it through insurance under you because it cannot be used under you.

[Todd Palmer]
So I have a couple comments as to how to reduce cost…

[Sam Steffen]
This is Dr. Todd Palmer speaking.  Dr. Palmer is the Addiction Fellowship Director at the Family Medicine Residency of Idaho in Boise.  He’s also one of ECHO Idaho’s staple Medication for Addiction Treatment Waiver Trainers.

[Todd Palmer]
One thing you can do is, instead of paying the $140, they have these atomizers that you can buy for three bucks, and you can take a syringe and draw up the naloxone and then hook the atomizer onto it and spray it in the nose. That's only $3 for the atomizer.

[Brenda Hoyt]
And how much are the vials? Can they still—

[Cathy Oliphant]
Anywhere from $40 to $50 for those kits. And so you can either get, like the Carpujects, you can screw that right into the atomizer at the end, or you can get a vial actually, you know, then you have to draw it up with a needle and take that off and put the atomizer on and use it that way.

[Todd Palmer]
So the vial—to get 2.4 milligram vials—it’s still a lot cheaper. It’s like—what is it $40 or $50 bucks or so?

[Cathy Oliphant]
Yeah, $40 to $50 bucks.

[Todd Palmer]
—It’s still better than $140. But it takes some doing because somebody has to draw it up and they have to put the atomizer on or they have to inject it, but I mean it’s a lot cheaper than using the nasal ones. The other thing about naloxone is, it's really good to encourage people to carry it around with them, you know, and if they're going to be around circles of people that are using, rather than sitting at home in their drug cabinet, like carrying it around in your community, if you’re out at a party—it saves lives. And I don't think we encourage people to do that enough.

[Lachelle Smith]
Before you move on, does anybody know anything about Idaho’s Good Samaratin Laws to speak articulately about it?

[Ian Trosoyer]
I know a little bit about it, Lachelle.

[Lachelle Smith]
Go, Ian, go.  Will you remind us who you are?

[Ian Trosoyer]
Yeah, so my name’s Ian Troesoyer and I am a doctor of nursing practice and my day job currently is at Southeastern Public Health, the local health department in Pocatello. And last legislative session, Representative Chu and the legislature passed a kind of hold-harmless bill for people who call first responders, whether that's law enforcement or like 911 and they send an ambulance…it holds those people harmless for possession of heroin and for possession of paraphernalia if they call to ask for help to deal with someone who's experiencing an acute crisis and acute overdose that needs immediate medical attention. In many cases, especially the local law enforcement people that I've talked to, they said it has made a huge difference in the number of people getting like just dropped off in the parking lot of an ER and then driving off. Instead people are calling you know, EMTs or other first responders to show up to a place where someone's actually experienced an overdose.

[Todd Palmer]
I mean, the danger here is that since naloxone, you know, only works 20 to 30 minutes, maybe sometimes a little longer. We don't want these people giving them naloxone, calling paramedics and then leaving, right? And then the patient goes into—they become comatose again and stop breathing.

[Cathy Oliphant]
I did a Naloxone training two weeks ago. And there were a couple individuals in recovery, one that actually had his life saved from naloxone. And then were actually a couple current users. They were very negative on—which I thought was interesting—on the Good Samaritan laws, that they didn't believe that law enforcement were actually enforcing it and why would they call 911 when they had drugs on them? So I do think there is a lack of public knowledge about the Good Samaritan Law. And I think that is to claim that all of us probably need to get out there. There was a lady in the audience whose son had actually passed at a party that—actually there was naloxone there, and no one would give it to him because they didn't want to call 911. So there's still some of that stigma and that yeah, maybe there, but I don't believe that that is truly being enforced. But it's really unfortunate that that's the thought out there.

[Todd Palmer]
Just the fact that, Lachelle brings up the question: “who knows a lot about the Good Samaritan Law?” and we have all these people and no one, you know—if not all of us know, how do we get the information out to the public or the people that could be affected? I mean, I think, you know, certainly at opioid treatment centers, that could be used to educate anybody who walks through the door. We could do a better job at the residency on that. I think targeting these populations that this is out there, that this exists.

[Lachelle Smith]
When you write that opioid prescription, right? Talk about naloxone and maybe add Good Samaratin Law.

[Brenda Hoyt]
I know that we hand out one nasal Narcan, so Raise the Bottom buys nasal Narcan and we give it out to all of our new patients when they first come in, and we educate them on use. And we have patients that have come back months later and said, “Well, I have to use this on somebody, can I get another one?” If they don't have insurance, we try to give them at least one more. And if they have insurance, they want a prescription for it or providing those prescriptions. Just trying to get it out there. I have one in my car, I typically have one on my purse—I don't right now. All of the offices, all of our counselors or medical staff, all have one available, and front office staff, just in case somebody were to come in. 

[Todd Palmer]
And you’re talking about “one” meaning the one that has two doses?

[Brenda Hoyt]
No, we just give them the one dose.

[Todd Palmer]
Oh.

[Brenda Hoyt]
And then explain to them that this only works for sometimes 20, 30 minutes, so…

[Todd Palmer]
Well, sometimes you need the two doses. And then with fentanyl, you could use more than two doses.

[Brenda Hoyt]
But since we’re…I mean, at Raise the Bottom, at least we’re getting it out there, at least a dose…

[Todd Palmer]
Yeah, that’s great.

[Brenda Hoyt]
Currently, some of the harm reduction programs and strategies that are out there: So needle exchange programs, medication assisted treatment, so suboxone, methadone, Vivitrol. And then cooperation with law enforcement. So Boise has the LEAD pilot program right now. So law enforcement identifies some of those patients and clients when they arrest them, or pull them over, rather than immediately charging them with drug related offenses. If they meet the criteria for the program, they get them set up with Recovery 4 Life, and then bring them over to Raise the Bottom and we try and get him started in treatment as quickly as possible. And then outreach programs for high-risk populations. Like I said, like in Baltimore, they have their community health department goes out to those high risk population areas where they've noted those significant number of overdose deaths and provide Naloxone, nasal Narcan to people and literally at bus stops, they'll provide education and hand those out.

[Todd Palmer]
So this is a topic that comes up a lot. And there's some physicians that will, they will mandate counseling, like you can't get MAT unless you're, you're getting counseling, and you're documenting attendance to Narcotics Anonymous. So I would say most of the folks now are not doing that anymore. There's actually not good evidence, believe it or not, that counseling adds to MAT. Do I encourage counseling? Absolutely. I strongly encourage counseling. It doesn't necessarily have to be addiction counseling. I mean, a lot of the counseling they do would probably at Raise the Bottom, it’s around life issues. And then of course, relates to their use. But um, we've changed this at the residency recently, and a lot of other people are changing it, saying that that is not a deal breaker. I mean, if someone will not get counseling, they refuse to do it, or they can't do it—you don't deprive them of MAT. And that's a key point. And it really relates to harm reduction.

[Brenda Hoyt]
So we do require an hour of contact with a counselor.

[Todd Palmer]
But that’s the—isn’t that federally mandated?

[Brenda Hoyt]
It is, yeah. I mean, a lot of that is, we’re not seeing every patient—a provider isn’t seeing a patient every month. Yeah, they're coming in. So that's their justification to continue, especially methadone. To continue receiving their methadone without having to see a provider. And a lot of them are working on budgeting life skills. It's not necessarily directly related to their addiction or even mental health. Some of it is just figuring out how to cope with day-to-day life.

[transition music] 
[Sam Steffen]
That again was a didactic presentation by Brenda Hoyt titled “Harm Reduction”. That lecture was recorded live during an ECHO session that took place on May 23, 2019 as a part of ECHO Idaho’s Opioid Addiction and Treatment Series.

If you’d like to watch the Zoom recording of that presentation, that video is currently available on the ECHO Idaho YouTube channel, which you can access through our website. The powerpoint slide deck that accompanied that presentation is also available on our website: www.uidaho.edu/ECHO

[Banjo strum]

I’m going to transition now to a more recent conversation I had with two members of Idaho’s Central District Health, an organization serving Idaho’s Ada, Boise, Elmore and Valley Counties. Courtney Boyce is the Health Education Specialist Senior and heads up D.O.P.P. or DOPP, the Drug Overdose Prevention Program.  Shelly Hitt is the program coordinator for VCORP, the Valley County Opioid Response Project, which—full disclosure—is the primary funding source for this podcast.  Courtney and Shelly joined me for a special interview to talk a little bit about some of the education initiatives and projects that CDH has going on right now.

[Sam Steffen]
Welcome to the program, Courtney and Shelly!  So, for starters, I’m wondering if I could just ask both of you to introduce yourselves to our audience—tell us who you are and what you do.

[Courtney Boyce]
So my name is Courtney Boyce and I’m the Drug Overdose Prevention Program Coordinator at Central District Health, and my formal title is Health Education Specialist Senior 

[Shelly Hitt]
I’m Shelly Hitt, I’m a Licensed Clinical Social Worker and I’m the Project Coordinator for the Valley County Opioid Response Project. 

[Sam Steffen]
Alright, thank you! Welcome!  So Courtney, I’d like to start off with you: can you just provide a brief overview of the scope and some of the aims of the Drug Overdose Prevention Program?

[Courtney Boyce]
Sure! So for the Drug Overdose Prevention Program, we go by DOPP. Our main mission is to help decrease fatal and non-fatal drug overdoses in our region. So Ada, Boise, Valley and Elmore County. And really what we're doing right now is working to improve community capacity to address substance use and use through prevention, intervention, treatment and recovery support services. And one of the evidence-based strategies that we employ is to provide technical assistance, education, training and material development. And we've been targeting law enforcement, first responders and crisis systems and Valley County and that can include social media graphics or other social media promotion for drug take back events and other community-based education opportunities. And something that we did over the last couple of months is a Valley County specific overdose prevention and response training where participants learn about overdose risk factor education, alternative pain management, safe storage and disposal. And mainly they learned how to recognize and respond to an overdose including the administration of two forms of naloxone, and then learn where to access those tools and resources.

[Sam Steffen]
Just so our listeners are aware echo Idaho has a video demonstration of how to use and administer Narcan available on our website. That information is also linked in our show notes.

[Courtney Boyce]
And then we provide additional individual and organizational skill development by providing them certificates of attendance for participating in that training. And after they attend them. We work with our local and state partners to distribute overdose rescue kits.

[Sam Steffen]
And just for the folks who may not be familiar with naloxone, can you just briefly talk about what that is and how it’s administered?

[Courtney Boyce]
So naloxone is the only medication that can help reverse an overdose an opioid overdose specifically, it can be administered in two different ways. There's the intramuscular naloxone, which is administered by syringe, and then there's also the inter-nasal naloxone otherwise known as the Narcan nasal spray. And that is similar to any other type of nasal medication like Afrin where it's administered through either nostril and then it's absorbed through the nasal membranes. And it takes anywhere from two to five minutes depending on the form of naloxone and that a person has to get a response but it can prevent fatal overdose if a person is experiencing an overdose by reversing that process for 30 to 60 minutes, depending on their tolerance, to give them enough time to access emergency medical services and be revived from an overdose. 

[Sam Steffen]
So, my next question is for Shelly: so VCORP is something that the people who have maybe tuned into our podcast before might have heard me mention in our credits as one of the organization that makes this podcast possible—but they might not know anything else about it.  So can you tell us: what is VCORP? 

[Shelly Hitt]
Sure, um, we received a million dollar grant for over a three year period that's funding the Valley County opioid response project. And the focus of the grant is on prevention, treatment and recovery from opioid use disorder in specifically in Valley County and the surrounding communities 

[Sam Steffen]
And why, specifically in Valley county? What, if anything, is unique about the opioid situation in valley county as opposed to say, anywhere else in Idaho?

[Shelly Hitt]
So, when we wrote the grant, the statistics that we used was that Valley County had 11 overdose deaths from 2014 to 2018 with a 5-year population of 52,005. This puts the mortality rate for drug overdose deaths at 21.2% according to IDHW. It’s a higher risk than Idaho’s drug overdose mortality rate of 20.4. per 100,000 people in the population. So the drug overdose rate in Valley County is higher than our normal population.

[Courtney Boyce]
Between Ada, Boise, Valley and Elmore County, Valley County has the highest drug overdose mortality rate and HRSA indicated in 2014, that 88.08% of people that were needed to have addiction treatment are unable to receive it. So that just highlights some of the systematic issues that Valley County residents experience, not being able to access services or care. 

[Sam Steffen]
So Shelly, who are some of the organizations involved in VCORP?

[Shelly Hitt]
So we have five sub-grantees that are funded through the grant. We have Boise State University, the ROC—that’s a recovery oriented community. It's a hub that we actually established in Valley County, meaning there's an office there. And we also have the Youth Advocacy Coalition that handles the prevention, which is another sub-grantee, they're co-located in that office. And then we have EPIC, which is through Dr. Hulbert. And then our last one is ECHO, which is helping with this podcast!

[Sam Steffen]
And we are glad to be a part of it…you mentioned a minute ago the mortality rate of Valley County being higher in Valley County than in other Idaho counties.  It might be worth mentioning here that Valley county and most of Idaho is defined as rural.  Can you talk a little bit about how the rural environment of Valley county might be impacting the trends in opioid use that we’re seeing?

[Shelly Hitt]
And actually, Valley County is considered “frontier.”

[Sam Steffen]
Oh, frontier, right. Okay.  So what’s the difference between rural and frontier?

[Courtney Boyce]
The best of my understanding, it’s geographic location and population density.

[Shelly Hitt]
Yeah, it’s defined as having a population density of less than six people per square mile is considered frontier, so it’s less populated.

[Courtney Boyce]
So the question kind of like was how the rural environment of valley county impacts opioid trends and what we're seeing is that the rate of drug overdose deaths in rural areas of Idaho have surpassed urban areas, based on their population size. And that's a huge public health concern for us. And something specifically that we're addressing through the drug overdose prevention program and through VCORP. And there's a lot of differences as to why that can happen. That could be socio-economic factors, health behaviors, physical conditions of the environment. So infrastructure, recreation, larger geographic distances, limited transportation, kind of some of those access-to-services issues. And there's also differences in social conditions, because people's networks, their social networks, and connections. That can be a protective factor, but they can also amplify risk through a lack of knowledge about treatment or risk behaviors. And then there's real and perceived issues around being anonymous around use and accessing services to address an opioid use disorder, for example. And then the stigmatization of people who use substances in addition to accessing treatment for that. And then there's different policy conditions, including limited coverage and availability of harm reduction and drug treatment services, including intensive outpatient substance use services. For example, in Valley County, there isn't any BPA funded intensive outpatient substance use services, so that can really limit options of care based on funding source, and then individual service provider practices, which can limit the scope of care. 

[Sam Steffen]
So, your mention of lack of services in Valley county has me wondering: what are some resources that are available to folks in Valley County? Shelly, you mentioned a minute ago the ROC, and that’s actually something that Skip Clapp mentioned in our last episode. Can I get you to say a little bit more about the ROC?   

[Shelly Hitt]
Sure, so the ROC which stands for Recovery Oriented Community is the newest recovery center that we have in Valley County and it's a subsidiary of PEER Wellness. And they have peer-led groups and recovery coaching as part of their services. They're in Valley County and so it's a new service in Valley County that we didn't have before. They also have peer recovery social activities. And they've also partnered with the Phoenix gym to they're going to host sober activities and fitness activities. And now I think some of that's been on hold because of COVID. But I think it's going to—once the precautions get lightened up—we can hopefully move forward with that. The ROC has been involved in also identifying some of the gaps and services that we have in Valley County as part of the VCORP consortium. And we're all working together to try to identify those and develop partnerships through the consortium to fill those service gaps for substance use disorder treatment, and prevention services in the county. 

