Incorporating a Drug User Health Framework and Working ......60%-90% have HCV after 5 years Median...
42
Incorporating a Drug User Health Framework and Working with People who use Drugs Laura Pegram, MSW, MPH Manager, Drug User Health
Transcript of Incorporating a Drug User Health Framework and Working ......60%-90% have HCV after 5 years Median...
Incorporating a Drug User Health Framework and Working with People who use Drugs
Laura Pegram MSW MPHManager Drug User Health
2
WHO A non-profit non-partisan national association founded in 1992 that represents public health officials who administer HIV and hepatitis programs funded by state and federal governments
WHERE All 50 US states the District of Columbia Puerto Rico the US Virgin Islands seven local jurisdictions receiving direct funding from the Centers for Disease Control and Prevention (CDC) and the US Pacific Island jurisdictions
MISSION NASTADrsquos mission is to end the intersecting epidemics of HIV viral hepatitis and related conditions by strengthening domestic and global governmental public health through advocacy capacity building and social justice
VISION NASTADs vision is a world free of HIV and viral hepatitis
About NASTAD
National HIV amp Hepatitis Overview
Injection Drug Use accounts for~9 of new HIV casesOver 65 of HCV cases
Among people who inject drugs60-90 have HCV after 5 yearsMedian time to HCV transmission is ~3 yearsAnd each year ~ 20-30 of PWID acquire HCV
ComorbidityAmong PWID and have HIV 80 also have HCVAmong PLWHIV wo IDU 25 have HCV
Life time cost of each HIV infection is over $380000
Accumulated costs of HCV care over the next 20 years on this trajectory over $78 billion
3
Presenter
Presentation Notes
httpswwwncbinlmnihgovpubmed2180213413httpswwwncbinlmnihgovpubmed1612267913httpswwwncbinlmnihgovpmcarticlesPMC307273413httpswwwncbinlmnihgovpubmed1884930313httpswwwncbinlmnihgovpmcarticlesPMC2867351
Hepatitis C is the leading cause of death among all infectious diseases The CDC estimates 41200 acute
HCV cases in the US in 2016 Estimated 39 million people have
HCV in the US 85 of HCV infection leads to
progresses to chronic infection IDU is currently the most common
risk factor for HCV in developed countries (60-80 worldwide)
Diseases Associated with Injection Drug Use
bull Viral infections (bloodborne)bull Hepatitis C Virus (HCV)bull Hepatitis B Virus (HBV)bull Hepatitis A Virus (HAV)bull HIV
bull Bacterial Infections (soft tissueskin)bull Septicemiabull Bacteremiabull Cellulitisbull Abscesses (staph strep)bull Endocarditisbull Necrotizing fasciitisbull Wound botulism
4
Presenter
Presentation Notes
httpswwwncbinlmnihgovpmcarticlesPMC549123213httpswwwcdcgovhepatitishcvcfaqhtm13httpswwwcdcgovmediareleases2016p0504-hepc-mortalityhtml
Among 18- to 29-year-olds there was a 400 percent increase in acute hepatitis 817 percent increase in admissions for
injection of prescription opioids 600 percent increase in admissions for
heroin injection
Among 30- to 39-year-olds there was a 325 percent increase in acute hepatitis C 169 percent increase in admissions for
injection of prescription opioids 77 percent increase in admissions for
heroin injection
There were also sharp increases among whites and among women
Huge Increases in HCV related to IDU
5
Presenter
Presentation Notes
httpswwwcdcgovnchhstpnewsroom2017hepatitis-c-and-opioid-injectionhtml
North Dakota Specific Increases
Injection Drug Use accounts for
North Dakota Specific Statistics
7
Approximately 186 of all HIV diagnoses among men (IDU+MSMIDU) and 143
of new diagnoses
Approximately 141 of all HIV diagnoses among
women and 222 of all new diagnoses
In 2010 an estimated 4400 people in North Dakota had hepatitis C or 830100000
Considering nationwide increases and gaps in HCV
surveillance in North Dakota and the US this actual
numberrate is likely MUCH higher
Presenter
Presentation Notes
The rate of black men living with HIV is 107 times that of white men and latinos are 17 times higher13The rate of black females living with HIV is 1209 times that of white women and Latinas are 152 times higher1313334 total PLHIV134400 total PLWHCV1377 OD deaths in 201613Nearly HALF of total AIDS diagnoses occur in the 3 months after an initial HIV diagnosis131313httpsaidsvuorg13httpmaphepvuorg 1313
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
2
WHO A non-profit non-partisan national association founded in 1992 that represents public health officials who administer HIV and hepatitis programs funded by state and federal governments
WHERE All 50 US states the District of Columbia Puerto Rico the US Virgin Islands seven local jurisdictions receiving direct funding from the Centers for Disease Control and Prevention (CDC) and the US Pacific Island jurisdictions
MISSION NASTADrsquos mission is to end the intersecting epidemics of HIV viral hepatitis and related conditions by strengthening domestic and global governmental public health through advocacy capacity building and social justice
VISION NASTADs vision is a world free of HIV and viral hepatitis
About NASTAD
National HIV amp Hepatitis Overview
Injection Drug Use accounts for~9 of new HIV casesOver 65 of HCV cases
Among people who inject drugs60-90 have HCV after 5 yearsMedian time to HCV transmission is ~3 yearsAnd each year ~ 20-30 of PWID acquire HCV
ComorbidityAmong PWID and have HIV 80 also have HCVAmong PLWHIV wo IDU 25 have HCV
Life time cost of each HIV infection is over $380000
Accumulated costs of HCV care over the next 20 years on this trajectory over $78 billion
3
Presenter
Presentation Notes
httpswwwncbinlmnihgovpubmed2180213413httpswwwncbinlmnihgovpubmed1612267913httpswwwncbinlmnihgovpmcarticlesPMC307273413httpswwwncbinlmnihgovpubmed1884930313httpswwwncbinlmnihgovpmcarticlesPMC2867351
