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Frequently Asked Questions What are the requirements for license renewal? Licenses Expire

CE Hours Required

Social Workers, Professional Counselors and Marriage and Family Therapists - Biennial renewals are due on February 28th of odd years.

30 (20 hours are allowed through home study)

Mandatory Courses 3 hours of Ethics NEW 2015 Requirement - 2 hours of Child Abuse Recognition and Reporting

How do I complete this course and receive my certificate of completion? Online Go to SocialWork.EliteCME.com and follow the prompts. Print your certificate immediately.

How much will it cost? Cost of Courses Course Title

CE Hours

Price

Child Abuse Recognition and Reporting in Pennsylvania (State mandatory requirement)

2

$24.97

Ethics and Boundaries (State mandatory requirement)

3

$12.00

The Heroin Epidemic in America: Identification, Tratment and Prevention

4

$16.00

Medication Management of Opioid Dependence

5

$20.00

Obesity in Children

2

$8.00

The Use of the Inernet in Therapy: Guidelines and Best Practices

4

$16.00

 BEST VALUE  SAVE $27.97  Complete Entire 20-Hour Course Online

20

$69.00

Are you a Pennsylvania board approved provider?

Elite is a National Association of Social Workers (NASW) approved provider. Provider number 886463821. Pennsylvania accepts course providers that are approved by this national organization. The Child Abuse Recognition and Reporting in Pennsylvania is approved by the Pennsylvania Department of Human Services.

Do I have to complete the new Child Abuse Recognition and Reporting course and why do I have to provide the last 4 digits of my social security number?

Yes, all health-related licensees must complete the 2 hour Child Abuse Recognition and Reporting course in order to renew their license. The Department of State requires us to obtain your date of birth and the last 4 digits of your social security number in order to report your hours. We are required to report your child abuse training course to the Pennsylvania Department of State.

Are my credit hours reported to the Pennsylvania board?

No, the Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors requires licensees to certify at the time of renewal that he/she has complied with the continuing education requirement. The board performs audits at which time proof of continuing education must be provided.

Is my information secure?

Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties.

What if I still have questions? What are your business hours?

No problem, we have several options for you to choose from! Online – at SocialWork.EliteCME.com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or Email us at [email protected] or call us toll free at 1-866653-2119, Monday - Friday 9:00 am - 6:00 pm EST.

Important information for licensees.

Always check your state’s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. See Customer Information page (last page) for board contact information.

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Table of Contents CE for Pennsylvania Mental Health Professionals CHAPTER 1: CHILD ABUSE RECOGNITION AND REPORTING IN PENNSYLVANIA

Page 1

This course is designed to help you recognize possible clinical, behavioral, and physical indicators of suspected child abuse and neglect, evaluate situations to determine whether there is reasonable cause to suspect child abuse or neglect, apply the updated requirements and protocol for reporting, and describe the reporting procedure. Child Abuse Recognition and Reporting in Pennsylvania Final Exam Page 15

CHAPTER 2: ETHICS AND BOUNDARIES

Page 16

Ethical issues are common in any profession. But mental health work, which relies heavily on relationship building and which can directly impact the health and welfare of its clients, poses even greater responsibilities and challenges. Ethical decision-making is a complex process, requiring mental health practitioners to look at not just the immediate impact, but also the long-term and future consequences of their actions. Ethics and Boundaries Final Exam

CHAPTER 3: THE HEROIN ABUSE EPIDEMIC IN AMERICA: IDENTIFICATION, TREATMENT AND PREVENTION

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The purpose of this course is to familiarize professionals with basic information concerning heroin addiction, which has reached epidemic proportions in the United States and around the globe. This includes facts about heroin and addiction, effects on the brain, progression of the disease, psychological and physical effects of short-term and chronic use, screening, treatment, and prevention. The review includes evidencebased treatment and prevention programs, as well as the current trends in progress to advance prevention and treatment of the disease. The Heroin Abuse Epidemic in America: Identification, Treatment and Prevention Final Exam

All 20 Hrs ONLINE ONLY

69

$

What if I Still Have Questions? No problem, we have several options for you to choose from! Online at SocialWork.EliteCME. com you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or Email us at [email protected] or call us toll free at 1-888-8576920, Monday - Friday 9:00 am - 6:00 pm, EST.

Visit SocialWork.EliteCME.com to view our entire course library and get your CE today!

PLUS...

Lowest Price Guaranteed Serving Professionals Since 1999

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©2016: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.

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Table of Contents CE for Pennsylvania Mental Health Professionals CHAPTER 4: MEDICATION MANAGEMENT OF OPIOID DEPENDENCE

Page 49

In recent years, opiate dependence has become a catastrophic problem in the United States, causing thousands, especially younger people, to lose their lives, and leaving loved ones behind to question these senseless losses. People included in this grave epidemic come from the full spectrum of socio-economic backgrounds. It is an addiction, where, truly, no one gets left behind. Medication Management of Opioid Dependence Final Exam

CHAPTER 5: OBESITY IN CHILDREN

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Childhood obesity affects over 9 million children, making it the most common chronic disease of childhood. Today, more and more children are being diagnosed with diabetes, hypertension and other co-morbid conditions associated with obesity and morbid obesity. Health care professionals within the United States and increasingly throughout the world are gravely concerned about the number of seriously overweight and obese children and youth. Obesity in Children Final Exam

CHAPTER 6: THE USE OF THE INTERNET IN THERAPY: GUIDELINES AND BEST PRACTICES

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The field of online therapy is likely to continue to grow as the Internet and other forms of electronic communication become part of our daily lives. A therapist should stay abreast of the constantly changing regulatory and ethical issues with online therapy. Certainly, the advantages are there: Flexible schedules, low overhead, and the ability to reach more clients in a larger geographical area. The potential of online therapy cannot be ignored and providers should be aware of the growing trend in this area. The Use of the Internet in Therapy: Guidelines and Best Practices Final Exam

SocialWork.EliteCME.com

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All 20 Hrs ONLINE ONLY

69

$

Why are your colleagues using Elite? “This manner of learning and accomplishing CEUs is absolutely wonderful and much appreciated. Material is excellent.” - Mary S. “This was fantastic! My supervisor recommended it and I will surely recommend it to colleagues.” - Cathy L. “Love the courses and the ability to complete them online...thanks.” - Jessica D. “I appreciated your courses, given I have limited funds and time for travel to distant workshops. All material was very easy to use.” - Richard S. “I was very impressed with the course. It was a great learning experience.” - Linda M.

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Chapter 1:

Child Abuse Recognition and Reporting in Pennsylvania 2 CE Hours

By: Wade Lijewski, Ph.D.

Learning Objectives This course is designed to help you: ŠŠ Recognize possible clinical, behavioral, and physical indicators of suspected child abuse and neglect. ŠŠ Explain criteria of mandated reporters in accordance with Pennsylvania law. ŠŠ Evaluate situations to determine whether there is reasonable cause to suspect child abuse or neglect. ŠŠ Apply the updated requirements and protocol for reporting child abuse or neglect. ŠŠ Describe the reporting procedure. ŠŠ Describe the scope of human trafficking and identify human trafficking victims at risk.

Outline: ŠŠ Introduction. ŠŠ Overview of Child Welfare in Pennsylvania. ŠŠ Child Protective Services vs. General Protective Services. ŠŠ Recent Changes to the Pennsylvania Child Protective Services Law. ŠŠ Definitions related to Child Protective Services. ŠŠ Mandated Reporters. ŠŠ The Reporting Process. ŠŠ Failure to Report. ŠŠ Recognizing Signs of Abuse and Neglect. ŠŠ Identify Children at Risk for Human Trafficking.

Introduction Child abuse and neglect remains a significant problem for us all in the United States as well as Pennsylvania. Approximately 3.4 million children in the U.S. were the subjects of at least one report (HHS, 2015 Child Maltreatment Report). In Pennsylvania alone, there were 40,590 reports of suspected child and student abuse in 2015, which is an increase of 11,317 reports from the previous year (Pennsylvania Department of Public Welfare Annual Child Protective Services Report, 2015) In Pennsylvania; there were 23 legislative bills signed in 2013 and 2014 and enacted in 2014 to protect the children of our state. In 2015 and 2016 there were two more acts that were passed. These changes to Title 23, Chapter 63 of the Pennsylvania Child Protective Services

Law (CPSL) were implemented with the intention to help reduce the recurrence of child abuse and neglect by helping to improve procedures governing child protection and reporting processes, expanding the list of individuals mandated to report, and helping to improve the investigation of child abuse cases via applicable technology and monitoring. The legislation focused again on child abuse legislation in 2015 and 2016 enacting two more protective service acts which include Act 15 of 2015 and Act 115 of 2016 (both described below). These two new acts focus on expanded reporting requirements for child abuse as well as the identification of youth at risk for human trafficking. The children of our state need to be protected by us all to prevent them from the trauma and associated outcomes incurred as a result of child abuse and neglect.

Overview of Child Welfare in Pennsylvania To help families achieve positive outcomes, child welfare systems throughout the country, including Pennsylvania, have strengthened their approaches to practice. Practice models guide the work of those involved with the child welfare system, enabling them to work together to improve outcomes for children, youth, and families. A significant achievement over the course of the past five years has been the development and implementation of the PA Child Welfare Practice Model (practice model) (Pennsylvania Department of Public Welfare, Office of Children, Youth and Families, Title IV-B Child and Family Service Plan, 2014). The practice model consists of the following core elements: outcomes – the areas that need to change in order to achieve improved outcomes; values and principles – the value base that provides guidance about

how those in the field of child welfare are to work together; and skills – operationalized standards that provide direction while still allowing for flexibility in how to best meet the child, youth and family’s unique needs. Improved outcomes are absolutely necessary as noted in Pennsylvania Department of Public Welfare Annual Child Abuse Report 2013. Out of Pennsylvania’s 67 counties, 33 received more reports of child and student abuse in 2013 than in 2012, and sexual abuse was involved in 53% of all substantiated reports. To put this more into perspective, in 2013 the total number of reports in Pennsylvania was 9.6 reports per 1,000 children with the total number of substantiated reports at 1.3 per 1,000 children. So, for every 1,000 children in our state, 1 child is abused and or neglected.

What is the Child Protective Services Law (CPSL)? The Pennsylvania Child Protective Services Law (CPSL) was signed into law in 1975. It was enacted to protect children from abuse, allow the opportunity for healthy growth and development, and, whenever possible, preserve and stabilize the family.

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The Child Protective Services Law ensures that each county establishes a protective services program to protect our children, locally. County agencies are charged with the responsibility of investigating suspected reports of child abuse. Each county agency submits a annual plan of how they will implement the law, and submits a yearly report on child abuse statistics and analysis within Page 1

their respective county. Section 6302(b) of the Child Protective Services Law, explains the purpose of this chapter regarding county responsibility: “to establish in each county protective services for the purpose of investigating the reports swiftly and competently, providing protection for children from further abuse and providing rehabilitative services for children and parents involved so as to ensure the child’s well-being and to preserve, stabilize and protect

the integrity of family life wherever appropriate or to provide another alternative permanent family when the unity of the family cannot be maintained.” Pennsylvania’s substantiation rate (suspected reports of abuse that are verified) remained the same as in 2012 at 13%. Forty counties out of 67 were at or above this average in 2013 (Pennsylvania Department of Public Welfare Annual Child Abuse Report, 2013).

Child Protective Services vs. General Protective Services It is important for mandated reporters to differentiate between Child Protective Services (CPS) and General Protective Services (GPS). PA

law requires agencies to provide both services to youth and children in their respective county.

General Protective Services General Protective Services are defined in section 6303 of the Child Protective Services Law as: “Those services and activities provided by each county agency for cases requiring protective services, as defined by the department in regulations.” These types of services are provided for case reports of non-serious injury or neglect, such as insufficient shelter, school truancy, and abandonment. These types of conditions threaten a child’s health and well-being. General Protective Services can be provided to families, whose religious beliefs deny medical care to their child, because the

health and welfare of the child is now at risk. This may not rise to the level of an abuse report, but does lead to being provided General Protective Services for the child. GPS also includes services to families that DO NOT meet the criteria for legal adjudication, (the act of making a judicial ruling, such as a judgment or decree). At times, assessments may conclude that while court involvement may not be necessary, the family, child, or both may benefit from additional services. GPS provides referrals for such services.

Child Protective Services Section 6303(a) of the Child Protective Services law defines Child Protective Services “as those services and activities provided by the department and each county agency for child abuse cases”. Child Protective Services (CPS) has the responsibility of receiving and investigating alleged reports of abuse. They conduct safety assessments and develop a safety plan for the child and intervene when necessary to protect them from harm. CPS is responsible for receiving and evaluating reports of suspected child abuse and neglect, determines if the reported information meets the statutory and agency

guidelines for child maltreatment, and judges the urgency with which the agency must respond to the report. CPS provides or arranges services to achieve a secure home environment for the child, whether that is reunification with the family, or some alternative home in order to provide them with the care and safety that every child deserves. Their mission is to achieve safety, wellbeing and permanency for the abused and/or neglected child. For the cases that do not warrant an abuse report, GPS assesses the need for services and can offer assistance.

Recent Changes to the Pennsylvania Child Protective Services Law Twenty five pieces of legislation were signed into law in Pennsylvania in 2013 and 2016 which changed how Pennsylvania responds to child abuse. These changes amended the definitions of child abuse and perpetrator, grounds for involuntary termination of parental rights, significantly expanded the list of mandated reporters and streamlined

the mandatory reporting processes. Please note that the following list does not include all legislative bills but rather highlights some of the recent changes in legislation impacting mandated reporters and the process of recognizing and reporting suspected child abuse.

Reporting of infants born and identified as being affected by illegal substance abuse The new Child Protective Service Law requires a health care provider to immediately make a report or cause a report to be made to the appropriate county agency if the provider is involved in the delivery or care of a child under one year of age who is born and identified as being affected by any of the following:

1. Illegal substance abuse by the child’s mother. 2. Withdrawal symptoms resulting from prenatal drug exposure. 3. A Fetal Alcohol Spectrum Disorder. Note: The only change was that the Fetal Alcohol Spectrum Disorder was added.

Child abuse education and training The Child Protective Services Law requires licensed professionals identified as mandated reporters to receive training on recognizing and reporting child abuse. Professionals applying for a license or certificate with their professional licensing board on or after January 1, 2015, are required to complete at least 3 hours of approved child abuse recognition and reporting training. This training must be approved by the Department of Human Services. Professionals applying for renewal of their license or certificate on or after January 1, 2015, are required to complete at least 2 hours of continuing Page 2

education per licensure cycle. This training must be approved by the appropriate licensing board in consultation with the Department of Human Services. The state approved provider is required to report these hours to the Pennsylvania Department of State electronically, you are NOT required to submit documentation. This law took effect December 31, 2014.

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Mandated reporters The Child Protective Services Law expanded the list of mandated reporters of suspected child abuse. An individual identified as a mandated reporter commits an offense if they fail to report suspected

child abuse or neglect immediately. The list of these mandatory reporters will be discussed later in this course.

Whistleblower protection The Child Protective Services provides persons required to report suspected child abuse protection from employment discrimination.

Governor Corbett signed this act into law April 15. This law took effect December 31, 2014.

Definitions Related to the Child Protective Services Law Child An individual under the age of 18. Child Abuse Child abuse in Pennsylvania, according to the CPSL, means intentionally, knowingly or recklessly doing any of the following: 1. Causing bodily injury to a child through any recent act (abuse within the last 2years) or failure to act (not doing anything to prevent the abuse). 2. Fabricating, feigning or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act. 3. Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act. Example: Berating a child verbally in public places in front of others. 4. Causing sexual abuse or exploitation of a child through any act or failure to act. Example: You allow a predator to sexually abuse a child. 5. Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act. Example: a parent leaves their small child in the car, with the windows up on a hot day,while in the grocery store for an hour. 6. Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act. Example: Leaving a child alone in the presence of a registered sexual predator. 7. Causing serious physical neglect of a child. Example: Not providing food or water to a child. 8. Engaging a child in a severe form of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000. 9. Engaging in any of the following recent acts: i. Kicking, biting, throwing, burning, stabbing or cutting a child in a manner that endangers the child. ii. Unreasonably restraining or confining a child, based on consideration of the method, location or the duration of the restraint or confinement. Example: Keeping a child locked in a closet or isolated room as punishment for misbehaving. iii. Forcefully shaking a child under one year of age. iv. Forcefully slapping or otherwise striking a child under one year of age. v. Interfering with the breathing of a child. vi. Causing a child to be present at a location while a violation of 18 Pa.C.S. § 7508.2 (relating to operation of methamphetamine laboratory) is occurring, provided that the violation is being investigated by law enforcement. vii. Leaving a child unsupervised with an individual, other than the child’s parent, who the actor knows or reasonably should have known: A. Is required to register as a Tier II or Tier III sexual offender under 42 Pa.C.S. Ch. 97 Subch. H (relating to registration of sexual offenders), where the victim of the sexual offense was under 18 years of age when the crime was committed.

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B. Has been determined to be a sexually violent predator under 42 Pa.C.S. § 9799.24 (relating to assessments) or any of its predecessors. C. Has been determined to be a sexually violent delinquent child as defined in 42 Pa.C.S. § 9799.12 (relating to definitions). 10. Causing the death of the child through any act or failure to act. Restatement of culpability.- Conduct that causes injury or harm to a child or creates a risk of injury or harm to a child shall not be considered child abuse if there is no evidence that the person acted intentionally, knowingly or recklessly when causing the injury or harm to the child or creating a risk of injury or harm to the child. “Perpetrator” is defined in section 6303 of the Child Protective Services Law as: A person who has committed child abuse. The following shall apply: The term includes only the following: ○○ A parent of the child. ○○ A spouse or former spouse of the child’s parent. ○○ A paramour or former paramour of the child’s parent. ○○ A person 14 years of age or older and responsible for the child’s welfare. ○○ An individual 14 years of age or older who resides in the same home as the child. ○○ An individual 18 years of age or older who does not reside in the same home as the child but is related within the third degree of consanguinity or affinity by birth or adoption to the child. Because of the increased focus on human trafficking, in 2016, the definitions of a perpetrator was expanded by Act 115 which amended Title 23 (Domestic Relations) and 42 (Judiciary and Judicial Procedure) of the Pennsylvania Consolidated Statutes to include: ●● An individual 18 years of age or older who engages a child in severe forms of trafficking in persons or sex trafficking as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000. Note: Relations within the third degree of consanguinity include: 1. Child’s parents. 2. Child’s brothers/sisters. 3. Child’s nephews/nieces. 4. Child’s grand nephews/nieces. 5. Child’s grandparents. 6. Child’s aunts and uncles. 7. Child’s first cousins. 8. Child’s great grandparents. 9. Child’s great aunts and uncles. 10. Child’s great-great grandparents. A modification to Title 23 of the Pennsylvania Consolidated Statute instituted when the 2015 Act 15 was passed. This act modified the definition of a perpetrator to include: ●● A person of 14 years of age or older and responsible for the child’s welfare or having direct contact with children as an employee of child-care services, a school or through a program, activity or services. Page 3

However, only the following may be considered a perpetrator for failing to act: ●● A parent of the child. ●● A spouse or former spouse of the child’s parent. ●● A paramour or former paramour of the child’s parent. ●● A person 18 years of age or older and responsible for the child’s welfare. ●● A person 18 years of age or older who resides in the same home as the child. Note: This excludes a person 14 to 17 years old for failing to act. Note: This expanded definition of perpetrator now includes school employees. The prior version of the CPSL captured them in a separate category. “Human Trafficking” is defined as the recruitment, harboring, transportation, provision or obtaining of a child for labor or services through use of force, fraud, or coercion. Under federal law, sex trafficking (such as prostitution, pornography, exotic dancing, etc.) does not require there be force, fraud or coercion if the victim is under 18. “Person Responsible” is defined as a person who provides permanent or temporary care, supervision, mental health diagnosis or treatment, training or control of a child in lieu of parental care, supervision and control. The term includes any such person who has direct or regular contact with a child through any program, activity, or service sponsored by a school, for-profit organization or religious or other notfor-profit organization. “Recent” is defined as an abusive act within 2 years from the date ChildLine is called. Sexual abuse, serious mental injury, serious physical neglect and deaths have no time limit. Types of Child Abuse Child welfare generally recognizes four types of child abuse – Neglect, Physical, Emotional and Sexual . In this section we provide an overview of those types using terminology and definitions found in the CPSL. Neglect Child Neglect is a form of child abuse that occurs when someone intentionally does not provide a child with food, water, shelter, clothing, medical care, or other necessities. Child neglect is not always easy to spot. Sometimes, a parent might become physically or mentally unable to care for a child, such as with a serious injury, untreated depression, or anxiety. Other times, alcohol or drug abuse may seriously impair judgment and the ability to keep a child safe. Serious physical neglect.” Any of the following when committed by a perpetrator that endangers a child’s life or health, threatens a child’s well-being, causes bodily injury or impairs a child’s health, development or functioning: 1. A repeated, prolonged or egregious failure to supervise a child in a manner that is appropriate considering the child’s developmental age and abilities. 2. The failure to provide a child with adequate essentials of life, including food, shelter or medical care. Serious physical neglect may be manifested in inadequate nutrition (i.e., malnutrition or starvation), infant failure to thrive syndrome, failure or delay in seeking medical care, prolonged exposure to the elements, or malnutrition. Cases of serious physical neglect is one of the nine categories of child abuse listed in the definition section and will be addressed through Child Protective Services. Emotional Abuse “Serious mental injury.” A psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment, that:

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1. Renders a child chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic or in reasonable fear that the child’s life or safety is threatened; or 2. Seriously interferes with a child’s ability to accomplish ageappropriate developmental and social tasks. Some examples of “serious mental injuries” may be: ●● Ignoring. Either physically or psychologically, the parent or caregiver is not present to respond to the child. He or she may not look at the child and may not call the child by name. ●● Rejecting. This is an active refusal to respond to a child’s needs (e.g., refusing to touch a child, denying the needs of a child, ridiculing a child). ●● Isolating. The parent or caregiver consistently prevents the child from having normal social interactions with peers, family members, and adults. This also may include confining the child or limiting the child’s freedom of movement. ●● Exploiting or corrupting. In this kind of abuse, a child is taught, encouraged, or forced to develop inappropriate or illegal behaviors. It may involve self-destructive or antisocial acts of the parent or caregiver, such as teaching a child how to steal or forcing a child into prostitution. ●● Verbally assaulting. This involves constantly belittling, shaming, ridiculing, or verbally threatening the child. ●● Terrorizing. The parent or caregiver threatens or bullies the child and creates a climate of fear for the child. Terrorizing can include placing the child or the child’s loved one (such as a sibling, pet, or toy) in a dangerous or chaotic situation, or placing rigid or unrealistic expectations on the child with threats of harm if they are not met. ●● Neglecting the child. This abuse may include educational neglect, where a parent or caregiver fails or refuses to provide the child with necessary educational services; mental health neglect, where the parent or caregiver denies or ignores a child’s need for treatment for psychological problems; or medical neglect, where a parent or caregiver denies or ignores a child’s need for treatment for medical problems. Physical Abuse Physical abuse is redefined as “bodily injury” to the child which requires impairment of a physical condition or substantial pain, rather than severe pain or lasting impairment. It may be the result of a deliberate attempt to hurt the child, but not always. It can also result from severe discipline, such as using a belt on a child, or physical punishment that is inappropriate to the child’s age or physical condition. Many physically abusive parents and caregivers insist that their actions are simply forms of discipline—ways to make children learn to behave. But there is a big difference between using physical punishment to discipline and physical abuse. “Serious bodily injury” creates a substantial risk of death or causes serious permanent disfigurement or protracted loss of impairment of function of any bodily, organ or member (i.e., broken bones, second or third degree burns, internal injury, suspected homicide, head injury or hemorrhage, puncture or bullet wounds). The injury may constitute a criminal act in addition to child abuse. Sexual Abuse Sexual abuse or exploitation is defined by the Child Protective Services Law as: The employment, use, persuasion, inducement, enticement or coercion of a child to engage in or assist another individual to engage in sexually explicit conduct, which includes, but is not limited to, the following: ●● Looking at the sexual or other intimate parts of a child or another individual for the purpose of arousing or gratifying sexual desire in any individual.

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●● Participating in sexually explicit conversation either in person, by telephone, by computer or by a computer-aided device for the purpose of sexual stimulation or gratification of any individual. ●● Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual. ●● Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting or filming. This does not include consensual activities between a child who is 14 years of age or older and another person who is 14 years of age or older and whose age is within four years of the child’s age. ●● Any of the following offenses committed against a child: ○○ Rape as defined in 18 Pa.C.S. § 3121. ○○ Statutory sexual assault as defined in 18 Pa.C.S. § 3122.1 ○○ Involuntary deviate sexual intercourse as defined in 18 Pa.C.S. § 3123 ○○ Sexual assault as defined in 18 Pa.C.S. § 3124.1 ○○ Institutional sexual assault as defined in 18 Pa.C.S. § 3124.2 ○○ Aggravated indecent assault as defined in 18 Pa.C.S. § 3125 ○○ Indecent assault as defined in 18 Pa.C.S. § ○○ Indecent exposure as defined in 18 Pa.C.S. § 3127 ○○ Incest as defined in 18 Pa.C.S. § 4302 ○○ Prostitution as defined in 18 Pa.C.S. § 5902 ○○ Sexual abuse as defined in 18 Pa.C.S. § 6312 ○○ Unlawful contact with a minor as defined in 18 Pa.C.S. § 6318 ○○ Sexual exploitation as defined in 18 Pa.C.S. § 6320 Sexual abuse includes sexual intercourse or its deviations. Yet all offenses that involve sexually touching a child, as well as non-

touching offenses and sexual exploitation, are just as harmful and devastating to a child’s well-being (American Humane Association, 2014). According to the National Child Abuse and Neglect Data System (NCANDS), an estimated 9.3 percent of confirmed or substantiated child abuse and neglect cases in 2005 involved sexual abuse (U.S. Department of Health and Human Services, 2007). This figure translates into over 83,800 victims in 2005 alone (USDHHS, 2007). Other studies suggest that even more children suffer abuse and neglect than is ever reported to child protective services agencies. Statistics indicate that girls are more frequently the victims of sexual abuse, but the number of boys is also significant. Touching sexual offenses include: ●● Fondling. ●● Making a child touch an adult’s sexual organs. ●● Penetrating a child’s vagina or anus, no matter how slight, with a penis or any object that does not have a valid medical purpose. Non-touching sexual offenses include: ●● Engaging in indecent exposure or exhibitionism. ●● Exposing children to pornographic material. ●● Deliberately exposing a child to the act of sexual intercourse. ●● Masturbating in front of a child. Sexual exploitation can include: ●● Engaging a child or soliciting a child for the purposes of prostitution. ●● Using a child to film, photograph, or model pornography.

Human Trafficking From 2007 to September 2016, the National Human Trafficking Hotline (NHTH) received 3,052 calls from Pennsylvania; 688 calls were to report cases of human trafficking (Nationalities Service Center). In response, the Pennsylvania legislature passed Act 115 of 2016 amended Title 23 (Domestic Relations) and 42 (Judiciary and Judicial Procedure) of the Pennsylvania Consolidated Statutes have expanded to include human trafficking. When a child, under 18 years of age, is recruited and harbored for the purposes of sex, prostitution, pornography, exotic dancing, etc., and is being forced to work for little or no pay, it is considered to be labor trafficking. The victim is often threatened of serious harm, physical restraint or abuse of legal process if there is not compliance with the wishes of the perpetrator. Types of human trafficking: ●● Labor trafficking may force the victim to work (frequently in factories or farms) for little or no pay; domestic servitude to include providing services within a household from 10 to 16 hours

doing such tasks as child care, cooking, cleaning, yard work and/ or gardening. ●● Labor or services trafficking may include the recruitment, harboring, transportation, provision, or obtaining a person for labor or services. There may be use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage (paying off a debt through work), debt bondage (debt slavery, bonded labor or services for a debt or other obligation), or slavery (a condition compared to that of a slave in respect of exhausting labor or restricted freedom). ●● Commercial sex trafficking may include the recruitment, harboring, transportation, provision, or obtaining a person for sexual services. This type of trafficking involves a commercial sex act that is induced by force, fraud, or coercion or in which the person under the age of 18 years of age is induced to perform such an act. Commercial sex act is any sex act on account of which anything of value is given to or received by any person.

Exclusions from child abuse per the CPSL Pennsylvania has identified scenarios that should not be considered to be child abuse. Pennsylvania statute § 6304 (Exclusions from child abuse) details those scenarios that have been excused from such a determination: ●● Environmental factors. No child shall be deemed to be physically or mentally abused based on injuries that result solely from environmental factors, such as inadequate housing, furnishings, income, clothing, and medical care, which are beyond the control of the parent or person responsible for the child’s welfare with whom the child resides. This subsection shall not apply to any childcare service as defined in this chapter, excluding an adoptive parent.

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Example: If a family lives at the poverty level through no fault of the parents it is not considered child abuse. ●● Practice of religious beliefs. If, upon investigation, the county agency determines that a child has not been provided needed medical or surgical care because of sincerely held religious beliefs of the child’s parents or relative within the third degree of consanguinity and with whom the child resides, which beliefs are consistent with those of a bona fide religion, the child shall not be deemed to be physically or mentally abused. (This is not applicable to child care services and not applicable if the failure to provide care results in the death of a child.)

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Example: If one’s religion does not believe in seeking medical attention for their child that has a cold this is not considered child abuse unless it results in the death of a child. In such cases the following shall apply: 1. The county agency shall closely monitor the child and the child’s family and shall seek court-ordered medical intervention when the lack of medical or surgical care threatens the child’s life or long-term health. 2. All correspondence with a subject of the report and the records of the department and the county agency shall not reference child abuse and shall acknowledge the religious basis for the child’s condition. 3. The family shall be referred for general protective services, if appropriate. 4. This subsection shall not apply if the failure to provide needed medical or surgical care causes the death of the child. 5. This subsection shall not apply to any child-care service as defined in this chapter, excluding an adoptive parent. ●● Use of force for supervision, control, and safety purposes. The use of reasonable force on or against a child by the child’s own parent or person responsible for the child’s welfare shall not be considered child abuse if any of the following conditions apply: ○○ The use of reasonable force constitutes incidental, minor, or reasonable physical contact with the child or other actions that are designed to maintain order and control. ○○ The use of reasonable force is necessary: ■■ To quell a disturbance or remove the child from the scene of a disturbance that threatens bodily injury to persons or damage to property. ■■ To prevent the child from self-inflicted physical harm. ■■ For self-defense or the defense of another individual. ■■ To obtain possession of weapons or other dangerous objects or controlled substances or paraphernalia that are on the child or within the control of the child. Example: In the grocery store, you witness a woman (parent) who is upset with her child for climbing on a half-empty shelf. The parent grabs the child’s arm, pulls the child down, and the child falls to the floor and sprains his or her ankle. This is not child abuse as the parent or caregiver is using “reasonable force” to prevent the child from several actions, including the self-inflicted harm of the child falling. Using reasonable physical contact to maintain order and control of their child is another condition that does not constitute abuse. Another example is a parent or caregiver who finds an illegal substance in their child’s room and when trying to remove the substance, the child becomes confrontational and a physical struggle arises between the two. The parent has to restrain the child and begins grabbing the child’s arms and hands. In the process, the child’s arm is cut by some means and the child begins to bleed. The parent or caregiver has not abused the child; they have used “reasonable force” to maintain order, to obtain possession of a controlled substance, and to prevent the child from self-inflicted harm of using the illegal substance. Finally, the physical contact between the two of them constitutes self-defense on the parent or caregiver’s part. It is important to note that only one condition has to be met, not all or more than one when discussing when the use of reasonable force is necessary. ●● Rights of parents. Nothing in this chapter shall be construed to restrict the generally recognized existing rights of parents to use reasonable force on or against their children for the purposes

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of supervision, control, and discipline of their children. Such reasonable force shall not constitute child abuse. Example: Spanking a child is a perfect example of parental rights. Many people do not believe in spanking their child or any type physical discipline. It was not long ago, when spanking was a generally accepted method of discipline, there are those parents who believe a little spanking goes a long way in reprimanding your child. Today, not all parents agree on this issue, but in Pennsylvania we believe in the rights of parents to use reasonable force on or against their child in order to maintain control, to supervise, and to discipline. ●● Participation in events that involve physical contact with child. An individual participating in a practice or competition in an interscholastic sport, physical education, a recreational activity, or an extracurricular activity that involves physical contact with a child does not, in itself, constitute contact that is subject to the reporting requirements of this chapter. Example: A 12 year old plays basketball with his team member at Church. These members are of all ages (adults and children). The 12 year old is hit by an adult and ends up with a broken nose. The individual that hit him is not abusing the 12 year old, he was playing a game that involves expected, physical contact. ●● Child-on-child contact. Harm or injury to a child that results from the act of another child shall not constitute child abuse unless the child who caused the harm or injury is a perpetrator. Notwithstanding the above, the following shall apply: ○○ Acts constituting any of the following crimes against a child shall be subject to the standard reporting requirements outlined in this course: ■■ rape as defined in 18 Pa.C.S. § 3121 (relating to rape); ■■ involuntary deviate sexual intercourse as defined in 18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse); ■■ sexual assault as defined in 18 Pa.C.S. § 3124.1 (relating to sexual assault); ■■ aggravated indecent assault as defined in 18 Pa.C.S. § 3125 (relating to aggravated indecent assault); ■■ indecent assault as defined in 18 Pa.C.S. § 3126 (relating to indecent assault); ■■ indecent exposure as defined in 18 Pa.C.S. § 3127 (relating to indecent exposure). Example: One child goes to his house. The two children begin to rough-house and wrestle and as a result one child, whose home it is, hurts the other child considerably. The boy’s mother finally separates the two but only after the visiting child has a fractured rib and bloody nose. The parent of the injured child insists this is a child abuse case because her child was in the care of another parent and their child hurt her child. This exclusion is not considered child abuse due to the fact that there is no perpetrator, only one child who hurt another child. In this situation, both of these children were participating in the rough-housing. ○○ No child shall be deemed to be a perpetrator of child abuse based solely on physical or mental injuries caused to another child in the course of a dispute, fight or scuffle entered into by mutual consent. Example: Two boys in a consensual fist fight after school does not deem either one of them a “perpetrator.” Example: A couple girls begin to argue over a boy and one of them starts to verbally abuse the other, calling the other

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girl such terrible names, she begins to cry. Though this may be modeling bad behavior, it is not classified as child abuse –neither girls are perpetrators and both entered into the argument of their own volition. ○○ A law enforcement official who receives a report of suspected child abuse is not required to make a report to the department under section 6334(a) (relating to disposition of complaints received), if the person allegedly responsible for the child abuse is a nonperpetrator child. First, a law enforcement official in Pennsylvania includes the following: 1. The Attorney General 2. A Pennsylvania district attorney 3. A Pennsylvania State Police Officer 4. A municipal police officer A law enforcement official that receives a report of suspected abuse is required to immediately notify the department of the

report. If it is done orally by telephone, the law enforcement official will attempt to collect as much information as possible relating to the reporting procedure and will submit either, a written report or report by electronic means, within 48hours. The exclusion applies if the person allegedly responsible for the child abuse is a nonperpetrator child, then the law enforcement official is not required to submit the report to the department. ●● Defensive force. Reasonable force for self-defense or the defense of another individual, consistent w ith the provisions of 18 Pa.C.S. §§ 505 (relating to use of force in self-protection) and 506 (relating to use of force for the protection of other persons), shall not be considered child abuse. Note: These are exclusions to child abuse, not exclusions to reporting child abuse. If you suspect that an identifiable child is the victim of child abuse, please make a report. Trained professionals will determine whether or not child abuse has occurred.

Mandated Reporters Mandated reporters in Pennsylvania is the category that submits the most reports of suspected child abuse and in 2013 they reported 21,076 reports of suspected abuse, which is 78% of all suspected abuse reports. Of the substantiated reports, 79% came from mandated reporters. Pennsylvania is making a difference and it is beginning to show in the numbers. While some occupations determined as mandated reporters are listed by name in recent legislative updates (see below), the common factor among mandated reporters is that these are individuals who come into direct contact with children in the course of their employment, occupation, practice of their profession or outside their employment or are persons responsible for the welfare of children. Example: You volunteer at a church group, you are now considered a mandated reporter because you are in contact with children . You

regularly examine children in the course of your employment as a nurse you are a mandated reporter. Note: How is direct contact with children defined? Direct contact with children is defined in § 6303 (relating to definitions) as the care, supervision, guidance or control of children or routine interaction with children. Note: How is person responsible for the child’s welfare defined? A person who provides permanent or temporary care, supervision, mental health diagnosis or treatment, training or control of a child in lieu of parental care, supervision and control. The term includes any such person who has direct or regular contact with a child through any program, activity or service sponsored by a school, for-profit organization or religious or other not-for-profit organization.

Section 6311 of the Child Protective Services Law. Persons required to report suspected child abuse. Effective December 31, 2014, the new definition of a mandated reporter includes anyone who comes into contact, or interacts, with a child or is directly responsible for the care, supervision, guidance, or training of a child. In 2015, Act 15 of 2015 amended Title 23 of the Pennsylvania Consolidated Statutes by strengthening its child welfare laws to expand the definition of information to be reported, mandated reporters, streamlined the reporting process, increased penalties for mandated reporters who fail to report abuse or neglect, and provided protections from employment discrimination for filing a report in good faith. The law now specifically includes volunteers with children’s programs and employees (not just administrators, teachers, and nurses) of elementary, secondary, and postsecondary schools. The entire list of mandated reporters as outlined by section 6311 of Child Protective Services Law as well as Act 15 of 2015 include: ●● A person licensed or certified to practice in any health-related field under the jurisdiction of the Department of State. ●● A medical examiner, coroner or funeral director. ●● An employee of a health care facility or provider licensed by the Department of Health, who is engaged in the admission, examination, care or treatment of individuals. ●● A school employee who provides a program, activity or services sponsored by a school. The term does not apply ot administrative or other support personnel unless the administrative or other support personnel have direct contact with children. Psychology.EliteCME.com

●● An employee of a child-care service who has direct contact with children in the course of employment. ●● A direct volunteer who provides care, supervision, guidance or control of children. ●● A clergyman, priest, rabbi, minister, Christian Science practitioner, religious healer or spiritual leader of any regularly established church or other religious organization. ●● An individual paid or unpaid, who, on the basis of the individual’s role as an integral part of a regularly scheduled program, activity or service, accepts responsibility for a child. ●● An employee of a social services agency who has direct contact with children in the course of employment. ●● A peace officer or law enforcement official. ●● An emergency medical services provider certified by the Department of Health. ●● An employee of a public library who has direct contact with children in the course of employment. ●● An individual supervised or managed by a person listed above, who has direct contact with children in the course of employment. ●● An independent contractor. ●● An attorney affiliated with an agency, institution, organization or other entity, including a school or regularly established religious organization that is responsible for the care, supervision, guidance or control of children. ●● An individual supervised or managed by a person listed above and who has direct contact with children in the course of employment. ●● A foster parent. Page 7

●● An individual paid or unpaid, who, on the basis of the individual’s roles an integral part of a regularly schedule program, activity or service, is a person responsible for the child’s welfare or has direct contact with children. ●● An adult family member who is a person responsible for the child’s welfare and provides services to a child in a family living home, community home for individuals with an intellectual disability or host home for children who are subject to supervision or licensure by the department under Article IX or X of the act of June 13, 1967 (P.L. 31, No. 21), known of the Public Welfare Code. If they suspect abuse, mandated reporters are required to immediately report the abuse to ChildLine electronically or by phone. They are not required to conduct an investigation, that is the responsibility of the county agency that the report is assigned to. Staff members of public or private agencies, institutions, and facilities. Licensees who are staff members of a medical or other public or private institution, school, facility, or agency, and who, in the course of their employment, occupation, or practice of their profession, come into contact with children shall immediately report the suspected abuse or neglect. There is no longer a “chain of command”. Whereas employees of institutions and facilities including school employees were previously directed to report the concern to the ‘person in charge’, such mandated reporters are now required to report the concern immediately to ChildLine and then inform the ‘person in charge’ of their report and concerns.

Please Note: As a mandated reporter, you do not have to determine whether or not the person meets the definition of perpetrator to make the report. A mandated reporter shall report information if they have reasonable cause to suspect that a child is a victim of child abuse under any of the following circumstances: ●● The mandated reporter comes into contact with the child in the course of employment, occupation and practice of a profession or through a regularly scheduled program, activity or service. (Information obtained through your professional role). ●● The mandated reporter is directly responsible for the care, supervision, guidance or training of the child, or is affiliated with an agency, institution, organization, school, regularly established church or religious organization or other entity that is directly responsible for the care, supervision, guidance or training of the child. (Information obtained through your professional role). ●● A person makes a specific disclosure to the mandated reporter that an identifiable child is the victim of child abuse. (Information obtained through professional role or outside of professional role). ●● An individual 14 years of age or older makes a specific disclosure to the mandated reporter that the individual has committed child abuse. (Information obtained through professional role or outside of professional role). The circumstances above all pertain to abuse information obtained through your professional role but the last two bulleted items can be obtained from information outside your professional role, as well.

