Connecticut Best Practices Technical Assistance and

1. Connecticut Best Practices Technical Assistance and Building Prevention Capacity to Address Prescription Drugs, Tobacco, Marijuana, and Heroin Wethersfield, CT Nov 29, 2010 Jo Romano, CAPT NE RT Associate Matt Myers, CAPT NE RT Associate

2. Objectives for the Day • Increase knowledge and deepen understanding about the impact and consequences of Prescription Drug Misuse, Tobacco, Marijuana, and Heroin • Identify Risk Factors and Evidence Based Strategies for the prevention of Prescription Drug Misuse, Tobacco, Marijuana and Heroin.

3. Objectives for the Day (cont’d.) • Determine shared risk factors and strategies across problem areas including underage drinking, Prescription Drug Misuse, Tobacco, Marijuana and Heroin • Examine sample community logic models for Prescription Drug Misuse, Tobacco, Marijuana and Heroin to provide effective TA to local communities • Identify challenges and solutions for TA

4. Overview of Prescription Drug Misuse, Tobacco, Marijuana and Heroin Share what we know about: • Prescription drug use and misuse • Tobacco • Marijuana • Heroin • Cultural considerations • Availability • Onset usually under 18 • Low perception of harm

5. Prescription Drug Consequences • Opioids, including OxyContin and Vicodin, depress the respiratory system and may be fatal if taken in large doses. • Prolonged use of central nervous system depressants like Valium and Ambien can lead to serious withdrawal symptoms, including seizures1.

6. Prescription Drug Health Consequences • High doses of stimulants like Adderall and Dexedrine can cause irregular heartbeat, high body temperature, and cardiovascular failure1. • Excessive amounts of dextromethorphan, the active ingredient in over-the-counter cough medicine, can lead to vomiting, increased heart rate, high blood pressure, and impaired coordination1.

7. Take Back Program Prescription DrugsRisk Factors and Strategies Risk Factor Coalitions / Marketing Project Northland Sample Strategy Lock Medicine Cabinet Social Access/Availability Early Initiation Community Norms Prior Marijuana Use Reconnecting Youth Parent Monitoring Parental Internet Controls

8. Strengthening Families Prescription Drug Risk Factors and Strategies (cont’d.) Risk Factor Sample Strategy Skill Enhancement Training Information Dissemination Community Mobilization Parent Approval Perception of Harm Parent/Sibling Use Lack of Awareness Transitions School Climate Change

9. Logic Model Short-Term Outcomes Community- Specific Risk Factors Strategies Resources and Inputs Long-Term Outcomes

10. Sample Community Logic Model Problem: Prescription Drugs Short Term Outcomes Increased awareness of risk of improper storage Increased use of safer storage and/or disposal practices Increased demand for take-back programs Increased perception of harm or social disapproval Community- Specific Risk Factors Strategies Resources and Inputs Collect and analyze data on the intervention Recruit local DEA or police department to staff take-back event. Drug Dispersal Take-Back Program Access Ease of Availability Collect and analyze data on the intervention Develop a marketing plan Partner with media Secure earned and paid media Community Norms Perceived Risk Social Marketing Lock Up Your Medicine Cabinet Long-Term Outcomes Reduction in Use Delayed Onset Reduction in Availability

11. Prescription Drug UseSome Considerations for TA Providers • What drug(s)? • Pain relievers, stimulants, psychotherapeutics • Non medical use or misuse (with prescription) • Different risk factors and strategies • Poly-substance abusers • Communities may not have resources to work with prescription monitoring programs • Sources for young people are mostly social

12. Prescription Drug UseSome Considerations for TA Providers • What are challenges and pitfalls communities may face when planning and implementing for Prescription Drug Misuse Prevention? • What resources can you provide and/or will you need to provide effective TA?