Hepatitis C is the leading cause of death among all infectious diseases The CDC estimates 41200 acute
HCV cases in the US in 2016 Estimated 39 million people have
HCV in the US 85 of HCV infection leads to
progresses to chronic infection IDU is currently the most common
risk factor for HCV in developed countries (60-80 worldwide)
Diseases Associated with Injection Drug Use
bull Viral infections (bloodborne)bull Hepatitis C Virus (HCV)bull Hepatitis B Virus (HBV)bull Hepatitis A Virus (HAV)bull HIV
bull Bacterial Infections (soft tissueskin)bull Septicemiabull Bacteremiabull Cellulitisbull Abscesses (staph strep)bull Endocarditisbull Necrotizing fasciitisbull Wound botulism
4
Presenter
Presentation Notes
httpswwwncbinlmnihgovpmcarticlesPMC549123213httpswwwcdcgovhepatitishcvcfaqhtm13httpswwwcdcgovmediareleases2016p0504-hepc-mortalityhtml
Among 18- to 29-year-olds there was a 400 percent increase in acute hepatitis 817 percent increase in admissions for
injection of prescription opioids 600 percent increase in admissions for
heroin injection
Among 30- to 39-year-olds there was a 325 percent increase in acute hepatitis C 169 percent increase in admissions for
injection of prescription opioids 77 percent increase in admissions for
heroin injection
There were also sharp increases among whites and among women
Huge Increases in HCV related to IDU
5
Presenter
Presentation Notes
httpswwwcdcgovnchhstpnewsroom2017hepatitis-c-and-opioid-injectionhtml
North Dakota Specific Increases
Injection Drug Use accounts for
North Dakota Specific Statistics
7
Approximately 186 of all HIV diagnoses among men (IDU+MSMIDU) and 143
of new diagnoses
Approximately 141 of all HIV diagnoses among
women and 222 of all new diagnoses
In 2010 an estimated 4400 people in North Dakota had hepatitis C or 830100000
Considering nationwide increases and gaps in HCV
surveillance in North Dakota and the US this actual
numberrate is likely MUCH higher
Presenter
Presentation Notes
The rate of black men living with HIV is 107 times that of white men and latinos are 17 times higher13The rate of black females living with HIV is 1209 times that of white women and Latinas are 152 times higher1313334 total PLHIV134400 total PLWHCV1377 OD deaths in 201613Nearly HALF of total AIDS diagnoses occur in the 3 months after an initial HIV diagnosis131313httpsaidsvuorg13httpmaphepvuorg 1313
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
National HIV amp Hepatitis Overview
Injection Drug Use accounts for~9 of new HIV casesOver 65 of HCV cases
Among people who inject drugs60-90 have HCV after 5 yearsMedian time to HCV transmission is ~3 yearsAnd each year ~ 20-30 of PWID acquire HCV
ComorbidityAmong PWID and have HIV 80 also have HCVAmong PLWHIV wo IDU 25 have HCV
Life time cost of each HIV infection is over $380000
Accumulated costs of HCV care over the next 20 years on this trajectory over $78 billion
3
Presenter
Presentation Notes
httpswwwncbinlmnihgovpubmed2180213413httpswwwncbinlmnihgovpubmed1612267913httpswwwncbinlmnihgovpmcarticlesPMC307273413httpswwwncbinlmnihgovpubmed1884930313httpswwwncbinlmnihgovpmcarticlesPMC2867351
Hepatitis C is the leading cause of death among all infectious diseases The CDC estimates 41200 acute
HCV cases in the US in 2016 Estimated 39 million people have
HCV in the US 85 of HCV infection leads to
progresses to chronic infection IDU is currently the most common
risk factor for HCV in developed countries (60-80 worldwide)
Diseases Associated with Injection Drug Use
bull Viral infections (bloodborne)bull Hepatitis C Virus (HCV)bull Hepatitis B Virus (HBV)bull Hepatitis A Virus (HAV)bull HIV
bull Bacterial Infections (soft tissueskin)bull Septicemiabull Bacteremiabull Cellulitisbull Abscesses (staph strep)bull Endocarditisbull Necrotizing fasciitisbull Wound botulism
4
Presenter
Presentation Notes
httpswwwncbinlmnihgovpmcarticlesPMC549123213httpswwwcdcgovhepatitishcvcfaqhtm13httpswwwcdcgovmediareleases2016p0504-hepc-mortalityhtml
Among 18- to 29-year-olds there was a 400 percent increase in acute hepatitis 817 percent increase in admissions for
injection of prescription opioids 600 percent increase in admissions for
heroin injection
Among 30- to 39-year-olds there was a 325 percent increase in acute hepatitis C 169 percent increase in admissions for
injection of prescription opioids 77 percent increase in admissions for
heroin injection
There were also sharp increases among whites and among women
Huge Increases in HCV related to IDU
5
Presenter
Presentation Notes
httpswwwcdcgovnchhstpnewsroom2017hepatitis-c-and-opioid-injectionhtml
North Dakota Specific Increases
Injection Drug Use accounts for
North Dakota Specific Statistics
7
Approximately 186 of all HIV diagnoses among men (IDU+MSMIDU) and 143
of new diagnoses
Approximately 141 of all HIV diagnoses among
women and 222 of all new diagnoses
In 2010 an estimated 4400 people in North Dakota had hepatitis C or 830100000
Considering nationwide increases and gaps in HCV
surveillance in North Dakota and the US this actual
numberrate is likely MUCH higher
Presenter
Presentation Notes
The rate of black men living with HIV is 107 times that of white men and latinos are 17 times higher13The rate of black females living with HIV is 1209 times that of white women and Latinas are 152 times higher1313334 total PLHIV134400 total PLWHCV1377 OD deaths in 201613Nearly HALF of total AIDS diagnoses occur in the 3 months after an initial HIV diagnosis131313httpsaidsvuorg13httpmaphepvuorg 1313
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Hepatitis C is the leading cause of death among all infectious diseases The CDC estimates 41200 acute
