To improve public health, researchers “program a world”

Agent-based modeling simulates the interaction between people and environment–and may offer valuable insights about preventing substance use-related harms

Timelapse image of patrons at a bar. Source: Morguefile.com

Timelapse of bar patrons. Source: Morguefile.com

One of the first things Dr. Christina Mair did during our conversation was disabuse me of my whack-a-mole theories. “Like when bars get serious about carding, aren’t there just more house parties for minors to drink at?” I asked.

“You’d be surprised,” she said. “That’s a very commonly-held idea, that if you get rid of it here, it turns up there. And yes, there is some displacement, but it’s definitely not a 1:1 ratio.”

“Another example of the whack-a-mole theory is when you hear parents say, ‘Oh, well, I know my kid is going to drink anyway, so if I let him drink responsibly in the home, he won’t have problems.’ Which, of course, is not true. Studies show over and over again that those kids are drinking more,” Mair said.

Human behavior is context-dependent. No one lives in a vacuum. And according to Mair, when you make something harder to do, people do it less.

It’s an encouraging premise: making changes to the context of our lives can reduce substance use related harms. And nowadays, when the phrase “addiction should be treated as a public health issue” is being tossed around willy-nilly, this premise is an example of what that catchphrase actually looks like.

Dr. Christina Mair, University of Pittsburgh

Mair is an assistant professor at the University of Pittsburgh Graduate School of Public Health. She came to Pittsburgh from the Prevention Research Center (PRC) in Berkeley, CA, where she researched environmental prevention strategies—well, much more than that. Her research examines the “social ecology” of substance use, which means the messy fabric of life in which we make decisions about drugs and alcohol.

“Social ecology is about social mechanisms. How are people acting in different contexts? How do personal characteristics and environmental characteristics combine to affect the way people are behaving?” Mair explained.

Social ecological theories focus on integrating what we know about individual-level behavior—a person who tends to drink after an unusually stressful day, for example—and population-level behavior—like a neighborhood with high bar density that has higher levels of alcohol-related violence.

“The explicit integration of those different levels is a wide open field with all sorts of questions,” Mair said. “This work is just beginning.”

Historically, many prevention efforts have focused on school-based approaches to educate kids about the danger of drugs, including the now-debunked D.A.R.E. program. Mair’s investigation of social mechanisms that promote or discourage substance use and its harms can be used to develop a much wider range of interventions, from enforcing loitering bans outside of bars to publicizing roadside driver checks in target areas.

Unpacking what “socioeconomic status” really means

At the PRC, Mair researched the social ecology of substance use under an NIAAA grant–an area that the NIAAA doesn’t often fund. “Most other NIAAA grantees are clinically-oriented or focus on biological or genetic issues related to alcohol. And we know that stuff is important,” Mair said. ”But this really spoke to me.”

Why? “As a public health person who’s always thinking about populations, the question for me about substance use is what can we do about prevention–specifically, environmental prevention. Because those efforts can reach so many people,” she said.

At the University of Washington, where she received her Master’s of Public Health in epidemiology, Mair’s interest was piqued when she took a class on the social determinants of health.

“There, I realized that a lot of people were simply plugging one big factor called ‘socioeconomic status’ into their models,” she said.

Mair wanted to take a more nuanced approach to understanding the social factors affecting disease.

“I realized that so much interesting work thinking about real world problems was happening in the area of social epidemiology.”

With that in mind, Mair studied for her PhD at the University of Michigan, examining how neighborhoods—their social and environmental composition—affect depression in men and women.

Her research showed that a better social neighborhood environment lowered depression in women but had no impact on men. In contrast, a negative physical environment (physical decay, litter, graffiti) was associated with higher levels of depression in both men and women.

After finishing her doctorate, she accepted a postdoc at the PRC, where she began specifically looking at behavior related to alcohol and drugs. “I came to substance use from mental health,” Mair said.

Agent-based modeling: understanding the complexity of human substance use

One of the exciting methods that Mair uses in her research is called agent-based modeling, an approach that biologists have been using for decades but has only recently been adopted by social scientists.

How do you make a model of the way people use substances? You start by doing descriptive research, looking at individual-level behavior and then population-level data. And from there, you generate a theory.

“What is one social mechanism that might be important? You need an idea about how the environment interacts with individual behaviors. Then you can program a world with certain environments where people have certain traits. And you can play with these characteristics–we say you can ‘parameterize them’–until you see that the models resemble what you see happening in the real world.”

An example of the complexity of agent-based modeling. Source: Christina Mair, “The Social Ecology of Substance Use: Model-Based Approaches to Identify Mechanisms”

And models are cool because you can play them forward in time. “You can see if it looks like what over time is actually happening in the world. You can see if the social mechanism works the way you think it does,” said Mair. “You can also model potential interventions. There’s a lot you can do with this method.”

If this sounds complicated, it’s because it is. Building good models for human behavior requires an interdisciplinary team knowledgeable about the many aspects of individual- and population-level substance use, including fields like epidemiology, public health, psychology, and neuroscience.

“You need the people who know the right questions to ask and you also really need a computer programmer. This approach explicitly forces cross-disciplinary work,” said Mair.