[Courtney Boyce]
I think the ROC has been really instrumental, because as Shelly mentioned, they are bridging that gap. But they're boots-on-the-ground. So while they're providing virtual services, they also have staff that is there to meet with people to be able to discuss safety planning to be able to help connect them to evidence-based treatment and resources in their community, and to have a stable point of contact. And those are services that were never offered in that community before. And having peer led services is really beneficial for people because they can use their lived experience to support others, other types of resources that we refer folks to. There's the Change Clinic that is in Donnelly that provides medication assisted treatment, in addition to other treatment services. And then there's St. Luke's that's located in McCall, but they do emergency primary and behavioral health services. And then Cascade Medical Center, obviously, in Cascade, and they also do emergency primary and behavioral health services. And then we also refer folks a lot to Central Idaho Counseling, which has treatment options located in Cascade and McCall. And then we refer folks to look at the West Central Mountains Youth Advocacy Coalition website, that's just westcentralmountainsyouth.org because they have a whole list of local resources that is run in facilitated by a local and Valley County. And then through the drug overdose prevention program, we list Valley County specific resources, regional resources that impact all four counties, in addition to the other counties that we serve. And we use an interactive mobile map option. So people that have the ability of accessing Google Maps can use these maps to filter out based on their location services that they're looking for. So if they're located in Cascade, and they want to know where their nearest medication assisted treatment location is, then they can get directions directly to the Change Clinic in Donnelly, for example. And then we have a comprehensive resource spreadsheet for those that are not interactively inclined to use those mobile maps that provide a whole bunch of information that would be really difficult to synthesize into an interactive map. And that's on housing, and employment, vocational assistance, clothing, food vouchers, treatment outpatient services, treatment options, recovery support services, things like that. So anyway that we can help address a person's social determinants of health when they themselves might be managing a substance use disorder or substance use, or family members or friends.

[Sam Steffen]
Yeah, wow.  Those sound like really great resources.  Something I wanted to ask you about is how, and you mentioned this earlier, is the stigmatization of substance use disorder and how that can really affect people’s willingness to seek treatment, especially in rural areas where everybody seems to know everybody else. I’m curious if you could talk a little bit about some of the educational strategies that might be employed to change the narratives that people might have about substance use and the assumptions, maybe, that they might have?

[Courtney Boyce]
So something that the Drug Overdose Prevention Program does is at the end of every overdose prevention and response training, we talk about harm reduction, and we talk about person-first language. We don't know when an overdose is going to occur. And we are trying to educate and inform the public on how they can be prepared in the case of an overdose. But having the information and knowledge about person-first language is something that they can start to practice immediately after the training. And that really helps reframe how people view themselves, how they access treatment services, how they identify a diagnosis. And what it does is it puts the person before the diagnosis. So an example of person-first language is instead of saying an “addict,” saying that “a person has a substance use disorder”, saying that a person is under supervision, rather than saying that they're on probation or parole. So those are some of the things that we do that try to combat stigma of not just substance use itself, substance use disorders and some of the larger issues that can come into play with folks that have behavioral health issues. But it's trying to provide an empathetic olive branch to folks so that they can access services and feel safe and comfortable to do so. Other educational things that I think are important for practitioners is to reassure local folks in particular, what their HIPAA privacy practices are, maintaining that their privacy is important to everybody that works in the facility and not just that individual provider, and letting them know what options are available for them for forms of treatment that might be better-suited to meet their needs. So maybe that's an appointment once every three months, maybe that's telehealth if they have that option, things like that. Other things related to stigma is accessing treatment services is an evidence-based strategy of being able to reduce the harms associated with substance use, and trying to provide that information wide and and encouraging community members, if they know somebody that has a substance use issue to access that and to start those conversations. And then something that we do a lot for the Drug Overdose Prevention Program is we really encourage people to carry Naloxone, and to know that “it's not scary to carry naloxone”, that it's a prescription medication, yes, but it's the only medication that can prevent an overdose of fatal overdose. And it's really important for folks specifically in Valley County to have naloxone on hand and have widespread community availability, because their response times especially in the case of a more severe overdose event, or the related harms from an overdose might be a little bit longer depending on where they're at, geographically, in Valley County. So those are some of the things that we do that try to encourage people to be a little bit more mindful of their interactions, to be more mindful of those that have those needs, and ways that we can support that community and knowing how stigma can be really damaging to folks. Shelly, what do you have to say?

[Shelly Hitt]
I really think that’s part of the Valley County Opioid Response Project. We have a cross-section of agencies that participate and we meet monthly and we also have a couple of members that have joined that also have life experiences. And I think it's the role of the consortium as we work through some of the needs in the in the county and the services that we're implementing that the stigma piece is always a part of that. It's part of I think, what we do we there's some other things that for some community events that we plan, too, to help educate the community, increase the awareness of the services through the grant of what's offered, again, to try to reduce that stigma.

[Sam Steffen]
Can you mention a few ways maybe that community members might be able to get involved in some of these projects?

[Shelly Hitt]
Well, I mean, there's a couple of ways. As the project director, they can always contact myself if they weren't interested in participating in the consortium. The ROC has an actual website, and Western Central Mountains Youth Advocacy Coalition, they also have a have a website as well. 

[Sam Steffen]
Just so people know, Shelly Hitt’s email address and contact phone number, as well as the website information for the ROC and the Western Central Mountains Youth Advocacy Coalition are listed in our show notes on our website.

[Courtney Boyce]
I would say another way that community members can get involved is to educate and inform themselves about resources available in the community to know the impact that behavioral health has had in their region, and how to start those conversations with people that have behavioral health needs in general. And to participate in an overdose prevention and response training. Because it's about an hour long, we do them virtually, I'll do them by appointment, but we also do them for organizations that are interested in having naloxone on site to really know how they can respond to an overdose in the case of an emergency, and how to be able to better support the residents in their community and to know what tools are available for them in the case of an overdose, not just the overdose itself, but also overdose prevention resources, like drug lockboxes Deterra Drug Deactivation pouches, which is super important for Valley County since a lot of residents are on septic systems and need to dispose of their medications safely, things like that. So I think those are some of the strategies that people can start employing today. And then any way that they can start learning about person-first language and employing that in their day-to-day language is going to be really important as well to help reduce stigma and to be better understand substance use as it pertains to their community and better equip themselves to address substance use in that capacity. 

[Shelly Hitt]
I think another good resource, too, is the SAMHSA website for Substance Abuse and Mental Health Services Administration, they have a lot of good information and resources as well.

[Courtney Boyce]
A lot of our Valley County folks that are interested or might be listening to this podcast that don't reside or work in Valley County, there's other resources available through their public health districts. So their drug overdose prevention programs are similar programs like VCORP. And then Google also has Recover Together map which is very similar to what we've created as well. But obviously, we would refer SAMHSA, too.

[Sam Steffen]
Cool, well thank you both for sharing all that. I do just kind of want to leave some space if there’s anything else you want to be sharing with people who may be hearing this, maybe people who are in recovery or folks in the healthcare workforce?

[Courtney Boyce]
I would encourage practitioners to explore implementing medication assisted therapy within their clinics, regardless of their specialty of practice. Because it's a needed service, especially in Valley County, I would encourage them to look at some of their policies and procedures around addressing substance use to have it be a little bit more comprehensive, if possible, and up to date with some of the best practices per CDC and SAMHSA. To reach out to Shelley and I, between our mutual programs and to see what we can do to support them. And for me, in my capacity, I have the ability of being able to work with some of those organizations on improving their policies and procedures around naloxone, substance use, things like that. And then really working to implement person-first language modalities and all of their clinic services, and continuously encouraging people to access naloxone, to carry naloxone. And to try to take down some of those personal barriers that people have when accessing services by being an inclusive organization and supporting folks with behavioral health needs. Those steps, even though it seems very broad, are really instrumental in changing so the culture in Valley County, that is creating a safe space for people with substance use issues to come forward, and their family members and friends as they can also get the support that they need as well.

[Shelly Hitt]
You know, Courtney and I, our programs overlap, but our roles are a little different. She's really, her role really is more around the training piece minds more around community development, even you know, we received the grant to increase capacity in the prevention and treatment services in the county. But, you know, the goal of the consortium really is to sustain a collaborative relationship and partners to increase you know, services in the in the county, whether it be prevention, treatment, recovery. You know, and it's an ongoing process. And we're always looking for folks that want to be involved to help us with that, because it takes the community to do that. And we have a really good core group of folks but we're always looking for other partners or community members that have lived life experiences to be part of the consortium, because it takes all different perspectives to develop a really good working system.

[transition music]

That again was an interview with VCORP program coordinator, Shelly Hitt, and DOPP Program Coordinator, Courtney Boyce, from Central District Health.  Information about some of the resources Courtney and Shelly mentioned during that interview, including The Change Clinic, the ROC, the Youth Advocacy Coalition, and Central District Heath can be found in our podcast show notes on our podcast webpage: www.uidaho.edu/echo-podcast 

Banjo strum
Banjo music

If you’re interested in joining our free, live ECHO sessions to receive Continuing Education credit, learn best practices, ask a question, grow your community, or simply because you’re curious—please visit our website at www.uidaho.edu/ECHO where you can register to attend, sign-up to receive announcements, donate, and find out more information about our programs. 
Something for the Pain is brought to you by ECHO Idaho, supported by the WWAMI Medical Education Program and the University of Idaho, and is made possible by VCORP, the Valley County Opioid Response Project. 

[Fade banjo music]
[Guitar strum and guitar and theme song w/ words in background]

We here at ECHO also want to hear your feedback.  We welcome your questions, comments and suggestions and invite you to email us at echoidaho@uidaho.edu.  And don’t forget to subscribe to Something for the Pain using your podcast app.  And if you have a moment, write us a review!

That’s about all the time we have for today, but join us next time when we’ll be hearing a lecture on Motivational Interviewing delivered by Deb Thomas, Certified Alcohol and Drug Counselor, Licensed Professional Counselor and CEO of the Walker Center in Gooding. We’ll also be speaking with Barbara Norton from the Change Clinic in Donnelly, Idaho. That’s coming up next time on Something for the Pain. Until then, Idaho, take care of yourself! 

Something for the Pain is made possible by GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDI-1 or HRSA.

The voices you heard at the beginning of the episode were those of Abby Abbondondalo, Amy Jeppesen, Cathy Oliphant, and Brenda Hoyt, respectively. 
Big thanks also to the other contributing voices on today’s episode: Lachelle Smith, Todd Palmer, Ian Troesoyer, Shelly Hitt and Courtney Boyce. And a big thanks to all of our listeners without whom none of this would be possible. Without you, we’d just be talking to ourselves.

Lachelle Smith is the ECHO Idaho Program Director; Katy Palmer is our Assistant Director; our Marketing Manager is Lindsay Lodis; our Program Managers are Karley Kline and Lynsey Winters Juel; and our Program Coordinators are Kayla Blades, Jessica Whitlock, and Sam Steffen. 

Episode 3 – Deescalation Techniques and the Valley County Court Services' Diversion Program

Featuring: Abbey Abbondondalo, St. Lukes Security Director and Skip Clapp, Valley County Court Services Director

Claim CE for this Episode

Didactic Presentation Details

  • Didactic Presenter: Abby Abbondondalo, Security Director, St. Luke’s Health System
  • Didactic Presentation Title: “Deescalation”
  • Didactic Presentation Date: April 15, 2020
  • ECHO Idaho Series: Behavioral Health in Primary Care
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Interview Details

  • Interviewee: Skip Clapp, Director of Court Services, Valley County

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services, Boise
  • Speaker: Jeff Seegmiller, WWAMI Medical Education Program Director
  • Speaker: Abbey Abbondondalo, Director of Security, St. Luke’s Health System
  • Speaker: Radha Sadacharan, MD, MAT Provider, Boise VA Medical Center
  • Speaker: Lachelle Smith, ECHO Idaho Program Director
  • Speaker: Skip Clapp, Director of Valley County Court Services

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Other Acknowledgements

  • This Episode was reviewed for content by Jeremy Stockett, LCSW, Social Worker, St. Luke’s Psychiatric Wellness Services

SOMETHING FOR THE PAIN
EPISODE 3: Deescalation Techniques and the Valley County Court Services’ Diversion Program
(45:00 min)

(0:00) 
[Somber Music]

[Amy Jeppesen]
…I mean the last SAMHSA study showed that 99% of incarcerated women and 76% of incarcerated men had massive trauma…

[Jeff Seegmiller]
…most of Idaho, all of Idaho is actually health provider shortage areas for behavioral and mental health, and so in a rural setting, you may not have those resources…

[Abbey Abbondandolo]
…these individuals that we’re helping are our friends and our families and our neighbors, and that just because they’re in crisis, we shouldn’t forget that…

[Radha Sadacharan]
…PTSD, depression, anxiety, addiction… all of these are far more likely in individuals who are justice involved when we compare them to the general population…  

[Sam Steffen]
Welcome back! This is Something For the Pain…a podcast produced by Project ECHO in Idaho made for Idaho’s healthcare professionals working to learn best practices in the fight to prevent, treat and facilitate recovery from opioid and substance use disorders in communities across the state of Idaho. I’m your host, Sam Steffen. 

[Theme song]

[Sam Steffen]
On our last episode…

[Amy Jeppesen]
A year ago, if I saw 10 clients coming into Recovery 4 Life, maybe one of those clients, possibly two, but typically one out of ten would say that they had an issue with opiates in the past…

[Sam Steffen]
we heard from Director of Recovery 4 Life, Amy Jeppesen, who was talking all about the state of opioid use in the state of Idaho. 

[Amy Jeppesen]
...now it’s about 8 out of 10 clients coming through the door will talk about opiate use in the past.

[Sam Steffen]

We also got to talking about some of the medications used in medication assisted treatment for opioid use disorders, namely, Methadone, buprenorphine, suboxone, naltrexone, and naloxone. On today’s episode, EPISODE 3, we’re going to be looking at some of the cross-over between opioid prevention, treatment and recovery services and behavioral health services.  As WWAMI Director Jeff Seegmiller pointed out last time…

[Jeff Seegmiller]
…most of Idaho, all of Idaho, is actually health provider shortage areas for behavioral and mental health...

[Sam Steffen]

Idaho currently ranks lowest in the country when it comes to Mental Health spending—just $32 dollars per capita.  Idaho also ranks 49th in the nation for delivery of mental healthcare services.  Due to the severe shortage of mental health specialists, the majority of Idahoans who receive help for mental health conditions are treated not by mental health specialists, but by their primary care providers, which are also small in number. A little over 1600 serve the state’s 1.7 million residents.  Think about that for a second.  That means there’s 1 doctor for every 1,062 people in the state of Idaho. Primary care providers are routinely in contact with individuals who may be in crisis.  For people who have a substance use disorder, not having access to the substance they need can also put them in crisis. Not surprisingly these primary care providers are four times more likely to be exposed to violence in their workplace than those employed in the private industry. A 2016 article from the New England Journal of Medicine found that 71% of physicians reporting have never received any kind of formal workplace de-escalation training.

Today we’re going to be learning some de-escalation techniques from Abbey Abbondandolo, who is the Security Director at St. Luke’s Health System. In the second half of our episode, we’re going to change topics from de-escalation techniques to talk with Skip Clapp, the director of court services in Valley County. Skip’s going to be telling us about some programs the courts have in place to address opioid and substance use disorders as they intersect with Valley County court services.  All of that is coming up in the next forty-five minutes, so stick around.