HCV cases in the US in 2016 Estimated 39 million people have
HCV in the US 85 of HCV infection leads to
progresses to chronic infection IDU is currently the most common
risk factor for HCV in developed countries (60-80 worldwide)
Diseases Associated with Injection Drug Use
bull Viral infections (bloodborne)bull Hepatitis C Virus (HCV)bull Hepatitis B Virus (HBV)bull Hepatitis A Virus (HAV)bull HIV
bull Bacterial Infections (soft tissueskin)bull Septicemiabull Bacteremiabull Cellulitisbull Abscesses (staph strep)bull Endocarditisbull Necrotizing fasciitisbull Wound botulism
4
Presenter
Presentation Notes
httpswwwncbinlmnihgovpmcarticlesPMC549123213httpswwwcdcgovhepatitishcvcfaqhtm13httpswwwcdcgovmediareleases2016p0504-hepc-mortalityhtml
Among 18- to 29-year-olds there was a 400 percent increase in acute hepatitis 817 percent increase in admissions for
injection of prescription opioids 600 percent increase in admissions for
heroin injection
Among 30- to 39-year-olds there was a 325 percent increase in acute hepatitis C 169 percent increase in admissions for
injection of prescription opioids 77 percent increase in admissions for
heroin injection
There were also sharp increases among whites and among women
Huge Increases in HCV related to IDU
5
Presenter
Presentation Notes
httpswwwcdcgovnchhstpnewsroom2017hepatitis-c-and-opioid-injectionhtml
North Dakota Specific Increases
Injection Drug Use accounts for
North Dakota Specific Statistics
7
Approximately 186 of all HIV diagnoses among men (IDU+MSMIDU) and 143
of new diagnoses
Approximately 141 of all HIV diagnoses among
women and 222 of all new diagnoses
In 2010 an estimated 4400 people in North Dakota had hepatitis C or 830100000
Considering nationwide increases and gaps in HCV
surveillance in North Dakota and the US this actual
numberrate is likely MUCH higher
Presenter
Presentation Notes
The rate of black men living with HIV is 107 times that of white men and latinos are 17 times higher13The rate of black females living with HIV is 1209 times that of white women and Latinas are 152 times higher1313334 total PLHIV134400 total PLWHCV1377 OD deaths in 201613Nearly HALF of total AIDS diagnoses occur in the 3 months after an initial HIV diagnosis131313httpsaidsvuorg13httpmaphepvuorg 1313
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Among 18- to 29-year-olds there was a 400 percent increase in acute hepatitis 817 percent increase in admissions for
injection of prescription opioids 600 percent increase in admissions for
heroin injection
Among 30- to 39-year-olds there was a 325 percent increase in acute hepatitis C 169 percent increase in admissions for
injection of prescription opioids 77 percent increase in admissions for
heroin injection
There were also sharp increases among whites and among women
Huge Increases in HCV related to IDU
5
Presenter
Presentation Notes
httpswwwcdcgovnchhstpnewsroom2017hepatitis-c-and-opioid-injectionhtml
North Dakota Specific Increases
Injection Drug Use accounts for
North Dakota Specific Statistics
7
Approximately 186 of all HIV diagnoses among men (IDU+MSMIDU) and 143
of new diagnoses
Approximately 141 of all HIV diagnoses among
women and 222 of all new diagnoses
In 2010 an estimated 4400 people in North Dakota had hepatitis C or 830100000
Considering nationwide increases and gaps in HCV
surveillance in North Dakota and the US this actual
numberrate is likely MUCH higher
Presenter
Presentation Notes
The rate of black men living with HIV is 107 times that of white men and latinos are 17 times higher13The rate of black females living with HIV is 1209 times that of white women and Latinas are 152 times higher1313334 total PLHIV134400 total PLWHCV1377 OD deaths in 201613Nearly HALF of total AIDS diagnoses occur in the 3 months after an initial HIV diagnosis131313httpsaidsvuorg13httpmaphepvuorg 1313
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
North Dakota Specific Increases
Injection Drug Use accounts for
North Dakota Specific Statistics
7
Approximately 186 of all HIV diagnoses among men (IDU+MSMIDU) and 143
of new diagnoses
Approximately 141 of all HIV diagnoses among
women and 222 of all new diagnoses
In 2010 an estimated 4400 people in North Dakota had hepatitis C or 830100000
Considering nationwide increases and gaps in HCV
surveillance in North Dakota and the US this actual
numberrate is likely MUCH higher
Presenter
Presentation Notes
The rate of black men living with HIV is 107 times that of white men and latinos are 17 times higher13The rate of black females living with HIV is 1209 times that of white women and Latinas are 152 times higher1313334 total PLHIV134400 total PLWHCV1377 OD deaths in 201613Nearly HALF of total AIDS diagnoses occur in the 3 months after an initial HIV diagnosis131313httpsaidsvuorg13httpmaphepvuorg 1313
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Injection Drug Use accounts for
North Dakota Specific Statistics
7
Approximately 186 of all HIV diagnoses among men (IDU+MSMIDU) and 143
of new diagnoses
Approximately 141 of all HIV diagnoses among
women and 222 of all new diagnoses
In 2010 an estimated 4400 people in North Dakota had hepatitis C or 830100000
Considering nationwide increases and gaps in HCV
surveillance in North Dakota and the US this actual
numberrate is likely MUCH higher
Presenter
Presentation Notes
The rate of black men living with HIV is 107 times that of white men and latinos are 17 times higher13The rate of black females living with HIV is 1209 times that of white women and Latinas are 152 times higher1313334 total PLHIV134400 total PLWHCV1377 OD deaths in 201613Nearly HALF of total AIDS diagnoses occur in the 3 months after an initial HIV diagnosis131313httpsaidsvuorg13httpmaphepvuorg 1313