At Pitt’s School of Public Health, Mair joins Dr. Christopher Keane, another young researcher who favors agent-based modeling as a research methodology. Keane’s recently published book, Modeling Behavior in Complex Public Health Systems, is summarized chapter-by-chapter online. Its underlying premise, according to Keane: “Public health behavior makes the most sense in light of evolutionary games.”

Sprinkled throughout the book are psychedelic videos that illustrate Keane’s models.

I like the optimism that underlies the use of agent-based models. What a tall order, simulating the many internal and external factors that combine to produce human behavior at any given moment. It’s sure to be slow-going and to miss the mark. But as new research is conducted, new theories are developed, and we watch the epidemiology of substance use-related phenomena unfold, these models can be continually tweaked. They can become increasingly useful.

In that sense, the decision to incorporate models into public health research represents a commitment to looking more and more deeply at the factors that affect human behavior, however complex those turn out to be.

“People are really confusing and messy and complicated,” Mair said. “It’s harder work to use these methods in the social world than in the biological world, which is one of the reasons that this work is just beginning.”

Agent-based models can also be used to anticipate the effects of a policy before it is created and to project the cost-benefit of various interventions–two challenging issues for the public health field.

Of course, learning which types of interventions are effective doesn’t mean they will be implemented. ”What is the role of a prevention researcher,” I asked, “who knows that applying certain environmental strategies may be more effective than designing certain curricula?”

“Research and politics, of course, can’t be separated,” Mair said. “A prevention researcher can look at certain policies, like taxation and pricing, and make recommendations about implementing them. She can say, ‘There’s a lot of good evidence that reducing access to alcohol does make a difference so if you’re thinking of making a policy, this is something we would recommend.’”

“Of course, that’s not a politically popular thing to do,” I said.

Mair laughed. “No, it’s not. It’s definitely not.”

Drinking habits linked to partner violence

Sunday Alcohol Blue Laws: Keeping Consumption in Check?

Alcohol-free Liverpool Bar The Brink scoops three awards at national ceremony

Saving the Party: Councilman Bruce Kraus and the Responsible Hospitality Institute address Pittsburgh nightlife issues

New York City to ban tobacco sales to anyone under 21

Drugs are Double Edged

Nov22 by Jessica Williams

Three thoughts on the NYT buprenorphine story

Last week, the New York Times published “The Double Edged Drug,” a two-part series on the addiction treatment medication buprenorphine. Given that Reckitt Benckiser’s buprenorphine-naloxone combination suboxone is the “the blockbuster drug most people have never heard of” that surpassed “well-known medications like Viagra and Adderall” and “generated $1.55 billion in United States sales last year,” it’s high time serious news outlets took a closer look at its use to treat addiction.

Part 1, “Addiction Treatment with a Dark Side,” lays out suboxone’s clinical and commercial successes alongside its abuse by addicted patients and profit-driven doctors

Part 2, “At Clinics, Tumultuous Lives and Turbulent Care,” focuses on treatment experiences, highlighting two clinics within 100 miles of Pittsburgh, and some of the obstacles people face in legally obtaining buprenorphine.

You can’t get through a paragraph without bumping into the “double edged” theme. From the outset, author Deborah Sontag contrasts two patients–one who found recovery through buprenorphine and another who overdosed and died on it. And in the second article, she points to the double edged circumstances of two prescribing doctors–one in a sweatsuit, the other in a white lab coat, both professing a desire to help patients, both financially incentivized to prescribe suboxone.

All of these double edges may well lead readers to conclude that “This whole situation is a big old mess,” which is, in fact, the quote Sontag chooses as the last line of part one.

And as the articles (and the comment section) demonstrate, the use of buprenorphine to treat addiction and prevent substance use-related harms is messy. Interlacing text and video, the NYT pieces illustrate those complexities skillfully. Here are three points to keep in mind as you read:

1) Medication-assisted treatment reduces overdose deaths.

2) It is necessary and good that buprenorphine treatment is investigated and reported on.

3) Drugs are double edged.

Medication-assisted treatment reduces overdose deaths. Buprenorphine prevents more overdoses than it causes. Although buprenorphine has contributed to many thousands of ER visits in the past ten years (the number increased nearly ten-fold from 2005-2010), a buprenorphine overdose death is relatively rare. For example, the NYT cites a Reckitt study of 2,380 buprenorphine overdoses in young children, which “found that 587 had to be hospitalized in intensive care units and that four died.” Buprenorphine overdose deaths pale in comparison to overdose deaths from opioid analgesics (almost 20,000 in 2010…100 people every day). Appreciating the scale of the difference is important.

SAMHSA Toolkit, 2013

What’s more, as Dr. Andrew Kolodny points out in the NYT, the US opioid overdose epidemic, which has coincided with the availability of office-based buprenorphine, would surely have been worse without it. With so many friends and family members lost every day to overdose, Americans are mobilizing to tackle this thorny issue: communities are forming coalitions, states are upgrading prescription drug monitoring programs, and parents are learning the word “naloxone.” Ensuring access to medication-assisted treatment, especially buprenorphine, is recommended in the statewide plan “Overdose Prevention Strategies in Massachussetts” (2012) and SAMHSA’s newly released opioid overdose toolkit, among other documents.