Protections for Mandated Reporters As a mandated reporter, and you make a report of suspected child abuse in good faith, you are protected. You are protected as a mandated reporter when you: ●● Make a report of suspected child abuse or making a referral for general protective services, regardless of whether the report is required to be made. ●● Cooperating or consulting with an investigation ●● Testify in a proceeding arising out of an instance of suspected child abuse or general protective services.

●● Engaging in any action authorized as a result of suspected child abuse such as taking photographs, medical tests and X-rays of child subject to report, taking a child into protective custody, admission to private and public hospitals or mandatory reporting and postmortem investigation of deaths. An official or employee of the department or county agency who refers a report of suspected child abuse for general protective services to law enforcement authorities or provides services as authorized by this chapter shall have immunity from civil and criminal liability that might otherwise result from the action.

Penalties for failure to report suspected child abuse Section 6319 of the Child Protective Services Law. Penalties for Failure to Report or to Refer. If you are a mandated reporter and you willfully fail to report suspected child abuse, you could be charged with a second degree misdemeanor up to a second degree felony. Failing to report multiple times, increases the level of the penalty. The statute of limitations for reporting generally mirrors that of the crime. An offense under this section is a felony of the third degree if: ●● The person or official willfully fails to report. ●● The child abuse constitutes a felony of the first degree or higher. ●● The person or official has direct knowledge of the nature of the abuse. An offense not otherwise specified above is a misdemeanor of the second degree. A report of suspected child abuse to law enforcement or the appropriate county agency by a mandated reporter, made in lieu of a report to the department, shall not constitute an offense under this subsection, provided the report was made in a good faith effort to comply with the requirements of this chapter.

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Continuing course of action: If a person’s willful failure continues while the person knows or has reasonable cause to believe the child is actively being subjected to child abuse, the person commits a misdemeanor of the first degree, unless the child abuse constitutes a felony of the first degree or higher, then the person commits a felony of the third degree. Multiple offenses: A person who commits a second or subsequent offense under subsection commits a felony of the third degree, unless the child abuse constitutes a felony of the first degree or higher, then the penalty for the second or subsequent offenses is a felony of the second degree. Statute of limitations: The statute of limitations for an offense of failing to report or refer shall be either the statute of limitations for the crime committed against the minor child or 5 years, whichever is greater.

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Privileged and Confidential Communications Section 6311.1 of the Child Protective Services Law. Privileged communications states that the privileged communications between a mandated reporter and a patient or client of the mandated reporter shall not:

●● Apply to a situation involving child abuse. ●● Relieve the mandated reporter of the duty to make a report of suspected child abuse.

Attorneys and Other Professionals Involved in Patient or Client Privileged Communication An attorney affiliated with an agency, institution, organization, or other entity, including a school or regularly established religious organization that is responsible for the care, supervision, guidance, or control of children is now considered a mandated reporter. Confidential communication: The following protections shall apply: ●● Confidential communications made to a member of the clergy are protected under 42 Pa.C.S. § 5943 (relating to confidential communications to clergymen). Example: A priest was told in confessional about child abuse, this is considered confidential communication and is not required to be reported. But in the course of his role he

overhears or is told during the course of a conversation about alleged child abuse this is a case that must be reported. ●● Confidential communications made to an attorney are protected so long as they are within the scope of 42 Pa.C.S. §§ 5916 (relating to confidential communications to attorney) and 5928 (relating to confidential communications to attorney), the attorney work product doctrine or the rules of professional conduct for attorneys. Example: An attorney is employed by an organization (daycare or a school) that is responsible for the care of children is required to report suspected child abuse or neglect. If an attorney is told about suspected child abuse or neglect from a client in confidence outside the above setting they are not required to report the information.

Mandated vs. Permissive Reporting In Pennsylvania everyone is permitted to report child abuse. Let’s take a closer look at the difference between mandated reporters and permissive reporters. Mandated reporters are required by the Pennsylvania Child Protective Services Law to immediately report suspected child abuse or neglect.

Section 6312 of the Child Protective Services Law. Persons encouraged to report suspected child abuse “Any person may make an oral report of suspected child abuse, to the department, county agency or law enforcement, if that person has reasonable cause to suspect that a child is a victim of child abuse.”

Permissive reporters are encouraged but not required to report child abuse.

Investigations and types of reports Confidentiality In all cases, the county maintains written records of the investigation. Information regarding cases of child abuse is confidential except in certain instances specified by law. In most circumstances, the release of data by the department, county, institution, school, facility or agency

or designated agent of the person in charge that would identify the person who made a report of suspected child abuse or who cooperated in a subsequent investigation is prohibited. Law enforcement officials shall treat all reporting sources as confidential informants.

Difference between indicated, founded, and unfounded child abuse reports ●● Indicated report is a report based on the medical assessment, the child protective service investigation or the admission of acts of abuse by the perpetrator or perpetrators that abuse or neglect has occurred. Example: A 3-month-old baby is examined in the emergency room where its determined to have bleeding on the brain, a broken leg and five rib fractures in various stages of healing. There are three individuals in the home who are responsible for the care of the child but evidence does not exist to determine who inflicted this child’s injuries. The investigation clearly substantiates that abuse has occurred so the report is an indicated report of child abuse. A report may be indicated which lists the perpetrator as “unknown” if substantial evidence of abuse by a perpetrator exists, but the department or county agency is unable to identify the specific perpetrator. Note: previous law did not allow for indicating child abuse when a perpetrator could not be named.

Perpetrators of indicated reports are recorded in the ChildLine abuse reporting system. They are not considered criminals because the report did not lead to criminal charges. Indicated reports do not require law enforcement or court involvement. ●● Founded report is a child abuse or neglect report that was escalated to the legal system and went to court. A judicial adjudication (the legal process by which a judge reviews the evidence) takes place that may or may not lead to criminal charges against the perpetrator. Founded reports take place in the legal system. ●● Unfounded report: Any report made that does not qualify as a “founded report” or an “indicated report.” The evidence did not support the assertion of child abuse.

The Reporting Process Reports of suspected child abuse are to be made immediately and directly by the person who suspects that an identifiable child is the victim of child abuse.

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How do I report suspected abuse or neglect? ChildLine is the 24-hour reporting system operated by the Department of Human Services to receive reports of suspected child abuse. ChildLine forwards the report of suspected child abuse to the local county children and youth agency, which investigates the report to

determine if the allegations can be substantiated as child abuse/neglect and also arranges for or provides the services that are needed to prevent the further maltreatment of the child and to preserve the family unit.

Reporting procedure Reports of suspected child abuse shall be made electronically or by telephone. ●● Electronic reports are made via the Child Welfare portal at WWW. COMPASS.STATE.PA.US/CWIS. This is the fastest and most efficient way for you as a mandated reported to file your report. There is no need for any follow-up reports when submitting your reports electronically. The state encourages everyone to visit this website now and setup your account so if and when you need to make a child abuse report you can log in and start immediately. ●● Oral reports of suspected child abuse shall be made immediately by telephone to ChildLine, 1-800-932-0313. ●● Written reports must be made within 48 hours after the oral report is made by telephone. Written reports shall be made on form CY47 available from a county children and youth agency. Written reports are made on form CY47. The following information is requested and helpful if available: 1. The names and addresses of the child, the child’s parents and any other person responsible for the child’s welfare.

2. Where the suspected abuse occurred. 3. The age and sex of each subject of the report. 4. The nature and extent of the suspected child abuse, including any evidence of prior abuse to the child or any sibling of the child. 5. The name and relationship of each individual responsible for causing the suspected abuse and any evidence of prior abuse by each individual. 6. Family composition. 7. The source of the report. 8. The name, telephone number and e-mail address of the person making the report. 9. The actions taken by the person making the report, including those actions taken under section 6314 (relating to photographs, medical tests and X-rays of child subject to report), 6315 (relating to taking child into protective custody), 6316 (relating to admission to private and public hospitals) or 6317 (relating to mandatory reporting and postmortem investigation of deaths). 10. Any other information required by Federal law or regulation. 11. Any other information that the department requires by regulation

What happens when a report of suspected abuse is made to ChildLine? Childline assesses whether it is CPS or GPS and whether immediate action is required and assigns it to the appropriate county agency. ChildLine forwards the report of suspected child abuse to the local county children and youth agency, which investigates the report to determine if the allegations can be substantiated as child abuse/ neglect and also arranges for or provides the services that are needed to prevent the further maltreatment of the child and to preserve the family unit. If the alleged perpetrator named in the report does not meet the definition of perpetrator under the CPSL, but does suggest the need for investigation, ChildLine will forward the information to the district attorney’s office in the respective county. ChildLine also maintains a statewide central register, which contains the names and vital information about children who have been abused in PA since 1976. This information can be accessed by county children and youth agencies when investigating new reports of suspected child abuse. If the County receives a call of suspected child abuse from a source other than ChildLine they assess whether there is an immediate need

to protect the safety of the child and if there is determine the steps to be taken to protect the child. The safety of the child or children is the number one priority when assessing reports and offering services to the family. After taking the appropriate immediate action they then file a report with ChildLine. If the county-based children and youth agency determines that no immediate action is required they must initiate an investigation within 24 hours and file a report with ChildLine. A thorough inquiry is conducted to determine if the child was abused and what services are appropriate for the child and family. This must be completed within 30 days unless the agency provides justification as to why the investigation cannot be completed, including attempts being made to obtain medical records or interview subjects of the report. If the report is not completed in 30 days and justification for extension is provided, the county only has an additional 30 days (a maximum of 60 days) to complete the investigation.

Additional Actions by Mandated Reporters There may be specific expectations and actions beyond making the initial report that mandated reporters must adhere to. A mandated reporter may be required to cooperate with the investigation and testify in proceedings that result from the case they filed if legal action is sought. Only a court official, law enforcement officer, treating physician, or treating hospital administrator can take protective custody of a child. A

caseworker must obtain a court order. This action may be taken when it is immediately necessary to protect the child from further harm. Please Note: As a mandated reporter, you do not have to determine whether or not the person meets the definition of perpetrator to make the report.

Section 6368 of the Child Protective Services Law. Investigation of reports. Response to direct reports. Upon receipt of a report of suspected child abuse by a perpetrator from an individual, the county agency shall ensure the safety of the child and any other child in the child’s home and immediately contact the department.

Response to reports referred to county agency by department. Upon receipt of a report of suspected child abuse from the department, the county agency shall immediately commence an investigation and see the child either Immediately, if emergency protective custody is required, has been or will be taken; or it cannot be determined from the report whether emergency protective custody is needed or within 24 hours of receipt of the report in all other cases.

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Upon conclusion of the child abuse investigation, the county agency will provide the results of its investigation to the department and within 3 business days of receipt of the results of the investigation from the county agency, the department shall send notice of the final determination to the subjects of the report, other than the abused child. Notice to mandated reporter: If a report was made by a mandated reporter under section 6313 (relating to reporting procedure), the

department shall notify the mandated reporter who made the report of suspected child abuse of all of the following within 3 business days of the department’s receipt of the results of the investigation: ●● Whether the child abuse report is founded, indicated, or unfounded. ●● Any services provided, arranged for, or to be provided by the county agency to protect the child.

Recognizing Signs of Abuse and Neglect The first step in helping abused or neglected children is learning to recognize the signs of child abuse and neglect. The presence of a single sign does not mean that child maltreatment is occurring in a family, but a closer look at the situation may be warranted when these signs appear repeatedly or in combination. The following signs may signal the presence of child abuse or neglect. The Child: ●● Shows sudden changes in behavior or school performance. ●● Has not received help for physical or medical problems brought to the parents’ attention. ●● Has learning problems (or difficulty concentrating) that cannot be attributed to specific physical or psychological causes. ●● Is always watchful, as though preparing for something bad to happen. ●● Lacks adult supervision. ●● Is overly compliant, passive, or withdrawn. ●● Comes to school or other activities early, stays late, and does not want to go home. ●● Is reluctant to be around a particular person. ●● Discloses maltreatment. The Parent: ●● Denies the existence of—or blames the child for—the child’s problems in school or at home.

●● Asks teachers or other caregivers to use harsh physical discipline if the child misbehaves. ●● Sees the child as entirely bad, worthless, or burdensome. ●● Demands a level of physical or academic performance the child cannot achieve. ●● Looks primarily to the child for care, attention, and satisfaction of the parent’s emotional needs. ●● Shows little concern for the child. The Parent and Child: ●● Rarely touch or look at each other. ●● Consider their relationship entirely negative. ●● State that they do not like each other. The above list may not be all the signs of abuse or neglect. It is important to pay attention to other behaviors that may seem unusual or concerning. In addition to these signs and symptoms, the Child Welfare Information Gateway provides information on the risk factors and perpetrators of child abuse and neglect fatalities: https://www. childwelfare.gov/can/risk_perpetrators.cfm. We defined the nine different types of child abuse in Pennsylvania earlier in this course. We will now list the types of abuse within the signs of abuse and neglect in this section.

Signs of Physical Abuse Consider the possibility of physical abuse when the child: ●● Has unexplained burns, bites, bruises, broken bones, or black eyes. ●● Has fading bruises or other marks noticeable after an absence from school. ●● Seems frightened of the parent(s) and protests or cries when it is time to go home. ●● Shrinks at the approach of adults. ●● Reports injury by a parent or another adult caregiver. ●● Abuses animals or pets. Types of child abuse: ●● Causing bodily injury to a child through any recent act or failure to act. ●● Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act. ●● Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act.

●● Engaging in any of the following recent acts: ○○ Kicking, biting, throwing, burning, stabbing or cutting a child in a manner that endangers the child. ○○ Unreasonably restraining or confining a child, based on consideration of the method, location or the duration of the restraint or confinement. Consider the possibility of physical abuse when the parent or other adult caregiver: ●● Offers conflicting, unconvincing, or no explanation for the child’s injury, or provides an explanation that is not consistent with the injury. ●● Describes the child as “evil” or in some other very negative way. ●● Uses harsh physical discipline with the child. ●● Has a history of abuse as a child. ●● Has a history of abusing animals or pets.

Signs of Neglect Consider the possibility of neglect when the child: ●● Is frequently absent from school. ●● Begs or steals food or money. ●● Lacks needed medical or dental care, immunizations, or glasses. ●● Is consistently dirty and has severe body odor. ●● Lacks sufficient clothing for the weather. ●● Abuses alcohol or other drugs. ●● States that there is no one at home to provide care.

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Types of child abuse: ●● Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act. ●● Causing serious physical neglect of a child. Consider the possibility of neglect when the parent or other adult caregiver: ●● Appears to be indifferent to the child. ●● Seems apathetic or depressed. ●● Behaves irrationally or in a bizarre manner. ●● Is abusing alcohol or other drugs. Page 11

Signs of Sexual Abuse Consider the possibility of sexual abuse when the child: ●● Has difficulty walking or sitting. ●● Suddenly refuses to change for gym or to participate in physical activities. ●● Reports nightmares or bedwetting. ●● Experiences a sudden change in appetite. ●● Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior. ●● Becomes pregnant or contracts a venereal disease, particularly if under age 14. ●● Runs away. ●● Reports sexual abuse by a parent or another adult caregiver. ●● Attaches very quickly to strangers or new adults in their environment. Types of child abuse: ●● Causing sexual abuse or exploitation of a child through any act or failure to act.

●● Leaving a child unsupervised with an individual, other than the child’s parent, who the actor knows or reasonably should have known: ○○ Is required to register as a Tier II or Tier III sexual offender under 42 Pa.C.S. Ch. 97 Subch. H (relating to registration of sexual offenders), where the victim of the sexual offense was under 18 years of age when the crime was committed. ○○ Has been determined to be a sexually violent predator under 42 Pa.C.S. § 9799.24 (relating to assessments) or any of its predecessors. ○○ Has been determined to be a sexually violent delinquent child as defined in 42 Pa.C.S. § 9799.12 (relating to definitions). Consider the possibility of sexual abuse when the parent or other adult caregiver: ●● Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex. ●● Is secretive and isolated. ●● Is jealous or controlling with family members.

Signs of Emotional Maltreatment Consider the possibility of emotional maltreatment when the child: ●● Shows extremes in behavior, such as overly compliant or demanding behavior, extreme passivity, or aggression. ●● Is either inappropriately adult (e.g., parenting other children) or inappropriately infantile (e.g., frequently rocking or headbanging). ●● Is delayed in physical or emotional development. ●● Has attempted suicide. ●● Reports a lack of attachment to the parent. Types of child abuse: ●● Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act.

Childhood is a time of enormous growth and development. Hagele (2005) noted that child maltreatment—including physical, sexual, and emotional abuse; neglect; and exposure to domestic violence— represents an extreme traumatic insult to the developing child. Specifically, maltreatment results in disruption of the bond between child and caregiver, and it causes upregulation of the biological stress response system. Chronic traumatic exposure may then lead to persistent changes in brain structure and chemistry. Research suggests that these biological alterations contribute to long-term physical, emotional, behavioral, developmental, social, and cognitive dysfunction seen in adults who have experienced childhood maltreatment.

Physical Development Injuries due to abuse can cause permanent physical disability or even death. One example includes shaking a baby or child, which can result in brain injury equal to that caused by a direct blow to the head and may lead to spinal cord injuries with subsequent paralysis.

Types of child abuse: ●● Forcefully shaking a child under one year of age. ●● Forcefully slapping or otherwise striking a child under one year of age. ●● Interfering with the breathing of a child.

Medical Neglect Medical neglect, as in withholding treatment for treatable conditions, can lead to permanent physical disabilities such as hearing loss from untreated ear infections, vision problems from untreated strabismus (crossing of the eyes), respiratory damage from pneumonia or chronic bronchitis.

Types of child abuse: ●● Causing bodily injury to a child through any recent act or failure to act. ●● Fabricating, feigning or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act. ●● Causing serious physical neglect of a child.

Neglected Infants and Toddlers Neglected infants and toddlers often have poor muscle tone and motor control, exhibit delays in gross and fine motor development and coordination, and fail to develop and perfect basic motor skills.

Types of child abuse: ●● Unreasonably restraining or confining a child, based on consideration of the method, location or the duration of the restraint or confinement ●● Forcefully shaking a child under one year of age. ●● Forcefully slapping or otherwise striking a child under one year of age. ●● Interfering with the breathing of a child.

Cognitive Development ●● Absence of stimulation. ●● Interferes with the growth and development of the brain and can result in generalized cognitive delay or mental retardation.

●● Language and speech delays. Abused and neglected toddlers typically exhibit language and speech delays. They fail to use language to communicate with others. Some do not talk at all. This

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cognitive delay can also affect social development, including the development of peer relationships. Types of child abuse: ●● Unreasonably restraining or confining a child, based on consideration of the method, location or the duration of the restraint or confinement. ●● Forcefully shaking a child under one year of age.

●● Forcefully slapping or otherwise striking a child under one year of age. ●● Interfering with the breathing of a child. ●● Causing serious physical neglect of a child. ●● Fabricating, feigning or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act.

Characteristics of Maltreated Infants Maltreated infants often are apathetic and listless, placid or immobile, do not manipulate objects, or do so in repetitive, and do not explore their environments which restricts opportunities for learning, lack mastery of object permanence and lack development of basic problemsolving skills.

●● Interfering with the breathing of a child. ●● Causing serious physical neglect of a child. ●● Fabricating, feigning or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act.

Maltreated infants: ●● Fail to form attachments to primary caregivers and do not appear to notice separation from the parent. ●● May not develop separation or stranger anxiety. ●● May be passive, apathetic, and unresponsive to others. ●● May not maintain eye contact with others. ●● May not become excited when talked to or approached. ●● Cannot often be engaged into vocalizing (cooing or babbling) with an adult.

Abused or neglected toddlers may not develop play skills, and cannot often be engaged into reciprocal, interactive play.

Types of child abuse: ●● Unreasonably restraining or confining a child, based on consideration of the method, location or the duration of the restraint or confinement. ●● Forcefully shaking a child under one year of age. ●● Forcefully slapping or otherwise striking a child under one year of age.

Maltreated infants often fail to develop basic trust, which can impair the development of healthy relationships. Maltreated infants are often: ●● Withdrawn or listless. ●● Apathetic or depressed. ●● Unresponsive to the environment. ●● Passive and immobile, but intently observant. Abused toddlers may feel that they are “bad children” affecting the development of self- esteem; they may become fearful and anxious, depressed and withdrawn, aggressive and physically hurt others. Punishment (abuse) in response to normal exploratory or autonomous behavior can interfere with the development of a healthy personality, and children may become chronically dependent, subversive, or openly rebellious.