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
HIV Outbreak in Austin Indiana (pop 4200) in 2015Over 200 cases of HIV were
eventually attributed to injection drug use behaviorOnly had 5 reported cases of HIV
in the previous decadeWithin this initial outbreak 115
persons were co-infected with HCV and currently 92 are co-infected
Scott County Indiana
8
Presenter
Presentation Notes
httpswwwnejmorgdoifull101056NEJMoa1515195
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
9
HIVHCV Vulnerable Counties
Presenter
Presentation Notes
After the Scott County outbreak of HIV in 2015 the CDC assessed counties across the country to determine vulnerability to outbreakmdashin Scott County there were over 200 cases of HIV attributed to injection drug use within that community1313One thing to note here13-while these are the MOST vulnerablendash they are far from the ONLY vulnerable counties The opioid epidemic is really much more of a PANDEMIC situationhellip1313This is particularly powerful as this index identifies counties at risk for an HIV andor HCV outbreak in many rural areas 1313Of course we know that HCV and HIV risk is not confined to the areas indicated on this map ndash that they continue to also be suburban and urban epidemics as well 1313httpeuropepmcorgarticlespmc547963113
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
HARM REDUCTION and Syringe Service
Programs Most effective way to prevent infectious disease transmission for PWIDs Do not increase drug use or crime SSP participants are 5 times more likely than nonparticipants to enter treatment
So What Can Be Done
10
Presenter
Presentation Notes
httpeuropepmcorgarticlespmc547963113httpswwwcdcgovvitalsignshiv-drug-useindexhtml13httpwwwemcddaeuropaeupublicationsmonographsharm-reduction_en13httpswwwncbinlmnihgovpubmed20513304131313Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Harm Reduction Philosophy
A set of practical public health strategies designed to reduce the negative consequences of drug use and
promote healthy individuals and communities
11
Presenter
Presentation Notes
Now working with folks who are actively using drugs and not necessarily ready forwanting treatment requires working with a harm reduction philosophy1313Harm Reduction program participants are five times more likely to seek servicesengage in treatment than non-participants
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Harm Reduction Principles
12
Presenter
Presentation Notes
Low-barrier low threshold nonjudgmental services designed to lsquomeet the client where they are atrsquo 13Often the most common entry point to engage highly stigmatized hard-to-reach clients such as PWID into care 13Alternative to rigid abstinence based treatment programs 13Recognizes the person behind the substance use 13Allows the individual the opportunity to take active steps to protect their personal health and the health of their communities while still retaining personal control and agency over their substance use13
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Prochaska DiClemente amp Norcross -1992 Transtheoretical Model Change is gradual Change is cyclical and constant Change is progressive and
sequential Change has six basic stages Relapse is likely and still progress Important to meet people at their
stage not yours
13
Stages of Change
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
14
Stages of Change
Precontemplation Contemplation Preparation ActionMaintenance RelapseRecycle
Presenter
Presentation Notes
13Pre-Contemplation ndash Within the pre-contemplation stage the individual has no intention of changing behaviors and may not identify and behavior as being problematic 13Contemplation ndash This stage differs in that it indicates that an individual might recognize the need to alter or address certain behaviors or issues yet has not made any plans to do so Here the client displays a general ambivalence about changing behaviors Ambivalence often indicates a readiness to discuss altering behavior 13Preparation ndash At this stage the individual begins to envision what it would look like to take action and brainstorm strategies to effect that change 13Action ndash Here concrete plans are developed and put into action to address the behavior and implement strategies to modify that behavior 13Maintenance ndash Within this stage older behaviors that are negative are ideally replaced with those that carry less harm for the individual 13Relapse and Recycle are often also included as a stage in the transtheoretical model It recognizes the gradual and fluid nature of behavior change and is a normal element of the behavior change process However relapse is an expected and accepted stage yet does not fall within any certain order as it can and likely will be experienced throughout the change process and is not necessarily negative Relapse and recycling can provide valuable insights into areas to which the individual might still need to devote attention or resources and to areas where the individual might be experiencing ambivalence about whether or not they wish to alter those behaviors
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
15
So why do people use drugs
Presenter
Presentation Notes
Because they WORK People use drugs because they do something for the person taking themmdashgiving people a chance to understand those reasons behind drug use is a big part of getting folks to imagine how they might change their usepatterns with substances
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Continuum of Drug Use
1616