Whether you consider them harm reduction measures or recovery-oriented treatment tools, methadone and buprenorphine reduce opioid-related deaths. Increasing access to them is an important (and under acknowledged) aspect of a public health response to the overdose epidemic.

It is necessary and good that buprenorphine treatment is investigated and reported on. An important piece of the NYT series is the revelation that buprenorphine prescribing physicians have higher rates of disciplinary action taken against them for professional violations than non-prescribing doctors. Nationally, Sontag reports that over 10% of bup prescribers have been sanctioned for professional offenses. That number, not reported in the research literature (to my knowledge), shines a clearer light on some of the problems with bup treatment on the ground. The series also reports on buprenorphine advocates’–both individual and orgnaizational–ties to pharmaceutical companies that distribute buprenorphine. Again, useful information. With suboxone (and an injectable naltrexone drug called Vivitrol), addiction treatment is interfacing with Big Pharma in new ways. We ought to pay attention to these relationships.

Turning a blind eye to critical investigations of buprenorphine will not improve patient outcomes and public health. When major news outlets report on addiction treatment, the conversation expands. Those with experience in the field have an opportunity to comment and clarify their positions. Reading the tweets and posts of experts weighing in on the NYT series has been a major learning opportunity for me and many others.

Drugs are double edged. The NYT series eagerly painted buprenorphine as a two-faced paradox, as “a menace or a savior,” which, as a literary device, perhaps clouded the truth rather than elucidating it.

Paracelsus, father of toxicology Photo: Wikimedia Commons

Paracelsus
Photo: Wikimedia Commons

If the average reader comes away from the series thinking that buprenorphine does as much harm as good, that it’s not worth it, and that we’ve reached an impasse in our treatment of opioid addiction or prevention of opioid overdose, then Sontag got it wrong. All medications with therapeutic value carry risk. Indeed, the double edge-edness of opioid painkillers themselves helped create this epidemic and the solution is not to do away with them.

One of the fundamental principles of toxicology, put forth by Paracelsus in the 16th century, is that “All things are poison, and nothing is without poison; only the dose permits something not to be poisonous,” often paraphrased nowadays as “the dose makes the poison.”

And most patients do not take prescription drugs as prescribed.

All this is to say that singling out buprenorphine as “the” double edged drug seems an inaccurate and potentially stigmatizing view of it.

Yes, I’m Annoyed, and You Should Be Too – thoughtful and prolific blogger bemoans the healthcare establishment’s handling of buprenorphine treatment

The Anti-Addiction Pill that’s Big Business for Drug Dealers – NPR’s Planet Money podcast reports on the history of buprenorphine’s development, how government agencies have worked at cross purposes, and how that plays out in legal and illegal economies

New York Times Reax - commentary from another thoughtful and prolific blogger who does not favor buprenorphine maintenance

Women have been particularly affected by the War on Drugs

Nov8 by iretablog

Orange is the New Black and the disproportionate impact of drug policy on women

Part of IRETA’s ongoing series on substance use and criminal justice

Photo: Wikimedia Commons

The wildly popular Netflix television series Orange Is the New Black has garnered an enthusiastic following for its frank portrayal of female inmates in a federal prison: their raunchy wit, their ingenuity, their desires and intimacies, their checkered pasts, and their suffering.

The show features Piper Chapman, a fashionable yuppie blonde serving a 15-month sentence for a 12 year-old drug charge. OItNB follows, through Piper’s often naïve perspective, relationships among inmates and their experiences with bureaucracy, injustice, and abuse in the criminal justice (CJ) system.

Piper Kerman
Photo: Wikimedia Commons

The series is based on the memoir by Piper Kerman, former inmate at the Federal Correctional Institution at Danbury, today a formidable figure speaking out for prison reform. Her personal experience in a federal prison lends urgency to her calls for reform in women’s prisons, especially when it comes to prosecution and sentencing of drug offenses.

In a recent editorial for the New York Times, Kerman contends, “Harshly punitive drug laws and diminishing community mental health resources have landed many women in prison who simply do not belong there, often for shockingly long sentences.”

According to The Sentencing Project (2013), women have been “particularly affected by the policies of the ‘war on drugs.’” Their report continues,

Since women have always represented a small share of persons committing violent crimes, their numbers in prison would not have grown as dramatically had it not been for changes in drug enforcement policies and practices. As law enforcement increased targeting of drug law violators and as sentences for drug offenses became more severe, drug offenders came to represent a rapidly growing share of the incarcerated population, with the proportion of women in prison for drug crimes exceeding that of men. In 1986, 12% of women in state prison were serving time for a drug offense compared to 8% of men. Over time, these proportions increased, and as of 2009, 25.7% of women in prison were serving time for drug offenses, as were 17.2% of men. [emphasis added]

Although OItNB is peppered with funny moments and dry wit—like Piper commenting to a dour-faced guard as she’s given prison-issue footwear, “Oh, these are kinda like TOMS”—it also generates outrage at the system and pity for the women in it. On the show, Piper herself seems out of place, not just for her white-breadness, but for having been incarcerated for a single non-violent drug charge over a decade old.

In reality, it’s not an uncommon story.