[Theme song] 

[Sam Steffen]
So let’s get to today’s lecture.  The recording we’re going to be hearing was recorded live during an ECHO Idaho session on April 15, 2020.  This was a part of ECHO Idaho’s series on “Behavioral Health in Primary Care.”  And here to introduce today’s lecture and presenter, I’m going to turn it over to ECHO Idaho Program Manager, Lachelle Smith.

[Lachelle Smith]
Welcome, glad to have you for ECHO Idaho Behavioral Health in Primary Care. We are joined by Mr. Abbey Abbondandolo, who is the Security Director at St. Luke’s Health System he’s been doing that in Texas and in Idaho for going on 40 years, he’s also a former homicide detective with the Houston police department and a detective on a TV show called Cold Justice… but he’s not here to talk about those things. He’s here to talk about de-escalation, and we’re going to learn a lot and I’m really looking forward to it.  Abby, the floor is yours.

[Abbey Abbondandolo]
Thank you. I want to talk about some of the things that I oversee at St. Luke’s as it relates to de-escalation. The St. Luke’s health system employs about 160 security people who assist with de-escalation, with patients who are combative or aggressive. And sometimes those aren’t patients, they can be visitors as well. So our team is made up mostly of former law-enforcement officers, so they do have a lot of background in the ability to deescalate and what we do is we kind of hone their skills and we provide this instruction and collaboration with the clinical staff to really make things as safe as possible. 

One of the things I like to start out with with our team is that we remind everyone that these individuals that we’re helping are our friends and our families and our neighbors and that just because they’re in crisis we shouldn’t forget that. And that’s really an important piece to our de-escalation model that we use. We’re trying to accomplish a short-term outcome of something positive. The larger issue is going to be dealt with by the clinical staff, but really we’re just trying to keep everyone safe. And that’s easy to say and unfortunately sometimes very difficult to do. 
So our objectives really today in this very brief period that we’re together are to help recognize combative/ aggressive behavior, talk about some simple and very effective de-escalation steps, and then really hone in on some things as it relates to situational awareness. One of the things that we find in the healthcare setting is that during de-escalation or prior to, oftentimes the staff, primarily the clinical staff, aren’t as aware of their surroundings as they should be. I was a cop for 32 years in Houston. That was something that was pounded into our heads, essentially, every single day, because you’re ability to recognize your surroundings really does make your life and your job a whole lot safer. And we’ll talk a little bit about recognizing combative and aggressive behavior. A clenched fist, the mouth open, the eyes that are focused, those expressions are things that we should notice during these interactions with both patients and visitors. Do we notice these things? Are we aware of these things? And, seeing them and recognizing them, how do we keep ourselves safe as we attempt to take care of the patient? And how do we communicate when it comes to hostile and angry patients?

We should be aware that much of our communication is non-verbal. And I think a lot of times in this position, we forget our own body language and what we’re saying to that patient. We should be recognizing their body language. And we should be looking for or listening to subtle verbal cues. But really we should consider how we’re standing. Where we have our hands. How we have our hands facing towards the patient. Are they open? Are they closed? Do we have our arms folded? Think about how we approach the patient and how we set the tone for the interaction. And this is in response to the patient’s anxiety level going up. Entering the room and the patient is already upset. But again, we need to train ourselves to recognize that non-verbal communication that the patient is providing us with. We as professionals should recognize that and start thinking about how we’re going to approach this situation. Providing ourselves with some distance between the patient and ourselves. But really it’s recognizing and being cognizant of our own body language. The verbal cues sometimes are hard to pick up on. And all of you I’m sure are doing this day in and day out, so you’ve become experts, but it’s easy to become desensitized to that. Looking for and listening for certain phrases, certain words that would help you understand that this person is going to go from being upset, anxious, maybe slightly aggressive to being physically aggressive. And that’s where kind of the line changes, that’s where everything changes for us. So I think it’s very difficult to remain as vigilant as we should be in those interactions, so that we do keep ourselves safe. Again, the focus of this is to keep that healthcare worker safe as they try to provide the best patient care that they can. You can’t do that if you’re fearful, or if you’re not recognizing these signs, or if you are injured in some sort of interaction.

At St. Luke’s we record every physical confrontation with a patient in terms of documenting, we keep track of those, we look for trends, this is something that we share with other healthcare organizations in Idaho and across the United States. I co-chair the Workplace Violence Committee for the Leadership Institute and this body of work is something that is on the forefront virtually in every conversation that we have. How do we keep our employees safe in dealing with combative/aggressive patients? So let’s talk about recognizing pre-assaultive behavior.
These are a little more direct and certainly something that we should pay attention to. The balled fist, the blading of the body, someone turning themselves to you as you’re trying to talk to them, trying to calm them down and you notice these things, that’s the time when you should be backing up, giving yourself some distance. I really focus on watching people’s eyes. Experience and anecdotal evidence has certainly taught me that the individual’s eyes will tell you a lot about what they might do. And this is something that we repeat at St. Luke’s routinely, is that if you notice the person that you’re talking with, appears to be looking through you, that’s a very good sign that they are considering becoming physically violent. So if you get that sensation that the person is looking through you while you speak, I would say, give yourself a little more room. Really a double arms’ length. We’ve had this discussion a number of times about how far you should be away, that a single arms’ length, about three feet, two and a half feet, is probably not enough. When we’re talking to a patient that’s exhibiting some of these behaviors, I think that six foot level is a good distance to be standing at. I would say it’s important to take away that once you recognize these pre-assaultive behaviors, that you should really consider no longer participating in any type of negotiation or de-escalation, but at this point you should back up. Perhaps step out of the room or bring someone into the room with you so that you’re not stuck in there with somebody who might be physically stronger, larger or more determined to hurt you. These are the steps to take really to start keeping yourself safe. 

So when we talk about de-escalation, there are three techniques that I’m a fan of, and I know these work very well. It’s what we teach our staff and the feedback is very good. The first is to speak slowly. So changing the cadence of your voice is difficult. I know, it’s specifically difficult for me. I grew up in New York, I’m used to talking fast, and I run into problems with it. But during that de-escalation, learn to speak slowly, almost to where it feels a little uncomfortable. Lowering the tone of your voice also, dropping down an octave if that’s possible, makes a difference as well. When I worked for the police department in Houston, we had a very robust mental health unit for all of the patrol officers, a lot of the testing that we did, a lot of the training that we did, involved lowering the tone of the voice and we found that the lower your voice was, the individual you were dealing with who might be upset, might even be yelling, if you continued talking slowly with a lowered tone, they eventually stopped yelling and would listen to what you had to say. It’s a great technique.

The other piece of this triad here is to repeat that individual’s first name often. Almost to where you feel uncomfortable, and I’ll give you an example: the patient, his name is Bill. And he’s upset, he’s thrown his food on the floor. Or maybe he’s made some indirect threats. In that de-escalation where you’re speaking slowly to him, where you’re saying, “Bill, Bill, I want you to listen to me. I’m here to talk to you, Bill, about what’s going on. But, Bill, you need to get back into the chair, because you’re safe there, and I’m safe with you there. Do you understand, Bill?” And it’s that reaffirming statement and that repeating that first name slowly we have found works very effectively. And again, it’s really to keep you safe and those individuals safe.
It's difficult to continue talking while that person is yelling at you or is anxious or upset, but I would say if you can practice that and continue to speak slowly even as they’re yelling, they will eventually listen to what you have to say. And it’s okay to talk as they’re speaking and not raise your voice, cause they’re going to be curious about what you’re saying, and they will…and again, this isn’t a long-term fix. It’s to get through that anxious period. 

When it comes to that verbal discussion, that verbal piece, and listening to what they’re saying, where you’re using your basic de-escalation techniques, those three, all good if that individual’s yelling, if that patient’s cursing, and maybe even if that individual makes an indirect threat. But if there is a direct threat—a direct threat being, “I’m going to punch you in the face, I’m going to kick you”—that’s the time where we suggest you walk away, step out of the room, ask for help. You’re not going to make any headway at that point and you’re entering into an area where you’re becoming unsafe at that point. And this is where you really have to remove your ego and maybe recognize that you’re being less than effective. And it may not be anything that you’re doing, it’s just that individual doesn’t like you, doesn’t like the way you look, has a bias against you. But recognizing that I’m not effective and I’m going to step away. 
These are also some techniques that we used when I was in the police department. I was a homicide detective for 21 years. We found that individuals won’t relate well to certain people. If you’ve got a bald head, if you’ve got a goatee. It’s nothing about you, it’s just that individual. Step away and let somebody else take over. So again, keeping yourself safe is at the forefront, and once that direct threat comes up, it’s time to step away.

Situational awareness is one of my favorite things because…I find that law enforcement professionals are good at this because their safety is always an issue. So noticing what’s in the room. Maybe a razor blade that somehow just appears on a cabinet. Or the individual has something in their pocket. Or someone in the room that’s not getting along with you or them. Do you have an escape plan? Is there a way to get out of the room? That is part of that situational awareness. Always positioning yourself in the room so that you don’t have to go through the patient to get out. And that there’s always a way out. Not just out of that room, that treatment room, but out of that area overall if this person becomes so violent or fabricates some kind of weapon, grabs a gate belt or some tubing, something that you have a way to get out. And that’s where being aware of your surroundings makes a difference. And that’s something that you have to practice. Where you notice everything, almost on a level that feels, again, maybe a little uncomfortable. Bulges in pockets, bulges along the waistline, something that’s on the table in the table nearby, anything…it’s something that you really have to work on to be situationally aware.

So some takeaways: regardless of how much training you get, regardless of what your security team does or whether you do or don’t have security, ultimately you’re responsible for your own safety. You have to be willing to take certain risks, or recognize those risks, and not give in to them. Don’t give away the fact that you’re fearful of that individual. During that negotiation period, you should be fearful if they are upset, if they are making a direct threat and you’re trying to get out of the room. Don’t cry. I know that’s easy to say and hard to do sometimes, but don’t give in to your fear. Be cautious, but be confident. And as you navigate through this event, think about your body language, how you’re being perceived by this person. And as you work through this, whether it has a positive outcome or not, be aware of what’s going on around you, your physical surroundings, what’s in the room, what’s near the patient, what’s in his clothing or her clothing. Those are the things that I think will really make you safe and will give you a level of confidence that increases your ability to have a positive outcome.

[transition music]

[Sam Steffen]
That was a didactic presentation by Abbey Abbondandolo titled “De-Escalation.”  That lecture was recorded live during an ECHO session that took place on April 15, 2020 as a part of ECHO Idaho’s Behavioral Health in Primary Care series.

If you’d like to watch the Zoom recording of that presentation, that video is currently available on the ECHO Idaho YouTube channel, which you can access through our website. The powerpoint slide deck that accompanied that presentation is also available on our website: www.uidaho.edu/ECHO  

I’m going to transition now to a more recent conversation I had with the director of Court Services in Valley County, Skip Clapp.  If you’ll remember in our last episode, one of the things Amy Jeppesen mentioned in her talk about the State of Opioid and Drug Use in Idaho was the piloting of some new programs aimed at getting people who have substance use disorders who have also become involved in the justice system, into treatment.

[Amy Jeppesen]
For the first time two years ago, Idaho actually entertained on the state side paying for medication for assisted therapy. And there’s some pilots going on right now, including one for people who are picked up for having heroin or opiates, to allow them to go to treatment, rather than being charged with that…

[Sam Steffen]
Skip joined us for a special interview from his office in McCall to talk with us a little bit about the opioid and substance use trends in Valley County as they intersect with the Valley County Court System. Welcome to the program, Skip

[Skip Clapp]
Thank you Sam, I appreciate it.

[Sam Steffen]
Can we just start off by having you introduce yourself to our folks who might be listening and having you tell us a little bit about your work?

[Skip Clapp]
Okay, sure. So I’ll start with my position: as the director of Valley county court services I oversee probation for adult misdemeanor and juvenile, that includes programs, restart programs like adult and juvenile diversion, community service, and then as grants and other things apply, sometimes we have other programs. But primarily our job is to hold people accountable, but more than that, it’s to help them be successful, so that whatever struggles they’re having, if they need assistance with it, we do our best to place them with the right people so that they can get the help they need and move on with their lives.

[Sam Steffen]
You just mentioned the Diversion Program—can you explain to our listeners what the premise of that program is? 

[Skip Clapp]
Yeah, the premise of diversion is, it’s based on the best practice principle that you don’t want to take low-risk level people and insert them into a place and environments where there’s high-risk level people. Over and over again it’s showed that taking low-level offenders, and that can be people that just made a mistake, that can be people that maybe have a mental health issue or possibly a disability, social, economic, education, sometimes that can fall into these kinds of categories too where they’re just disadvantaged for some reason, but they’re not really a risk. The premise is just giving them a little bit of assistance, a little bit of oversight and help themselves correct on their own. 

[Sam Steffen]
So when you are talking about “low-level offenses” here, what kinds of things are you talking about?

[Skip Clapp]
Yeah, so as far as diversion goes, first of all, we’re looking at first-time offenders, right? So if they have a record of something, they’re not going to be qualified for diversion. But drugs and alcohol would absolutely qualify. And that’s complicated because some drugs are an automatic felony like prescription medication, opioids, methamphetamine, cocaine, heroin, LSD, mushrooms—those are automatic felonies. And in larger counties, most larger counties here in Idaho have a drug court that’s specifically meant for that because it’s a felony. Here in Valley County, it’s possible that somebody could get into diversion with one of those, but it’s not likely. But on the other hand, if it’s marijuana, that’s very likely. If it’s simple possession of marijuana or paraphernalia, they’d qualify for diversion on that.

[Sam Steffen]
So Skip, I have in front of me the 2020 Annual Community Gap Analysis report put out by The Idaho Department of Corrections in partnership with the Idaho Department of Health and Welfare. And in that report they found that of everyone currently involved in the justice system in Idaho, only 15% of those people were NOT in need of substance use disorder treatment. So another way to say that is 85% of people who are involved in the justice system are in need of that treatment. They also stated that individuals who struggled with a substance use disorder were much more likely to recidivate. There’s been a lot of work in recent years to start looking at some of this data to say that this really should be defined as a public health crisis rather than a criminal behavior. It makes me curious how some of these encounters between law enforcement and people with a substance use disorder take place. For the individuals who are being brought into court services with drug and alcohol charges, what do those charges typically look like? 

[Skip Clapp]
I mean, the vast majority of people that we get in here on drug and alcohol crimes are on the highway. It’s driving. A lot of times it’s not necessarily for driving badly, it’s failing to use a turn-light, it’s getting pulled over for some other stuff, but they forget they have that out in the open, or the officer smells it or the officer sees something else that leads into that. So that’s a good portion of it. I would say the second greatest portion outside of driving is public disturbances. Probably 50% are the kind from a home where law enforcement’s called because there’s a concern by a neighbor or maybe somebody in the home calls because of concerns of safety or property damage. But I would say that’s likely, you know, 10%, and driving is probably 90%.

[Sam Steffen]
So what are the demographics of the people who are encountering court services in Valley County?

[Skip Clapp]
We just went through that, and actually went through the juvenile, the state, for Valley County data for 2020 and our demographics are 97% white, about 75% are males. And the vast charges that we see, criminal charges, are drug and alcohol related. Like I said, we do misdemeanor, but a good portion of our adult section are people that, it was a felony DUI that was reduced as part of the plea bargain, or they were caught with opioids or some other pill or prescription they shouldn’t have and that was reduced to a misdemeanor so they wouldn’t get a felony. And a lot are DUIs, not just alcohol DUIs but just driving under the influence in general.