Experimental Misuse Dependence ChaoticSocialRitual Situational Binge Use
Presenter
Presentation Notes
Drug use happens on a continuum ndash and that doesnrsquot necessarily occur in a linearsequential trajectory1313Question how many of you smoke Or did in Collegehellip Was your smoking 100 consistent What happened around finals If you started then are you up to like 5 packs a day now13 13No obviously notmdashso what are some ways you reduced risk Or modified that behavior Any of you quit cold turkey Its not easy and we know it changesvacillates a lotmdashit isnrsquot necessarily consistent Substance use happens on a spectrum from benign to chaotic and it is not necessarily a progressive process ndashnot a one-way street1313Even recent SAMHSA publications on OUD indicate the difference between relapse and return to usemdashthese are different and it is important to note that a return to use doesnrsquot necessarily mean relapse if that use looks different and is more controlled ndash 1313I like to think of drug use as a symptommdasha coping mechanism or toolmdashand those can be healthy or not and exist on this spectrum13
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Circumstances of Drug UseDrug Set and Setting - Norman Zinberg studies between 1972 ndash 1984
Found 3 major criteria for what created either benign or chaotic useo The Drug ndash this is the type of drug the amount the route of administration the frequency of
use etco The Set ndash refers to the mindset or attitude about use o The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with
whom
The Vietnam Studies ndash Lee Robbins 1974
Examined heroin use among Vietnam Veterans once they completed service Found that MOST did not continue use (99) even though they exhibited physical
dependence previously without obtaining treatmento Most cited a change in stress level change in environment and family perceptions of drug use
17
Presenter
Presentation Notes
Zinberg ndash importance of holistic approach to working with folks who use drugs1313-so Zinberg tracked social use patterns of drugs namely heroin and other drugs later He found that among groups of folks who used drugs socially that very few actually adopted lifelong use or problematic use patterns Many agedmatured out got bored got other things happening that took precedence etc 13 13His study and theory basically posits that the spectrum of benign to chaotic drug use is based on 3 primary things13-The Drug ndash this is the type of drug the amount the route of administration the frequency of use etc13-The Set ndash refers to the mindset or attitudes about use Are you celebrating anxious avoiding calming etc ndash this is the lsquowhyrsquo I referred to earlier13-The Setting ndash this refers to the context of usemdashbasically where the drug is consumed and with whomhellipis it a solitary practice Is it only at parties Is it with your girlfriend Before work 13 13He found that the combination of these factors would dictate and could maybe predict the severity and potential for eventual problematic use As we talk about harm reductionmdashits is key to break down the context AND the use to successfully work with folks 13 13-Also itrsquos key to recognize that not all use is abusemdashlots of folks will just age out or might never exhibit problematic use 13 13-so some things to remember 13-use isnrsquot linear ndash just like relationshipsmdashitrsquos a lot of up and down and side to side13
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Social Determinants of Drug User Health
18
Racism poverty access to care stigma etc
Lack of housing availability of alcohol amp drugs
Substance use mental health
HIV HCV overdose
166182
Presenter
Presentation Notes
Some of the services we provide to support DUH are actually about environment as well as the person using drugs13In other words we will also have to address the person using drugs holistically1313Providing services and supports that address the structural and social barriers that may underlie drug use instead of a lsquotreatment onlyrsquo approach IS what engages individuals to seek and return for services from compassionate providers1313Folks have LOT going on and within a DUH framework it is everyonersquosorganizationrsquos responsibility to address those barriersissues to promote stability and increase help for people struggling with their substance use
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Common Drugs and Highs
Marijuana
cannabinoids hashish THC dabs tinctures etc
Opioids
opium morphine codeine fentanyl carfentanyl
Oxycodone (oxycontin) heroin Percocet
Pain Relievers SedativesAnxiolytics barbiturates Quaaludes
benzodiazepines diazepam (valium) Ativan klonopin
Xanax
Stimulants
cocaine crack methamphetamine speed Ritalin Dexedrine Adderall
HallucinogensPsychedelics
LSD psilocybin mescaline ecstasy molly MDMAMDA
Legal DrugsMinor StimulantsAlcohol
tobacco chew snuff vaping (nicotine) ndash Caffeine coffee
soda tea energy drinks wine beer spirits
19
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Routes of Administration
OralSwallowing
Inhaling
Snorting
Intravenous InjectionIV
Intramuscular InjectionsIM
Skin Popping
PluggingBooty Bumping
20
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Polysubstance use is often where the biggest dangers exist - Know your substances know how they interact and make sure others know everything you take
Administration Route Less Risk
Oral Less DrugAvoid Polysubstance Use
Inhaling OralLess Drug
Snorting InhalingOral
Injecting Snorting Oral Inhaling
21
Safer Drug Use
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Risk Factorsbull Typebull Route of Administrationbull AdulterantsPotency