Cristina Rathbone tells the story of Charlene Williams, an inmate at Massachusetts Correctional Institution-Framingham, in her 2005 investigative book, A World Apart: Women, Prison and a Life Behind Bars. Charlene, 19, is serving a mandatory 15 years for a single first-time, non-violent drug offense with no possibility of parole or time off for good behavior. In that block of time, her infant daughter will have grown into a teenager without her mother.

And A World Apart features Denise, also a mother, who is serving a five-year mandatory term at MCI-Framingham for a first-time, non-violent, low-level drug offense. At one point in her communications with Rathbone, Denise writes frustratedly about the discrepancy between her sentence and those given to offenders guilty of child rape and molestation:

These guys […] received good time, parole eligibility, and work release! I do every day of my 5 years. I have over 120 days that I’ve earned—I cannot use them towards reducing my sentence. […] Imagine! Then studies prove that kids who are molested or raped have a much greater chance at substance abuse. So take a group of 10 kids who were molested or raped, follow their lives for 15-20 years… Guess who’s in prison? Non-violent, drug offenders!

I was molested at age 11 by my neighbor. Julie was raped at 14, Susan Grissin was repeatedly raped…And the people who kick start the beginning of our destinies go free, or do little time? I’m doing two more years than a child rapist!?!

It is often the case, according to Silja J. A. Talvi, the author of Women Behind Bars, that women take the blame for the men in their lives: husbands, boyfriends, sons, pimps. Story after story reveals women who refuse to “snitch” on relatives or boyfriends who are dealing—and are then slapped with federal conspiracy charges on top of the mandatory sentence. The real perpetrators of the crime often serve less time.

“Conspiracy offenses,” according to the Drug Policy Alliance, “represent one of the most egregious examples of the drug war’s inequitable treatment of women.”

And this is cause for alarm, says Talvi: “One of the most profound indicators of a criminal justice system gone awry is the fact that we are incarcerating the most vulnerable members of our society en masse. In essence, prosecutors and judges are sending the people with the fewest resources and least ability to afford decent legal representation to the slammer, often for very lengthy periods of time.” (Women Behind Bars, 2007, p 5).

Who Are the Women in Prison?

Number of Incarcerated Women, 1980-2010. Credit: the Sentencing Project

Credit: The Sentencing Project, Incarcerated Women Factsheet

The Women’s Prison Association supplies these statistics on the female prison population:

The number of women in prison has grown by over 800% in the past three decades. The female prison population grew by 832% from 1977 to 2007. The male prison population grew 416% during the same time period.
Two thirds of women in prison are there for non-violent offenses, many for drug-related crimes. In the 10-year period from 1999 to 2008, arrests of women for drug violations increased 19%, compared to 10% for men.
Nearly two-thirds of women in prison are mothers. At midyear 2007, approximately 65,600 women in federal and state custody reported being the mothers of 147,400 minor children.
Women of color are disproportionately represented in prison. Ninety-three out of every 100,000 white women were incarcerated at midyear 2008. During the same time period, 349 out every 100,000 black women and 147 out of every 100,000 Hispanic women were incarcerated.
Women in prison are largely in their thirties and forties. Fifty-one percent of sentenced women were between the ages of 30 – 44, with 36% of those between the ages of 35 – 39 at midyear 2008.

OItNB’s opening credits are designed to capture this demography:

Moreover, women’s pathways to prison look different from men’s, says the National Resource Center on Justice-Involved Women, and often begin with victimization and abuse, leading to mental illness, including depression, anxiety and PTSD, and substance use and abuse.

In their research informed by trauma theory, Barbara Bloom and Stephanie Covington explain that the painful experiences of past and current traumas often cause three responses: retreat, self-destructive behaviors and destructive behaviors. Men tend toward destructive behavior, while women tend to retreat or engage in self-destructive behaviors, including substance abuse.

With these factors in mind, expert recommendations for treating incarcerated women take into account the high percentage of female offenders that have experienced abuse, struggle with SUDs, and have children or families they are leaving behind. According to SAMHSA’s publication, Substance Abuse Treatment for Women Offenders, Guide to Promising Practices, promising practices in gender responsive treatment in women’s prisons include:

Building a treatment approach that is rooted in an understanding about how women grow and develop, and about how these social and developmental factors affect addiction.
Using sanctions in creative and reasonable ways that will reinforce treatment goals and engage women in treatment for the necessary length of time.
Assessing each woman’s needs in a comprehensive, yet flexible, manner so that needs are matched to the intensity and length of care required.
Providing continuity of care, from the pre-sentencing period through in-custody treatment, to continuing treatment and support during the months following release, so that women have an opportunity to develop the skills and resources to survive and contribute to their communities.
Ensuring that women receive the housing and other services that they need so desperately in the early post-release period, to help them avoid both relapse and recidivism.

In future posts, we will examine existing models that promote recovery among women in the criminal justice system and policy reforms that can begin to reduce the immeasurable damage to women and families wrought by our decades-long “war on drugs.”

Resources

Further reading and viewing

“Women Convicted of Felonies May Get Chance to Stay Out of Prison,” New York Times article on JusticeHome

Rathbone, Cristina. (2005). A World Apart: Women, Prison and Life Behind Bars. New York: Random House.

Solinger, Rickie, et al., eds. (2010). Interrupted Life: Experiences of Incarcerated Women in the United States. Berkeley: University of California Press.