13. Tobacco: Health Consequences • Heart disease is the leading cause of death in Connecticut. Smoking is the leading cause of heart disease3. • Women who reported smoking during pregnancy were 1.5 times more likely to experience premature labor. • Connecticut reports spending over $1.6 billion on health care expenditures attributable to tobacco use each year. • The consequences of secondhand smoke include increased risk of respiratory illness and asthma6.

14. Tobacco: Mental Health Consequences • 45% to 88% of individuals with schizophrenia smoke cigarettes and 40% to 60% of individuals with clinically significant depression use cigarettes. These rates are substantially higher than those of the general population7. • ADHD is associated with higher rates of smoking and an earlier onset of smoking7.

15. Environmental Strategies* Tobacco Risk Factors and Strategies Risk Factor Sample Strategy Cessation Interventions/NOT Mentoring / “Across Ages” Coalition Development Access and Availability Onset of Use Community Norms Prior Use/Mixed Drugs Parent/Sibling Use SMART Leaders/Life Skills

16. Information Dissemination Tobacco Risk Factors and Strategies (cont’d.) Risk Factor Sample Strategy Prevention Policies Perception of Harm Workforce

17. Sample Community Logic ModelProblem: Tobacco Community- Specific Risk Factors Strategies Resources and Inputs Short-Term Outcomes Decrease in Compliance Failure Rates Increase in Accurate Perception of Smoker Prevalence Increase in Intentions Not to Smoke Collect and analyze data on the intervention Recruit staff and/or train youth to conduct compliance checks Develop and distribute vendor education packets Compliance Checks Easy Access to Tobacco Vendor Education Normative Beliefs Prevalence estimates; Motivation to comply with other smokers; Beliefs Collect and analyze data on the intervention Identify staff to design and implement intervention Normative Education Curriculum infusion Long-Term Outcomes Reduction in Lifetime Tobacco Use

18. Tobacco UseSome Considerations for TA Providers • There are possibilities for efficient of use youth across tobacco and alcohol • Youth can be effective in working on policy initiatives • Counter-advertising may be an efficient, low-cost strategy • Environmental scanning is a useful assessment method coalitions can employ to gather visible information on local conditions surrounding tobacco

19. Tobacco UseSome Considerations for TA Providers • What are challenges and pitfalls communities may face when planning and implementing for Tobacco Prevention? • What resources can you provide and/or will you need to provide effective TA?

20. Marijuana Consequences • Of those individuals who initiate use during adolescence, one in six will go on to become marijuana dependent4,6. • Heavy adolescent users have shown deficits in learning, attention, and memory even after one month of abstinence9.

21. Marijuana: Mental Health Consequences • Marijuana users may have an increased risk of schizophrenia. In fact, researchers have estimated that 14% of schizophrenia diagnoses could be prevented if marijuana use was similarly prevented3,4. • Heavy marijuana use has also been linked to depression, suicide, and panic disorder3,5.

22. Environmental Strategies Marijuana Risk Factors and Strategies Risk Factor Sample Strategy Project Northland Community Mobilization Access/Availability Early Age of Onset Community Norms Peer Approval Keepin’ It R.E.A.L.

23. Social Norms Campaign Marijuana Risk Factors and Strategies (cont’d.) Risk Factor Sample Strategy Guiding Good Choices Drug Free School Zone Social Refusal Skills Prior Use/Mixed Use Perception of Harm Peer Use School Performance

24. Sample Community Logic ModelProblem: Marijuana Short-Term Outcomes Increase in School Bonding Improved Academic Achievement Reduction in Problem Behavior Community- Specific Risk Factors Strategies Resources and Inputs Collect and analyze data on the intervention Purchase curriculum, train teachers, provide booster sessions Academic Skills Enhancement Academic Failure Interactive Curriculum Collect and analyze data on the intervention (e.g., Raising Healthy Children) Provide teacher/ staff development workshops Provide booster session Lack of Commitment Low Bonding to School Enhanced Socialization Social Support Long-Term Outcomes Reduction in Lifetime Marijuana Use Reduction in Delinquency

25. Marijuana UseSome Considerations for TA Providers • Available literature is largely focused on illicit drug use • The relationship between drugs and crime is key • Perception of harm and social disapproval are influenced by the observance of peers using • Reduced influence of parental attitudes from middle to high school • Easy social access is a strong factor • Environmental strategies are being studied • Parental monitoring shows promise

26. Marijuana UseSome Considerations for TA Providers • What are challenges and pitfalls communities may face when planning and implementing for Marijuana Prevention? • What resources can you provide and/or will you need to provide effective TA?