Drug
bull RushedIn Withdrawalbull Public Space Unstably housedbull Fearing Criminalization
Circumstance
bull Celebration vs Copingbull SolitaryIsolatedbull Unsterile worksbull Partner injection
Context
22
Presenter
Presentation Notes
13Drug The drug itself its potency how much is used how it is used what itrsquos ldquocutrdquo or mixed with 13Usually we donrsquot have any control over the drug itself and providers cannot intervene in this area13However providers can share local current information such as s strong batch of drug the same weekend several people overdose in the neighborhood or when authorities send alerts of fentanyl found in street heroin13Regarding potency might be less difficult to determine with prescription pills than illicit street drugs13The drug can also be affected by the social environment--for example the sale of heroin in a prohibitive environment is very risky and because of those risks there is an associated profit attached for the people selling it Thus heroin is cut perhaps with baby laxative or aspirin in order to bulk it up and increase profits 1313Circumstance of Drug Use13If they are in withdrawal (or dope sick) this will change circumstances regarding drug prep and drug administration (eg not applying lsquobest practicesrsquo for disease prevention in prep using in public places)13Another reason a person shoots up in a public place is that they are dope sick they are in withdrawal and might shoot up right after obtaining the drug13People who use drugs are not in a constant state of withdrawal we encourage the individuals to plan their highs to decrease their chances to get dope sick to set aside some money (buy the Pampers first or asthmas inhaler) cultivate more than one dealer so there is more than one source to obtain drugs and essentially to prepare for their drug use1313Context of drug use13Providers consider the personrsquos setting of drug use when discussing options to reduce risk and changeunderstand behavior13For example when people shoot up in public placesmdashdoorways restrooms bus stationsmdashthey have to inject quickly for fear of getting caught This increases the probability of injecting incorrectly injecting too much of the drug not having the time to inject just a little to check potency then shoot up the rest of the drug One of the reasons that people shoot up in public places is that they may be unable to do so at home or they are homeless 13Another example try to create safer environments in which to use advocate for policy changes which would allow pharmacy sale of syringes trying to change the pervasive negative attitude towards drug users among our community members service providers and the general public1313
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
23
So who works with people who use drugs
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Systems that touch People who use Drugs
24
Drug User
Health
Medicaid (state
program MCOs)
Housing and Economic
Development Programs
Infectious Disease
Programs
Others
Bureau of Substance Abuse and
Mental Health
Criminal Justice System
FQHCS and Hospitals
Presenter
Presentation Notes
Right so LOTS of our interconnected systems touch people who use drugs---13Yet we often lack a common understandinglanguageframework to address people who use drugs ndash 13What we want ideally is a common starting point ndash a drug user health FRAMEWORK1313So how do we get there1313
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Prevention and Treatment Binary
25
Prevention Harm Reduction Treatment
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Continuum of Drug User Health Services
26
Presenter
Presentation Notes
-So we all know that there is a huge grey area between prevention and treatmentmdashyet thatrsquos all we ever hear about in terms of services ndash utilizing a DUH framework is about moving past that prevention and treatment binary to work with people who use drugs lsquowhere they are atrsquo13-Our services need to reflect that and be targeted at that grey area because that is where the biggest risk happensmdashwhen someone isnrsquot connected to services and doesnrsquot know how (or canrsquot because of legal or social barriers) to take care of themselves or their community while using substances1313-SO we can look again at the range of services that might help engage with people using drugs131313
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
According to the SAMHSA in 2016
Approximately 10 of the US population used illicit substances (past month)
118 million people over the age of 12 or 44 of the US population used prescription pain killers or heroin (past year)
27
Prevention and Treatment Binary
Note Opioid misuse is defined as heroin use or prescription pain reliever misuse
Figure 27 Past Year Opioid Misuse among People Aged 12 or Older 2016
Presenter
Presentation Notes
First itrsquos good to touch on just who we are talking about here 13We all know that there is a lot of drug use in the USmdashif you believe popular media itrsquos literally everyone1313And we know that canrsquot be trueaccurate13Some real numbers (slide) explain breakdown of image13
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Prevention and Treatment Binary Within the same data we can see that a majority of Substance Use Disorders are
related to alcohol ndash not illicit drugs Drug User HealthHarm Reduction services are useful for everyone using
substances legal or not
28
Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder 2016
Presenter
Presentation Notes