[Sam Steffen]
What sorts of resources exist for folks who may be struggling with a substance use disorder who find themselves caught up in the courts or the criminal justice system? In your experience, are there ways for people who are struggling with those things to get into treatment?

[Skip Clapp]
Yeah, so we have in-county, as far as substance [use] treatment providers…and most of the time what that looks like is when they’re on probation, part of their judgment was to get an evaluation follow-up recommendations. And we have two up here right now. We have one in Donnelly, the Change Clinic, and we have one in McCall, and over the years that’s been problematic because we’ve had one and then you have one person in each one of these places, and it doesn’t offer a whole lot of variety for people. It’s a very small community. We know each other. And sometimes with those relationships and treatment, you just really need the right fit. And so that’s been problematic for us. Having the ROC come in, which is peer support recovery, has been awesome. I really like the sense that they’re not required to report into probation. Which is a big deal. The treatment providers, when we send someone there, they have to tell us…they don’t tell us about what’s going on as far as the comments and the work, necessarily, but they tell us if somebody tests positive for drugs or alcohol, they have to tell us if someone’s attending class, they have to tell us about the participation in class, and that requirement can inadvertently cause a wedge between the treatment provider and the client. 

[Sam Steffen]
So peer support is referring to counseling and guidance that’s offered by folks who are in recovery themselves?

[Skip Clapp]
So it’s people that have gone through it, have been through it, understand addiction, giving good support. They don’t have to contact us. They don’t. I mean, maybe it was like a self-harm issue or something, they might, but…it really gives our clients the freedom to be able to talk to someone and have that support and know it’s just between them and their peer recovery coach. And I just see a lot of value in that. I’m excited to see the next few years, how that develops, and the work we can do with them. It is still new though, so right now there’s only one person that locally lives in Valley County that’s a peer recovery coach, and the rest are filling in from Treasure Valley. But I see that growing. Monica Forbes, also, who’s the CEO that runs it, has developed a wonderful treatment program for the jail which hasn’t existed in our jail for years and years and years. So she’s put that together, at least, a really strong first step for peer recovery coaches. In could also work in tangent, hand-in-hand, with substance abuse treatment providers.

[Sam Steffen]
So would that involve taking folks who are in jail and prison to treatment centers or would that involve bringing those resources into spaces like jails and prisons?

[Skip Clapp]
The way it’s set up is really, let’s say we have these people who are in custody and they’re pending a PV—probation violation—or new charge, and the court hasn’t released them from custody, or kept a high bond because of the concern for community safety, primarily related in these cases to substance use, whether it’s alcohol, drug use, whatever…and what the program would do, it would offer this peer recovery coach, so it’s voluntary by the clients in the jail, and they can reach out. This peer recovery coach could meet with them and find out what they need to get set up to get out so they can have their needs provided for and be able to do it safely in the community, so they would find out about what medications they have and if they have them or not, and help work that out; sign them up for Medicaid and other insurance, if they need it; housing; food; finding a treatment provider; support for them, before they get out so they can develop this plan and we can bring it back to the court, say, look, this person is ready for release, and here is the recovery plan. Here’s the safety plan for them to be released. And I think it’s just a great idea. I think sometimes it’s necessary but it’s certainly not desired to house people in jail or prison just because of addiction, you know? It’d be way better for the community, for the tax-payers, if they could get out and start getting on with their life and getting things set up, start working again, get the treatment.

[transition music] 
(33:50)

[Sam Steffen]
You're listening to my interview with Skip Clapp, the director of Court Services in Valley County. Skip's with us today to discuss the intersections between substance use disorder treatment services and the court system in Valley County. So far, we've discussed how a peer recovery coach can help assist people with a substance use disorder. I'd like to transition a little bit to talk about the rural aspect of Valley County. Skip I remember you're saying last time we spoke that… you were talking a bit about just because of the rural nature of Valley County, that some folks might be required to like attend a class as a part of their probation, that might be an hour away from their house. And if they don't have access to transportation, that can be a real barrier to success in a in a probation program. If you have anything else to add about the how the rural nature of Valley County and Idaho in general impacts folks who are coming through court services and how other services like that might benefit it.

[Skip Clapp]
Yeah, and this has been a grump of mine that I've shared with judges for over a decade, really close to two decades. And it's not just Valley County. But, you know, if you start in McCall and you go all the way, you know, west to Oregon, or Washington, depending where you're at in the state, and all the way east over to Wyoming or Montana, there's this great big hole from McCall all the way up to Lewiston, expanding that area where the opportunity for mental health or substance use [treatment] providers can be non-existent. And it can be cruel, I think when a probationer is ordered to complete something like, say domestic violence treatment, which, if they're convicted of domestic violence, it's a mandatory statute, the judge doesn't have a choice, of 52 weeks domestic violence classes, and that's once a week. So for here in Valley County, we've never had one except for the last few years where we had a pilot program. And you had people that were required once a week, and this is during working hours to almost always, they had to get out of work ease, some early or not at all, take it off the day, drive 100 miles down to Boise or Caldwell, do the class and drive back. Some of them didn't have vehicles or didn't have a driver's license, or quite frankly, just the burden of that cost for some people was too big. And so you see the same thing with substance abuse, like a level one treatment for somebody that's ordered that who lives in, say, Elk City, or the closest place that they could go would be Orofino, which is 40 miles, but then you put in winter conditions you put in not having a driver's license and relying on someone else. And that level one can be meeting with someone up to three times a week in person. And it's just been an ongoing issue. I've heard it from a lot of different administrators. The brick and mortar part is essential, where people, people that provide the services, they can't afford to have a center set up with that amount of clientele. And up until recently, with COVID the availability of doing it online just hasn't been acceptable. I mean, they just haven't allowed domestic violence is when we tried for years and years to allow to get that allowed to be done over zoom or over teleconference and they just wouldn't allow it. So I think there's a desperate need in our rural communities to have that access via internet connection and through total communication. And I think it would be outstanding in those programs, if there was if there was a group or people that could travel and make a make an in person meeting with these clients once a month or a group of them once a month. But it's an ongoing issue that I think still needs resolved up here.

[Sam Steffen]
Is there anything else that you want to people to know about your work or ways the community could get involved in advocating for some of the resources you're talking about?

[Skip Clapp]
I think when you're talking specially about a rural community, I really don't see the answer and just a treatment provider or, you know, one thing I think what makes a difference in people's life is a relationship. And people that actually care. And that's something that we strive to do here that we treat people with respect and dignity. And we expect to be treated the same. But I think a lot of these people that do struggle with it, they don't. Nobody wants to be an addict. Nobody wants to be a slave to things, but it's terribly difficult to get out of, it's very often something that people just can't do on their own. And I would say just you know, to our community, and I think they do a good job of when you see those people just reaching out, you know, with respect and care, and making that offering, making that offering of partnering with them, being with them. You know, I heard a great sermon the other day, and it was really about you know, sometimes the best thing we can do for people is just sit by them and listen, that try to reach them not try to coax and not try to educate them, but just to care. And I think if people in our community continue to do that, they'll reach those people that are struggling, that don't know how to say something that are embarrassed or ashamed. But I think that that'll make the biggest difference in a person's life or just those relationships with people that just actually care if they're doing good or bad.

[Sam Steffen]
Well, thanks so much, Skip.  It’s been really great talking with you today.

[Skip Clapp]
You’re very welcome.

[Sam Steffen]
That again was an interview with Skip Clapp, the Director of Court Services in Valley County.  Just to highlight a few things Skip mentioned in there: 

Skip mentioned the Change Clinic, which is located in Donnelly, Idaho, 83615. The change clinic offers medication assisted treatment, counseling services, and more.  Information about the change clinic’s hours of operations and services can be found on their website, www.idthechangeclinic.weebly.com

Skip also mentioned the ROC—R.O.C.— which stands for Recovery Oriented Community. The ROC is a recovery oriented community center that opened in 2020, founded by the Valley County Opioid Response Project in partnership with PEER Wellness, with the mission of advocating for and supporting individuals who are seeking to initiate or maintain recovery from behavioral health and/or substance use issues.  Its exact location is 106 E Park St, Suite 227 in McCall Idaho, 83638.  Information about their hours of operation, recovery services, ways to donate and ways to volunteer are all available on the ROC website: www.theroc.center

Details about some of the court service programs Skip mentioned in there, like the adult and juvenile probation programs, can be found online, on the Valley County Court Services website, at www.co.id.valley.us

[Banjo strum]

If you’re interested in joining our free, live ECHO sessions to receive Continuing Education credit, learn best practices, ask a question, grow your community, or simply because you’re curious—please visit our website at www.uidaho.edu/ECHO where you can register to attend, sign-up to receive announcements, donate, and find out more information about our programs. 
Something for the Pain is brought to you by ECHO Idaho, supported by the WWAMI Medical Education Program and the University of Idaho, and is made possible by VCORP, the Valley County Opioid Response Project. 

[Fade banjo]
[Guitar strum and guitar and theme song w/ words in background]

We here at ECHO also want to hear your feedback.  We welcome your questions, comments and suggestions and invite you to email us at echoidaho@uidaho.edu.  And don’t forget to subscribe to Something for the Pain using your podcast app.  And if you have a moment, write us a review!

That’s about all the time we have for today, but join us next time when we’ll be delving further into the treatment methods for opioid and substance use disorder, hearing a lecture from Brenda Hoyt on Harm Reduction. We’ll also be speaking with Courtney Boyce and Shelly Hitt from Central District Health, an organization serving Idaho’s Ada, Boise, Elmore and Valley Counties, and hearing about some education programs they’ve got in place to help connect existing prevention, treatment and recovery resources.  That’s coming up next time on Something for the Pain.  Until then, Idaho, take care of yourself! 

Something for the Pain is made possible by Grant Number GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDI-1 or HRSA.

The voices you heard at the beginning of the episode were those of Amy Jeppesen, Jeff Seegmiller, Abbey Abbondandalo and Radha Sadacharan, respectively. 
Big thanks also to the other contributing voices on today’s episode: Lachelle Smith and Skip Clapp. I’d also like to thank Jeremy Stockett, LCSW and social worker at St. Luke's Psychiatric Wellness Services for reviewing this episode. And a big thanks to all of our listeners without whom none of this would be possible.  Without you, we’d just be talking to ourselves.

Lachelle Smith is the ECHO Idaho Program Director; Katy Palmer is our Assistant Director; our Program Managers are Karley Kline and Lynsey Winters Juel; our Marketing Manager is Lindsay Lodis; our Program Coordinators are Kayla Blades, Jessica Whitlock, and Sam Steffen. 

Bonus Episode – Project ECHO Origin Story & The Vandal Theory

Featuring: ECHO Program Founder Sanjeev Arora, MD and ECHO Idaho Director, Lachelle Smith

This episode is not eligible for CE credit.

*This episode is not eligible for CE credit

ECHO Idaho Session Details

  • Featured Speakers:
    • Lachelle Smith, Program Director, ECHO Idaho, Boise
    • Sanjeev Arora, MD, MACP, FACG, ECHO Founder and Director, University of New Mexico
    • Terry Box, MD, Associate Professor, University of Utah
    • Magni Hamso, MD, MPH, Medical Director, Division of Medicaid, Idaho Department of Health and Welfare
    • Abby Davids, MD, MPH, AAHIVS, Associate Program Director, HIV & Viral Hepatitis Fellowship Director, Family Medicine Residency of Idaho
  • Didactic Presentation Title: “The State of HCV in Idaho and Actionable Steps for Change”
  • Didactic Presentation Date: April 12, 2021
  • ECHO Idaho Series: Hepatitis C
  • Didactic Presentation Video 

The Vandal Theory: Season 4, Episode 1: Lachelle Smith – Connecting Idaho’s Medical Communities

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Sanjeev Arora, MD, MACP, FACG, ECHO Founder and Director, University of New Mexico
  • Speaker: Leigh Cooper, Science Writer, Host of The Vandal Theory, University of Idaho, Moscow
  • Speaker: Lachelle Smith, ECHO Idaho Program Director

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

Episode 2 – State of Substance Use in Idaho

Featuring: Amy Jeppesen, LCSW

Claim CE for this Episode

Didactic Presentation Details

  • Didactic Presenter: Amy Jeppesen, LCSW, Executive Director of Trivium Life Services (formerly Recovery 4 Life)
  • Didactic Presentation Title: “The State of Use in Idaho”
  • Didactic Presentation Date: February 28, 2019
  • ECHO Idaho Series: Opioid Addiction and Treatment
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Edits/Commentary/Errata/Redactions

  • Throughout the recording, Amy Jeppesen is referred to as the Executive Director of Recovery 4 Life.  Recovery 4 Life recently changed its name to Trivium Life Services. 

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho, Boise
  • Speaker: Amy Jeppesen, LCSW, Executive Director, Trivium Life Services, Boise
  • Speaker: Coire Weathers, MD, Psychologist, Lost River Wellness, Boise
  • Speaker: Radha Sadacharan, MD, MAT Provider, Boise VA Medical Center
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director, Family Medicine Residency of Idaho, Boise
  • Speaker: Lachelle Smith, ECHO Idaho Program Director
  • Speaker: Monte Moore, MD, Pain Specialist
  • Speaker: Cathy Oliphant, PharmD, College of Pharmacy Chair, Idaho State University, Pocatello
  • Speaker: Brenda Hoyt, APRN, NP, Raise the Bottom, Boise
  • Speaker: Steven Kohtz, MD, St. Luke’s Health System, Twin Falls
  • Speaker: Neil Ragan, MD, Health West, Idaho State University, Pocatello
  • Speaker: Magni Hamso, MD, MPH, FACP, Medical Director, Division of Medicaid, Idaho Department of Health & Welfare
  • Speaker: Jeff Seegmiller, WWAMI Medical Education Program Director
     

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

SOMETHING FOR THE PAIN
EPISODE 2: State of Substance Use in Idaho

(47:00 mins)

(0:00)
[Amy Jeppesen]
…the most dangerous time of all for a [person who uses drugs] to overdose is when they stop using because they go back to the same amount that they were using and that and that is when they are the highest risk to overdose…

[Coire Weathers]
…and a lot of times when folks come in and they say they’ve failed, you know, ‘I can’t take SSRIs, no SNRIs work,’ a lot of times it’s about expectation, too…

[Radha Sadacharan]
…The more trauma that someone incurs, the more likely they are to struggle with things like addiction, to struggle with incarceration, and so a lot of this really focuses on what can we do to prevent these types of situations…

[Todd Palmer]
…and if you look at the mortality, you know, people that are using opiates…it’s six times the general population, but then if they get MAT, it goes down to two times the general population…(0:55)

[Guitar strum, Theme Song guitar]
[Sam Steffen]
Welcome back! This is Something For the Pain…a podcast produced by Project ECHO in Idaho made for Idaho’s healthcare professionals working to learn best practices in the fight to prevent, treat and facilitate recovery from opioid and substance use disorders in communities across the state of Idaho. I’m your host, Sam Steffen. 

[Theme song]

[Sam Steffen]
On our last episode…we heard from clinical psychologist Craig Lodis about how to conceptualize addiction.   