Talvi, Silja J. A. (2007). Women Behind Bars: The Crisis of Woman in the U.S. Prison System. New York: Seal Press, 2007.

Gender-Responsive Policies and Practices in Maine: What Incarcerated Women at the Women’s Center Say They Need from the Criminal Justice System

Guides for Organizations

Substance Abuse Treatment for Women Offenders, Guide to Promising Practices (1999)

Achieving Successful Outcomes with Justice-Involved Women: A Review of the Research, Tools and Resources for Practitioners

Ten Truths That Matter When Working With Justice Involved Women

Organizations

National Resource Center on Justice Involved Women, Women’s Prison Association, The Sentencing Project, American Civil Liberties Union: Women in Prison, Families Against Mandatory Minimums (FAMM)

How can justice reforms support recovery? (9/16/13)

What makes recovery difficult for the criminal justice population? (7/22/13)

Updates on a Prescription Drug Monitoring Program in Pennsylvania

Nov8 by iretablog

Tracking progress on our home state’s efforts to modernize our PDMP

800px-Computer_keyboard_in_use_for_a_Windows_7_Desktop_Computer

Photo: Wikimedia Commons

Editor’s note: As information related to PA’s PDMP becomes available, we are sharing it on the Institute Blog. This post will be updated frequently. Feel free to email relevant news and information to jessica@ireta.org.

Recent news

Efforts to limit prescription pills could push heroin use November 8, 2013

Discusses the potential for heroin use to rise if a prescription monitoring database reduces access to painkillers; proposes better, longer access to treatment as one solution.

STFriday: monitoring Rx drugs & Political Junkie Ken Rudin October 25, 2013

Interview with bill sponsor Rep. Matt Baker (R-Bradford/Tioga) and Dauphin County District Attorney Ed Marsico. Discusses the bill in its current form, passed this week by the PA House of Representatives, which requires law enforcement to have search warrant to access the database.

Pa. prescription drug database bill heads to senate October 22, 2013

Drug monitoring plan tweaked for patient privacy October 20, 2013

Pa.’s proposed law to track more prescription drugs is on fast-track October 20, 2013

Prescription drug database stalls in Pa. House October 16, 2013

Lawmakers assess heroin use in PA October 15, 2013

Pa. ranked 14th in number of drug overdose deaths, gets low marks for efforts to curb abuse October 7, 2013

Pennsylvania ranks high in painkiller overdoses, low in measures to prevent them: new report October 7, 2013

PA doctors: Prescription pill tracker could violate patient confidentiality October 4, 2013

ACLU calls for patient privacy after PA pill-tracking database vote September 24, 2013

***

Background

In October 2013, the Trust for America’s Health (TFAH) released Prescription Drug Abuse: Strategies to Stop the Epidemic, a state-by-state analysis of harms related to prescription drug abuse (including overdose) and the extent to which each state utilizes a set of 10 indicators of known strategies to help curb the epidemic.

The result in Pennsylvania? Survey says:

Of the 10 indicators, Pennsylvania did receive a point from the TFAH for having an existing Prescription Drug Monitoring Program (PDMP). However, PA did not receive a point for “requiring mandatory utilization by prescribers” within our PDMP.

In fact, although Pennsylvania had one of the first PDMPs in the country (begun in 1972), ours is currently one of the most limited in the nation. It tracks only Schedule II controlled substances, data is updated monthly, and access is limited to law enforcement officers.

It seems that political will is building to modernize our current PDMP and the 2013-14 session may be a window of opportunity to create policy change that will reduce harms associated with prescription drug abuse.

Governor Corbett’s Medicaid Redesign Proposal, Healthy Pennsylvania, includes an upgrade to our PDMP.

And on September 23, House Bill 1694 (a revision of House Bill 317), was approved by the House Human Services committee. From there, the bill headed to the House floor for deliberation.

For more information on PDMPs and their use in PA, read our previous post on the subject (published 6/21/13).

And be sure to check back often; we will be publishing updates here on the blog as news and information become available.

Pennsylvanians, policy wonks, anyone with expertise: we welcome your comments and information.

A Message from the Executive Director

Nov4 by iretablog

“Whatever your life’s work is, do it well. A man should do his job so well that the living, the dead, and the unborn could do it no better.”
- Martin Luther King, Jr.

Peter F. Luongo, PhD

How do you know when you are doing your life’s work well? Is there a standard? How is it set? How is performance judged? What is the result of a life’s work not well done? Well done? How can you learn to do it better if it is not going so well or to keep it going if it is?

These questions are not meant to be abstractions, nor points for philosophical elaboration. Yet, they are difficult to answer. The emerging reality is that organizations and practitioners working to improve the lives of individuals, families and communities affected by substance use need to grapple with these questions. And get to answers.

Why now?

Health care is evolving into a performance-, rather than procedure-, driven industry. Changes in practice will soon be primarily motivated by the need to demonstrate improved individual and community outcomes to both consumers and payors of services. And this often means improving performance at all levels in an organization.