So here we see how many folks actually meet diagnostic criteria for a SUD1313MOST drug use happens LONG before it becomes problematic - so those risk factors for HIV and HCV are happening then too13And lastly just meeting criteria for problematic use DOESNrsquoT mean that someone is ready to engage in treatment (remember stages of change)
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
29
Prevention and Treatment BinaryReasons for Not Receiving Substance Use Treatment in the Past Year among Adults Aged 18 or Older Who Felt They Needed Treatment in the Past Year Percentages 2016
Perceived Need for Substance Use Treatment among Adults Aged 18 or Older Who Needed but Did Not Receive Substance Use Treatment in the Past Year 2016
Presenter
Presentation Notes
From the SAMHSA NSDUHmdash1313So again we need to target a good amountmdasharguably the majorityndash of our services towards these folks who are using substances and not yet ready for treatment
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Of the 118 million people who used opioids in 2016 only 24 million were diagnosed as having an Opioid Use Disorder (OUD) ndash this is less than 1 of the US population
Which leaves 94 million people using opioids who do not qualify as having an OUD
Regardless of OUD numbers some individuals might not ever want or seek treatment
EVERYONE using drugs needs a range of services to reduce overdose risk prevent HIV and hepatitis transmission and reduce collateral consequences related to their substance use
So that means 79 or 94 million people who are actively using opioids will not be identified as
needing OUD services
30
Prevention and Treatment Binary
79 2121
Prescription Drug Misuse and Heroin Use age gt12 2016
Used Opioids Used Opioids and had OUD
Presenter
Presentation Notes
Or put in a different waymdashhere we have the total number of people who used opioids in 201613Only 21 of those actually met criteria for dependence1313And really letrsquos remember that just having met criteria for OUD doesnrsquot mean someone is going to want treatment1313Everyone requires harm reduction around substance use---you can OD or get HIVHCV without being dependent (arguably those who are not long-termexperienced users are MORE likely to experience these negative consequences)
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Mythsbull You always know when people
are on a drugbull An ldquoaddictrdquo will ALWAYS be an
ldquoaddictrdquobull Abstinence is the only real
recoverybull Using medication as treatment
mean you arenrsquot really recovered
Factsbull Many people use drugs and
yoursquod never knowbull PWUDs will transition from
chaotic to benign usebull Recovery can include abstinence
but could also look differently bull MAT is evidence-based and
considered the gold standard
31
Myths and Facts
Presenter
Presentation Notes
Values assessment
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Stigma
ldquoa set of negative and often unfair beliefs that a society or group of people have about somethingrdquo
ldquoa mark of shame or discredit---an identifying mark or characteristic specifically a specific diagnostic sign of a
diseaserdquohttpswwwmerriam-webstercomdictionarystigma
32
Presenter
Presentation Notes
more recent discussions reinforce the dynamic nature of the processes of stigmatisation (Link amp Phelan 2001) through a combination of labelling stereotyping separation status loss and discrimination Stigma and the extent to which it is successfully attributed and accepted should be understood from the unequal (social) power relations from within the context it operates 13
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Stigma
Based on Social Control Theory ndash Hobbes Foucault Puritanso A social process which reinforces relations of power and controlo Stigma and the extent to which it is successfully attributed and accepted
should be understood from the unequal (social) power relations from within the context it operates
Stigma is Intersectional ndash multiple stigmatized identities will equal compounded experience of stigma and repressiono Many groups are stigmatized for the same activity differently
Stigma takes several forms ndash individual institutional internalized by association
33
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Whitney HoustonldquoLet me break down this autopsy for you She had a perforated nasal septum (that where the septum dissolved from SO much coke) longstanding chronic use of cocaine chronic emphysema fatty liver which means she drankhellipA LOT So the idea that she had a heart attackmdashletrsquos be realrdquo httpswwwyoutubecomwatchv=NVxvzGXBmjM
Amy WinehouseldquoDescended into a world of drink and drugs and detoxesrdquohttpswwwyoutubecomwatchv=mj8JXlarsSQ
Phillip Seymour HoffmanldquorsquoHere you have an extraordinarily talented actor who had the resources who had been in treatment who obviously realized the problem of drugs and had been able to stay cleanrdquo she said adding that Hoffmanrsquos case shows how devastating addiction can berdquo
Heath LedgerldquoStill part of what made Ledger such a passionate curious actor capable of reaching extraordinary emotional depths in his work is inextricably linked to the sensitivity that left him vulnerable to addiction and shutting himself off from others many of whom tried to help himrdquo
34
Gender and Stigma
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Stigma
Stigma Serves
to
bullRegulate - Control and enforce behavior
bullIsolate - Decrease contact with the stigmatized
bullRelegate - Distinguish the stigmatizer from the stigmatized
bullDiscriminate - Perpetuatemaintain difference
35
Presenter
Presentation Notes