[Craig Lodis]
You know, if you’ve ever had a friend or family member who’s struggled with addiction, it can be very hard to be accepting and compassionate and set boundaries.  In some ways it can feel easier to say, oh this is a choice, I watched the show, “Intervention,” I know what I need to do, I need to make my relationship contingent upon their sobriety, it gives us a sense of power…I think it also perpetuates guilt and shame and some really unhelpful narratives surrounding addiction… 

[Sam Steffen]
On today’s episode—EPISODE 2—we’re going to be hearing from some of Idaho’s frontline opioid addiction treatment specialists, honing in on the state of opioid and substance use in the state of Idaho. We’re going to look at some of the current trends and figures and talk about what measures have been put in place to address them. We’re also going to talk a little bit about some of the medications that are available for treating opioid use disorder.  All of that is coming up in the next 45 minutes, so stick around.

[Theme Song]

[Sam Steffen]
Let’s get to today’s lecture.  The recording we’re going to be hearing was recorded live during an ECHO session on February 28, 2019.  This was a part of our series on “Opioid Addiction and Treatment.”  And here to introduce today’s lecture and presenter, I’m going to turn it over to ECHO Idaho Program Director, Lachelle Smith.

[Lachelle Smith]
Today our lecture is on “The State of Use in Idaho” and will be led by LCSW Amy Jeppesen who is also the executive director of Recovery 4 Life and because we have some new faces here today and I want to get the panel identified plus the panelists we’ve got in the room with us today, we’re going to start with some introductions here.  My name’s Lachelle Smith, I manage the ECHO program.

[Cathy Oliphant]
I’m Cathy Oliphant, I’m a pharmacist at ISU College of Pharmacy.

[Amy Jeppesen]
Amy Jeppesen, LCSW, executive director at Recovery 4 Life.

[Todd Palmer]
Todd Palmer, family medicine doc and patient medicine doc.

[Brenda Hoyt]
Brenda Hoyt, I’m a nurse practitioner at Raise the Bottom.

[Coire Weathers]
Coire Weathers, psychiatrist at Cottonwood, Lost River Wellness. 

[Lachelle Smith]
Alright, welcome all! So another quick reminder that we want your questions and thoughts throughout, so don’t be shy, and now I’m going to pass it to Amy. (5:15)

[Amy Jeppesen]
So today we are going to talk a little bit about where is the state of Idaho as far as the opioid epidemic, and what is the state of Idaho doing about that and what are some resources that might be accessible to you that maybe you haven’t heard of, or don’t know about at this time. So I titled my talk “the State of the State: The Opioid Epidemic.” And our objectives are really to address the addiction trends, populations most affected, discuss some current treatment options and how the state is planning to address the issue. 

So first I thought we would start with some current trends. So SAMHSA, which is the federal government’s agency that oversees the substance abuse across the United States does a survey each year, and according to that survey, what we know is that we still have a problem with… millions continue to misuse prescription pain relievers and this, they’ve broken it down into sort of the populations or the different types of drugs that people are using. Another thing that’s really interesting that came out of this study that I want to point out is that the population that’s most affected is 18-25 year olds. I think maybe sometimes we tend to think that maybe the population that’s most affected are maybe chronic pain folks.  They are definitely affected, but right now the growing trend and the fastest group or age group that is starting to get into drug use is 18-25 year olds. And we’ll talk a little bit more about that.

I think it’s also important to point out from their study, what types of prescription drugs are being misused. We’ve got Hydrocodone, we’ve got Oxycodone, Tramadol. Do you see the huge increase in buprenorphine? And so in 2017 it was the number one prescription drug that was misused and so we kind of have to ask ourselves some questions about that, like, “Why?” Why would buprenorphine be the most misused drug? I think there’s a couple of answers or hypotheses that I have about that.  The first is that, when you’re treating addiction, there is something inherently different about opiate addiction than other types of addiction, such as methamphetamine [addiction], alcoholism…my experience in working with opiate addiction is there’s an intrinsic piece inside people who are addicted to opiates, not that it’s not true with other kinds of addiction, but there’s this intrinsic piece that actually wants to get better. And it’s more common than not when people come into treatment, they say, “I’ve been trying to stop so I purchased suboxone on the street…” or “I’ve been trying to curb my use so I purchased some suboxone from a friend to try to get myself on it to get in here today.” And so that’s sort of an interesting differentiation between opiate addiction and other types of addiction.  Not that other types don’t want to get well, but it usually…they don’t usually come in with that intrinsic wanting to get better…

[musical interlude]

The other thing that we know is that heroine use has climbed and that it has stabilized.  It actually went down a little bit in 2017, but the interesting thing to note is that the number of deaths from heroine actually increased. And there’s a really interesting reason for that.  One is, the most dangerous time of all for a [person who uses drugs] to overdose is when they stop using. Because they go back to the same amount that they were using and that is when they are the highest risk to overdose, that is their very highest-risk time.  So while heroine use is going down, the death number is rising up and I think it’s also attributable to more people getting into treatment, but that’s also the most dangerous time for them.  And that’s also why as we trend forward, we really have to look at making Naloxone and those type—Narcan—much more available to people, because they’re at the greatest risk.

Another thing, and this is probably not too surprising for you, but the drug that increased its usage the most in 2017 was marijuana. 40.9 billion people were using marijuana.  I think we can attribute that to the states that have legalized, but right underneath it, the second fastest-growing was psychotherapeutic drugs. Those are things like opiates, tranquilizers and sedatives. And heroine is relatively small as compared to the rest of it, so that’s also something that’s interesting to note. 

So some of the summaries that I’ll just pop through a couple of these, that SAMHSA had, one is that the generation that is increasing with the greatest use is 18-25 year olds and 18-25 year old women.  The other thing that I think is really significant is that the other fastest growing group of users are pregnant women.  And they are growing in the most…just as fast as the 18-25 year old group of people, which I think is really interesting. Now that same group of 18-25 year olds is not only struggling with opioids and heroine problems, but they—we saw a decrease in the methamphetamine use and methamphetamine is coming back to life in that age group, as well as LSD, which we’ve seen kind of a decrease in over the years. It’s starting to make a resurgence.
The other thing is that more people are actually able to access treatment, now, which I think is a really good thing.

[Sam Steffen]
Just a reminder that these national trends Amy is reporting from originate from the Substance Abuse and Mental Health Services Administration survey and that this lecture was given in 2019.  (10:00) Next, Amy will give us the rundown on opiate use here in the Gem State.

[Amy Jeppesen]
So what are Idaho trends? So if you think about the opiate epidemic, some of the bigger states the bigger cities really got hit pretty hard in the beginning and they’re starting to see some of the decrease, and what I would say in Idaho is, we’re actually on the opposite side of that, we’re seeing an increase.  So as it filtrates across the United States, we’re seeing more and more and more and more and more people coming in for opiate…just to give you an example: a year ago, if I saw ten clients coming in to Recovery 4 Life, maybe one of those clients, maybe two, but typically one or two out of ten clients would maybe say that they had an issue or that they had maybe used opiates in the past. Now it’s about eight out of ten clients coming through the door will talk about opiate problems, or opiate use.  

The other thing that’s really interesting about what’s trending is that, not only are they using opiates or heroine, but they’re using methamphetamine.  In my career, I never thought that we would talk about people using those two drugs together, because as you know, opiates are, they calm you down, they’re a relaxant, they make you feel good, and methamphetamine is like a chipmunk on too much coffee, you know, it’s got you up, it’s got you going, you’re all amped, and so it’s a really interesting trend right now.  But it’s very rare that we see someone who’s currently using opiates who’s not also combining that with methamphetamine use.  And talking with them, you know, I’ve asked, “Why would you do that? Why would you take something that makes you totally relaxed, really calm, and then pair it with something that makes you like chippy chipmunk where you’re like up all night?” And they say, “well, you know, it helps me because I can use my opiates but I can still get up and I can manage my life.  I can clean my house, I can get more done.” So they’re mixing those two things.

The other thing that we’ve seen an insurgence of are bathsalts. Bathsalts, we’ve talked a little bit about them in here, they really made their debut about 4 years ago and then kind of went away.  And so what we’ve seen a lot of is people are taking a new formulation for bathsalts and these, when I say bathsalts, I’m not talking about you’re taking a bath and you’re putting bathsalts in, you’re relaxing.  I’m talking about a chemical formula that basically has an effect of kind of like an LSD, an acid, it really makes you kind of out there.  And they’re cutting the bathsalts into the methamphetamine or the heroine, and so we get a lot of clients that are coming in that are saying “I used meth but something was weird about it, it was like nothing that I’ve ever had.” They have some temporary psychosis, they might be hallucinating. So we are seeing more bathsalts coming back into the Valley but it’s not on its own, it’s typically cut into the opiates or the heroin or the meth that they’re using.

Then there’s also Kratom. So, Kratom is actually legal and you can buy it at any smoke shop. So what’s happening, too, is people that are struggling with opiate use or opiate use disorder or maybe they’re trying to get off heroin and they can’t afford, or maybe they don’t want to go in to Medicated Assisted Therapy…they go down to the smoke shop and they buy Kratom. And Kratom is sort of a natural plantlike thing that mimics the effects of opiates, and so sort of the word on the street is, “if you start taking Kratom, it’s like taking suboxone and you can sort of wean yourself off of your opiates or your heroin and it’s a lot safer for you.” But in fact that’s not actually true because we don’t know enough about what Kratom is, what it does, and pretty commonly, a lot of our clients that go out and start on Kratom, they feel more addicted to the Kratom than they actually did to the opiates.  And they talk about that.  And if you know anything about opiate withdrawals, it’s one of the worst things you can even experience, but they talk about coming off of Kratom as being twice as hard as coming off of the opiates.  And unfortunately, it’s something that you can pick up at any smoke shop. And you can smoke it, and I think there’s a pill form as well. There’s different ways you can use that.

And then, ease of access: one of the things, when we think about opiates or heroin, we kind of think about your neighborhood drug dealer…but to be honest with you, a lot of drugs are coming in through drug dealers, but even moreso, they’re coming through the mail. So you can get online, you can go on the Dark Web, you can use some Bitcoin, you can purchase your heroin and have it mailed straight to your front door. You purchase fentanyl, it’s mailed straight to your front door. So, in reality, the UPS is sort of becoming our drug mule, if you will. So you can get it mailed to you. And while we still have dealers and we still have people doing things like that, we have a lot of…and again, look at the generation that we’re talking about, the 18-25 year old generation. This is a generation that’s grown up in a digital era. This is a generation that’s very familiar with apps. This is the generation that, when you’re having a problem with your phone, you find one of those guys and they know exactly what to do. And so it’s really much easier for them to just access their drugs through just ordering them online.  We’re seeing more and more of that. (15:00) 

In particular, Pocatello has had a large problem with fentanyl in the past and that was where it was kind of coming from. We’ve also seen an increase with opioid overdoses. Two things have happened here that would account for this:  one is that Dotti, who is the current person here…

[Sam Steffen]
Amy is referring here to Dotti Owens, the Ada County Coroner.

[Amy Jeppesen]
…really implemented across the state a way for us to really start counting opiate deaths instead of just ruling them out as sort of an “unknown.” So we’ve had a lot more measures in our state to be able to tell whether it’s an opioid overdose versus just an “unknown death.” In 2017 there were 100 recorded opioid overdose deaths, and then that highest risk is when they get clean, when they stop using, that’s when they’re at the highest risk for overdose.  And that was Ada County, that was just in Ada County.

What we’ve seen in Idaho is, we definitely have, obviously, a lot of people doing opiates, we have heroin, and then we’ve seen a significant increase in the number of fentanyl…fentanyl coming into the state. And again, a lot of the fentanyl is being brought in by the mail, quite frankly.

The other thing that we haven’t seen a whole lot of yet, but our neighboring state, Utah, has had some experience with this is, car-fentanyl. So if you look, morphine is one-times powerful, heroin is two times as powerful as morphine, fentanyl is 100 times and then car-fentanyl is 10,000 times more potent than morphine. And we also know, too, in the 1970s when heroin made its debut, it was a yellow substance, it was more of a by-product and had a much lower grade to it, but in 2017 the average heroin contained 45% pure, and that also changes it into a white, substancy powder. So you look at heroin which is more pure than it’s ever been before, and you look at fentanyl that’s still 100 times more powerful than that heroin and then you look at car-fentanyl. So car-fentanyl on the street is called “pink,” “China-rush,” different things like that. And we haven’t seen as much of it in Idaho, but literally people that are overdosing…there were two kids up in Park City that ordered “pink” off of the mail, they tried it, and both of them died instantly. Car-fentanyl was developed to be an elephant tranquilizer and a giraffe tranquilizer.  It was built for large-animals, to tranquilize them. As we know, fentanyl was developed as an anesthesia or an extreme pain-killer. So, you look at those kinds of thing and you can see why some of our stuff is rising.So, what is the state of Idaho doing about this, and what options do you have for fundings for treatment? And how can you access those options?

I’ll just give you a quick overview. So the legislation, I don’t know if you’ve been following, but I’ve been following the mandatory minimums. So there’s some work to change the mandatory minimums. A lot of our drug-laws currently really came to be during the time of the War on Drugs. And we’ve learned a lot since that period of time, and so our laws sort of reflect the war on drugs, but we’ve learned that that’s not necessarily always the best way to handle the problem. So they’re actually doing some work on mandatory minimums and changing those. Idaho’s also working on making Narcan more available. For the first time, two years ago, Idaho actually entertained, on the state-side, the state-payer-source, paying for Medication Assisted Therapy, and that’s kind of a new, although it’s been done in other states for a long time, and there’s some pilots that are going on right now, including one that’s looking at a diversion program for people that get picked up for having heroin or opiates, and allowing them to go to treatment rather than being charged with that. But, given our time is almost up, I’m just going to open it up for questions for what we have talked about today. 

[Steven Kohtz]
I’d love to hear you wax philosophical a little bit about seeing such a high buprenorphine rate being diverted…

[Sam Steffen]
This is an ECHO participant speaking, Dr. Steven Kohtz. 

[Steven Kohtz]
I mean, I don’t really know what to say. In a way I’m glad to see that people are trying to take their recovery into their own hands.  I do see it as possible different in terms of how severe of a diversion a buprenorphine prescription would be compared to say a morphine or oxycodone.

[Amy Jeppesen]
Yeah, so some hypotheses that I have there’s a couple.  One, again, is what I talked about, which I think…my experience is that with people that are using opiates, or are addicted to those, they have this inherent thing that they want to get help, they’re just not sure how to do it, and so you’ve got different levels of medication assisted therapy clinics—you’ve got the level where they check in every day. (20:00) You’ve got the level where they leave with a prescription for three days, then they come back in three days, get another prescription, then get a 15-day prescription; and so, then you’ve also have, while we desperately need it, more people getting certified to dispense suboxone, and we really need that, but we also have to be really careful in how we roll that out, that we don’t create the same problem that we had with the opiate epidemic. And so, all three of those things are, I think, contributing to that larger number of buprenorphine kind of roaming around on the street, so, maybe I’ve got my three day prescription, maybe I go home from the doctor’s and I decide that, hmm, I really didn’t want to start this, I’m just going to do one last time, so I sell it to my buddy, but yeah. I was kind of surprised by that as well. That is, that’s the biggest drug that’s kind of floating around out there.   

[Todd Palmer]
I think, also, a lot of people don’t want to go through opiate withdrawal.

[Sam Steffen]
This is Dr. Todd Palmer speaking.  Dr. Palmer is the Addiction Fellowship Director at the Family Medicine Residency of Idaho in Boise.  Along with Amy Jeppesen, Dr. Palmer is one of our long-standing experts on the opioid series specialist panel and also partners with ECHO Idaho to give a free X-Waiver training twice annually.