In the past year, IRETA’s practice has continued to evolve beyond its traditional training and education activities to provide consultation and expert assistance for states, agencies and systems seeking to improve their practice. We do this by applying a diverse, distinct and expanding body of knowledge to tackle clinical, administrative, process improvement, measurement and information systems problems that inhibit organizations from getting to outcomes that will now be expectations, not merely aspirations.

IRETA’s projects of the past year are discussed in our 2012-13 Annual Report. Our clients are a diverse group that we have assisted by understanding how they saw their problem, how they tried to solve it, what outcomes they wanted to achieve and then fitting practical solutions that were self reinforcing and sustainable.

This work has a theme to it, “Helping helpers do what they do…better.”

Coupled with IRETA’s strong base in training, education and applied research, this practical approach to helping has resulted in a second consecutive year of a budget surplus and growth in net assets.

My profound thanks to the Board and the creative, energetic and dedicated staff at IRETA for making this past year so professionally and personally rewarding for me.

Health Literacy Has Momentum

Oct28 by Jessica Williams

As the concept gains traction, how can we use it to think about addiction and substance use?

Health Literacy: the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions.

–The Institute of Medicine, 2004

On October 16, I attended the Regional Health Literacy Coalition (RHLC) conference, “Health Literacy: Public Health, Our Health,” at the University of Pittsburgh. There, I learned that October is the CDC’s Health Literacy Month and with a little more investigation, I learned that we have just finished up the Society for Public Health Education (SOPHE)’s National Health Education Week, which runs Oct. 21-25.

All signs seem indicate that now is the time to be thinking about health literacy.

I have been thinking a lot about learning these days. I try to learn a great deal every day—with uneven success. Oftentimes, it’s retention that causes me problems. I encounter so much information, written and spoken–I even post some of it on my or IRETA’s Facebook wall–but how do I understand these ideas about substance use and addiction so that I can use them when I need them?

This is exactly the kind of question the RHLC is designed to address.

“No one chooses to be sick, but staying well requires a healthy understanding,” write RHLC co-chairs, Candi Castleberry-Singleton and Yvonne Cook.

These days, health literacy is a hot topic. The CDC points to the year 2010 as a “tipping point” for the concept, when it entered the mainstream of health policy. Most significantly, the Affordable Care Act passed in 2010; several ACA provisions directly acknowledge the need for greater attention to health literacy, and many others imply it (more here).

Click here to view full slideshow from the RHLC conference

In the same year, the Plain Writing Act of 2010 was signed into law, which requires the federal government to write all new publications, forms, and publicly distributed documents in a “clear, concise, well-organized” manner that follows the best practices of plain language writing (this includes health information). Also in 2010, HHS released a National Action Plan to Improve Health Literacy, which “envisions a restructuring of the ways we create and disseminate all types of health information in this country.”

Why this sudden buzz around health literacy?

“Low health literacy has been estimated to cost the U.S. economy between $106 billion and $236 billion annually.” (Vernon et al, 2007) Right. Healthcare costs are skyrocketing. And we’re trying to understand why.

Health literacy may help the US manage healthcare costs, now a bigger part of our overall spending than any other developed nation
Image: George Mason University

One of the major themes of the RHLC conference is that most of us have difficulties with health literacy. According to a national survey, 88 percent of adult English-speaking Americans need help understanding health care information. And, in fact, that number becomes 100% when you reach a certain threshold of complexity and specificity.

Given the universality of the problem, responsibility for improving health literacy doesn’t lie solely with the patient.

"I'm nodding like I understand but I have no idea what you just said."

“I’m nodding like I understand but I have no idea what you’re talking about.”

Karen Komodor, RN, BSN, CCRN, Director of the Health Literacy Institute at St. Vincent Charity Medical Center in Cleveland, Ohio, led a presentation about the formation of the HLI and its goals at the RHLC conference.

“A big focus, initially, was on the low-literate patient, the individual’s ability to understand,” she said. “It has since evolved and now includes the caregiver’s ability to communicate so that the patient can understand.”

And the HLI has gotten onboard with the Agency for Healthcare Research & Quality (AHRQ) campaign, “Questions are the Answer,” which emphasizes the vital importance of asking questions of your medical practitioner. Below is a video produced by the AHRQ for use in healthcare waiting rooms.

Quote from the video: “Communication is a two-way street. Sometimes Starbucks does a better job at this than we do in healthcare.” (4:33)

UPMC Chief Inclusion Officer and RHLC co-chair Candi Castleburg-Singleton agreed wholeheartedly. “We need to arm a consumer with the courage to ask the right questions,” she said in her presentation.

Other presenters touched on a host of issues related to health literacy—both obvious and less-obvious. For example, did you know that American Sign Language is based on the French language? And that when you pass a deaf person a note written in English about how to take medication or manage a chronic condition, that person may have difficulty understanding it? I didn’t know that.

Another presenter gestured to a humorous linguistic mix-up that could have not-so-humorous consequences. Instructions to “take one pill once a day,” to a Spanish-speaker, could have disastrous results: “once” is “eleven” in Spanish.

How does this apply to substance use and addictions, I kept thinking. Answer: in so many ways.

Health literacy is the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions. Just obtaining information about substance abuse and addiction treatment can be extremely difficult. And no one is asking enough questions.