Preschool Children The following are typical consequences of maltreatment on the development of preschool children: ●● Physical ○○ Small in stature, and show evidence of delayed physical growth. ○○ Sickly, and susceptible to frequent illness; particularly upper respiratory illness (colds, flu) and digestive upset. ○○ Poor muscle tone, poor motor coordination, gross and fine motor clumsiness, an awkward gait, lack of muscle strength. ○○ Delayed or absent gross motor play skills. ●● Cognitive ○○ Speech may be absent, delayed, or hard to understand. The preschooler whose receptive language far exceeds expressive language may have speech delays. Some children do not talk, although they are able. ○○ Poor articulation/pronunciation, incomplete formation of sentences, incorrect use of words. ○○ Cognitive skills may be at a level of a younger child. ○○ Unusually short attention span, lack of interest in objects, and an inability to concentrate. ●● Social ○○ Demonstrate insecure or absent attachment; attachments may be indiscriminate, superficial, or clingy. The child may show little distress, or may overreact, when separated from caregivers.

○○ Appear emotionally detached, isolated, and withdrawn from both adults and peers. ○○ Demonstrate social immaturity in peer relationships; may be unable to enter into reciprocal play relationships; may be unable to take turns, share, or negotiate with peers; may be overly aggressive, bossy, and competitive with peers. ○○ Prefer solitary or parallel play, or may lack age appropriate play skills with objects and materials. Imaginative and fantasy play may be absent. The child may demonstrate an absence of normal interest and curiosity, and may not actively explore and experiment. ●● Emotional ○○ Excessively fearful, easily traumatized, have night terrors, and seem to expect danger. ○○ Show signs of poor self esteem and a lack of confidence. ○○ Lack impulse control and have little ability to delay gratification; may react to frustration with tantrums, aggression. ○○ Have bland, flat affect and be emotionally passive and detached. ○○ Show an absence of healthy initiative, and must often be drawn into activities; may emotionally withdraw and avoid activities. ○○ Show signs of emotional disturbance: anxiety, depression, emotional volatility, or exhibit self-stimulating behaviors such as rocking, or head banging, enuresis or encopresis.

School-age Children The following are common outcomes of maltreatment in school-age children: ●● Physical ○○ May show generalized physical developmental delays. ○○ Lack the skills and coordination for activities that require perceptual-motor coordination. ○○ Sickly or chronically ill. Psychology.EliteCME.com

●● Cognitive ○○ Display thinking patterns that are typical of a younger child, including egocentric perspectives, lack of problem solving ability, and inability to organize and structure his thoughts. ○○ Speech and language may be delayed or inappropriate. ○○ Unable to concentrate on school work, and may not be able to conform to the structure of the school setting; may not have Page 13

developed basic problem solving or “attack” skills and have considerable difficulty in academics. ●● Social ○○ May be suspicious and mistrustful of adults; or, overly solicitous, agreeable, and manipulative, and may not turn to adults for comfort and help when in need. ○○ Talk in unrealistically glowing terms about her family; may exhibit “role reversal” and assume a “parenting” role. ○○ May not respond to positive praise and attention; or, may excessively seek adult approval and attention. ○○ Feel inferior, incapable, and unworthy around other children; may have difficulty making friends, feel overwhelmed by peer expectations for performance, and may withdraw from social contact; may be scapegoat by peers. ●● Emotional ○○ May experience severe damage to self-esteem from the denigrating and punitive messages received from the abusive

○○ ○○ ○○

○○

parent, or the lack of positive attention in a neglectful environment. Behave impulsively, may have frequent emotional outbursts, and may not be able to delay gratification. May not develop coping strategies to effectively manage stressful situations and master the environment. Exhibit generalized anxiety, depression, and behavioral signs of emotional distress; act out feelings of helplessness and lack of control by being bossy, aggressive, destructive, or by trying to control or manipulate other people. If punished for autonomous behavior may learn that selfassertion is dangerous and may assume a more dependent posture; may exhibit few opinions, show no strong likes or dislikes, not be engaged in productive, goal-directed activity; lack initiative, give up quickly, and withdraw from challenges.

Adolescents The following are common outcomes of maltreatment in adolescents: ●● Physical ○○ Sickly or have chronic illnesses. ○○ Sensory, motor, and perceptual motor skills may be delayed and coordination may be poor. ○○ The onset of puberty may be affected by malnutrition and other consequences of serious neglect. ●● Cognitive ○○ May not develop formal operational thinking; may show deficiencies in the ability to think hypothetically or logically, and to systematically problem-solve. ○○ Thinking processes may be typical of much younger children; the youth may lack insight and the ability to understand other people’s perspectives. ○○ Academically delayed and may have significant problems keeping up with the demands of school. School performance may be poor. ●● Social ○○ Difficulty maintaining relationships with peers; they may withdraw from social interactions, display a generalized dependence on peers, adopt group norms or behaviors to gain acceptance, or demonstrate ambivalence about relationships. ○○ Likely to mistrust adults and may avoid entering into relationships with adults.

○○ Maltreated youth, particularly those who have been sexually abused, often have considerable difficulty in sexual relationships. Intense guilt, shame, poor body image, lack of self-esteem, and a lack of trust can pose serious barriers to a youth’s ability to enter into mutually satisfying and intimate sexual relationships. ○○ Limited concern for other people, may not conform to socially acceptable norms, and may otherwise demonstrate delayed moral development. ○○ Unable to engage in appropriate social or vocational roles. They may have difficulty conforming to social rules. ●● Emotional ○○ Emotional and behavioral problems, including anxiety, depression, withdrawal, aggression, impulsive behavior, antisocial behavior, and conduct disorders. ○○ Lack the internal coping abilities to deal with intense emotions, and may be excessively labile, with frequent and sometimes volatile mood swings. ○○ Considerable problems in formulating a positive identity. Identity confusion and poor self-image are common; may appear to be without direction and immobilized. ○○ No trust in the future and may fail to plan for the future; verbalize grandiose and unrealistic goals, but unable to identify steps necessary to achieve goals; often expect failure.

Human Trafficking Populations at risk: While human trafficking may occur at any age, young and older teens are at highest risk. Those at highest risk for human trafficking include: ●● Youth in the foster care system. ●● Youth who are identified as LGBTQ. ●● Youth who are homeless or runaway. ●● Youth with disabilities. ●● Youth with mental health or substance abuse disorders. ●● Youth with a history of sexual abuse. ●● Youth with a history of being involved in the welfare system. ●● Youth who identify as native or aboriginal. ●● Youth with family dysfunction. Victim Identification: Identifying victims of human trafficking are often a complex and difficult task. There is often fear for victim safety and/or loyalty to the perpetrator. This may result in little cooperation of the victim when trying to validate or verify clinical findings. Some victim identification and/or warning signs are but not limited to: ●● A youth that has been verified to be under 18 years of age and is in any way involved in the commercial sex industry, or has a record of prior arrest for prostitution or related charges. ●● Has an explicitly sexual online profile.

●● Excessive frequenting of internet chat rooms or classified sites. ●● Depicts elements of sexual exploitation in drawing, poetry, or other modes of creative expression. ●● Frequent or multiple sexually transmitted diseases or pregnancies. ●● Lying about or not being aware of their true age. ●● Having no knowledge of personal data, such as but not limited to age, name, and/or date of birth. ●● Having no identification. ●● Wearing sexually provocative clothing. ●● Wearing new clothes of any style, getting hair and/or nails done with no financial means. ●● Secrecy about whereabouts. ●● Having late night or unusual hours. ●● Having a tattoo that he/she is reluctant to explain. ●● Being in a controlling or dominating relationship. ●● Hot having control of own finances. ●● Exhibit hyper-vigilance or paranoid behaviors. ●● Express interest in or in relationship with adults or much older men or women.

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References ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ

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American Humane Association (2014). Emotional abuse. http://www.americanhumane.org/children/ stop-child-abuse/fact-sheets/emotional-abuse.html Child Welfare Information Gateway. (2013). Making and screening reports of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Commonwealth of Pennsylvania (2014). Pennsylvania Code. http://www.pacode.com/ Hagele, D.M. (2005). The impact of maltreatment on the developing child. NC Med Journal, September/October 2005, 66 (5). http://www.ncmedicaljournal.com/wp-content/uploads/2010/11/ Hagele.pdf Hospital & Healthsystem Association of Pennsylvania (2014). Child protection services law amendments change requirements for mandated reporting of suspected child abuse. https://www. haponline.org/Newsroom/News/ID/283/Child-Protection-Services-Law-Amendments-ChangeRequirements-for-Mandated-Reporting-of-Suspected-Child-Abuse National Child Welfare Resource Center for Organizational Improvement (2012). Guide for Developing and Implementing Child Welfare Practice Models.

ŠŠ ŠŠ ŠŠ ŠŠ

ŠŠ

Nationalities Service Center. (2017). Prevalence of Human Trafficking in Pennsylvania. https:// nscphila.org/publications/prevalence-human-trafficking-pennsylvania Pennsylvania General Assembly (2014). CHAPTER 63 CHILD PROTECTIVE SERVICES.http:// www.legis.state.pa.us/WU01/LI/LI/CT/HTM/23/00.063..HTM U.S. Department of Health and Human Services, Administration on Children, Youth, and Families. (2007). Child maltreatment 2005. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2013). Child Maltreatment 2012. http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/childmaltreatment United States Government Accountability Office (2011). Child maltreatment: strengthening national data on child fatalities could aid in prevention (GAO-11-599). http://www.gao.gov/new.items/ d11599.pdf

Child Abuse Recognition and Reporting in Pennsylvania Final Examination Questions

Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination. 1. The new ___________ requires a health care provider to immediately make a report to or cause a report to be made to the appropriate county agency if the provider is involved in the delivery or care of a child under one year of age who is born and identified as being affected by any of the following: illegal substance abuse by the child’s mother, exhibits withdrawal symptoms resulting from prenatal exposure, or has developed a fetal alcohol spectrum disorder. a. Child Protective Services Law. b. Protective Services Law. c. Domestic Violence Law. d. General Protections Law. 2. The Child Protective Services Law requires licensed professionals identified as mandated reporters to __________ on recognizing and reporting child abuse. a. Provide Training b. Receive Training c. Ignore the signs d. Do Nothing 3. “__________”is defined in section 6303 of the Child Protective Services Law as: A person who has committed child abuse. a. Abuser. b. Perpetrator. c. Offender. d. Violator. 4. Effective December 31, 2014, the new definition of a ________________ includes anyone who comes into contact, or interacts, with a child or is directly responsible for the care, supervision, guidance, or training of a child. a. Permissive reporter. b. Child welfare advocate. c. Guardian Ad Litem. d. Mandated reporter. 5. If they suspect abuse, mandated reporters are required to immediately report the abuse to ChildLine electronically or by telephone. Written reports must be made within __________ after the oral report is made by telephone. a. 48 hours b. 72 hours c. 24 hours d. 1 week

6. Section 6311.1. of the Child Protective Services Law states that the ____________ between a mandated reporter and a patient or client of the mandated reporter shall not apply to a situation involving child abuse or relieve the mandated reporter of the duty to make a report of suspected child abuse. a. Binding contract. b. Privileged communications. c. Professional interactions. d. Historical clinical file. 7. Only certain individuals have the legal authority to take protective custody of a child when they believe it is immediately necessary to protect the child from further harm. These individuals include which of the following? a. Attorney. b. School official. c. Treating physician. d. Legislator. 8. If the county-based children and youth agency determines that no immediate action is required they must initiate _____________ within 24 hours. a. Intake paperwork. b. An investigation. c. Collateral contacts. d. A diligent search for parents and relatives. 9. If you are a mandated reporter and you willfully fail to report suspected child abuse, you could be charged with a _______________ up to a second degree felony. a. Third-degree misdemeanor. b. Second-degree misdemeanor. c. First-degree felony. d. Third-degree felony. 10. __________ can lead to permanent physical disabilities such as hearing loss from untreated ear infections, vision problems from untreated strabismus (crossing of the eyes), or respiratory damage from pneumonia or chronic bronchitis. a. Medical neglect. b. Shaken baby syndrome. c. Sexual abuse. d. Emotional abuse.

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Chapter 2:

Ethics and Boundaries 3 CE Hours

By: Rene’ Ledford, MSW, LCSW, BCBA and Kathryn Brohl, MA, LMFT

Learning objectives ŠŠ Understand the importance of professional values and ethics in mental health practice. ŠŠ Identify the role and the impact of law in mental health practice. ŠŠ Recognize and distinguish between problematic and nonproblematic boundary issues in mental health practice. ŠŠ Describe ways mental health practitioners can prevent unethical or illegal behaviors in daily practice.

ŠŠ Identify elements and conditions of informed consent. ŠŠ Understand the basic requirement of HIPAA and the Privacy Rule as it relates to practice. ŠŠ Understand the impact of technology on mental health practice and the unique responsibilities that are included. ŠŠ Identify a protocol for ethical decision-making.

Introduction Ethics and mental health practice Ethical issues are common in any profession. But mental health work, which relies heavily on relationship building and which can directly impact the health and welfare of its clients, poses even greater responsibilities and challenges. Mental health practitioners must rely on internal guides of character and integrity and external guides such as laws and ethical codes of conduct. Consider these two examples: ●● Mary, a mental health counselor, provided counseling services at a community mental health center. Most of her clients did not have insurance nor could afford to pay privately anywhere else. After several years of postgraduate full-time practice, Mary felt competent providing services for most issues. After three sessions with one of her clients, her client confessed that he wanted a sex-change operation and would need Mary’s support through the process. Mary had taken few graduate level courses in human sexuality and had no other specialized training in this specialized area. If there was another clinician available who specialized in gender reassignment issues, her client could not afford it.

Given her strong belief in client self-determination, the client’s belief in her ability to assist, and her willingness to read the literature and consult the Internet on protocol, Mary agreed to revise their plan of treatment and proceed. ●● Joaquin, a licensed clinical social worker, and his client, a young man with schizophrenia, have successfully worked together to achieve stability in symptom management and independent living. Joaquin and his client are close in age, have many interests in common and consequently have achieved a strong rapport and mutual trust. Now Joaquin is transferring to a supervisory position, which will effectively end his professional relationship with the client. His client wishes to continue their relationship as friends, and Joaquin is tempted to do so. In these two examples, each mental health practitioner demonstrates both a compassion for and commitment to their respective clients. They are at a crossroads in their relationship with their clients. What they decide to do next must consider various issues that include what is in the best interest of the client and the client’s right to self-determination.

The primary reason for action What is easiest, most comfortable, and/or desired by these mental health practitioners should never be the primary reason for action. If the needs of the client versus mental health therapist were the only considerations, decision-making would be easy. However, the mental health worker must also consider the ethical guidelines established by various government agencies and national mental health professional associations, as well as the law. In the first scenario, Mary must balance both her and her client’s desire to continue what appears to be a comfortable and trusting therapeutic relationship, with the need to provide the most effective service for the client. Clearly Mary is not qualified to provide the service this client needs. Is her plan for a crash course in transgendered treatment adequate? Should she make a referral to a more competent therapist? Should she work with the client to overcome the financial barriers he is facing?

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If Mary makes the wrong decision, she might either violate ethical guidelines or the law, or both. She may be committing a medical error and putting her client at risk of harm. Her actions may also result in Mary being sued and/or censured. Joaquin must ask himself the question, “Am I considering crossing the boundaries of our professional relationship for my own needs or for those of my client?” Clearly both Joaquin and his client value a friendship but what potential harmful impact could this have on one or both of them? Ethical decision-making is a complex process, requiring mental health practitioners to look at not just the immediate impact, but also the long-term and future consequences of their actions.

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Defining ethics The word “ethics” is derived from both the Greek word “ethos,” which means character, and the Latin word “mores,” meaning customs. Ethics defines what is good for both society and the individual. Though closely related, law and ethics do not necessarily have a reciprocal relationship. While the origins of law can often be based upon ethical principles, law does not prohibit many unethical behaviors. Likewise, adherence to certain ethical principles may challenge a mental health practitioner’s ability to uphold the law.

For example, documenting that a service has occurred when it hasn’t may be unethical, but not subject to prosecution. Unfortunately, it may take high-profile adverse consequences of unethical behavior, such as the discovery that a child under protective custody has been missing for months, to create new laws that support ethical standards of behavior. For instance, in a well-publicized case, the state of Florida made the falsification of documentation, e.g., visitations that never took place, illegal for people employed as child welfare workers.

Implications for practice Ethical standards are, according to Reamer (Ethical Standards in Social Work, 1998), “created to help professionals identify ethical issues in practice and provide guidelines to determine what is ethically acceptable and unacceptable behavior.” What makes mental health work unique is its focus on the person as well as its commitment to the well-being of society as a whole. The social work profession adopted the first code of ethics for the profession in 1947. In 1960, following the formation of the National Association of Social Work, another code of ethics was drafted, with multiple revisions in the following years. Ethics have been developed for other national mental health licensing associations and boards that include among others, The American Association for Marriage and Family Therapy, The American Counseling Association, and The American Mental Health Association. The American Association for Marriage and Family Therapy “strives to honor the public trust in marriage and family therapists by setting standards for ethical practice as professional expectations” that are

enforced by its own ethics committee. The American Counseling Association “promotes ethical counseling practice in service to the public.” The primary mission of the National Association for Social Workers is to “enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty.” Being part of a professional association not only brings a wealth of knowledge and expertise but also certain rights and privileges for its members. But those benefits must not overshadow the professional’s commitment to promote ethical behavior on behalf of clients. When an individual identifies with a mental health profession, he or she is pledging to practice in an ethical and responsible manner. In addition to allegiance to the professional ethics and standards of practice it promotes, the individual also has a duty to support the values, rules, laws, and customs of the society with which they remain a part.

The law and mental health Here is one scenario that illustrates how law can interface with mental health practice: A licensed mental health practitioner believes a foster teen’s allegations of abuse toward her foster father merely represent countercoercive behavior related to her adjustment within a more stable, rule-enforced environment and chooses not to report it. He rationalized that this family had successfully helped many children before without incident.

legal responsibility to learn and follow any and all regulations in the jurisdiction within which they practice.

As pointed out earlier, criminal law and professional and ethical guidelines are not one and the same – they may complement each other or be in opposition of one another depending on the issue and on the state. For example, a minor legal offense may result in a small fine but could then lead to loss of a professional license. Licensed mental health practitioners have not just an ethical responsibility but also a

With the advent of technology-based practice, such as e-therapy, the mental health practitioner’s scope of responsibility is even larger; some jurisdictions identify the location of practice, and thus the applicable laws and rules, as that of the client’s. We will explore more about technology-based and other practice implications later in this course.

In the case described above, federal and state laws about mandatory reporting leave little choice for a professional but to report the allegations of abuse. Sometimes we can be too sure of our abilities or too fearful (in this case, potentially losing a foster parent), and in doing so ignore the very real consequences of violating the law. Or, in less obvious circumstances, we may just not know.

Impact of law on practice Currently the United States, including all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and other countries regulate some form of mental health practice. Many typically regulate practice through statutes, i.e., practice acts that stipulate who may practice and/or call themselves mental health practitioners (Saltzman and Furman, 1998). State oversight boards give authority to practice to qualified individuals, typically defined by three competencies: ●● Education. ●● Experience. ●● Passing score on an examination. Failure to abide by these regulations can have serious and negative legal and financial consequences. For example, mental health professionals need to understand that they may not be covered by their insurance

policy if they were not practicing legally at the time of a questionable ethical occurrence; i.e., were not licensed as required by law. There are also laws that impose legal obligations to abide by practices that further serve to protect the consumer, such as federal and state statutes requiring mandatory child abuse reporting, practices that ensure client confidentiality, or competence to perform certain services. Unlike regulation under the law, adherence to regulations set forth by private credentialing bodies is voluntary. However, the regulations and codes of ethics are universally respected. Mental health professionals also practice in accordance to the professional standards of care established by private professional association organizations such as ACA, NASW, or AAMFT.

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Establishing ethical codes of conduct In addition to professional affiliation code of ethics, (such as established within national professional associations), state licensing laws and licensing board regulations identify basic competencies for mental health practice. Failure to follow the ethical codes of one’s profession may result in expulsion from the profession, sanctions, fines, and can result, if sued, in a judgment against the practitioner. For example, Strom-Gottfried (2000) reviewed 894 ethics cases filed with NASW between July 1, 1986, and December 31, 1997. About 48 percent of the cases resulted in hearings and of those, 62 percent concluded that violations had occurred for a total of 781 different violations. The study clustered those violations into 10 categories: 1. Violating boundaries. 2. Poor practice. 3. Competence. 4. Record keeping. 5. Honesty. 6. Confidentiality. 7. Informed consent.

