The systems currently in place to prevent diagnose and treat substance use disorders have often been counterproductive. Hampered by lack of evidence based practices, and by policies built on criminalizing drug use and blaming those with these disorders. That being said, there are steps in the right direction that leverage existing evidence to reform poorly designed policies. In this lesson, you will learn practices that are proven to encourage those with substance use disorders, to use with less harm. Help reduce the consumption of addictive substances and prevent substance use issues from developing in the first place through early intervention. Given the opioid crisis the first few examples are specific to those with opioid use disorders. One approach to reducing opioid overdose mortality has been to make the naloxone, an opioid antagonist that reverses overdose available in community settings. Targeting those using opiates illicitly and family members of those prescribed opioids. Innovative methods such as standing orders allowing community pharmacist to offer naloxone over-the-counter, trainings at churches and other communities. Or co-prescribing opioid medications and naloxone have allowed broader community access. Our own research demonstrates that individuals who use drugs and a trained to administer naloxone. Are as capable as emergency medical technicians and emergency room staff and knowing when and how to employ this life-saving medication. Studies in Chicago, North Carolina, San Francisco, Massachusetts and Scotland all found evidence that overdose rates can be reduced when naloxone is available in communities at risk of overdose. Such strategies called harm reduction keep people healthier and alive long enough to receive treatment. There is finally growing acceptance a half a century after the evidence was in, that opioid agonist medications methadone and buprenorphine in its oral or injectable forms, are effective in treating opioid use disorder. They reduce the consumption of illicitly acquired opioids, and help control the compulsion to seek them out. Summarizing data from numerous clinical trials meta-analyses, make clear the effectiveness of methadone and buprenorphine. Methadone for ample reduces illicit opioid consumption by 68%, reduces overdose deaths by 75%, reduces drug-related crime by 61%, reduces injection and risk-taking associated with infectious disease transmission by 78% and reduces HIV transmission by 73%. It improves retention and treatment for patients with HIV, hepatitis C virus and invasive bacterial and fungal infections. If the purpose of any medication is to improve health and quality of life, there is no denying the benefits of agonist medications to treat opioid use disorder. So the question becomes, how do we overcome the stigma? Increase the acceptance of medications and scale up their accessibility, especially in communities hard hit by the opioid crisis. Progressively operated methadone programs have reduced the time from seeking treatment to starting treatment to 90 minutes, eliminating waiting lists that deter initiation. Many of these same programs have expanded counseling options to include training and life and employment skills and even legal help. Program have changed their policy so that patients are no longer kicked out of programs for missed appointments, or evidence of drug use. Let's keep in mind that no other chronic disease treatment denies care for treatment non-compliance, or for ongoing signs and symptoms of the very disease that is being treated. Another delivery improvement would be to make take-home doses of methadone easier to obtain. For a more fundamental Improvement, more facility should be authorized to dispense methadone. Such as community or hospital-based medical settings or via mobile services. Mobile methadone has a record of success overseas in providing low threshold easily accessible treatment. In the US, early efforts with mobile delivery seemed promising, but the DEA has not approved a new mobile service since 2007. This barrier could be easily remedied with Federal Executive or legislative action. The expansion of buprenorphine also requires regulatory changes, it is odd that more training and limitations are mandated to prescribe this DEA schedule 3 drug for addiction treatment. Than it is to prescribe more dangerous schedule 2 drugs such as oxycodone or fentanyl, the data 2000x waiver system that contains these mandates needs to be reformed. I am optimistic that efforts underway to do this will a successful expand buprenorphine availability and improve treatment outcomes. Another area with an urgent need for expanded agonist medication treatments is in correctional settings. There's a growing movement to accomplish this goal, jails and prisons in several states and municipalities offer treatment. And their successes have begun to break down resistance at many state and county jurisdictions, we can expect to see expansion here. Of course, it might make more sense to keep people with substance use disorders out of jails and prisons in the first place. Incarceration comes at a high cost to individuals families and society, it disenfranchises the individual as they are denied employment opportunities, civil liberties and voting rights. It disrupts the families and complicates parenting, the financial burdens on communities incurred by locking up nonviolent offenders should be lifted consequently. Consequently there is a growing trend in diversion programs, either through drug courts that divert those to treatment post-arrest or interventions pre-arrest, with the latter appearing quite successful. In these law enforcement assisted diversion lead programs, which