Anne Fletcher drives home this point again and again in her recently published book, Inside Rehab. The shortcomings she observes about health literacy related to addiction treatment align with the messages we hear from the AHRQ: information needs to be clearly communicated; consumers need to proactively engage with it. It’s a two-way street.

Two_Lane_Blacktop_filming_in_Boswell_Oklahoma

A two-way street
Photo: Wikimedia Commons

Information about addiction and addiction treatment is not clearly communicated, nor is it readily available. A local example is the report generated by Pennsylvania nonprofit, MOMSTELL, which conducted an Access to Treatment Barriers Survey in 2009. The results were discouraging (though unsurprising): nearly 30% of respondents seeking treatment had no idea who to call.

And consumers rarely engage proactively with information about treatment–often because they are in a time of urgent need when they are trying to obtain information. In Inside Rehab, the issue of asking questions comes up again and again. Fletcher quotes Tom McLellan on the topic, who says drily, “When it comes to picking a rehab, most people ask more questions before buying a vacuum.” (Inside Rehab, p 6).

Every chapter of Fletcher’s book concludes with a list of questions for a consumer to ask about the rehab facility. And she includes, as an appendix, “A Consumer Checklist for Checking Out Rehabs.” Examples include:

“How soon do you accept people into treatment after they have an assessment and decide they want to come to your program?”

“How much time is spent in group counseling? How much time is spent in individual counseling?”

“Describe your use of any medications that help people overcome addictions. Do you send people home on these medications?”

These are the types of questions that improve a consumer’s health literacy when seeking treatment for (and eventually managing his or her own) substance abuse and addiction. Fletcher wrote her book in response to a dearth of helpful guides for treatment-seekers. (Here, I would be remiss if I didn’t also mention NIDA’s excellent brochure Seeking Drug Abuse Treatment: Know What To Ask.)

Although asking questions is important, we know that it’s complicated by stigma and lack of knowledge about addiction and its treatment. This stigma exists in our general culture and pervades the healthcare industry.

One of the evidence-based practices that IRETA works often to implement, SBIRT, is designed to combat these barriers. SBIRT stands for Screening, Brief Intervention, and Referral to Treatment. It’s a protocol that healthcare providers can implement to identify, reduce and prevent problematic substance use.

The “SBI” portion provides health education related to serving size, frequency of use, and harms associated with various patterns of use. The “RT” portion helps consumers better understand how to access services to address substance use and addiction. Here’s an example of SBIRT with an older adult.

Questions are the Answer: “Would you mind if I spent a few minutes going over your alcohol screening form with you?” (0:48)

Broad implementation of SBIRT will improve health practitioners’ literacy in the area of substance use and addiction and contribute to higher health literacy among the general public.

We know that health information exists that can save money and pain. Health literacy advocates ask, “How can we get that information to patients so that they can understand it to better manage their own health?”

And in our efforts to better address substance use and addictions to improve outcomes for individuals, families, and communities, how can we tap into the strategies and tools generated by health literacy advocates to guide our work?

Recommended Resources

Decoding Medical Gobbledygook: Health Literacy Puts Patients First

#healthlit on Twitter

Health Literacy: A Prescription to End Confusion Report Brief, Institute of Medicine (2004)

Inside Rehab: The Surprising Truth about Addiction Treatment–And How to Get Help That Works on Amazon

Inside Rehab (blog) on Psychology Today by Anne Fletcher

SBIRT on ireta.org

From the conference

Regional Health Literacy Coalition website

Overview of Health Literacy and the Regional Health Literacy Coalition (PPT presentation led by RHLC co-chair Candi Castleberry-Singleton)

Health Literacy Journey at St. Vincent Charity Medical Center (PPT presentation led by Karen Komodor, RN, BSN, CCRN)

UPMC and Highmark agree: Our community needs more and better health information (op-ed) by RHLC co-chairs in the Post-Gazette

Community Conversations

Oct16 by Jessica Williams

IRETA asks local educators and faith leaders: “How could SBIRT help you?”

On October 4, in conjunction with Gateway Rehab, Waynesburg University, and the Pittsburgh Theological Seminary, IRETA hosted a day-long conference titled “Screening, Brief Intervention and Referral to Treatment for Educators and Faith-Based Organizations.” The training was designed to educate and inform participants about the SBIRT model and–at least as importantly–to consult with the audience about implementation opportunities in their settings.

SBIRT is an evidence-based practice used to identify, reduce and prevent problematic substance use. While it may be adapted for use in many settings, primary care and emergency medical settings have thus far received more attention than other community-based environments like schools and churches. As the National SBIRT ATTC, IRETA works to advance SBIRT to realize its full potential impact on the health of Americans.

Introduction to SBIRT

Geneva Sanford, MSW, LSW, LICDC led the morning session, titled “Introduction to SBIRT.”

But before she said a word about SBIRT, she handed out a worksheet filled with…brain teasers?

Playing with paradigms
Image: scribd.com

“This game is called Paradigms,” she announced, and encouraged participants to work together to solve the puzzles.

These brain teasers, Sanford explained, are about creating that “aha moment.” You don’t see the answer–and then suddenly you do.

This, she said, is quite often what happens with the patients she sees in her job as a Substance Abuse Coordinator at Grant Trauma Center in Columbus, Ohio. The connections between substance abuse and its consequences become clear. Accidents, violence, other health problems. Troubled relationships, stress.