8. Collegial actions. 9. Reimbursement. 10. Conflicts of interest. Of the 267 individuals found to have violated ethical standards, 26 percent were found to have violated only one ethics category, while 74 percent had violated more than one. Most of the cases (55 percent) involved boundary violations, such as those involving sexual relationships and dual relationships. Given the frequency that these violations occur, (and remember, this study only examined reported violations) we will be exploring these two violation types in more depth later. The findings reflected a variety of inappropriate behaviors that blurred the helping process and exploited clients including: ●● The use of physical contact in treatment. ●● The pursuit of sexual activity with clients, either during or immediately after treatment. ●● Social relationships. ●● Business relationships. ●● Bartering.

Unintended actions Some mental health professionals may argue that an action is ethical as long as you are not intending harm and/or are not knowingly violating an ethical standard or law. Or, what about those unique situations that don’t readily lend themselves to a reference in law or codes of conduct? What defines prudent practice? Grappling with questions about what is unethical and what isn’t ethical is a situation faced by any person in the helping professions.

Literalization The principle (or rationalization) of literalization states that if we cannot find a specific mention of a particular incident anywhere in legal, ethical, or professional standards, it must be ethical.

Pope and Vasquez (1998) discuss the tendency to rationalize that an action is acceptable, as it relates to the practice of psychotherapy and counseling.

Ethical standards of practice for mental health generally benefit both the practitioner and the public and include: 1. Identifying core values. 2. Establishing a set of specific ethical standards that should be used to guide mental health practice. 3. Identifying relevant considerations when professional obligations conflict or ethical uncertainties arise. 4. Providing ethical standards to which the general public can hold mental health professionals accountable. 5. Providing mental health ethical practice and standards orientation to practitioners new to the mental health field. 6. Articulating formal procedures to adjudicate ethics complaints filed against mental health practitioners.

This rationalization encompasses two principles: 1. Specific ignorance. 2. Specific literalization. Specific ignorance The principle (or rationalization) of specific ignorance states that even if there is a law prohibiting an action, what you do is not illegal as long as you are unaware of the law.

Assisting mental health practitioners in resolving ethical dilemmas that may arise in practice is just one of several purposes for establishing ethical codes of conduct.

Core values and ethical principles The core values espoused by mental health ethics codes incorporate a wide range of overlapping morals, values, and ethical principles that lay the foundation for the profession’s unique duties. They generally include: ●● Service. ●● Autonomy – Allowing for freedom of choice and action. ●● Responsibility to clients. ●● Responsibility to the profession. ●● Responsibility to social justice. ●● Responsibility for doing no harm. ●● Dignity and worth of the person. ●● Confidentiality. ●● Importance of human relationships. ●● Do good and be proactive. ●● Professional competence. ●● Integrity. ●● Engagement with appropriate informational activities. ●● Treating people in accordance with their relevant differences. ●● Responsibility to students and supervisees. ●● Fidelity. ●● Responsibility to research participants. SocialWork.EliteCME.com

●● Financial arrangements conform to accepted professional practices. Depending on a particular professional association’s Code of Ethics, ethical professional practice can include: ●● Helping people in need. ●● Challenging social injustice. ●● Respecting the inherent dignity and worth of the person. ●● Recognizing the central importance of human relationships. ●● Behaving in a trustworthy manner. ●● Practicing within areas of competence and developing and enhancing professional expertise. The intent of some of the principles, such as responsibility to students and supervisees, are what mental health practitioners can aspire to, while others are much more prescriptive, clearly identifying enforceable standards of conduct (Reamer, 1998). Most ethics codes describe specific ethical standards relevant to six areas of professional functioning. These standards provide accepted standards of behavior for all mental health clinicians concerning ethical responsibilities: 1. To clients. Page 18

2. To colleagues. 3. To practice settings. 4. As professionals.

5. To a particular mental health profession focus. 6. To the broader society. This course will continue to look at issues around each of those areas.

Ethical responsibilities to clients This illustration highlights the complexity of ethical responsibility to clients: Example: A depressed, 80-year-old client, suffering from the painful, debilitating effects of arthritis, asks Rene, his mental health therapist, for information on assisted suicide. He tells her

that he only needs help downloading information from the Internet and then it is his right to weigh the options of proceeding. Rene believes the client’s depression is directly related to the pain, because the client is otherwise of sound mind, and therefore has a right to determine his future.

Commitment Client interests are primary. The example above epitomizes the difficulties often faced by mental health practitioners when the principles of law, personal belief, professional codes of ethics, client need, and cultural and societal norms intersect and at times contradict

each other. The professional is then faced with a conundrum that offers a multitude of potential decisions, actions, and consequences. We will discuss more about how the worker can best weigh all these considerations to make the most ethical decision later in this course.

Self-determination Another standard that strongly reflects the mental health practitioner’s commitment to a client is that of self-determination. Professionals have an obligation to support and assist clients in accomplishing their goals, only deviating from this when a client’s goal puts them or others imminently at risk. Defining risk can be difficult – most mental health professionals cannot argue that suicide or homicide do not present a clear risk to the

client or to others. Other client choices, such as staying in an abusive relationship or living in squalor or on the streets, may challenge a professional’s personal values and sincere desire to protect, also known as “professional paternalism.” (Reamer, 1998.) In the absence of clear and present harm, the client has a right to choose his or her own path and make his or her own decisions, whether we agree or disagree.

Suicide: The right to choose versus duty to protect Sometimes a mental health practitioner may be faced with a choice between a client’s right to choose suicide and the duty to protect his or her life. The request by the emotionally stable and rational terminally ill client is a good example of a situation that is not as “cut and dried” as that involving a severely depressed young woman contemplating suicide. Would one client deserve individual consideration and thus not be assessed for possible hospitalization over the other? Most workers choose this profession because it supports respect for the strengths and abilities of clients, and thus their ability to learn, make good decisions, and be self-sufficient. But aside from laws prohibiting assisted suicides, workers also rely on intuition and judgment in determining whether to take action to protect a client from harm. This scenario blurs the line between respect for the client’s wishes and society’s obligation to

protect. It also raises the issue of client autonomy versus the professional obligation to prevent discrimination. Thus, it is essential that mental health practitioners establish clear procedures that ensure impartial assessment while valuing client autonomy and individual treatment. Since laws and professional codes of ethics are not always clear and do not always spell out our specific duties and responsibilities, it is recommended that workers not only do everything to assist clients in taking advantage of any options to alleviate their distress, but also rely on practice guidelines that call for: ●● Careful evaluation, such as the client’s ability to make rational choices based on the mental state and social situation. ●● A good therapeutic alliance. ●● Consultation.

Informed consent Informed consent services should only be provided when valid informed consent can be obtained. Therefore, clients must know the exceptions to self-determination before consenting to treatment or other services. Mental health professionals working in child welfare or forensic practice settings are faced with additional challenges. In their article about informed consent in court-ordered practice, Regehr and Antle (1997) state: Informed consent is a legal construct that is intended to ensure that individuals entering a process of investigation or treatment have adequate information to fully assess whether they wish to

participate. This concept of informed consent is closely linked with the value of self-determination. Generally, potential threats and factors to be considered in ensuring the validity of informed consent are: ●● Language and comprehension. ●● Capacity for decision making. ●● Limits of service refusal by involuntary clients (including courtmandated clients). ●● Limitations and risks associated with electronic media services. ●● Audio and videotaping.

Competence (or professional and ethical competence) Another section that relates to informed consent, competence, is mental health professionals’ responsibility to represent themselves and to practice only within the boundaries of their education, experience, training, license or certification, and level of supervisory or consultant support. For example, poor practice, or the failure of a worker to provide services within accepted standards, was the second most common form of violation found in Strom-Gottfried’s study of code violation allegations resulting in social work practice (2000).

The study also revealed findings of incompetence, in conjunction with other forms of unethical behavior, in 21 percent of the cases. In these cases, reasons why a social worker was not competent to deliver services included: ●● Personal impairments. ●● Lack of adequate knowledge or preparation. ●● Lack of needed supervision.

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Conflicts of interest One of the most difficult areas of responsibility to clients is conflict of interest. Workers need to avoid conflicts of interest that interfere with the exercise of: ●● Professional discretion. ●● Impartial judgment.

The issue of informed consent should include both prescribing the need to inform clients of potential or actual conflicts, and taking reasonable steps to resolve the conflict in a way that protects the client’s needs and interests.

Dual or multiple relationships Dual or multiple relationships occur when mental health professionals relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively. Dual or multiple relationships with current or former clients should be avoided whenever possible, and the exploitation of clients for personal, religious, political, or business interests should never occur. Further, workers should not engage in dual or multiple relationships with clients or former clients where there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, workers should take steps to protect

clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. Recognizing that there are many contexts within which mental health work is practiced, dual relationships are not always entirely banned by different professional association ethical codes. The word “should” in sections where dual or multiple roles are outlined within various codes of ethics, implies there is room for exceptions. However, what they are usually distinguishing is that dual relationships are not permitted when there is risk of exploitation or harm. In not banning all dual relationships, each worker bears the responsibility for both determining, and if needed, proving that the relationship was not harmful to the client.

Boundary violations Conflicts of interest relate closely to other types of unprofessional behavior such as boundary violations, which more specifically identifies harmful dual relationships. Most mental health professionals can easily recognize and identify common boundary issues presented by their clients. Likewise, most can identify examples of boundary violations around professional behavior, for example, sexual misconduct. While not exclusive to the clinical role, there are certain situations that are more challenging than others, especially for workers vulnerable to committing boundary violations. Boundary issues involve circumstances in which there are actual or potential conflicts between their professional duties and their social, sexual, religious or business relationships. These are some of the most challenging issues faced in the mental health profession and typically involve conflicts of interest that occur when a worker assumes a second role with one or more clients. Such conflicts of interest may involve relationships with: ●● Current clients. ●● Former clients. ●● Colleagues. ●● Supervisees and students. With that in mind, the following would be examples of inappropriate boundary violations, and thus unethical, in that they involved a dual

relationship that is exploitive, manipulative, deceptive, or coercive in nature. ●● Buying property from a disaster client at far below its market level. ●● Falsely testifying to support fraudulent actions of clients. ●● Imposing religious beliefs on a client. ●● Suggesting that a hospice client make you executor of his/her will. ●● Referring a client to your brother-in-law, the stockbroker. ●● Friendship with the spouse of a client you are treating for marital issues. Five conceptual categories with regard to boundary violations generally occur around five central themes: 1. Intimate relationships – These relationships include physical contact, sexual relations, and gestures such as gift giving, friendship, and affectionate communication. 2. Pursuit of personal benefit – The various forms this may take include monetary gain, receiving goods and services, useful information. 3. Emotional and dependency needs – The continuum of boundary violations ranges from subtle to glaring and arise from social workers’ need to satisfy their emotional needs. 4. Altruistically motivated gestures – These arise out of a mental health practitioner’s desire to be helpful. 5. Responses to unanticipated circumstances – Unplanned situations over which the social worker has little to no control.

Intimate relationships As discussed earlier, boundary issues involving intimate relationships are the most common violations. Those involving sexual misconduct are clearly prohibited and will be further explored.

and leads on jobs) is another matter. It is important to remember that this can apply both ways, i.e., the mental health professional needs to avoid offering assistance in areas outside his or her role.

While most professionals might agree that having other nonsexual relationships, such as a friendship, with a current clinical client is inappropriate, the rules are not as clear regarding ex-clients and even less so for those clients in case management, community action, or other non-clinical relationships.

“Your usefulness to your patients lies in your clinical skills and separation of your professional role from other roles which would be better filled elsewhere in their lives. Do not suggest, recommend, or even inform the patient about such things as investments, and be cautious about giving direct advice on such topics as employment and relationships. There is a difference between eliciting thoughts and feelings to encouraging good decision making and inappropriately influencing those decisions.” (Reid, W. 1999)

When a dual relationship results in personal benefit to the practitioner it also undermines the trusting relationship. Some of the scenarios mentioned earlier (getting property below market value, becoming the executor of the client’s will, and referring clients to a relative) are all examples. There are very respectful, sound and appropriate reasons for encouraging clients to share what they know and to listen to their strengths. Benefiting from information the client has (e.g., stock tips SocialWork.EliteCME.com

Another tricky area involves bartering arrangements, particularly involving the exchange of services. These should be considered carefully, and according to Reamer (2003), be limited to the following circumstances when they are: Page 20

●● ●● ●● ●● ●●

An accepted practice among community professionals. Essential to service provision. Negotiated without coercion. Entered into at the client’s initiative. Done with the client’s informed consent.

Again, the professional is in the unenviable position of determining whether an action presents the possibility of psychological harm to the client. Kissing on the cheek, for example, may be perfectly correct and clearly nonsexual in certain cultures and contexts, but may confuse or intimidate a client in other contexts. Another area fraught with peril is when workers engage in behavior arising from their own emotional needs. Most mental health practitioners are more familiar with examples of intentional and even more egregious examples, such as the practitioner who uses undo influence to “convert” the client or takes sides in a custody case in order to foster a relationship with one of the spouses. Many times the boundaries are crossed unintentionally, as in a practitioner who becomes overly involved in a case with which she personally identifies. Or the worker may be experiencing life issues that make him or her more vulnerable to the attention of a client. Mental health professionals have a responsibility to maintain competence in both the professional and emotional arenas. Regardless of the circumstances, the worker’s first responsibility is always to the client. There are also times when the intent of the professional is truly out of a desire to be helpful, such as buying merchandise from a client whose business is struggling or inviting a divorce recovery group client to a community function in order to help her broaden her social network. While some types of situations may not be considered unethical or illegal, the worker needs to carefully review his or her motivation and the potential consequences of each decision. Some helpful questions to ask are: ●● Would I do this for all my clients? ●● Am I doing this because I feel uncomfortable (e.g., saying no)? ●● Am I feeling at a loss to help the client any other way and thus feeling, “I must do something” to feel competent? ●● How might the client interpret my gesture? ●● Am I doing this just for the client’s interest or also for my own interest? ●● What are all the potential negative outcomes? There will be occasions when you incidentally come into contact with a client, such as finding your client’s daughter is on the same soccer team as your child. Some practitioners go out of their way to live in a different community so the chances are minimal that this could happen. Others see that as over-managing a potential situation that is unlikely to lead to harm for the client or colleague (as in the case of supervisees). The appropriateness of relationships with clients is often debated across the profession. The unique service settings and roles assumed by workers often contrast with the traditional clinical approach to human service. Applying strict rules around relationships can appear excessive and/or contradictory with sound mental health practice. A

worker, for example, may work in a small, isolated community that would expect its community members to share in social customs such as family meals and weddings. Ethical guidelines recommend giving students a copy of supervisees’ guidelines to guarantee client protection instead of blanket advice to avoid dual relationships altogether. (Boland-Prom and Anderson, 2005.) Freud and Krug (2002) also feel that “over-correcting a problem, as is a frequent tendency in our society, sometimes escalates the very transgressions against which the new rules are to protect us.” While necessary and healthy debate continues, practitioners need to, no matter what their scope of practice, seek guidance and input from a variety of sources to make good decisions around boundary issues. There are some areas where clear rules about dual relationships are essential and include: 1. Protection of the therapeutic process – In the context of current clinical practice, “even minor boundary trespasses can create unwarranted expectations.” Transference and countertransference issues are present and cannot be underestimated. According to Freud and King (2002), “The mystique of the tightly boundaried, hierarchical therapeutic relationship heightens transference phenomena.” 2. Client protection from exploitation – A clinician may be tempted to meet personal sexual, financial, or social needs with persons who may be particularly vulnerable to exploitation. Ethical guidelines serve to protect clients from exploitation. 3. Protection from potential legal liability – Workers are concerned about legal liability, and “careful adherence to the boundary specifications may protect clinicians from malpractice suits.” Ultimately, it is the mental health professional’s responsibility to establish culturally appropriate and clear boundaries for clients because doing so often prevents issues from surfacing in the first place. The worker cannot underestimate the importance of expectations – respecting the client means together creating a safe relationship where boundaries and expectations are unambiguous and openly discussed. To further minimize possible harm to all parties – the client, the worker, the employer, and so on – the following risk management protocols to address boundary issues are suggested: 1. Be alert to potential or actual conflicts of interest. 2. Inform clients and colleagues about potential or actual conflicts of interest; explore reasonable remedies. 3. Consult colleagues and supervisors, and relevant professional literature, regulations, policies, and ethical standards to identify pertinent boundary issues and constructive options. 4. Design a plan of action that addresses the boundary issues and protects the parties involved to the greatest extent possible. 5. Document all discussions, consultation, supervision, and other steps taken to address boundary issues. 6. Develop a strategy to monitor implementation of your action plan (clients, colleagues, supervisors, and lawyers.)

Sexual relationships, physical contact, sexual harassment, and derogatory language Ethical mental health practice limits sexual relationships with clients, former clients, and others close to the client, physical contact where there is risk of harm to the client, sexual harassment, and the use of derogatory language in written and verbal communication to or about clients.

Sexual harassment In 1980, the EEOC (Equal Employment Opportunity Commission), the agency that enforces Title VII, first defined sexual harassment as a form of sex-based discrimination and issued guidelines interpreting the law. These guidelines define unlawful sexual harassment as: ●● Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, when: ○○ Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment. ○○ Submission to, or rejection of, such conduct by an individual is used as the basis for employment decisions affecting such individual.

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○○ Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive working environment. In mental health practice, sexual harassment can take many forms including offensive or derogatory comments, sexually oriented jokes, requests or demands for sexual favors, leering, visual displays depicting sexual imagery, innuendos, pinching, fondling, impeding someone’s egress, etc. Workers should not sexually harass supervisees, students, trainees or colleagues. Sexual misconduct Some states also have laws making sexual misconduct subject to lawsuits and even arrest. Practitioners need to be sure about the rules that apply to them, as well as be aware of how their behavior may be perceived by others. For example, Reid points out that in most situations, consent will not be an effective defense against sexual misconduct allegations. The reasons Reid (1999) gives for a client’s ability to consent being called into question are: ●● The fiduciary trust between clinician and patient. ●● Exploitation of transference feelings. ●● The right of the patient to expect clinical needs to be the overriding priority. ●● Exploitation of the patient’s purported inability to resist the therapist’s influence.

●● The alleged “power differential” between any patient and his or her clinician. Anyone working in mental health practice has experienced different relationships with clients. Sometimes it is nearly impossible not to form respect and even affection for clients. However, practitioners must work diligently to avoid problems, i.e., either crossing the boundaries of the professional relationship or even appearing to do so. In addition to other previously discussed actions designed to prevent harm to the client, workers can proactively address this issue by doing the following: ●● Limit practice to those populations that do not cause your own needs to surface. ●● Seek clinical supervision to effectively deal with personal feelings. ●● Document surroundings and who was present during sessions and visits. ●● Avoid seeing the client at late hours or in locations that are atypical for routine practice. Reporting sexual misconduct by a colleague is an ethical responsibility of mental health practitioners. Many states have laws that require licensed professionals to report such misconduct as well as other ethical violations to their state boards. It is the responsibility of every professional to protect clients by reporting a reasonable knowledge or suspicion of misconduct between the client and colleague.

Professional boundaries self-assessment Below are red flags that professional boundaries may be compromised. Some relate to you and some to clients. As you honestly answer the following questions yes or no, reflect on the potential for harm to your client. 1. Have you ever spent time with a client “off duty”? 2. Have you ever kept a secret with a client? 3. Have you ever adjusted your dress for a client? 4. Has a client ever changed a style of dress for you? 5. Have you ever received a gift from a client? 6. Have you shared personal information with a client? 7. Have you ever bent the rules for a client?

8. Have you ever given a client a gift? 9. Have you ever visited a client after case termination? 10. Have you ever called a client when “off duty”? 11. Have you ever felt sexually attracted to a client? 12. Have you ever reported only the positive or only the negative aspects of a client? 13. Have you ever felt that colleagues/family members are jealous of your client relationship? 14. Do you think you could ever become overinvolved with a client? 15. Have you ever felt possessive about a client?

Clients who lack decision-making capacity The practitioner’s responsibility is to safeguard the rights and interests of clients who lack decision-making capacity.

Payment of services With regard to payment of services, it is most helpful to refer to your particular professional association’s financial arrangement ethical standards. Professional association ethical guidelines, in general, call for fair and reasonable fees for services, prohibition or no prohibition of solicitation of fees for services entitled and rendered through the workers’ employer, and avoidance of bartering arrangements. Other guidelines include no acceptance or offering of kickbacks, rebates,

bonuses, or other remuneration for referrals. Clear disclosure and explanation of financial arrangements, reasonable notice to clients for intention to seek payment collection, third-party pay or fact disclosure, and no withholding of records because payment has not been received for past services, except otherwise provided by law, are also examples of ethical financial guidelines.