[Todd Palmer]
So um they buy buprenorphine on the street, I heard it’s like $15 - $40 for an 8 milligram pill, I could be off a little bit. But you look at Oxycodone which is a dollar or more per milligram, maybe it’s a cheaper alternative and they don’t have to go through withdrawal…I’ve heard that from some patients, actually, that they just get ahold of it because they don’t want to go through the rigors of opiate withdrawal.

[Monte Moore]
And most of the buprenorphine is not suboxone.  

[Sam Steffen]
This is an ECHO participant speaking, Dr. Monte Moore, a pain specialist and contributing lecturer to ECHO Idaho’s Opioid Addiction and Treatment Series.

[Monte Moore]
Buprenorphine is not suboxone. It doesn’t have the naloxone with it.

[Todd Palmer]
Is that definitely true?  I mean, I know buprenorphine is diverted more when it’s not suboxone, but I imagine there’s still a lot of suboxone that’s being diverted as well.

[Amy Jeppesen]
Yes, there is.  We see clients that are buying suboxone, and then we see clients that are just buying buprenorphine.  In the past, it’s been more just buprenorphine, but in the last six months, it’s more suboxone. It’s, “oh, I got this suboxone from a friend,” suboxone, suboxone, so—we’re seeing an increase in people actually purchasing suboxone, and again, I think, as a state we’re doing a much better job of doing medicated assisted therapy, but it also puts a lot more suboxone out there, so.

[Todd Palmer]
Yeah.

[musical interlude]

[Sam Steffen] 
This may be a good time to pause to say a few words about some of the medications you’re hearing about.  Dr. Kohtz and Dr. Palmer were just talking about buprenorphine, Dr. Moore just mentioned suboxone and naloxone…  So, what are all of these medications? I want to take a second here and just define a few of these for our listeners who may not be familiar with them.  
The Food and Drug Administration has identified 3 approved medications for opioid use disorder treatment:  Methadone, Buprenorphine, and Naltrexone—I also want to talk about Suboxone and Naloxone, just because they’re probably going to keep coming up in these conversations.  To help me define these, I’m going to refer to some definitions provided by some of our Opioid Addiction and Treatment expert panelists.  Here to define Methadone is Brenda Hoyt, Nurse Practitioner at Raise the Bottom.

[Brenda Hoyt]
So what is Methadone? Methadone is one of 3 FDA approved medications used in the treatment of opioid use disorder (so, Methadone, Buprenorphine, Naltrexone)…it can be used to treat moderate to severe pain but it’s been used for treating opiate use disorder for more than 50 years. Methadone is a mu-opioid agonist, it’s administered orally, it comes in tablets, liquid, and wafers…so it is a schedule-2 medication and can only be dispensed through Federally Certified Opioid Treatment programs, and acute in-patient hospital settings for opiate use disorder. It’s typically dosed once daily because it has a really long half-life, and it stays in the body for up to 56 hours, so it reduces the frequency in dosing throughout the day, and it’s effective in suppressing and reducing opiate withdrawals and cravings. And, at effective doses, steady-state doses, it blocks the euphoric effects of self-administered illicit opiate use through occupancy of those receptors and cross tolerance. Some of the benefits [of Methadone], clinical studies and research have demonstrated that it’s safe and effective for long-term treatment, and does have some potential risks associated with it, just like any other medication (25:00) but is found to be generally safe. Along with being prescribed with strict program conditions and guidelines it reduces or cessates the use of illicit drugs, particularly opiates, reduction in overdose deaths, reduction in criminal behaviors, reduction in the spread of communicable diseases like HIV or AIDS, hepatitis C and hepatitis B, it’s safe to use during pregnancy and it’s cost-effective, so on average it’s $13 a day for dosing. 

Some of the adverse reactions or side effects, respiratory depression, constipation, excessive sweating, weight gain, somnolence or sedation, decreased libido or sexual function, and then neonatal abstinence syndrome for women who have been on methadone during pregnancy. 

[Sam Steffen]
For a definition of the second of these 3 FDA approved medications, Buprenorphine, here’s Todd Palmer, Addiction Fellowship Director at the Family Medicine Residency in Idaho.

[Todd Palmer]
So what are some characteristics of Buprenorphine? Well, it’s a partial opioid agonist, so it’s a partial mu agonist, so it doesn’t have the full effect on the mu receptor, but it has a very high affinity meaning that it binds very tightly.  It binds more tightly than other mu-agonists. And it disassociates slowly; it displaces other mu agonists. If you give it, it displaces them, and it stays on the receptor for a while so it blocks it from other mu agonists from getting to the receptor. The buprenorphine plateaus out at a lower level than the full-agonists, like methadone, heroin, morphine. It’s somewhat safer. It plateaus out, there’s less respiratory suppression, there’s less sedation, so it’s generally a safer med.

[Sam Steffen]
And for our third medication, Naltrexone, here’s Dr. Monte Moore, Pain Specialist.

[Monte Moore]
Naltrexone: it’s an opioid receptor antagonist, it’s classic use is to help maintain patients with an alcohol or opioid use disorder to help them stay abstinent because it blocks the opioid receptor, and makes it so that the opioids don’t have their usual effect. As opposed to Naloxone or Narcan, Naltrexone is absorbed through the GI tract.  It comes in a 50 millligram dose and has to be prepared at a compounding pharmacy.  Half-life is around 6 hours.  And I will begin at a dosage of a half- to one-and-a-half mg a day and then over a 3-6 month period titrate the dose up. One of the things I’ve seen out in the community is people have started to use this on their patients who are currently taking opiates and that’s not something you want to do, they need to be off their opiates.  So if they’re already on an opiate, it will put them into withdrawal, and if they’re taking an opiate…basically we’re giving the opiate receptor a rest when we do this so that things can repair.  So we don’t want to be stimulating that opioid receptor.  How it works, it’s kind of like if you have a hardware store and you close the doors so you can remodel. It somehow at a cellular, molecular level remodels the afferent pain pathways in the central nervous system.  And, so I’m not a neurophysiologist, but as a clinician, I like this drug.  It’s been really great. 

[Sam Steffen]
Now there’s two other drugs that are in the mix here, and will keep coming up in our conversations.  Naloxone is similar to naltrexone inasmuch as it is an opioid receptor antagonist, but it’s a different medication.  For a definition of Naloxone, here’s ISU College of Pharmacy Chair, Cathy Oliphant.

[Cathy Oliphant]
So what is Naloxone? Naloxone is an antidote to reverse the opioid-induced respiratory suppression as well as CNS depression of secondary 2 opioids. So it is a pure opioid antagonist that binds with very high affinity to the opioid receptors, and so the mu-receptors are probably the primary, we also have Kappa and Delta receptors, it’s got the greatest affinity for the mu-receptors.  And once Naloxone binds onto those receptors, it displaces the opioids off.  So if you have Naloxone binding it will push the opioid agonist off the receptor and an unbound, (30:00) it doesn’t have its physiologic effect, so what happens is when the Naloxone displaces the opioids, we get reversal of the clinical and toxic effects of the opioids which is what we want, and that can help to save a life.  When we knock the opioids off the receptors, though, individuals who are regular users of opioids or heroin—cause we’ll see that heroin fits into this as well—they can get the sudden withdrawal symptoms, and so, it’s not life threatening unless there are other comorbid conditions that would put them into the life-threatening category which hopefully would not be that common but they may experience some agitation, irritability, tacacardia, some GI side effects, those are just to name a few of what could happen once you knock those opioids off their receptors.

[Sam Steffen]
And finally for a definition of suboxone, here’s Dr. Palmer again. 

[Todd Palmer]
So what is this whole thing about buprenorphine and suboxone? Buprenorphine is Subutext, that’s the brand name, and that’s just buprenorphine, and then you’ve got suboxone, which is buprenorphine and naloxone. So why do we have buprenorphine and naloxone? Well, it turns out that Naloxone is not very bio-available when it’s taken sublingually. But when it’s taken perennially it’s about 100 times more bioavailable.  So the reason this preparation is out there is that it discourages people from injecting buprenorphine cause if you give them suboxone and they inject it, that naloxone is so potent that it doesn’t allow the buprenorphine to do very much, and we use suboxone on almost all of our patients except for pregnant patients.

[Sam Steffen]
So, there’s a lot more to say about each of these medications, as far as how to prescribe them, what the advantages of each are, how they’re administered, et cetera, and I’m hoping we’ll be able to get into some of the details of that in subsequent episodes. But for now, back to the conversation.

[Lachelle Smith]
I want to transition now if I can. Dr. Ragan, you also submitted some general, global, potpourri, I think you called them, questions…? Your first one I think blends right into this conversation, you ask: “Substance Abuse Counseling required in addition to or instead of regular counseling with folks who are getting MAT treatment?” Does that capture your question, and if so, who has thoughts about that?

[Neil Ragan]
Yes, that exactly captures the question.

[Todd Palmer]
I know for suboxone, Hey this is Todd, um you know so for the waiver, you have to say that you have access to counseling… 

[Sam Steffen]
The “waiver” Dr. Palmer is referring here is the MAT Waiver which stands for Medication-Assisted Treatment wavier.  It’s also known as an x-waiver.  This is a documentation requirement for anyone who is going to prescribe medications for opioid use disorder.

[Todd Palmer]
but it doesn’t have to be substance abuse counselor, it can be a general counselor—that being said, substance abuse counselors do a better job. 

[Amy Jeppesen]
So I’m teaching a substance abuse class up at BSU to the Master’s level students and one of the things I talk to them about is, so if you had a brain tumor, would you go see an orthopedic surgeon? And I think substance abuse counseling falls into that same category, it really is a specialty. So you have to master the basic counseling skills and then you add the specialty of substance abuse. My belief is that when you have someone on MAT, depending on their functioning level, if they’ve really struggled with an addiction, part of that struggle is psychological. Not only is it a physical addiction, but there’s a lot of psychological pieces that go along with that. And so, if I get on a medication where I feel better and I don’t need to go use anymore, but if I don’t learn new ways to deal with my stress…I mean, the last SAMHSA study showed that 99% of incarcerated women and 76% of incarcerated men had massive trauma, and we know that the average is 76% of people that have substance abuse also have trauma—if I don’t resolve those things, at some point I’m likely to go back. I might stay on the medication, or I might stop at some point because I encounter some kind of trigger, and so putting them on that substance abuse counseling when they get on the medically stable does of their MAT treatment, allows us, allows them to begin to process through that, and it really predicts long term recovery for them.  Like, I’ve learned coping skills, I’ve learned how to deal with this. And it’s different than regular mental health counseling, it really is very different, because I need to understand the substance, I need to understand the impact of the substance on the person, (35:00) I need to understand how the two work together, so that I’m not like, “oh, well you’ve got depression? Go out and run a couple miles, write a journal, talk to some friends.” If somebody’s really struggled with substance abuse, those types of things aren’t necessarily…they’re good for them, but they’re not likely to do them, and they may not work for them.  So you’ve really got to have that expertise.  And I’m a real proponent of, not everyone needs substance abuse counseling, that’s doing MAT, but if you’ve struggled with substance use addiction, you need to deal with…clean up that side, too, so that you can stay in recovery. 

[Lachelle Smith]
Brenda, what do you guys do at the Methadone clinic?

[Brenday Hoyt]
So all of our patients are required to have a minimum of one hour of counseling every month. I would say the majority of our counselors are CADCs, but

[Lachelle Smith]
…which is…?

[Brenda Hoyt]
Ah, I can never remember…

[Lachelle Smith]
Wait, I know this. “Certified Alcohol and Drug Counselors.”

[Brenda Hoyt]
Yes.

[Lachelle Smith]
There you go!

[Brenda Hoyt]
...and then we do have some that are social workers and a couple masters level, as well. 

[Lachelle Smith]
So the majority is Substance Use Counseling, not just garden variety?

[Brenda Hoyt]
And then we do have people that are coming, focusing on substance use, and then also working on other coping skills for working through the anxiety, working through trauma, because trauma is a significant component. So working on those things at the same time that they’re working on all of the substance use stuff.

[Amy Jeppesen]
And it’s not like we dismissed the mental health piece of it, we just have to, as a substance abuse counselor, you have to recognize that they’re intermingled. It’s not one or the other. They’re intermingled and so you have to deal with both of them.

[Magni Hamso]
Could I just add something, Lachelle?

[Lachelle Smith]
Please! Oh my gosh, remind us who you are, though.

[Magni Hamso]
So this is Magni Hamso, I’m an internest, I do a lot of substance use treatment at Terry Reilly and I’m also at the Boise VA. So I think in the medical literature, there’s not a ton of hard data saying that when someone’s on medication versus for addiction treatment that counseling and talk has a big impact. That said, it’s something that’s very hard to study and in general we think that people absolutely will benefit. And so that’s why that’s an ASAM recommendation, to offer people counseling. And that’s what I do generally…we, at Terry Reilly we are lucky enough to have drug and alcohol counselors who are also clinical social workers who can work with patients and we work closely with Recovery 4 Life, especially for our criminal justice-involved populations. I think the only sort of caution I would set is that sometimes we’re not completely patient-centered about it and if we create a program where we want the patient to jump through a lot of different hoops, some kind we can end up being a barrier to recovery. So I think just reminding everybody to make sure that it’s patient-centered. At different levels in the recovery they’re going to be able to do more or less. Some patients are going to need a ton of structure and would benefit from intensive outpatient and then there’s someone else who actually is quite functional with their substance use disorder, is holding a full-time job, for that person it could actually be problematic to add that many hours in the day. So really just thinking about who your patient is and what works for them at that time. I think the situations where I’m mandating treatment is you know obviously with somebody who’s struggling every time they come in, their urine has all kinds of different things in them, they’re missing appointments, right and left—that’s somebody who absolutely needs the structure of a formal program while again someone else who has small relapses in the setting of stress needs the support that Amy talked about, really explore whether that is their coping mechanism, or maybe they need less intensive services and we can sort of fit it out in and around their work schedule.

[Todd Palmer]
This is something I’ve struggled a little bit with, I mean there are all kinds of prescribers out there who just won’t prescribe unless somebody’s getting counseling and if it’s federally mandated, anybody going to a treatment center at least once a month. That being said, what Magni’s talking about, and in the literature, and the fact that harm reduction is really quite effective, I don’t…it’s…some of my patients, I don’t mandate that, and actually quite a few…I mean, if patients come in and they’re absolutely refusing counseling but they’re open to MAT, I see they’d value from MAT and they’re not or they’re fairly compliant, then I’ll allow that. And I think the benefits outweigh the risk.

[Magni Hamso]
No, and I mean and I think that’s exactly right, I should have used the Harm Reduction language cause that’s the right thing. And I mean I think that’s…that’s with everything we do in medicine. Some patients are going to…they’re never going to take insulin and you will work with them on oral medications for the diabetes (40:00) and you might not quite get your goal, but at least they’re not getting admitted with sort of severe dehydration from severe hyperglycemia, maybe reducing some of their complications. So I think it’s the same thing that you do everywhere, where we have to come up with a patient-centered approach. And some patients are not going to want to do counseling and that does not mean that they won’t benefit from the medication and that we should sort of prevent them from getting them.

[Jeff Seegmiller]
I would just add that…

[Lachelle Smith]
Remind us who you are.

[Jeff Seegmiller]
This is Jeff Seegmiller, Director of the WWAMI program…is that, most of Idaho, all of Idaho is actually a health provider shortage area for behavioral and mental health and so in a rural setting you may not have those resources available, you may have MAT waiver trainings but you may have individuals who may not have a psychiatrist or counselros that are even available for patients.