27. Enjoy Lunch!

28. Heroin: Health Consequences • 35% of admissions to drug and alcohol treatment programs in Connecticut during 2006 listed heroin as the primary substance of dependence3. • Heroin dependence is associated with serious withdrawal symptoms, including vomiting, cold flashes, joint pain, insomnia, intense craving for the drug, and involuntary movements. If a heavily dependent user is already in poor health, sudden heroin withdrawal may lead to death4

29. Heroin: Health Consequences • Street heroin can contain toxic additives that damage the cardiovascular system, causing serious and permanent damage to vital organs. Questions around drug purity and dose can lead to fatal overdose4. • Prolonged use can lead to collapsed veins, diseases of the liver and kidney, infection of heart valves and lining, and serious damage to the respiratory system4. • Injection of heroin can put users at risk for infectious disease, including HIV/AIDS and Hepatitis4.

30. Heroin: Mental Health Consequences • Psychiatric disorders are common among those with substance use disorders. National data have demonstrated that about 20% of those with a current substance use disorder also have at least one current mood disorder, and 18% have at least one current anxiety disorder6. • Nearly one-third of adolescents in treatment for heroin dependence/abuse have a co-occurring psychiatric disorder5.

31. Heroin Cultural Considerations • Heroin abuse among women who are pregnant may result in spontaneous abortion4. • Heroin abuse during pregnancy and associated factors like poor prenatal care and nutrition can lead to low birth weight, which can put babies at risk for later developmental delay4. • Infants born to mothers who have regularly abused heroin during pregnancy may be born heroin dependent, which can result in serious medical complications for the baby4.

32. Harm Reduction Approach Heroin Risk Factors and Strategies Risk Factor Project Northland Civil Anti-Drug Remedies Sample Strategy Access/Availability Age of Onset Prior Use Treatment

33. Family Management Heroin Risk Factors and Strategies (cont’d.) Risk Factor Sample Strategy Counseling Family Conflict Child Abuse

34. Sample Community Logic ModelProblem: Heroin Community- Specific Risk Factors Strategies Resources and Inputs Short-Term Outcomes Increased Perception of Harm of Heroin Use Increased Access to Mental Health and Treatment Services Improved Access to Parenting Skills Training via Drug Court Referrals Collect and analyze data on the intervention Curriculum, teacher training Hire and train community outreach workers Curriculum Perception of Harm Community Outreach Worker Education and Referral Collect and analyze data on the intervention Court and enforcement partnerships Low Parental Care Family Conflict Drug Court Long-Term Outcomes Reduction in Lifetime Heroin Use Reduction in Delinquency

35. Heroin UseSome Considerations for TA Providers • Difficult to influence access to diverted pharmaceuticals • Can be difficult to define and access the target population • Some strategies are considered risk reduction • Non-traditional sectors need to play strong roles • Prescribers, treatment, criminal justice, hospitals

36. Heroin UseSome Considerations for TA Providers • What are challenges and pitfalls communities may face when planning and implementing for Heroin Prevention? • What resources can you provide and/or will you need to provide effective TA?

37. What is a Health Disparity? Health disparities (also called healthcare inequality in the U.S.) refer to gaps in the quality of health and health care across racial, ethnic, sexual orientation and socioeconomic groups. The Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care."