Ethics in practice settings Administration Mental health administrators should advocate within and outside their agencies for adequate resources, open and fair allocation procedures,

and a work environment that is not only consistent with, but encourages compliance with ethical standards of practice.

Billing Practitioners need to establish and maintain accurate billing practices that clearly identify the provider of services. Many agencies,

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associations and boards include these expectations in their own values and codes of ethics, commonly under the category of stewardship.

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Client transfer Mental health practitioners should consider the needs and best interests of clients being served by other professionals or agencies before agreeing to provide services, and discuss with the client the appropriateness of consulting with the previous service provider.

Informed consent is an important aspect of this issue, in that a practitioner must discuss all implications, including possible benefits and risks, of entering into a relationship with a new provider.

Client records Maintaining records of service and storing them is not always easy. Aside from the potential negative legal fallout of not doing so, there are good reasons for keeping records including: ●● Assisting both the practitioner and client in monitoring service progress and effectiveness. ●● Ensuring continuity of care should the client transfer to another worker or service. ●● Assisting clients in qualifying for benefits and other services. ●● Ensuring continuity of care should the client return.

To facilitate the delivery and continuity of services, the practitioner, with respect to documentation and client records, must ensure that: ●● Records are accurate and reflect the services provided. ●● Documentation is sufficient and completed in a timely manner. ●● Documentation reflects only information relevant to service delivery. ●● Client privacy is maintained to the extent possible and appropriate. ●● Records are stored for a sufficient period after termination.

Recordkeeping State statutes, contracts with state agencies, accreditation bodies and other relevant stakeholders prescribe the minimum number of years records should be kept. For example, HIPAA has a requirement of six years for electronic records. The Council on Accreditation requires records be kept a minimum of seven years. The NASW Insurance Trust actually strongly recommends retaining clinical records indefinitely.

Again, professionals who are primary custodians of client records should refer to additional legal requirements, such as those established by state licensing boards, regarding care for client records in the event they retire and/or close their business or practice.

The Privacy Rule (HIPAA) In 1996, the 104th Congress amended the Internal Revenue Code of 1986, and created Public Law 104-191, the Health Insurance Portability and Accountability Act. This established the first-ever national standards for the protection of certain health information. These standards, developed by the Department of Health and Human Services, took effect April 14, 2003. The Privacy Rule standards address who can use, look at, and receive individuals’ health information (protected health information or PHI) by organizations (covered entities) subject to the rule. These organizations include: ●● Most doctors, nurses, pharmacies, hospitals, clinics, nursing homes, and other health care providers. ●● Health insurance companies, HMOs, and most employer group health plans. ●● Certain government programs that pay for health care, such as Medicare and Medicaid. Key provisions of the standards include: ●● Access to medical records – Patients may ask to see and get a copy of their health records and have corrections added to their health information. ●● Notice of privacy practices – Patients must be given a notice that tells them how a covered entity may use and share their health information and how they can exercise their rights. ●● Limits on use of personal medical information – The privacy rule sets limits on how health plans and covered providers may use individually identifiable health information. Generally, health information cannot be given to the patient’s employer or shared for any other purpose unless the patient signs an authorization form. ●● Prohibition of marketing – Pharmacies, health plans and other covered entities must first obtain an individual’s specific authorization before disclosing their patient information for marketing. ●● Stronger state laws – As stated earlier, confidentiality protections are cumulative; any state law providing additional protections would continue to apply. However, should state law require a certain disclosure – such as reporting an infectious disease outbreak – the federal privacy regulations would not pre-empt the state law. ●● Confidential communications – Patients have the right to expect covered entities to take reasonable steps to ensure communications

with them are confidential. For example, a patient may want to be called on a work phone rather than home telephone. ●● Complaints – Patients may file a formal complaint regarding privacy practices directly to the provider, health plan, or to the HHS Office for Civil Rights. Consumers can find out more information about filing a complaint at http://www.hhs.gov/ocr/ hipaa or by calling 866-627-7748. It is very important to know that professionals who work in the mental health field are responsible for following and enforcing the HIPAA Privacy Rule. The American Recovery and Reinvestment Act of 2009 put new teeth into the laws and penalties for HIPAA violations when it implemented tiered penalties reflecting the circumstances surrounding the violation. These acknowledged whether the violator did not know about the violation, had reasonable cause, allowed the violation because of willful neglect but subsequently corrected it or allowed the violation because of willful neglect and did not correct it. ●● For violations that the entity did not know about, minimum fines are $100 per violation; up to $50,000 may be imposed, with an annual maximum of $1.5 million. ●● For violations that had reasonable cause and were not due to willful neglect, a minimum fine of $1,000 and up to $50,000 may be imposed, with an annual maximum of $1.5 million. ●● For violations due to willful neglect that were corrected within the required time period, a minimum fine of $10,000 and up to $50,000 may be imposed, with an annual maximum of $1.5 million. ●● For violations due to willful neglect that were not corrected, a minimum fine of $50,000 per violation may be imposed, with an annual maximum of $1.5 million. However, courts in some cases have treated multiple violations as separate cases, allowing the maximum fines to be much higher that $1.5 million. In addition, criminal penalties may apply in some cases. A person who knowingly obtains or discloses individually identifiable health information in violation of HIPAA faces a fine of $50,000 and up to one year of imprisonment. The criminal penalties increase to $100,000 and up to five years imprisonment if the wrongful conduct involves false pretenses,

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and up to $250,000 and up to 10 years imprisonment if the wrongful conduct involves the sale, transfer or use of individually identifiable health information for commercial advantage, personal gain or malicious harm. Criminal sanctions are enforced by the Department of Justice. This rule ensures protection for clients by limiting the way covered entities can use personal medical information. The regulations protect medical records and other individually identifiable health information (identifiers) whether it is transmitted in electronic, written, or verbal format. This, then, would include faxes, e-mail, online databases, voice mail, and video recordings, as well as conversations among practitioners. Examples of identifiable health information include: ●● Name or address – including city, state, or ZIP code. ●● Social Security numbers. ●● Dates related to birth, death, admission, discharge. ●● Telephone and fax numbers. ●● E-mail or URL addresses. ●● Medical record numbers, account numbers, health plan beneficiary numbers. ●● Vehicle identifiers such as driver’s license numbers and license plate numbers. ●● Full face photographs distributed by the agency. ●● Any other unique identifier, code, or characteristic used to identify clients is protected under HIPAA. In addition to reasonable safeguards, covered entities are required to develop and implement policies and procedures that limit the sharing of protected health information and to implement them as appropriate for their practices. The policies must limit who has access to protected health information, specify the conditions under which it can be accessed and designate someone to be responsible for ensuring procedures are followed (privacy officer).

It may seem that the law only places limits on the sharing of information; however, it does allow the sharing of protected health information as long the mental health worker takes reasonable safeguards with the information. Some steps professionals can follow include: ●● Ensure that protected health information is kept out of sight. This could mean keeping it in separate, locked files, covering or turning over any material on your desk, or setting your computer to “go blank” after a minute or two in case you walk away. ●● If you must discuss protected health information in a public area, such as a waiting room, hospital hallway, or courtroom, make sure you speak quietly so others cannot overhear your conversation. If this cannot be assured, move to another area or schedule another time to discuss the information. ●● Use e-mail carefully. Make sure you send the information only to the appropriate people. Watch the “CC” lines to make sure your e-mail is not copied to unauthorized parties. Use passwords and other security measures on computers. ●● If you send a fax, don’t leave the material unattended. Make sure that all of the pages go through and check the fax numbers carefully to make sure it is sent to the correct person. You should also add a disclaimer stating that the information in your fax is confidential. ●● Avoid using client names in hallways, elevators, restaurants, etc., unless absolutely necessary. ●● Post signs and routinely review standards to remind employees to protect client privacy. ●● Secure documents in locked offices and file cabinets. Note that there is another law that provides additional protections for clients receiving alcohol and drug treatment. Information is available at the Substance Abuse and Mental Health Services Agency website at www.samhsa.gov.

Supervision and consultation Mental health supervision and management generally include three primary aspects of the supervisory role: 1. Administration. 2. Support. 3. Education. (Kadushin, 1992). While the supervisor of mental health work is increasingly involved in the administrative and political realm, to get the work done, supervision, coaching, mentoring, and consultation remain key roles. Mental health practitioners need to be keenly aware of the role of a supervisor, because he/she is responsible for both the actions and omissions by a supervisee, aka, vicarious liability. To provide competent supervision, supervisors, particularly those in clinical settings, should remember the following: ●● They need to possess the necessary knowledge and skill, and do so only within their area of competence. ●● They must set clear, appropriate, and culturally sensitive boundaries that would include confidentiality, sexual appropriateness and others outlined earlier in this training.

●● They should not engage in dual or multiple relationships with supervisees when there is risk of exploitation or potential harm. ●● They should fairly and respectfully evaluate supervisee performance. ●● They should avoid accepting supervisees when there has been a prior or an existing relationship that might compromise the supervisor’s objectivity. ●● They should take measures to assure that the supervisee’s work is professional. ●● They should not provide therapy to current students or supervisees. Supervisors should consult their particular professional association guidelines regarding supervision, human resource policy, and other applicable resources. Effective and ethical supervisory practices not only benefit the supervisees and their clients but the supervisor as well. Supervisors can manage their vicarious liability in several ways through: ●● Clearly defined policies and expectations. ●● Awareness of high-risk areas. ●● Provision of appropriate training and supervision. ●● Understanding supervisee strengths and weaknesses as practitioners. ●● Developing an adequate feedback system. ●● Supervisors knowing their own responsibilities.

Commitment to employers Several standards that address issues around loyalty and ethical responsibilities in one’s capacity as an employee are formally or informally discussed in professional association ethical guidelines. Generally, mental health practitioners should: ●● Adhere to commitments made to employers. ●● Work to improve employing agencies’ policies, procedures and effectiveness of service delivery. ●● Take reasonable steps to educate employers about mental health workers’ ethical obligations.

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●● Ensure that the employing organization’s practices do not interfere with one’s ability to practice consistent with one’s mental health association professional ethical guidelines. ●● Act to prevent and eliminate discrimination. ●● Accept employment, or refer others to only organizations that exercise fair personnel practices. ●● Be diligent stewards of agency resources. In general, mental health practitioners should support their agency’s mission, vision, and values and also its policies and practices; in essence, maintain loyalty to the organization or agency they are Page 24

committed to. That is not to say one should disregard the profession’s standards and ethical codes of conduct. When an employer engages in unethical practices, whether knowingly or not, the worker still has an obligation to voice those concerns through proper channels and advocate for needed change while conducting oneself in a manner that minimizes disruption. But what does the worker do when faced with an ethical dilemma in the workplace that is not easily solved? This issue has been discussed with regard to the practice of social work when Reamer (1998), in his review of the NASW Code of Ethics, discussed the challenge a social worker may have in deciding whether or not to continue honoring a commitment to the employer: “This broaches the broader subject of civil disobedience, that is, determining when active violation of laws, policies and regulations is

justifiable on ethical grounds. Most social workers acknowledge that certain extraordinary circumstances require social disobedience.” He believes that it is possible to provide clear guidelines about when it is acceptable to break one’s commitment to an employer. He poses several questions that must be explored before taking action: ●● Is the cause a just one? Is the issue so unjust that civil disobedience is necessary? ●● Is the civil disobedience the last resort? ●● Does the act of civil disobedience have a reasonable expectation of success? ●● Do the benefits likely to result clearly outweigh negative outcomes, such as intraorganizational discord and erosion of staff respect for authority? ●● If warranted, does civil disobedience entail the least required to rectify the targeted injustice?

Labor-management disputes Mental health practitioners are generally allowed to engage in organized action, including the formation and participation in labor unions, to improve services to clients and working conditions.

When involved in a dispute, job action, or strike, workers should carefully weigh the possible impact on clients and be guided by their profession’s ethical values and principles prior to taking action.

Professional competence The following guidelines discuss professional competence in mental health practice: ●● Accept responsibilities or employment only if competent or there is a plan to acquire necessary skills. ●● Routinely review emerging changes, trends, best practices in the mental health field and seek ongoing training and educational opportunities. ●● Use empirically validated knowledge to guide practice/ interventions. ●● Disclose potential conflicts of interest. ●● Do not provide services that create a conflict of interest that may impair work performance or clinical judgment.

In addition to education and experience, mental health practitioners need to be cognizant of their personal behavior and functioning and its effects on practice: ●● Refrain from private conduct that interferes with one’s ability to practice professionally. ●● Do not allow personal problems (e.g., emotional, legal, substance abuse) to impact one’s ability to practice professionally, nor jeopardize the best interests of clients. ●● Seek appropriate professional assistance for personal problems or conflicts that may impair work performance or critical judgment. ●● Take responsible actions when personal problems interfere with professional judgment and performance.

Burnout and compassion fatigue An area receiving increasing attention is that of burnout and compassion fatigue. The consequences of burnout and compassion fatigue (or any other form of professional impairment) include the risk of malpractice action. Results from the effects of day-to-day annoyances, overburdened workloads, crisis, and other stressors in the work place, burnout and compassion fatigue can be serious and considered similar in many ways to acute stress and post-traumatic stress disorder. Burnout Burnout is a “breakdown of psychological defenses that workers use to adapt and cope with intense job-related stressors and syndrome in which a worker feels emotionally exhausted or fatigued, withdrawn emotionally from clients, and where there is a perception of diminishment of achievements or accomplishments.” Burnout occurs when gradual exposure to job strain leads to an erosion of idealism with little hope of resolving a situation. In other words, when mental health practitioners experience burnout: ●● Their coping skills are weakened. ●● They are emotionally and physically drained. ●● They feel that what they do does not matter anymore. ●● They feel a loss of control. ●● They are overwhelmed.

Compassion fatigue A newer definition of worker fatigue was introduced late in the last century by social researchers who studied workers who helped trauma survivors. This type of worker fatigue became known as compassion fatigue or secondary traumatic stress (STS.) Mental health practitioners acquire compassion fatigue or STS as a result of helping or wanting to help a suffering person in crisis. As a result, they often feel worthless and their thinking can become irrational. For example, they may begin to irrationally believe that they could have prevented someone from dying from a drug overdose. Burnout is gradually acquired over time and recovery can be somewhat gradual. Compassion fatigue surfaces rapidly and diminishes more quickly. Both conditions can share symptoms such as emotional exhaustion, sleep disturbance, or irritability. Dealing with burnout and compassion fatigue A professional mental health practitioner can take steps to increase her or his ability to cope and achieve balance in life. Maintaining a healthy lifestyle balance and recognizing the signs of burnout and compassion fatigue are one thing: the responsible mental health clinician will also take action, such as a vacation break or change in schedule or job duties. Practitioners also need to not only be aware of the signs and symptoms of burnout and compassion fatigue, but more importantly, the situations that may set the stage for their occurrence. Ongoing supervision is the mental health practitioner’s best defense. In addition, ongoing supervision and regular supportive contact with other practitioners to prevent isolation is recommended. Houston-

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Vega, Nuehring, and Daguio (1997), recommend the following measures to help prevent burnout or compassion fatigue: ●● Listen to the concerns of colleagues, family, and friends. ●● Conduct periodic self-assessments.

●● Take needed “mental health days” and use stress-reduction techniques. ●● Arrange for reassignment at work, take leave, and seek appropriate professional help as needed.

Related personal and professional integrity issues

Mental health practitioners must also address issues related to personal and professional integrity. They are: ●● Dishonesty, fraud, and deception. ●● Misrepresentation. ●● Solicitations. ●● Acknowledging credit. Practitioners have an obligation to avoid actions that are dishonest, fraudulent, or deceptive. Such actions, or in some cases, lack of action, put the continued integrity of both the individual mental health worker and the profession at risk. Some examples include: ●● Falsifying records, forging signatures, or documenting services not rendered. ●● Embellishing one’s education and experience history or qualifications (refer also to “misrepresentation”). ●● Lying to a client or their family to “protect” them from unpleasant information. ●● Not sharing legitimate options to a client because they violate the professional’s beliefs. ●● Misleading potential donors or current funders with false outcome data.

Misrepresentation occurs when mental health professionals present opinions, claims, and statements that are either false or lead the listener to believe facts that are not accurate. Three actions must be taken to ensure that clients and the public receive accurate information: 1. Clearly distinguish between private statements and actions, and those as representative of an organization, employer, etc. 2. Accurately present the official and authorized positions of the organization they are representing and/or speaking on behalf of. 3. Ensure accurate information about, and correct any inaccuracies regarding professional qualifications/credentials, services offered and outcomes/results. Client solicitation stems from a concern for clients who, due to their situation, may be vulnerable to exploitation or undue influence. Because of their circumstances, there is also the potential for manipulation and coercion. As such, mental health practitioners should refrain from doing the following: 1. Engage in uninvited solicitation. 2. Solicit testimonial endorsements from current clients or other potentially vulnerable persons. Mental health practitioners also have an ethical responsibility to the contributions of others by acknowledging credit. They should: 1. Take responsibility and credit only for work they have actually performed and contributed to. 2. Honestly acknowledge the work and/or contributions of others.

Ethical responsibilities to colleagues Licensed mental health practitioners should not only take responsibility for their own actions, but also take actions that ensure the safety and well-being of any clients served by others in the mental health profession. Thus, their responsibilities include: ●● Duty to clients. ●● Duty to colleagues. ●● Indirectly, duty to the mental health profession. In addition, they demonstrate further ethical responsibility by: ●● Respecting and fairly representing the qualifications, views and obligations of colleagues. ●● Respecting shared, confidential information. ●● Promoting interdisciplinary collaboration. ●● Not taking advantage of disputes between colleagues and employers or exploiting clients in disputes with colleagues.

●● Seeking advice and counsel of colleagues who have demonstrated knowledge, expertise and competence so as to benefit the interests of clients. ●● Referring clients, without payment for such, to qualified professionals and transferring responsibilities in an orderly fashion. ●● Consulting and assisting impaired and/or incompetent colleagues; and addressing impairments through proper channels when they are unable to practice effectively (e.g., reporting to professional associations or licensing and regulatory bodies). ●● Discouraging unethical conduct of colleagues; being knowledgeable about established procedures, and taking action as necessary through appropriate formal channels. ●● Defending and assisting colleagues who are unjustly charged with unethical conduct.

Ethical responsibilities to the mental health profession In general, national mental health professional associations discuss the responsibility to help maintain the integrity of their particular mental health focus, as well as issues related to mental health work evaluation and research. Maintaining the integrity of the profession is a responsibility of every licensed mental health professional and requires the active participation of each person whether it be collaborating on the creation of new standards, continuing to challenge mediocrity or complacency, or taking advantage of educational opportunities. Mental health professionals should demonstrate the following integrity safeguards:

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●● Maintain and promote high standards of practice. ●● Uphold and advance the values, ethics, knowledge, and mission of the profession through study, research, active discussion and reasonable criticism. ●● Contribute time and professional expertise to activities that promote respect for the value, integrity and competence of the profession. ●● Contribute to the knowledge base and share with colleagues their knowledge related to practice, ethics, and research. ●● Act to prevent unauthorized/unqualified practice of mental health work.

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More about informed consent The issue of informed consent relates closely to one of the most important values of ethical mental health practice: Self-determination. In order for informed consent to be valid, the following must be met: 1. Consent must be given voluntarily by a person of legal age. 2. The individual must be competent to refuse or to consent to treatment. 3. The client must be given thorough, accurate information about the service so she or he may weigh the benefits and risks of treatment. One of the newest challenges for mental health practitioners is the issue of informed consent in e-therapy. Kanani and Regehr (2003) point out the following reasons for this:

1. Anonymity on the Internet makes it more difficult to determine the client’s mental capacity and/or legal age. 2. Potential conditions, such as suicidal behaviors and eating disorders, may not be suitable for online therapy. 3. There is limited empirical research available, thus limiting both the practitioner and clients’ understanding of the efficacy and the risks associated with e-therapy. 4. Internet identity issues place more burden on the practitioner to determine whether the client is legally and ethically able to consent.

Ethics for specialized practice areas Responsible mental health practice can be found in a variety of settings and address multiple issues. As the world changes, practitioners are increasingly challenged to broaden their knowledge and adopt practices that meet the unique needs of their service populations and settings. Currently, most mental health associations provide additional guides or standards of practice that address areas including: substance

abuse, health care, marriage and family issues, couples work, clinical social work, child welfare, palliative/end of life care, work with adolescents, and long-term care. They also publish standards that address issues such as technology. It is helpful to review the relevant issue of technology and the impact on mental health practice.