[Sam Steffen]
Just to reiterate what WWAMI director Jeff Seegmiller just said, the entire state of Idaho has been designated a Mental Health Professional Shortage Area by the Idaho Bureau of Rural Health and Primary Care. A link to more information about that definition can be found in the show notes.

[Amy Jeppesen]
And sometimes, too, like Dr. Hamso’s talking about, until they get to a therapeutic dosage on their MAT, the Medication-Assisted Treatment, they’re not even open to, willing to, but once they get there sometimes they start having some insights and they’re like, “oh wait, maybe I do need a little bit of extra help with this,” so I totally agree. It’s got to be patient centered. But I do think if you are referring someone out because you think it’s a good fit, you’ve got to find a good substance abuse counselor that can work for or with that patient.

[Lachelle Smith]
How do you do that in Rural Idaho, Amy?

[Amy Jeppesen]
Um, it’s tricky. I mean, if you’re looking for a licensed facility that might have counselors that do that. The Department of Health and Welfare keeps a current list of all the licensed substance use treatment facilities, and I believe it’s also listed on there who does mental health and substance use…but it can be tricky to find good substance abuse [counselors]…unfortunately one of the things we have going on in the state is we don’t have a lot of education anymore in the counseling programs specifically for substance abuse so that’s something we’re kind of addressing as well, we have a real shortage of that. So it can be very tricky. There’s also telehealth, so the state has opened telehealth for substance use treatment and counseling, so that’s a possibility as well.

[Lachelle Smith]
And at risk of cutting us off abruptly, we are at time.  So that’s been a really rich conversation, thank you to all who came and spoke up.

[Sam Steffen]
That was a didactic presentation by Amy Jeppesen titled “Idaho Trends and Resources: The State of Use in Idaho.”  That lecture was recorded live during an ECHO session that took place on February 28, 2019 as a part of ECHO Idaho’s “Opioid Addiction and Treatment” series.

If you’d like to watch the Zoom recording of that presentation, that video is currently available on the ECHO Idaho YouTube channel, which you can access through our website. The powerpoint slide deck that accompanied that presentation is also available on our website: www.uidaho.edu/ECHO  

The resource materials that Amy mentioned in that lecture are currently available on our podcast webpage. For those, and instructions about how to claim continuing education credit for listening to this episode visit our podcast webpage: www.uidaho.edu/echo/podcast

If you’re interested in joining our free, live ECHO sessions to receive continuing education credit, learn best practices, ask a question, grow your community, or simply because you’re curious—please visit our website where you can register to attend, sign-up to receive announcements, donate, and find out more information about our programs. 
Something for the Pain is brought to you by ECHO Idaho, supported by the WWAMI Medical Education Program and the University of Idaho, and is made possible by VCORP, the Valley County Opioid Response Project. 

We here at ECHO also want to hear your feedback.  We welcome your questions, comments and suggestions and invite you to email us at echoidaho@uidaho.edu.  And don’t forget to subscribe to Something for the Pain using your podcast app.  And if you have a moment, write us a review!

That’s about all the time we have for today, but join us next time when we’ll be looking at some Deescalation Techniques with St. Luke’s Security Director, Abby Abbondandolo, and talking a little bit with Skip Clapp, the Director of Valley County Court Services.  That’s coming up next time on Something for the Pain.  Until then, Idaho, take care of yourself! 

Something for the Pain is made possible by Grant Number GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDI-1 or HRSA.”

The voices you heard at the beginning of the episode were those of Amy Jeppesen, Coire Weathers, Radha Sadacharan, and Todd Palmer, respectively.

The definitions of medications for Medication Assisted Treatment were provided by Brenda Hoyt, from an August 8, 2019, ECHO Idaho lecture titled, “Methadone”; Todd Palmer, from a July 19, 2018 ECHO Idaho lecture titled “Buprenorphine in Primary Care,”  Monte Moore from an August 22, 2019 ECHO Idaho lecture titled, “Non-Opioid Drugs for Treating Pain,” and Cathy Oliphant, from a September 13, 2018 ECHO Idaho lecture titled, “Naloxone: Saving Lives”. All of those lectures can be heard in their entirety on our YouTube channel which can be accessed through the ECHO Idaho website, www.uidaho.edu/echo.

Big thanks also to the other contributing voices on today’s episode: Lachelle Smith, Steven Kohtz, Monte Moore, Neil Ragan, Jeff Seegmiller, and Magni Hamso.  And a big thanks to all of our listeners without whom none of this would be possible.  Without you, we’d just be talking to ourselves.
Lachelle Smith is the ECHO Idaho Program Director; Katy Palmer is our Assistant Director; our Marketing Manager is Lindsay Lodis; our Program Coordinators are Kayla Blades, Jessica Whitlock, Karley Kline and Sam Steffen. 


Episode 1 – Framework for Addiction as Disease

Featuring: Craig Lodis, PhD

Claim CE for this Episode

Didactic Presentation Details

  • Didactic Presenter: Craig Lodis, PhD, Psychologist at the Boise VA Medical Center
  • Didactic Presentation Title: “Understanding the Disease of Addiction”
  • Didactic Presentation Date: January 7, 2021
  • ECHO Idaho Series: Counseling Techniques for Substance Use Disorders
  • Didactic Presentation Video
  • Didactic Presentation Slides

Resources and Publications Mentioned

Edits/Commentary/Errata/Redactions

  • At about (9:30) Dr. Lodis talks about “a psychiatrist who does a lot of really great work with mindfulness,” whom he names as Peter Seigel; it’s actually psychiatrist Dan Seigel he’s talking about.

Speaking Credits

  • Narrator/Host: Sam Steffen, Project Coordinator, ECHO Idaho
  • Speaker: Todd Palmer, MD, Addiction Fellowship Director at the Boise Family Medicine Residency of Idaho
  • Speaker: Craig Lodis, PhD, Clinical Psychologist at the Boise VA Medical Center
  • Speaker: Jason Coombs, MPC, CEO of Brick House Recovery in Boise
  • Speaker: Katy Palmer, ECHO Idaho Assistant Director, Boise
  • Speaker: Radha Sadacharan, MD, MPH, MAT Provider at the Boise VA Medical Center
  • Speaker: Haylee (ECHO Idaho Participant)
  • Speaker: Scott Jones, BS, Chapter Manager at The Phoenix Recovery Center in Boise

Music Contributions

  • “ECHO Idaho Theme Song” written and performed by Sam Steffen
  • Guitar instrumentals also provided by Sam Steffen

SOMETHING FOR THE PAIN
EPISODE 1: Framework for Addiction as Disease

Episode Transcript

(31:41 mins)

(0:00)
[somber music]

[Sam Steffen]
The Opioid Epidemic in America claimed 450,000 lives in America between 1999 and 2018.  That means that in the last 20 years, more people have died from opioid overdoses than firearms or car accidents.

[Todd Palmer]
…the mortality rate for people that are using opiates, it’s six times the general population…

[Sam Steffen]
In Idaho, 3.9% of Idahoans age 12 and older reported misuse of prescription pain relievers in 2016

[Craig Lodis]
…It’s important to point out that a lot of the research suggests that 40-60% of the variance, with regards to who struggles with addiction versus who doesn’t, 40-60% of that variance is accounted for by genetics… 

[Sam Steffen]
Among Idaho high school students, 13.9% have taken a prescription drug without a doctor’s prescription. 

[Jason Coombs]
…when I was in high school I had my first soccer injury, I was a senior in high school and I blew out my ACL and was prescribed Percocet, and that was my introduction to pills… (1:04)

[Sam Steffen]
The CDC classified 13 of Idaho’s 44 counties—that’s nearly 30%—in their highest category of opioids prescribed per person. Higher opioid prescribing puts patients at risk for addiction and overdose. If you’re a healthcare professional working with someone who is seeking treatment and recovery options for opioid addiction, or if you are a citizen interested in learning more about prevention, treatment and recovery education resources, ECHO Idaho is here to help. 
[cue music]
This is Something For the Pain…a podcast for Idaho healthcare professionals and citizens working to learn best practices in the fight to prevent, treat and facilitate recovery from opioid and substance use disorders in communities across the state of Idaho. I’m your host, Sam Steffen. (1:56)

[Theme Song Verse + Chorus]
…in the rurallest of places where the resources are scarce
They’re calling ECHO Idaho an answer to our prayers
ECHO Idaho—

[Sam Steffen]
Something for the Pain  is brought to you by the Idaho chapter of Project ECHO, or, Extensions for Community Healthcare Outcomes—an innovative strategy to increase the capacity of the local healthcare workforce to improve lives for patients and providers in the here and now.  Using video conferencing and adult learning techniques, ECHO Idaho connects community providers across the state with specialists in live on-line collaborative sessions.  The sessions, designed around case-based learning and mentorship, help healthcare professionals gain the expertise required to meet the needs of Idaho residents. 
Project ECHO has now been replicated throughout the United States and around the world to address a number of special health areas, including programs focused on increasing healthcare professionals’ capacity to better respond to Substance and Opioid Use Disorders. (3:00)

[Theme song]
…You can earn CE credit while you sit and eat your lunch
[End Music] 

[Sam Steffen]

(3:13) In today’s episode—EPISODE 1—we’re going to be hearing a lecture from Dr. Craig Lodis, a clinical psychologist at the Boise VA Medical Center who specializes in Substance Use Disorder and Post Traumatic Stress Disorder.  Dr. Lodis is going to be speaking on “Understanding the Disease of Addiction” and will be looking at some different narratives surrounding how we conceptualize addiction. The lecture we’re going to be hearing was recorded live during an ECHO session that took place on January 7, 2021 as a part of ECHO Idaho’s Counseling Techniques for Substance Use Disorders series.  Without further ado, let’s turn it over to Craig. 

(3:50)

[Craig Lodis]
So, my name’s Craig Lodis, I’m a clinical psychologist, I work at the Boise VA, I did my post-doctoral fellowship there I think it was about eight years ago, now? And I’ve been working there ever since. I work in the in-patient Substance Use / PTSD program, used to work over exclusively on the Substance Use side and within the last year I’ve moved over to the PTSD side.  

So, today, we’re going to be talking a little bit about how to conceptualize addiction. So, some learning objectives: I wanted to just kind of explore this question, we hear this so much: “Is Addiction a Disease or is it a choice?”  I think there’s overwhelming evidence to support that it’s much more of a disease process than a simple choice. It is very far from a simple choice, especially once we are active in our addiction. So I just want to explore a little bit the implications of how we conceptualize our answer to that question, how does it apply to our direct clinical care, how does it apply to kind of…on a larger, societal level in terms of legislation and how we respond to people who are struggling with addiction, and then more specifically for Substance Use Disorder Techniques for clinicians, look at how can we use this conceptualization and the information that we have regarding how addiction is a disease…how can we use this information to help our patients move through themes like shame and guilt that often are a barrier to treatment and often kind of complicate things or make it so that people aren’t able to receive the treatment that they need.

So, just some recommended resources: In the Realm of Hungry Ghosts is a book by Gabor Mate, which, he’s a brilliant physician who lives in Vancouver. “Everything You Know About Addiction is Wrong” is a TED talk by Johann Hari. Hopefully many of you have seen that.  If not, I would strongly recommend you check that out today. He wrote a book called Chasing the Scream among other books, but he’s got some very interesting views, and I think very helpful views, regarding addiction.  And then last but not least there’s a documentary called Pleasure Unwoven that we show in our program. A lot of the information that I’m going to be covering is coming from that documentary. This is by a physician, Kevin McCauley, who is in recovery himself.  I believe it is available for free on YouTube and I would strongly encourage you to check that out.

So I wanted to start by just acknowledging the huge amount of stigma. Substance abuse tends to evoke even greater negative attitudes even than schizophrenia.  And I think that if we kind of start to unpack this question a little bit, I think a lot of this has to do with where do we fall on the ‘disease vs. choice’ question. And if we’re honest…you know, if you’ve ever had a friend or family member who’s struggled with addiction, it can be very hard to be accepting and compassionate and set boundaries. In some ways it can feel easier to say, “oh, this is a choice, I watched the show Intervention, I know what I need to do, I need to make my relationship contingent upon their sobriety…” It gives us a sense of power.  I think it also perpetuates guilt and shame and some really unhelpful narratives surrounding addiction.
So the disease question: basically, we have this kind of dichotomy, and this seems to just be the way that our brains work and prefer to have “it is a disease” or “it’s a choice,” it’s one or the other. We have a harder time with more nuance and complexity. So basically the “choice” argument would say, if somebody’s struggling with addiction, if I go—and this is a blunt analogy, excuse me—but this is from Pleasure Unwoven—if I go to somebody who’s struggling with addiction and put a gun to their head and say, “stop using!” they will probably stop using, right? And our thought is, “they’re choosing to stop using.” But in reality I think more what’s happening when we’re active in addiction is we’re thinking, “Can I smoke this, snort this, inject this, drink this, before that bullet hits my brain?” because that just seems to be the way that addiction works. It kind of grabs hold of the more primitive parts of our brain.

So the “disease” question, it really helps if we’re able to conceptualize and really look at some of the neurobiology of addiction, it really helps to paint a different picture, and a picture that helps us understand why we see some of these behaviors and why we see people acting in ways that seem 180 degrees the opposite of their normal values and behavior…why do these occur when we’re active in our addiction? So, according to Kevin McCauley in Pleasure Unwoven, it is a disease and it’s a disease of choice. So, “a disorder of the very parts of the brain that we need to make proper decisions.” 

At this stage I’m going to give a caveat and say I am not a neuropsychologist, I am not a neuroscientist, I am a clinical psychologist, so I have some knowledge of the brain but there are people who are much more knowledgeable than I am, so I’m going to be speaking kind of in generalities…

(9:00) So focus is on the role of communication between the frontal cortex and the mid-brain via dopamine and glutamate. Don’t I sound smart? So, what do we take from this? The important things to take from this: the frontal cortex and the mid-brain, if you’ve ever done DBT (Dialectical Behavioral Therapy), this maps on really nicely to the reason-mind or the rational-mind versus the emotion-mind, the emotion-mind being more the mid-brain or limbic-system and the rational/reasonable-mind being our frontal cortex. Again, in general. Also, if you’ve ever seen Peter Siegel (sic) who is a psychiatrist who does a lot of really great work with mindfulness, he has a conceptualization for children where he talks about…he says, if my fist is my brain, you’ve got your upstairs brain which is the pre-frontal cortex and then we have your downstairs brain which is, in generalities, your mid-brain and your limbic system. So I think finding a language that is palatable for our patients and that they can really kind of understand is really important to keep in mind.

So, according to Dr. McCauley’s framework, addiction is a disease of “genes, reward, memory, stress, and choice.” So I think the first thing that’s really important to point out, especially when we have a patient who’s struggling with shame and guilt, it’s important to point out that a lot of the research suggests that 40-60% of the variance with regards to who struggles with addiction versus who doesn’t, 40-60% of that variance is accounted for by genetics. And variance is a statistical term, for those of you who aren’t stats nerds, it’s basically a statistical way to determine why do some people fall into addiction while others don’t and we can control for other variables and kind of isolate and say, it looks like genetics is responsible for 40-60%, so that’s a pretty big number.  The analogy that I like to make here, partly because I work in the VA system, and this is a little cheesy, but I make the analogy of body armor and say, you know, some of us have a different amount of body armor when we go into deployment or into a combat situation and that is based on our genetics and our early life experiences. Some of us are going to be much more flexible and able to bend and adapt, others are going to be much more rigid and likely to fall into that cycle of addiction.