originated in Seattle in 2011. Police work with community service agencies including substance abuse treatment, Supportive Housing Programs, legal aid and other social support provider's to connect homeless, marginally housed and problematic repeat nonviolent offenders with needed services. This kind of community collaboration has been shown to improve outcomes for individuals living with opioid stimulant and alcohol use disorders. Reduce neighborhood blight and ease the burden on police, lead programs are spreading across the country with the increasing recognition. That opioid use disorder is part of a constellation of problems that requires integrated systems to meet people's needs. Lead programs are also in many ways a test run of local drug decriminalization. There's a growing consensus in public health and social policy circles, that the international war on drugs has been an unmitigated disaster. It is not deterred the spread of drugs, rather with ongoing criminalization the number of countries in which drug use has expanded is increasing. Some countries and some states in the US are going the route of decriminalization or even outright legalization with regulation. One internal successful example of this is the Netherlands which decriminalized cannabis beginning in 1976. More than 40 years later, it can be concluded that the Dutch have experience decreased per capita cannabis consumption, and even greater decreases in the consumption of other drugs. Portugal decriminalize drug use possession and acquisition for personal use in 2001, and that alleviated its HIV epidemic among drug injectors, and reduce community blight and property crimes. In the US as of the fall of 2019 cannabis products are now fully legal in 11 states and the District of Columbia, and available for retail sale in a soon-to-be all 11. The psychedelic psilocybin is now legal in Denver, Colorado, decriminalization can keep people out of jail reduce overall rates of drug consumption. And even paved the way for novel research to investigate how previously illicit drugs may have therapeutic effects. Of course in the long run it will make sense to prevent the development of substance use disorders. We don't know all the factors that predispose people to developing these disorders, but in many cases this development is secondary to untreated mental health problems. Or the lingering effects of abuse experienced in childhood, and the impact of these problems can be mitigated before the onset of a serious use disorder. Several school-based programs show promise here, Preventure is a school-based program for students entering their teen years. In this program teachers are trained and personality tests are given to students to identify those with a combination of sensation-seeking, impulsiveness, anxiety sensitivity and hopelessness. For features that predict heightened risk for developing a use disorder, students are invited to sign up for a limited enrollment elective covering sex and drug education. But the trick is that the school already knows who they will enroll in the class based on the survey. This allows these students to be reached without becoming stigmatized for being labeled at high risk. In fact, they are envied because they get the class that nearly every student has signed up for. Preventure as reported in at least a dozen peer-reviewed publications covering programs operated in Britain, Australia, the Netherlands and Canada. Has been shown to reduce binge drinking, frequent drug use and alcohol related problems. It cut drinking in schools that ran the program by 29% compared to match schools that did not. Reductions were seeing even among students who didn't attend workshops, among the high risk kids who did attend binge drinking fell by 43%. Studies in 2009 and 2013 also showed that Preventure reduced symptoms of depression, panic attacks and impulsive behavior. An intervention for younger children has shown some promise in more limited studies, while scare based programs, like dare have never been proven effective. The good behavior game is a set of classroom activities for first and second graders and is evidence-based. It introduces a set of classroom behavioral norms, and seeks to reduce the early occurrence of disruptive behavior. Which is a known risk for later social problems, including the development of substance use disorders. Teachers create classroom teams that compete to adhere to the rules of proper student behavior, which are displayed on posters in the classroom. Analysis of data collected at follow-up showed that students who had played the game had lower rates of drug and alcohol use disorders and regular smoking. It also reduced antisocial personality disorder, delinquency, incarceration for violent crimes, and suicidal ideation at the ages of 19 to 21 than a comparison group of students who did not play the game. Another key venue for preventing the onset of substance use disorders is the family. Several programs all of which are designed to improve communication and lower tension within families, have proven effective at reducing the rate of onset and severity of substance use. These kinds of programs need to be better recognized as effective more widely offered and much better funded. Most of the interventions, programs, and general approaches I have described in this lesson are gaining wider acceptance. Some need better evidence for their effectiveness and all need heightened advocacy. But if evidence and advocacy lead to their expansion, I am optimistic that we can look back years from now. And see that expanding their implementation will have made a difference, in reducing the medical and social burden of substance use disorders.