38. Special Populations • Sexual Orientation: LGBT • Active Military and Veterans • Homeless • Older Adults • Women • Youth • Race • Ethnicity: African Americans, Alaska Natives, American Indians, Asian Americans, Hispanics/Latinos, and Pacific Islanders

39. Contributing Factors to Disparity • Poverty • Access to health care • Individual and behavioral factors • Educational inequalities • Disability • Geographic location: urban or city • Mental Illness

40. How Are Disparities Interrelated? Example: Education and Health • High level of education brings longer life span, easier access to health services • Less education predicts higher levels of health risks such as obesity, substance abuse and violence • Good health is associated with academic success • Poor health predicts substance abuse, inadequate physical activity, emotional abuse, teen pregnancy, and poor performance in school

41. Risk Factor / Causal Factor Multi-Cultural Risk Factors and Strategies Maternal Smoking Sample Strategies Veterans/Military Young Mothers Poverty Educational Inequity Mental Health Integrated Care Families Lock The Medicine Cabinet Campaign Project Northland Guiding Good Choices Home Visits Nurse/Family Partnerships Cognitive Behavioral Therapy

42. Common Risk Factors Across Multiple Problems • Tobacco, alcohol, marijuana, prescription drug misuse, heroin, other drug use, anti-social behavior, depression, sexual behavior and drunk/drugged driving are common among young people (Biglan, Brennan, Foster, & Holder, 2004) • These problems are interrelated; moreover the same young people tend to engage in multiple problem behaviors • The approach should concentrate on affecting the risk and protective factors influencing the involvement with multiple problems

43. Behavioral Health Connections to Substance Abuse

44. Success with Common Risk Factors The Seattle Social Development Project (SSDP) shows that 15 years after a childhood intervention ended: • 11% had fewer mental health disorders* • 12% had fewer STDs* • 9% were at or above the median in socio-economic * attainment SSDP is a long term study and intervention that looks at the development of positive and problem behaviors among adolescents and young adults. * Results are in comparison to the control group used for the study.

45. Finding the Fit The following are three criteria that determine the best fit to include in a comprehensive prevention plan: • Conceptual fit: Is the intervention relevant? • Practical fit: Is the intervention appropriate? • Strength of evidence: Is the intervention evidence- based?

46. Working Across Sectors • Start with who is at the table • Think strategically about new partnerships • Develop an outreach strategy • Create a plan for tracking changes in multiple problems

47. Goal: To identify a risk factor that is common to both underage drinking and your second priority Pre-populate the chart. Include: Community-specific risk factors (your choice) for underage drinking Identified strategies Community sectors with which you are already working Add your second priority Include risk factors, strategies, and sectors with which you will work Analyze Review the chart. Look for risk factors that have the potential to efficiently impact multiple drugs or problems Look for similar strategies in the same sector or domain Cross-Walking Risk Factors Community Specific Risk Factor(s) Risk Factor Risk Factor Risk Factor Risk Factor Primary Priority Secondary Priority Strategy Strategy Sector Sector or Domain

48. Cross-Walking Risk Factors Community Specific Risk Factor(s) Already Identified Risk Factors Already- Identified Risk Factors Risk Factor for Second Priority Literature Review in Binder Enforcement Levels Social Competence Early Initiation Access Data Sources in Binder Underage Drinking Marijuana Strategy Tables in Binder 2) Project Alert 1) Compliance Checks 1) Party Patrols 1) After-School Program 2) After-School Program Strategy 2) School 1) Business 1) School 2) School 1) Law Enforcement Partner or Sector

49. Cross-Walking Risk Factors : Create An Example Community Specific Risk Factor(s) Text Text Text Text Underage Drinking Prescription Drugs Strategy Partner or Sector

50. Primary Health Care Talking Points for TA Providers • Substance abuse, mental health and primary health care share risk factors • Substance use and abuse contributes to physical and mental health conditions early on • Poor primary care contributes to substance abuse • Patients not diagnosed and often not treated