Used as a means of self-elevation (I might do this but Irsquod at least I am better than those people)13Used as a means of social control (social control theory)13Used as means to separate morals even within groups of drug users1313Society thus responds to the attribute with lsquo interpersonal or collective reactions that serve to lsquoisolatersquo lsquotreatrsquo lsquocorrectrsquo or lsquopunishrsquo individuals engaged in such behaviourrsquo (Schur 1971 p 24)
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Stages of Stigma
Discrimination Action resulting from Bias
Status Loss (patronizing actions and collateral consequences from incarceration)
Separation as Punishment (tough love or criminalization)
Personal SeparationIsolation (feelings of unworthiness lead to withdrawal)
Stereotyping Cements notion of moralsocial failings
Labelling of lsquodeviantrsquo group lsquootherizersquo
Perceived Moral Failing Judgement
50
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Stigma ndash Impacts on Health
Limits willingness to access careservices
Internalization of stigma
affects PWUDs
personal view of being
lsquoworthyrsquo of services
Internalized stigmacreated
identity associated with stigma = harder to change behavior
Discrimination in
services (sobriety
restrictions and doctor
bias)
37
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Strategies for Challenging Stigma
38
Presenter
Presentation Notes
Review individual-level strategies for challenging and confronting stigma from a provider perspective13Highlight how these strategies may be used to confront stigma 1313Individual Level13Ex authentic relationship-building13Treat everyone as individuals 13Valuing their unique experiences and needs and see people more than simply their drug use or sex work1313Organizational Level13Ex training and education13Increase staff cultural competency through training and education 13Extend training to ALL staff -- anyone who interacts with drug users and sex workers should receive training (working board member custodial)1313Community Level 13Ex Participant Advisory Board 13PABs are organized groups of SAP participants and PWUDs who can offer feedback guidance and recommendations RE program design + services 13Ex policy and advocacy 13Legislative advocacy can be a useful tool when challenging institutional stigma 13(Re)Action that humanizes PWUD and sex workers such as Good Sam overdose prevention or collaborative efforts to circulate Bad Date Sheets
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Comprehensive Approach
HCVHIV Testing and Treatment
Mental Health Services
Medication Assisted
TreatmentPREP for PWUDs
Naloxone Syringe Service
Programs and Supervised
Injection Facilities
39
Presenter
Presentation Notes
ldquoMedical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection13Stevan A Gonzalez MD MS Daniel S Fierer MDdagger and Andrew H Talal MD MPHDagger13 rdquohttpswwwncbinlmnihgovpmcarticlesPMC5491232131313
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
40
Questions
Presenter
Presentation Notes
Today we talked a lot about a comprehensive response to working with people who use drugshellip1313What are some ways this feels different than what is happening now13Can you imagine a way that an awareness about the DUH framework could be incorporated into your work13Can you think of new partners (here or elsewhere) with whom you could collaborate1313What do you perceive as you greatest challenge in implementing this framework13What is still unknown 13What do we still need to work on13
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
Capacity Building Assistance ndashAvailable for health department and CBO staff on harm reduction principles best practices and implementationintegration efforts CRIS requests
Technical Assistance ndash Much can be learned from successes challenges and programs elsewhere NASTAD Peer-to-Peer Mentorship Programmatic Technical Assistance Policy Guidance
Technical Assistance
41
Presenter
Presentation Notes
Through the state HIVhepatitis programs ndash CT and CBA can be requested through NASTAD 1313You can also reach out to me directly for resources questions or concerns
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
42
Laura Pegram MSW MPHlpegramnastadorg
wwwnastadorg
- Incorporating a Drug User Health Framework and Working with People who use Drugs
- About NASTAD
- National HIV amp Hepatitis Overview
- Diseases Associated with Injection Drug Use
- Huge Increases in HCV related to IDU
- North Dakota Specific Increases
- North Dakota Specific Statistics
- Scott County Indiana
- Slide Number 9
- So What Can Be Done
- Harm Reduction Philosophy
- Harm Reduction Principles
- Stages of Change
- Stages of Change
- So why do people use drugs
- Continuum of Drug Use
- Circumstances of Drug Use
- Social Determinants of Drug User Health
- Common Drugs and Highs
- Routes of Administration
- Safer Drug Use
- Risk Factors
- Slide Number 23
- Systems that touch People who use Drugs
- Prevention and Treatment Binary
- Continuum of Drug User Health Services
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Prevention and Treatment Binary
- Myths and Facts
- Stigma
- Stigma
- Gender and Stigma
- Stigma
- Stages of Stigma
- Stigma ndash Impacts on Health
- Slide Number 38
- Comprehensive Approach
- Questions
- Technical Assistance
- Laura Pegram MSW MPHlpegramnastadorg wwwnastadorg
-
![Elizabeth Sherman, PharmD, AAHIVPhivaidsinstitute.med.miami.edu/documents/...HIV-HCV...• SVR rates similar to HCV monoinfected [1,2] • In HCV/HIV coinfection, treat HCV as though](https://static.fdocuments.net/doc/165x107/5fbc30e57653e03e261e9924/elizabeth-sherman-pharmd-aa-a-svr-rates-similar-to-hcv-monoinfected-12.jpg)