Using SBIRT, Sanford probes these issues in the context of an informative, motivational conversation about substance use that doesn’t take a hard line about what a patient should and shouldn’t do, but rather elicits information and explores options.

“Put a star next to this slide; this is an important one,” she told the group.

According to the 2011 National Survey on Drug Use and Health (NSDUH):

She paused and asked the audience to consider the 95.3% who do not feel they need treatment. While inadequate treatment access is a major problem, so too is the widespread misperception that substance abuse “is not a problem for me.” To further illustrate her point, Sanford shared a CDC video about binge drinking.

According to the video:

Binge drinking is responsible for a large proportion of alcohol-related harms: “88% of impaired driving events are caused by binge drinkers” and “Binge drinking is associated with over half of the 79,000 alcohol associated deaths that are estimated to occur in the US each year”
Binge drinkers don’t tend to look like troublemakers: “About 70% of the 1.5 billion episodes of binge drinking that occur annually in the US involve people who are 26 years of age and older” and “Binge drinkers most commonly make over $50,000 a year”
The major takeaway: “The majority of alcohol problems are caused by people who think they are not problem drinkers”

For many people, connecting these problems with substance abuse is like staring at a brain teaser, not yet able to see the meaning in it.

***
The goal of the morning session was to introduce the SBIRT model, available screening tools, and basic components of brief interventions, including Motivational Interviewing.

Throughout her presentation, Sanford emphasized the exploratory nature of the training. It presented a model that has been successful in many contexts and asked the faith leaders and educators in the audience: How could this help you?

For example, she observed that addiction has historically been perceived as a moral issue. This might, in fact, be advantageous for the use of SBIRT in a faith setting: people go to faith leaders to discuss moral issues, she said.

Debby Fye, D&A Prevention Supervisor at Mercer County Behavioral Health Commission, pointed to Pennsylvania’s Student Assistance Program (SAP) as an existing asset within educational venues with which SBIRT could be a natural fit. State mandate requires that each county in Pennsylvania have a SAP team, a referral service for school students modeled off of Employee Assistance Programs.

No matter how well-suited the setting, said Sanford, implementing SBIRT is not for the faint of heart:

“When you implement SBIRT, you’re taking a conversation that has historically been had in treatment centers out into the community. People may be shocked that you’re asking these questions. But it’s good that you’re asking these questions.”

Faith Leaders Discuss SBIRT

The afternoon featured breakout discussion groups specific to faith leaders and educators.

Reverend Dr. James Simms, Chairman of IRETA’s Board of Directors, and IRETA Project Associate Jim Aiello co-facilitated the faith leaders’ group.

Simms has substantial experience implementing SBIRT in pastoral settings, having coordinated the Caring Congregation Network (CCN) project in Pittsburgh’s East End between 2004 and 2006.

CCN began when Pittsburgh was chosen to receive technical assistance from the Office of National Drug Policy Control (ONDCP) as part of its 25 Cities Initiative, which was designed to help communities coordinate efforts and resources to prevent substance abuse. With additional funding from the Kingsley Association and training from IRETA, Simms was able to create and implement an SBIRT program among five predominantly African American churches in Pittsburgh’s East End.

The CCN was an innovative, complex project whose effects persist today.

As he recounted his experiences, Simms offered these insights:

On selling the program: “The pervasive use of alcohol and drugs in our community was a good starting point because we knew everyone was touched.”
On garnering support: St. Paul’s (where Simms is minister) has a public health ministry, which Simms leveraged to create the CCN. “We wanted to address health disparities in the African American community by doing grassroots-level education, so we created a public health ministry. When SBIRT came along, we were already kind of there.” Simms also targeted faith leaders with whom he has strong relationships. “I handpicked the churches I wanted to work with because I really didn’t have time to go with anybody who wasn’t ready, who had to be sold.”
On introducing SBIRT training: “We started with education about addiction as a disease,” he said. “To make sure we were all on the same page. It’s not uncommon for churches to think of addiction as a moral issue, that addicts are sinners, and to let God deal with them.”
On learning as they went: Early on, the CCN was having trouble with referrals. “People weren’t showing up. Then IRETA came in and gave us a big speech about warm handoffs.” He and others members of the CCN started driving to parishioners’ houses, picking them up and taking them to appointments.

Aiello, a longtime SBIRT trainer for IRETA, explained that SBIRT is a strategy to generate motivation and encourage behavior change in the long run–not necessarily right away. Faith-based settings can be particularly good places to provide support on an ongoing basis, wherever an individual falls on the readiness to change scale.

A person “might still be using, but that doesn’t mean that that moment in time has not been instrumental,” said Sanford.

“You don’t control the whole board,” Aiello told the faith leaders in attendance. “When you’re playing chess, you don’t get to control the other guy’s pieces.”

John Vaught, lead pastor at the Hills Church in Pittsburgh’s South Hills, thought that SBIRT was a good fit with his role in the church and the expectations of his congregation.

“People are specifically looking for help dealing with life issues,” he said. “That’s often why they’re in the church.”

Simms put it even more bluntly. “The business of the church is change. It’s just what happens in church. Because everybody is a former something in church.”

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