And the way that this is presented in Pleasure Unwoven, he uses Russian nesting dolls, I don’t know if you guys have ever encountered those, but they all kind of fit inside of each other, and I take that to be…I think he’s saying this is kind of a cumulative process, it’s kind of additive, so each layer is impacted and passes that impact onto the next layer. So reward is broken and passes that deficiencies onto memory areas in our brain.

So: reward. Some things that I’ve found really important and helpful for me for conceptualizing addiction (12:00) Reward, the role of dopamine.  So the way that it’s described that has really resonated with me, and again this is in Pleasure Unwoven so if you’re interested please check that out…dopamine is released to tell us when things are better than expected. That’s the way it’s been described to me.  So the analogy is if I go to a gumball machine and I pop in a quarter, I turn the knob, I get one gumball, there’s probably going to be a little squirt of dopamine. It’s not better than expected but it’s still good.  If I put in my quarter and turn the knob and by some miracle I get two gumballs, there’s going to be a larger squirt of dopamine. And we believe the function of that dopamine is to say, “Hey, this is rad. I like this. We should do this.” And part of what is helpful to remember is, when people talk about that idea of ‘chasing the dragon’ so to speak, or you know, the first high, or the first effect of your substance abuse was the best, it’s because you have expectations after that first use. I think it’s also important to remember that the levels of dopamine that are found in our brain when we ingest substances are much, much higher than our brain was designed for. So it’s kind of this huge spike in dopamine, and that helps us understand why I could be passed out on the bathroom floor and my brain is still like, “This is the best night ever!” There’s obviously still significant repercussions once our brain realizes, “oh, there’s way too much dopamine,” and it starts to push back. We’ll get to that when we talk a little bit about stress.

[musical interlude]
[Sam Steffen]
Dr. Lodis makes the case that addiction takes the form of disease, not choice, and that some of us are predisposed to addiction through genetics and early life experiences. The framework of addiction as disease has major implications for approaches to patient care, as well as on a larger societal level and in legislation and policy when it comes to conceptualizing treatment for people who are struggling with addiction. Let’s hear more from Dr. Lodis about the connection between cravings, stress and recovery.

[Craig Lodis]
So, we were talking a little bit about memory.  This helps us understand a little bit why people have these very vivid memories associated with use, it’s in large part because we are flooding our brain with dopamine and glutamate and that helps us also understand and normalize the experience of cravings. Research suggests that cravings are a natural part of the recovery process. They may never completely go away, and so one of the things that we need to do is if people are responding to cravings, thinking, “Oh, this means there’s something wrong with me,” or “I don’t really want to be sober,” or “What does this mean?” you know, and they start to struggle with that craving, that’s really problematic. So we want to use things like mindfulness and urge-surfing to help them just kind of observe and do their best to wade through that experience and then get back to living their life. (15:00)

Then we go on to talk about stress and the role of stress. We talk about how our brain kind of resets once our brain realizes that there’s excess dopamine, it’ll start to release CRF or what they call Corticotropin Releasing Factor and it will push down on the dopamine levels. And after repeated or binge use, or if we kind of go on a runner, so to speak, it can really upset the balance of our brain and what they call the hedonic setpoint, so what it takes—what amount of dopamine does it take—for me to feel good. This helps us understand a little bit of why is it so difficult, especially in the early stages of recovery when you’re doing everything that people are telling you, and you still feel crummy. It can take some time, and depending on our substance abuse that time may vary, and depending on our individual biology that time may vary as well.

The other piece of research that I think is really fascinating that I would encourage people to talk about with patients—they have hooked electrodes to parts of mice and rat brains, they keep them alive, but they hook them to the areas involved in the pleasure center and response, and then they have a lever that they can press. And every time they press that lever, they get a little electric shock that’s a release of dopamine. It feels good. It kind of mimics the effects of substances. What research has consistently found over and over and over again is that these rats and mice will consistently press that lever obsessively, seemingly coming into that cycle of addiction. They don’t eat, they don’t sleep, they don’t socialize. They do this until they die. They will even continue to do this if we put an electrified grate underneath that rat or that mouse.  They will stay on that grate and hit that lever to get that surge of dopamine until they die. So if rats and mice can have addiction, I don’t think this is about will power as much as some narratives suggest it is. I don’t think this is about morality and being a bad person as a lot of our narratives suggest. I think also, if we put a metal, electrified grate under them and shock them, and they still do it, that suggests to me that punishment isn’t always going to be helpful.

[musical interlude]
So the formulation that Kevin McCauley uses is that the majority of the population falls on the left-side, here, as a non-addict, and I…personally I don’t like that term, I wouldn’t use that term, and that’s something I want to touch on, too, real briefly, but before that…so, they’re either a non-user or they experiment, they use, they abuse, but to them and to their mid-brain, the drug is the drug. Somebody who goes into the cycle of addiction, their mid-brain is saying the drug equals survival, and it’s saying the drug is as important as things like eating, breathing, sleeping. Our mid-brain is responsible, in the simplest terms, for the next ten to fifteen seconds of our life and with keeping us alive.  And if my mid-brain thinks I need to keep using my substance to stay alive, I’m probably going to do that.

Okay, so the last thing I want to talk about, getting back to that upstairs-brain/ downstairs-brain, in a nutshell, the way that I explain this to patients is part of what happens when I am active in my addiction is the communication between my downstairs brain and my upstairs brain has been really damaged if not cut off completely. My upstairs brain, my prefrontal cortex where I have things like moral and executive functioning and I’m able to control my impulses, all of that is almost in someway off-line. So that helps us understand: this is what’s happening when you’re active in your addiction. It’s not that you’re a bad person or you don’t care about your family or your job or your other responsibilities, your brain, in essence, has kind of been hijacked.

So before we get to the key points, the other thing that I want to say is because of the amount of shame and guilt that we see in this population, it is imperative that we are really mindful and thoughtful with what language we use. So don’t call it their “substance of choice.” It’s not a choice. And if I say it’s a “substance of choice,” I’m implying that it is a choice. So instead I prefer to say “substance of use.” Other things: I don’t like the label of “addict” or “alcoholic,” even.  Personally I would rather say “I am” or “You are a person who struggles with addiction,” or “you are a person who has an alcohol use disorder.” Really just trying to humanize…and any way that we can chip away at some of that shame and guilt and treat them with that unconditional positive regard that Carl Rogers talked about, that’s going to be beneficial for our treatment.

So, key points: Addiction is a disorder of genes, reward, memory, stress, and choice and I think a bigger point is, how we answer this question: “Is Addiction a disease?” is going to inform how we interact with people who struggle with addiction, it’s going to inform our treatments, it’s going to inform our legislation. It’s going to inform whether our government is supportive of things like safe injection sites or supervised injection sites, it’s going to determine whether our legislators are supportive of things like suboxone and naltrexone and medication assisted treatments, so I think it’s important to say the message and let people know that this is much more a disease than a choice. 

Dopamine, reward, and glutamate, memory are heavily involved in that self-reinforcing nature of substance use disorders.  You get this quick almost immediate response depending on your substance of use, that is incredibly reinforcing. 

Living life on life’s terms is not always incredibly reinforcing. So setting realistic expectations for our patients I think is very important.
Guilt and shame are ubiquitous in substance use disorders. So stock up on kindness, compassion and non-judgment. We can use this framework to help assuage overwhelming guilt that may be a barrier to treatment.

And last but not least, part of our role is to offer unconditional positive regard to our patients, so be very mindful of the language that you use. And I think it’s really important, too, to distinguish that, you know, if they engaged in some shameful behaviors, using the qualifier, “You did this when you were active in your addiction,” versus “you were active in your recovery,” and just kind of letting them know that this does play a role. It doesn’t absolve you of accountability, but it plays a significant role.

[transition music] (21:58)
[Katy Palmer]
Are there any questions for Craig? Thoughts? Follow-up?

[Sam Steffen]
That’s the voice of ECHO Idaho’s Assistant Director, Katy Palmer. 

[Katy Palmer]
Yes, please!

[Hayley Brown]
Just thinking about Dopamine, and in the brain…

[Sam Steffen]
This is an ECHO participant speaking, Hayley. ECHO sessions like this one bring a myriad of professionals together virtually. In our Counseling Techniques for Substance Use Disorders series, we often have psychologists, psychiatrists, social workers, addiction specialists and counselors present on the same video call.

[Hayley Brown]
You know, long-term use generally results, if I’m correct, in less receptors for dopamine, it’s its way of coping with too much dopamine in the brain. Is it natural in [people who use substances] to already have a lower level of dopamine so then when they get a higher amount, that brain goes into their survival mode of wanting to get more dopamine, or how does that…work?

[Craig Lodis]
That’s a wonderful question, and to be totally honest with you, I’m not sure. (23:00) But one thing I would say is there is a lot of evidence that things like neglect or childhood trauma make us much more susceptible to addiction.

[Hayley Brown]
Okay, so I have one more question, then, on that line, um…thinking about preventative healthcare for children who have strong lines of addiction within their family how do you intervene or help families give resources to try to educate these children about possible risks but then also prepare these children for being more resilient?

[Radha Sadacharan]
(26:30) Craig, do you mind if I pick that one up, just as a family doc?

[Craig Lodis]
Yeah, of course. Please!

[Sam Steffen]
This is Dr. Radha Sadacharan, Primary Care Physician and MAT Provider at the Boise VA Medical Center. Dr. Sadacharan was one of the panelists present for this lecture.

[Radha Sadacharan]
One of the things we think about are ACES, just like you’re pointing out, Hayley, in terms of Adverse Childhood Experiences and that’s our way of quantifying trauma that people undergo, and you’re totally right, like, everyone knows this. The more trauma that someone incurs, the more likely they are to struggle with things like addiction, to struggle with incarceration, and so a lot of this really focuses on then what can we do to prevent these kinds of situations. And so, we don’t have much control over this, right? And so, we should be identifying problems, and so in pediatric practices, we should be screening for ACEs, if you’re working with kids you should be screening for ACEs and then based on that, you’re identifying the weak-points.  And so I actually really like SAMHSA—the Substance Abuse and Mental Health Services Administration’s—four pillars of recovery as a way to identify preventative, protective factors, and they talk about (1) health, (2) home, (3) community and (4) purpose. And I think that can start from when kids are really young.  And so identifying the things that they love in their life or the things that make them feel safe in their life, and then spanning out from that, like, are there people in your life that you feel like you can go to if there’s something that’s going on? They might not be the people that live in your house but is it your neighbors or is it your grandma? Is there someone else? And so identifying those points and then over time being able to work on that is resiliency. We can’t predict who’s going to be struggling with addiction later on, but we have a good idea of the risk factors that predispose someone to it, so can we modify those risk factors? (28:15)

[Katy Palmer]
Thanks so much, Radha.  So I actually think this is a great time to tee Scott. So Scott, if you can introduce yourself, tell us who and where you are, I’m wondering if you can talk a little bit about some of the services that the Phoenix offers, and the importance of resilience-building activities and kind of how people navigate and find those. (28:35)

[Scott Jones]
Great, thanks. So, again, Scott Jones, I’m in Boise, Idaho, I’m the chapter manager with The Phoenix. The Phoenix is a national organization, we’re a non-profit, we work with anybody who has struggled with substance use disorder or chooses to live a sober life.  We do an assortment of programs, most of them are based in fitness, so it could be yoga, mountain biking, we could be doing some strengths training, or whatever that event looks like, and it varies a little bit by each location.  We also throw in things like social and art and various things like that as activities. The only thing that we require for people to attend is 48 hours of continuous sobriety, or more. And again, those events are free. By people participating in these activities, it’s not so much about like how much weight we’re pushing up over our head or if we’re doing the perfect Warrior-III yoga pose, it’s more about the connections that are created by the people that are participating together. There’s levels of encouragement. And folks can maybe understand what someone else is going through, so there’s a lot of relatability. And we see that folks have a longer journey in recovery with a community of people that help and support them along their journey. So I know…Katy, you had a lot of questions in that one question, and I’m not sure if I hit all of them, but…

[Katy Palmer]
No, that’s great. Thank you so much. 

[Sam Steffen] (30:45) [Cue mellow transitional instrumental guitar]

That, again, was a didactic presentation by Dr. Craig Lodis titled “Understanding the Disease of Addiction.”  That lecture was recorded live during an ECHO session that took place on January 7, 2021 as a part of ECHO Idaho’s “Counseling Techniques for Substance Use Disorders” Series.

[End music]

If you’d like to watch the Zoom recording of that presentation, that video is currently available on the ECHO Idaho YouTube channel, which you can access through our website. The Powerpoint slide deck that accompanied that presentation is also available on our website: www.uidaho.edu/ECHO  
The recommended reading and viewing materials that Craig mentioned in his lecture are currently available on our podcast webpage.  For those, and instructions about how to claim continuing education credit for listening to this episode visit our podcast webpage: www.uidaho.edu/echo-podcast

[cue banjo music]

If you’re interested in joining our free, live ECHO sessions to receive Continuing Education credit, learn best practices, ask a question, or grow your community—please visit our website where you can register to attend, sign-up to receive announcements, donate, and find out more information about our programs.  
Something for the pain is brought to you by ECHO Idaho, supported by the WWAMI Medical Education Program and the University of Idaho, and is made possible by VCORP, the Valley County Opioid Response Project. 

[Fade banjo]
[Guitar strum and guitar and theme song w/ words in background]

We here at ECHO also want to hear your feedback.  We welcome your questions, comments and suggestions and invite you to email us at echoidaho@uidaho.edu.  And don’t forget to subscribe to Something for the Pain using your podcast app.  And if you have a moment, write us a review!
That’s about all the time we have for today, but join us next time when we’ll be exploring the topic of “Substance Use in Idaho” with LCSW and Director of Recovery 4 Life, Amy Jeppesen.  Until next time, Idaho, take care of yourself! 

[Bring up lyrics to first “ECHO Idaho” then fade and continue theme song]
In the rurallest of places where the resources are scarce
They’re calling ECHO Idaho an answer to our prayers
ECHO Idaho!

Something for the Pain is made possible by Grant Number GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDI-1 or HRSA.”
The voices you heard at the beginning of the episode were those of Todd Palmer, Craig Lodis, and Jason Coombs, respectively.

Big thanks to everyone who contributed to today’s episode: Craig Lodis, Radha Sadacharan, and Scott Jones.  We’d also like to thank the other members of our “Counseling Techniques for Substance Use Disorder” Series expert panel: Drew Holliday, Case Management Team Coordinator at Recovery 4 Life in Boise; Sara Bennet, Executive Director and Owner of Riverside Recovery in Lewiston; and Lindsay Brown, Lead Recovery Coach at Peer Recovery Supports of Idaho, LLC.

And a big thanks to all of our listeners without whom none of this would be possible.  Without you, we’d just be talking to ourselves.

Lachelle Smith is the ECHO Idaho Program Director; Katy Palmer is our Assistant Director; our Marketing Manager is Lindsay Lodis; our Program Coordinators are Kayla Blades, Jessica Whitlock, Karley Kline and Sam Steffen. 

[Theme song]  

 

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Something for the Pain is brought to you by Idaho’s chapter of Project ECHO and the University of Idaho, supported by the WWAMI Medical Education Program, in partnership with VCORP, the Valley County Opioid Response Project. Something for the Pain is made possible by Grant Number GA1RH39585 from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDH or HRSA.

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