Technology While there are many individuals who are hesitant to embrace new technology that can enhance best practice, one cannot ignore its many benefits. Currently, mental health professionals can use technology, particularly the Internet, to conduct research, provide e-therapy when permitted, advertise their services, and communicate on a global scale with both clients and other professionals. E-mail, though fraught with potential for security violations and miscommunication, has certainly increased the efficiency and speed with which people can communicate in another region. For example, a mental health researcher can conduct a search on the Internet to inquire about and then contact another professional in anther region to investigate innovative approaches to service delivery. Software applications (e.g., basic word processing, financial management systems and documentation templates) assist practitioners with service planning, delivery, evaluation and reporting. And wireless technology allows better utilization of their time away from the office. Cell phones have greatly increased accessibility as well. Mental health practice would be different without technology. National mental health associations, along with others, are continuing to develop and publish guidelines to assist practitioners in the appropriate use of technology, including those who provide virtual therapy services. Technology and practice are generally defined as any electronically mediated activity used in the conduct of competent and ethical delivery of services. For example, a copy of the standards as developed by NASW and ASWB is available for both review and print at: http://www.socialworkers.org/ practice/default.asp and is summarized as follows. Social workers shall: ●● Act ethically, ensure professional competence, and uphold the values of the profession.

●● Have access to, and ensure their clients have access to, technology and appropriate support systems. ●● Select and develop culturally competent methods and ensure that they have the skills to work with persons considered vulnerable (e.g., persons with disabilities, for whom English is not their primary language). ●● Increase their proficiency in using technology and tools that enhance practice. ●● Abide by all regulations in all jurisdictions in which they practice. ●● Represent themselves accurately and make attempts to confirm the identity of the client and their contact information. ●● Protect client information in the electronic record. ●● Provide services consistent with accepted standards of care, regardless of the medium used. ●● Use available technology to both inform clients and mobilize individuals in communities so they may advocate for their interests. ●● Advocate for technologies that are culturally sensitive, community specific, and available for all who can benefit from it. ●● For those in administrative practice, keep themselves informed about technology that can advance quality practice and operations, invest in systems, and establish policies that ensure security and privacy. ●● Conduct a thorough assessment, including evaluation of the appropriateness of potential clients for e-therapy. This includes the need for the social worker to fully understand the dynamics involved and the risks and benefits for the client. ●● Evaluate the validity and reliability of research collected through electronic means and ensure the client is likewise informed. ●● Continue to follow applicable standards and laws regarding supervision and consultation. ●● Adhere to NASW standards for continuing professional education and applicable licensing laws regarding continuing education.

Virtual or e-therapy Depending on their mental health focus and where they practice, many mental health practitioners offer online therapy services through realtime chats, e-mail, videoconferencing, telephone conferencing, and instant messaging. The benefits touted by supporters of online therapy, as described by Kanani and Regehr (2003), include the ability to: ●● Serve millions of people who would otherwise not participate (e.g., people with certain conditions, such as agoraphobia, persons

living in remote locations, or those concerned about the stigma of counseling). ●● Decrease inhibitions clients may have about fully disclosing relevant information. ●● Increase the thoughtfulness and clarity of communication as an unintended byproduct of written communication.

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●● Produce a permanent record that can be easily referred to and forwarded to clients or colleagues for review and consultation purposes. ●● Substantially reduce overhead costs, thus reducing costs for the consumer. As discussed earlier in this training, one of the major areas still under debate as a result of this new technology is that of jurisdiction. Here are some thought-provoking considerations. ●● When the client lives in a different state, it is difficult to avoid violating licensure laws because it is still unclear as to which state’s laws would be applicable. ●● Is the origin or location of counseling in the client’s community, the therapist’s, or is it somewhere in cyberspace? ●● What defines location, if a busy executive is involved in an online session while flying from Tucson to Bangkok?

This is clearly an ambiguous area that will undoubtedly continue to be debated. Kanani and Regehr (2003) have summarized some of the other concerns raised by others regarding the use of e-therapy: ●● E-therapy does not allow practitioners to observe and interpret facial expressions and body language. ●● The Internet poses a serious risk to security, and thus, to confidentiality. ●● Inappropriate counseling may occur due to therapist ignorance about location-specific factors related to the client (e.g., living conditions, culture). ●● Clients cannot be sure as to the credentials, experience, or even identity of the person they are trusting to provide services. ●● Clients may not have any legal recourse for malpractice, given unresolved questions about jurisdiction and standards of care.

Limiting risk in the practice of e-therapy Matthew Robb recommends these points for those practicing e-therapy: ●● Full disclosure – This relates to informed consent and the need to fully disclose the possible benefits and risks of distance counseling, including informing the client that this is a new area of practice, which has not had the benefit of long-term study. ●● Comprehensive assessment – Provide clients with detailed and complete assessment tools and encourage full disclosure by client. ●● Confidentiality and disclosure of safeguards – Take all precautions to safeguard the confidentiality of information and avoid misdirected e-mails, eavesdropping, hacking, etc. Alert the client to these potential risks as well. ●● Emergency contact – Obtain information for an emergency contact and together develop a clear emergency plan.

●● Consult your association’s code of ethics – Review standards regarding informed consent, confidentiality, conflict of interest, misrepresentation, etc. ●● Consult state licensing provisions – Research both the statutory regulations of your board, as well as those in the client’s home state. ●● Consult a malpractice/risk management attorney – Consider asking a legal specialist to review website materials to determine compliance with standards of care and potential malpractice issues. ●● Provide communication tips – If communicating solely by text-based messaging, provide client with clear tips regarding communication.

Conclusion Ethical dilemmas are varied, common and complex. Ethical decisionmaking can be difficult, as well as time-consuming, while sometimes, mental health practitioners are still left with a little ambivalence and uncertainty following their decision. Typically, there will be more than one person involved with the ethical decision-making process. It is always important to keep in mind the power of supervision and consultation regarding any mental health practice. With an ethical dilemma, this cannot be overstated.

presentation also does not constitute legal advice. If there is any discrepancy between the provisions of the HIPAA Privacy Rule, other laws or regulations, and the material in this presentation, the terms of the laws, rules, professional guidelines and regulations will govern in all cases. This information is not intended to describe all of the national mental health associations’ guidelines, but to ensure that learners are guided by their particular association’s code of ethics and state licensing regulations in order to make the most appropriate ethical decisions.

This information is not intended to provide all of the details of the HIPAA Privacy Rule, or of any other laws or guidelines. This

Any case examples used within this course do not reflect actual individuals.

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Ethics And Boundaries Final Examination Questions

Select the best answer for each question and proceed to SocialWork.EliteCME.com to complete your final examination. 11. The word ethics means: a. The word “ethics” is derived from both the Greek word “ethos,” which means character, and the Latin word “mores,” meaning customs. b. Ethics defines what is good for both society and the individual. c. Though closely related, law and ethics do not necessarily have a reciprocal relationship. d. All of the above. 12. Which of the following are NOT ACCURATE? a. The origins of law can often be based upon ethical principles. b. Laws prohibit many unethical behaviors. c. Adherence to certain ethical principles may challenge a mental health practitioner’s ability to uphold the law. d. All of the above. 13. The following are correct EXCEPT: a. Ethical standards are, according to Reamer (Ethical Standards in Social Work, 1998), created to help professionals identify ethical issues in practice. b. Provide absolute rules to determine what is ethically acceptable and unacceptable behavior. c. What makes mental health work unique is its focus on the person as well as its commitment to the well-being of society as a whole. d. All of the above. 14. Which of the following are accurate EXCEPT? a. The social work profession adopted the first code of ethics for the profession in 1947. b. In 1990, following the formation of the National Association of Social Work, another code of ethics was drafted, with multiple revisions in the following years. c. Ethics have been developed for other national mental health licensing associations and boards that include among others, The American Association for Marriage and Family Therapy, The American Counseling Association, and The American Mental Health Association. d. All of the above. 15. Which of the following are NOT CORRECT? a. The American Association for Marriage and Family Therapy “strives to honor the public trust. b. Marriage and family therapists sets standards for ethical practice as professional. expectations” that are enforced by the laws of the state ethics committee. c. The American Counseling Association “promotes ethical counseling practice in service to the public.” d. The primary mission of the National Association for Social Workers is to “enhance human well-being and help meet the basic human needs of all people.

16. Which of the following statements are CORRECT? a. When an individual identifies with a mental health profession, he or she is pledging to practice in an ethical and responsible manner. b. And allegiance to the professional ethics and standards of practice it promotes. c. The individual also has a duty to support the values, rules, laws, and customs of the community they serve and not the one in which they remain a part. d. All of the above. 17. Which of the following are NOT CORRECT? a. Currently the United States, including all 50 states regulate some form of mental health practice. b. The District of Columbia, Puerto Rico, the U.S. Virgin Islands are not included. c. Many typically regulate practice through statutes, i.e., practice acts that stipulate who may practice. d. All of the above. 18. State oversight boards give authority to practice to qualified individuals, typically defined by three competencies: a. Education, experience, passing score on an examination. b. Empathy, ethics, evaluation. c. Education, empathy, enlightenment. d. None of the above. 19. Failure to abide by these regulations can: a. Have serious and negative legal and financial consequences. b. Mental health professionals need to understand that they may not be covered by their insurance policy if they were not practicing legally at the time of a questionable ethical occurrence. c. There are also laws that impose legal obligations to abide by practices that further serve to protect the consumer. d. All of the above. 20. State statutes DO NOT require: a. Mandatory child abuse reporting, practices that ensure client confidentiality, or competence to perform certain services. b. Unlike regulation under the law, adherence to regulations set forth by private credentialing bodies is voluntary. c. The regulations and codes of ethics are universally respected but do not have to be followed to remain in professional practice. d. Mental health professionals also practice in accordance to the professional standards of care established by private professional association organizations such as ACA, NASW, or AAMFT.

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21. Failure to follow the ethical codes of one’s profession may result which of the following? a. Expulsion from the profession, sanctions, fines. b. If sued, in a judgment against the practitioner. c. All of the above. d. None of the above. 22. Ethics violations are clustered into 10 categories, which include the following EXCEPT: a. Violating boundaries, collegial actions. b. Poor practice, competence, honesty. c. Record keeping, confidentiality, informed consent. d. False credentials, lack of education. 23. Which of the following statistics are CORRECT? a. Of the 267 individuals found to have violated ethical standards, 26 percent were found to have violated only one ethics category. b. 74 percent had violated more than one category. c. Most of the cases (55 percent) involved boundary violations, such as those involving sexual relationships and dual relationships. d. All of the above. 24. The findings reflected a variety of inappropriate behaviors that blurred the helping process and exploited clients including the following EXCEPT: a. The use of physical contact in treatment. b. The pursuit of sexual activity with clients, either during or immediately after treatment. c. Prescribing illegal drugs. d. Bartering. 25. Specific Ignorance includes which of the following? a. The principle (or rationalization) of specific ignorance states that even if there is a law prohibiting an action, what you do is not illegal as long as you are unaware of the law. b. The rationalization that if you can get away with it is OK. c. No one will believe the patient over the therapist anyway. d. All of the above.

27. Ethical standards of practice for mental health generally benefit both the practitioner and the public and include the Following EXCEPT: a. Identifying core values. b. Establishing a set of specific ethical standards that should be used to guide mental health practice. c. Identifying relevant considerations when professional obligations conflict or ethical uncertainties arise. d. Providing ethical standards to which the law can hold mental health professionals accountable. 28. The core values espoused by mental health ethics codes incorporate a wide range of overlapping morals, values, and ethical principles that lay the foundation for the profession’s unique duties. They generally include: a. Service. b. Autonomy, allowing for freedom of choice and action. c. Responsibility to clients, responsibility to the profession, responsibility to social justice, responsibility for doing no harm. d. All of the above. 29. Six areas of professional functioning include the following EXCEPT: a. To clients, to colleagues, to practice settings. b. As professionals, to a particular mental health profession. c. Not to the broader society. d. All of the above. 30. Actions designed to prevent harm to the client include the following: a. Limit practice to those populations that do not cause your own needs to surface. b. Seek clinical supervision to effectively deal with personal feelings. c. Document surroundings and who was present during sessions and visits. d. All of the above.

26. The principle (or rationalization) of literalization states: a. Since it is not found in any legal, ethical, or professional standards it must be an original work or clinical break through. b. That if we cannot find a specific mention of a particular incident anywhere in legal, ethical, or professional standards, it must be ethical. c. No one will know what happens in a confidential setting. d. None of the above.

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Chapter 3:

The Heroin Abuse Epidemic in America: Identification, Treatment and Prevention 4 Contact Hours

By: Deborah Converse, MA, NBPTS

Learning objectives Upon completion of this course, the student will master the following objectives: ŠŠ Discuss the composition and properties of three types of heroin and the effect of the drug on the brain. ŠŠ Identify three ways heroin is introduced into the body and compare and contrast the effects of the three types of transmission

ŠŠ Describe two categories of signs and symptoms of heroin use and give four examples of each. ŠŠ Explain the differences between the psychological and physical effects of short-term and chronic heroin use, and give four examples of each. ŠŠ Discuss immediate and long-term treatment methods and including three evidence-based therapies to treat heroin use.

Introduction The purpose of this course is to familiarize professionals with basic information concerning heroin addiction, which has reached epidemic proportions in the United States and around the globe. This includes facts about heroin and addiction, effects on the brain, progression of the disease, psychological and physical effects of short-term and chronic use, screening, treatment, and prevention. The course covers

background information and statistics on the escalation of heroin addiction in the United States from 1850 to 2014 including causative factors. The review includes evidence-based treatment and prevention programs, as well as the current trends in progress to advance prevention and treatment of the disease.

Background Addiction to opiates, in the form of opium, became a significant problem in the United States during the 1850s. Morphine was introduced as a replacement because it was thought to be weaker and non-addictive. Soon, morphine addiction became an even larger problem, and the solution was the introduction of heroin. Heroin, also thought to be nonaddictive, was developed in 1898 by the Bayer pharmaceutical company in Germany as a treatment for tuberculosis and to address morphine addiction1. The addiction cycle continued because heroin turned out to be even more addictive than morphine. Continuing the cycle,

methadone was introduced to address heroin addiction. Methadone was also developed in Germany in 1937 as an anesthesia for surgery and was exported to the United States in 1947 under the name “Dolophine”1. Methadone was later used to treat heroin addiction but brought with it a new set of problems if not managed properly. Heroin rapidly became a significant health problem in the United States, and over the next 150 years, the death rate due to heroin addiction has soared to 20 times higher than the drug-free population.

What is heroin and how does addiction happen? Heroin is part of the class of drugs called opioids. The name relates to the heroin molecule that binds to the opioid receptors in the body. The term “opiates” refers to natural, or semi-natural opioids, and heroin has the chemical name diacetylmorphine. Heroin is derived from morphine which occurs naturally in the latex sap of the seed pod of opium poppy plants, which grow in Mexico, Columbia, Turkey, Asia, Afghanistan, and parts of Europe2. Heroin and morphine bind to the opioid receptors in the brain and body but heroin binds more effectively, enhancing pain relief and euphoria in the addict. Heroin and morphine, along with codeine, hydrocodone, oxycodone, and oxymorphone are similar in structure because they all bind to the opioid receptor. Many substances can be used to cut heroin, including sugar, caffeine, flour, baby powder, starch, powdered milk, quinine, strychnine, other poisons and drugs which increase the likelihood of death. Strychnine, rat poisoning, is deadly and if ingested, the person will show behavioral effects similar to other drug-induced behaviors, but marked physical symptoms include muscle tightness, pain, spasms in the muscles and jaw, rigidity of the arms and legs, and arching of the neck and back2. Heroin may be adulterated with compounds that are added to cheaply enhance the euphoric effects. Examples of adulterants are acetaminophen,

opiate painkillers, or anesthesia-like xylocaine. Users think that their numbness and “high” is coming from high quality heroin, when in fact, it is due to the combination of an adulterant. Sometimes adulterants produce the opposite effects to heroin, such as cocaine or other stimulants, and this combination can cause lethal effects on the central nervous system. Other adulterants, such as fentanyl, can be lethal because it is 200 times more potent than heroin. In March 2014, 22 people in Pennsylvania died due to overdose, in which stamp-sized bags of heroin were mixed with prescription fentanyl7. Fentanyl is a synthetic opioid that binds to the opioid receptors in the brain, and when combined with heroin, produces a deadly high3. The danger is that users will take the same dose of heroin as usual, but the effects may be enough to stop their breathing or heart due to central nervous system depression. Other dangerous adulterants, such as levamisole accelerate the heart rate and destroy the immune system, which leads to life-threatening infections throughout the body3. Not only do the addicts buying heroin on the street not know what substances are used to cut the drug, they also do not know the potency of the drug. The purity or the heroin can increase the chance of overdose and death. Street heroin is sold in different forms including black tar, brown powder, and white powder heroin. The purest form is a white powder that may be rose or gray depending on which diluting substances are used to “cut” the heroin to increase the bulk, weight, and profit.

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Black tar heroin is identified as a ball or chunk of hard, sticky, black or brown material, which is the cheapest and easiest form to make because it is incompletely processed from opium1. The next level of processing uses lactose as a diluting agent, which produces brown powder heroin. Some darker colored heroin contains dirt, ground-up brown paper, and black shoe polish as fillers. Contaminants and bacteria in black tar heroin have been known to carry allergens, botulism spores, and necrotizing bacteria causing poisoning, tissue damage, toxic shock, and death2. Death may also occur because these contaminants may not dissolve, thus blocking arteries and veins, which cut off blood and oxygen supply causing a deadly aneurism, stroke, or heart attack. Decreased blood flow due to contaminants may also lead to damage, infection, and ultimately failure of vital organs, as well as convulsions and death. Street heroin can range from highly potent to forms that are mostly fillers, adulterants, and garden-variety contaminants, but all forms of heroin are dangerous, especially when injected. During the process of manufacturing heroin, a number of chemicals may be left behind, including calcium oxide, ammonia, chloroform, hydrochloric acid, and acetic anhydride, which are all lethal ingredients2. White powder heroin is a salt form known as diacetylmorphine hydrochloride, and even though white heroin is the purest form, it will still contain lethal contaminants. The purer the heroin, the whiter and shiner it appears, while the more heavily cut heroin will appear duller in color2.

When injected, heroin enters blood stream and the effects are felt within seconds, as opposed to snorting or smoking the drug, in which it may take the user ten to fifteen minutes to feel the effects. Immediately following the heroin injection, users often describe feeling a strong euphoric “rush” or a sensation of exhilaration, euphoria, extroversion, enhanced sensations, increased social and communication skills, heightened sexual performance, and a general feeling of well-being1. Less pleasant are the dry mouth; warm, flushed skin; heavy arms and legs; and confused mental state. After the euphoria, users experience feeling alternately drowsy and awake, often described as being “on the nod”.2 When the drug is smoked or snorted the initial powerful rush of euphoria may absent but the later effects will be the same. Users often start by smoking or snorting heroin but progress to injecting to get the enhanced rush. When heroin enters the body and crosses the bloodbrain barrier, it is changed to morphine and binds to opioid receptors that are located throughout the brain and body3. Opioid receptors transmit nerve signals in the brain centers involved in signaling pain/ pleasure perception, motivation, and reward. Heroin initially increases pleasurable feelings, decreases pain, and motivates the user to seek the “reward” of another heroin high. Opioid receptors located in the brain stem control nervous system function that signal critical processes such as blood pressure and respiration8. Heroin overdose often involves a suppression of breathing, due to the effects of heroin that cancel the signal for the body to breathe, often with deadly results.

Tolerance and dependence Over time with chronic heroin use, the structure and function of the brain changes. These changes cause individuals to develop tolerance to the drug, requiring increasingly larger amounts to reach a high. The next progressive stage is physical heroin dependence and individuals

need to use the drug to avoid withdrawal symptoms known as drug sickness. Psychological dependence follows in which users believe they cannot live without heroin and drug-seeking behaviors motivate their every action.

Withdrawal Severe withdrawal symptoms occur if individuals try to taper or stop their heroin use. In a few hours after the last heroin dose, the person will begin to feel withdrawal symptoms which may include vomiting, anxiety, insomnia, diarrhea, chills, muscle spasms, panic,

hyper movements, and severe drug cravings8. It is very difficult and medically dangerous for the individual to go through withdrawal without medical assistance, and individuals will likely relapse to avoid the sickness of withdrawal.

Definitions The following definitions are included in the National Institute for Drug Addiction (NIDA) publication on the Science of Drug Abuse and Addiction3. ●● Addiction: A chronic, relapsing disease, characterized by compulsive drug seeking and use accompanied by neurochemical and molecular changes in the brain. (See below.) ●● Agonist: A chemical compound that mimics the action of a natural neurotransmitter and binds to the same receptor on nerve cells to produce a biological response. ●● Antagonist: A drug that binds to the same nerve cell receptor as the natural neurotransmitter but does not activate the receptor, instead blocking the effects of another drug. ●● Anxiety disorders: Varied disorders that involve excessive or inappropriate feelings of anxiety or worry. Examples are panic disorder, post-traumatic stress disorder, social phobia, and others. ●● Attention-deficit hyperactivity disorder: (ADHD): A disorder that typically presents in early childhood, characterized by inattention, hyperactivity, and impulsivity. ●● Anxiety disorders: Varied disorders that involve excessive or inappropriate feelings of anxiety or worry. Examples are panic disorder, post-traumatic stress disorder (PTSD), social phobia, and others. ●● Buprenorphine: A partial opioid agonist for the treatment of opioid addiction that relieves drug cravings without producing the “high” or dangerous side effects of other opioids. ●● Bipolar disorder: A mood disorder characterized by alternating episodes of depression and mania or hypomania.

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●● Co-morbidity: The occurrence of two disorders or illnesses in the same person, either at the same time (co-occurring co-morbid conditions) or with a time difference between the initial occurrence of one and the initial occurrence of the other (sequentially comorbid conditions). ●● Conduct disorder: A repetitive and persistent pattern of behavior in children or adolescents in which the basic rights of others or major age-appropriate societal norms or rules are violated. ●● Craving: A powerful, often uncontrollable desire for drugs. ●● Depression: A disorder marked by sadness, inactivity, difficulty with thinking and concentration, significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and, sometimes, suicidal thoughts or an attempt to commit suicide. ●● Detoxification: A process of allowing the body to rid itself of a drug while managing the symptoms of withdrawal; often the first step in a drug treatment program. ●● Dopamine: A brain chemical classified as a neurotransmitter, found in regions of the brain that regulate movement, emotion, motivation, and pleasure. ●● Dual diagnosis/mentally ill chemical abuser (MICA): Other terms used to describe the co-morbidity of a drug use disorder and another mental illness. ●● Major depressive disorder: A mood disorder having a clinical course of one or more serious depression episodes that last two or more weeks. Episodes are characterized by a loss of interest or pleasure in almost all activities; disturbances in appetite, sleep, or psychomotor functioning; a decrease in energy; difficulties in Page 32

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thinking or making decisions; loss of self-esteem or feelings of guilt; and suicidal thoughts or attempts. Mania: A mood disorder characterized by abnormally and persistently elevated, expansive, or irritable mood; mental and physical hyperactivity; and/or disorganization of behavior. Mental disorder: A mental condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological or behavioral functioning of the individual. Addiction is a mental disorder. Methadone: A long-acting opioid agonist medication shown to be effective in treating heroin addiction. Naloxone: An opioid receptor antagonist that rapidly binds to opioid receptors, blocking heroin from activating them. An appropriate dose of naloxone acts in less than two minutes and completely eliminates all signs of opioid intoxication to reverse an opioid overdose. Naltrexone: An opioid antagonist medication that can only be used after a patient has completed detoxification. Naltrexone is not addictive or sedating and does not result in physical dependence; however, poor patient compliance limits effectiveness. A new, long-acting form of naltrexone called Vivitrol® is now available that is injected once per month, eliminating the need for daily dosing, improving patient compliance. Neonatal abstinence syndrome (NAS): NAS occurs when heroin from the mother passes through the placenta into the baby’s bloodstream during pregnancy, allowing the baby to become addicted along with the mother. NAS requires hospitalization and treatment with medication (often a morphine taper) to relieve symptoms until the baby adjusts to becoming opioid-free. Neurotransmitter: A chemical produced by neurons to carry messages from one nerve cell to another. Opioid: A natural or synthetic psychoactive chemical that binds to opioid receptors in the brain and body. Natural opioids include morphine and heroin (derived from the opium poppy) as well as opioids produced by the human body (e.g., endorphins); semi-synthetic or synthetic opioids include analgesics such as oxycodone, hydrocodone, and fentanyl. Opioid use disorder: A problematic pattern of opioid drug use, leading to clinically significant impairment or distress that includes

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cognitive, behavioral, and physiological symptoms as defined by the new Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) criteria. Diagnosis of an opioid use disorder can be mild, moderate, or severe depending on the number of symptoms a person experiences. Tolerance or withdrawal symptoms that occur during medically supervised treatment are specifically excluded from an opioid use disorder diagnosis. Partial agonist: A substance that binds to and activates the same nerve cell receptor as a natural neurotransmitter but produces a diminished biological response. Physical dependence: An adaptive physiological state that occurs with regular drug use and results in a withdrawal syndrome when drug use stops. Post-traumatic stress disorder (PTSD): A disorder that develops after exposure to a highly stressful event (e.g., wartime combat, physical violence, or natural disaster). Symptoms include sleeping difficulties, hyper-vigilance, avoiding reminders of the event, and reexperiencing the trauma through flashbacks or recurrent nightmares. Psychosis: A mental disorder (e.g., schizophrenia) characterized by delusional or disordered thinking detached from reality; symptoms often include hallucinations. Schizophrenia: A psychotic disorder characterized by symptoms that fall into two categories: (1) positive symptoms, such as distortions in thoughts (delusions), perception (hallucinations), and language and thinking; and (2) negative symptoms, such as flattened emotional responses and decreased goal-directed behavior. Self-medication: The use of a substance to lessen the negative effects of stress, anxiety, or other mental disorders (or side effects of their pharmacotherapy). Self-medication may lead to addiction and other drug- or alcohol-related problems. Rush: A surge of euphoric pleasure that rapidly follows administration of a drug. Tolerance: A condition in which higher doses of a drug are required to produce the same effect as during initial use; often leads to physical dependence. Withdrawal: A variety of symptoms that occur after use of an addictive drug is reduced or stopped.

The definition of addiction It is well documented that heroin is a highly addictive substance and addiction can occur with only one use. In order to fully understand the process of addiction, professionals must first understand heroin addiction, treatment, and prevention. The American Society for Addiction Medicine in their Public Policy Statement included the following short definition addiction4: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by4: ○○ Inability to consistently abstain. ○○ Impairment in behavioral control.

○○ Impairment in cognitive functioning. ○○ Craving. ○○ Diminished recognition of significant problems with one’s behaviors and interpersonal relationships. ○○ Dysfunctional emotional response. ○○ Cycles of relapse and remission. ○○ Progression that can result in disability or premature death. As each stage of tolerance, dependence, and addiction progresses, the user requires increasing amounts of heroin to feel pleasure and combat the pain and sickness that now occurs as the body goes through withdrawal. This class of drugs is known by the name opioids or opiates. As defined by the DEA, heroin is a Schedule 1 substance under the Controlled Substances Act, which means it has high potential for abuse, no accepted medical use for treatment in the United States, and lacks accepted safety for use even under medical supervision7.

Today’s heroin epidemic Heroin was formerly viewed as a drug only found in back alleys of large urban areas. Today heroin addiction is found in every corner of the country and affects people of all ages in every socio-economic group in epidemic proportions. Heroin addiction still carries the stigma that it is a behavior or character flaw, though it affects a wide crosssection of America. No one is spared, from movie stars, such as Philip Seymour Hoffman who died from a heroin overdose after 20 years, to teenagers in suburbia and the homeless on inner-city streets.

The most alarming statistics show heroin addiction among youth is increasing in children as young as nine6. A number of factors contribute to this epidemic by making the drug inexpensive and readily available. As the use of heroin became more widespread in contemporary culture, it became more accepted among certain segments of society. Rock stars, actors, fashion models, photographers, and other celebrities in popular culture abuse heroin, and their deaths are almost commonplace today. In fact, the “heroin look” became popular in the fashion world in the mid 90’s and was characterized by a thin, pale, emaciated appearance,

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blank expression, dark sunken eyes, dirty hair, and disheveled clothing. Popular music and advertising campaigns included references to heroin abuse and death had the effect of making the drug seem safe, exciting, glamorous, and mainstream in the eyes of impressionable youth. Young people who would never inject a drug can now find heroin that can be smoked or inhaled. This makes heroine seem easier, safer, and more desirable, thus increasing their willingness to try the drug7. Many youth have become addicted, comatose, or have died after only one dose of heroin. If individuals survive the first dose and continues to use heroin, they quickly develop a tolerance to the previous amount used and must have increasing amounts of the drug to replicate the high they experienced the first time. When the high from smoking and snorting is no longer enough, as tolerance develops, users may inject the drug to enhance the rush and get the most they can from the amount they have. As the amount used and the frequency of use escalates, so does the danger of overdose. Similarly, if drug use is curtailed through incarceration or time in rehabilitation, users may overdose and die when they return to using heroin at the previous level. Sadly, another factor in the increasing number of deaths from heroin abuse is that those around them are unable or unwilling to summon help when problems occur. Death usually occurs due to the drug’s suppressive effects on the automatic breathing response of the victim, which can be easily reversed through mechanical measures or medication to restore breathing3.

Families, schools, health agencies, local, state and federal agencies across the country are now focused on addressing the epidemic rates of addiction and death caused by heroin. Heroin today is very different from the drug initially developed and can be found in many multiple drug combinations. With continued use, these euphoric feelings become more difficult for users to reach, and over time, the body tries to adjust to the damage caused by the drug. Individuals become addicted to heroin quickly and their immune and body systems are damaged, leaving the individual weak, sick, malnourished, thin, and if untreated, they will die. One addict reported from the time she started using heroin she never stopped, and in a week she went from snorting it to injecting and was addicted in a month.5 To support her habit, she sold everything she had, stole all she could from her family, ran her credit cards to the limit, sold her car, lost her job and house and became homeless. While living on the street she was raped, robbed, beaten, sick, and in constant fear for her life and desperate for her next heroin hit. She realized she would die and felt that living as a junkie was worse than death, so she sought help from a local agency and continues to struggle to end her addiction. Research into treatment and prevention programs around the world produced promising results, but it has not kept pace with the rampant addiction and death caused by heroin. The frequency of overdose among youth has increased so drastically that some states now allow family members to administer antidotal drugs in cases of near death that were previously only used by medical personnel.

Why heroin, why today? Heroin abuse and addiction has replaced other high-priced, commonly abused opiates and became the drug of choice in the United States, increasing rapidly since 20106. The general public was largely unaware of the epidemic until recent widespread media attention brought heroin addiction and death to the forefront and demands for solutions came from Vermont to California. The war against heroin must be fought on many fronts, and medical and mental health personnel must lead the charge. Typically the drug is supplied by Mexican cartels, for just $10 a hit called a “stamp bag,” and has gone up 600 percent in the last 10 years across the country7. As the United States cracks down on the sale of opiates such as Oxycodone by closing down pill mills throughout the country, an 80 milligram Oxycontin dose now costs $100, which makes heroine cheaper and easier to obtain7. Manufacturers are also making opiates and other prescription drugs in formulas that are more difficult for users to snort or dissolve to inject. Another reason heroin use is thought to have doubled in five years relates to the high rate of addiction to prescription opiate painkillers now replaced by heroin, which is a natural opiate. Approximately 34,000 12-17-year-olds experiment with heroin each year due to lower costs of the drug and its availability6. Even though heroin abuse exists throughout the United States, large cities are reporting dramatic increases in the rates of heroin addiction and death. In large cities like Chicago, heroin can be found on the west side, often sold on the streets in plain sight. Addicts know where they can go to in any city, and with a phone call, they can receive the drug in a few minutes. Local police are aware of the problem but seem unable to get it under control. Addicts can be seen shooting up on the street, bleeding from their injuries as they attempt to find a vein. Special Agent Jack Riley, Regional Representative of the Drug Enforcement Agency (DEA) and Special Agent in charge of the DEA’s Chicago Field Division, is familiar with the addicts on Lower Wacker Drive, a notorious drug-infested part of the community. Many addicts congregate under the overpass, injecting drugs or sleeping them off. Riley reports that the Mexican cartels supply 70 percent of the drugs used on Chicago’s streets and that statistic is mirrored nationwide7. One of the addicts he encountered first took heroin as young as eleven years old and now lives on the street with two young children. Riley states,” heroin addiction is probably at its all time high.” “Heroin is the SocialWork.EliteCME.com

drug of choice for street gangs,” says Riley, and he noted the increase started about three years ago, when Mexico’s Sinaloa Cartel began importing heroin through Chicago. “We are seeing it in places like Indianapolis, Madison, and Milwaukee, places where traditionally we really did not see an uptick in heroin7.” “The ability to smoke and snort today’s pure form of heroine has made it accessible and acceptable to people who normally wouldn’t come near it for fear of the needle,” says Riley. “That’s why it is spreading.” Riley continues, “I’ve been doing this for 30 years in virtually every corner of this country and if anything can be likened to a weapon of mass destruction on a family, on a community, on society, it’s heroin.” “I just don’t understand why people across the board don’t see its danger. Social services are overwhelmed, our healthcare services are overwhelmed, yet Mexican organized crime and street gangs make billions from it7.” Many youth come from suburban areas around Chicago and other large urban areas to buy the drug, and they may spend hundreds of dollars a day to feed their habit. The streets of Chicago are filled with stories of ruined lives caused by heroin addiction, including one from a college student who went from shooting up between classes to living homeless on the street, turning to prostitution to survive and stay high. In another tragic instance, a suburban high school girl tried it once, overdosed, and died. These stories are not unique to Chicago or large urban areas, but they are echoed through the farmlands of Wisconsin and Vermont. Illinois is not alone in its fight against the heroin epidemic that has plagued that state. Over one weekend in February 2014, a drug raid in the New York City Bronx area resulted in seizure of $8 million worth of heroin. “Heroin is pummeling the northeast, leaving addiction, overdoses, and fear in its wake,” said James Hunt, acting special agent in charge of the DEA’s New York office7. DEA heroin investigations in suburban Rockland County have doubled, and agents note that use is increasing in all age groups and across all socioeconomic levels. The Long Island Council on Alcoholism and Drug Dependence found an increase in families seeking assistance over the last five years from 100 to 850, and 80 percent of those were due to heroin addiction7. Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse (NIDA), described heroin addiction as consuming the user. “The most common and important outcome of using heroin is that it Page 34

can cause an addiction where people organize their lives around the drug,” Dr. Compton said. “They use it to the exclusion of all other aspects of their lives. It just becomes about scoring the next hit8.” The following NIDA statistics describe a nationwide problem6: ●● In Maryland, state health officials believe that heroin combined with other drugs is responsible for 30 or more deaths in the six months prior to March of 2014. They also note the number of deaths attributed to heroin rose 54 percent from 2011 to 2012 totaling 378 deaths. ●● The U.S. Drug Enforcement Agency (DEA) notes that Baltimore has the highest per capita heroin addiction rate in the country. In a city of 645,000, the Baltimore Department of Health estimates there are 60,000 drug addicts, with as many as 48,000 of them hooked on heroin. A federal report released last month puts the number of heroin addicts alone at 60,0007. ●● Virginia officials note 91 heroin deaths in the first nine months of 2012, up from 90 for all of 2011 and 70 for 2010. ●● Vermont Governor Peter Shumlin spent his entire 34-minute State of the State address this year discussing a “full-blown heroin crisis.” Heroin-related deaths in Vermont doubled in 2013 according to the governor, and there were twice as many federal indictments against heroin dealers than in the prior two years. Per capita, the heroin use in Vermont is second in the nation. ●● Heroin overdose deaths in the Minneapolis/St. Paul metro area nearly tripled from 2010 to 2011, increasing from 16 to 46 deaths, and these new heroin users were considerably younger. In Minneapolis, for example, arrestees testing positive for heroin were much younger:

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19.8 percent were less than 21 years of age, which is much younder than those testing positive for cocaine and methamphetamine, according to the Arrestee Drug Abuse Monitoring Report. In March 2014, Maryland, Vermont, New York, and Florida each reported an unprecedented number of deaths, according to the National Institute on Drug Abuse, which is still determining the numbers. NIDA reports these numbers could be the highest ever. In 2012, New Jersey saw more than 800 opioid overdoses, and half involved heroin. The DEA reports that drug seizures in New York comprise 20 percent of the total heroin confiscated each year. The amount seized by the DEA in New York City has increased 67 percent over the past five years because heroin is now mass-produced in city apartments.7 The New York City Department of Health notes fatal heroin-related overdoses increased 84 percent between 2010 and 2012, and 2012 showed a higher rate of heroin overdose deaths at 52 percent over deaths involving any other substance. The problem is particularly bad on Staten Island, where the death rate from overdoses is almost three times higher than the rest of New York City, according to the agency.7 Heroin is the most commonly found illicit substance in drug intoxication deaths in Philadelphia, PA. In 2011, 251 intoxication deaths involved heroin/morphine, a significant increase from 138 in 2010. Heroin is also the most commonly found substance in mortality cases where illicit drugs are present, with 32.4 percent in 2011. Dr. Karen Simone from the Northern New England Poison Center said the number of heroin-related calls doubled from 2007 to 2012. Only 20 percent of the estimated 810,000 heroin addicts seek or receive any form of treatment for their addiction.

Street names for heroin It is important to know the street names of the drugs to help identify the user’s drug of choice. There are many street names for heroin, including the following7: ●● Big H, H. ●● White, White lady, China white. ●● Mexican mud. ●● Scag, Skag. ●● Black tar, Tar. ●● Brown crystal, Brown sugar. ●● Nod. ●● Negra. ●● Chiba, Chiva. ●● Snowball. ●● Black pearl. ●● Junk. ●● Smack. ●● Hell dust. ●● Nose drops. ●● Thunder. ●● Horse. ●● Dragon (smoking heroin is called “Chasing the Dragon”). ●● Dope.

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Heroin combinations Heroin is often used in combination with other drugs that are known by specific names as follows:

Cheese heroin is a combination of Mexican black tar heroin and cold medicine obtained over the counter. It is a highly addictive substance, which is very inexpensive, only a few dollars, so it is often targeted at young people. Children as young as nine years old have been identified in emergency rooms with addiction, overdose, and withdrawal to this form of heroine which suppresses the central nervous system causing breathing and heartbeat to slow or stop. Since 2004, 40 deaths in North Texas are attributed to cheese heroin7.

Heroin and cocaine ●● Speedball, Snowball. ●● Belushi. ●● Boy-Girl.

H&C. Murder one, One and one. Smoking gun. Whiz bang.

Heroin and methamphetamine ●● Meth Speedball. Heroin and marijuana ●● Canade. ●● Woolie. ●● Woola. Heroin, cocaine, methamphetamine, rohypnol, and alcohol ●● The Five Way. Heroin and fentanyl ●● Theraflu. ●● Bud ice. Heroin, cocaine and tobacco ●● Flamethrowers. Heroin and cold medicine ●● Cheese.

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Facts and figures of increased heroin addiction, overdose and death Statistics from the United States Government Substance Abuse and Mental Health Services Administration (SAMHSA) noted the following statistics:9 ●● Nearly a half million Americans are addicted to heroin, and this number is thought to be the highest in history. ●● In 2011, 4.2 million Americans aged 12 or older (or 1.6 percent) had used heroin at least once in their lives. It is estimated that about 23 percent of individuals who use heroin become dependent. ●● NSDUH reports the number of new heroin users increased from 142,000 in 2010 to 178,000 in 2011. Both numbers are a sizeable increase from the average annual estimates of 2002 to 2008 (ranging from 91,000 to 118,000). ●● In 2012, there were 156,000 persons aged 12 or older who had used heroin for the first time within the past 12 months. ●● A SAMHSA study from August of 2012 found that persons aged 12 to 49 who abused prescription pain killers were 19 times more likely to try heroin than those who abused pain killers in the previous year. ●● In 2011, the average age at first use among heroin abusers aged 12 to 49 was 22.1 years and in 2010 it was 21.4 years, significantly lower than the 2009 estimate of 25.5 years. ●● The 2012 average age at first use among recent heroin initiates aged 12 to 49 was 23.0 years, which was similar to the 2011 estimate (22.1 years). ●● The annual Monitoring the Future survey of teens reported in 2012 that 20 percent of high school seniors felt that heroin was “easily available.” ●● From 2007 to 2012, the number of Americans using heroin nearly doubled, from 373,000 to 669,000, according to the federal government’s most recent National Survey on Drug Use and Health, released fall 2013. ●● One out of every four people who try heroin become addicted. ●● The number of people meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for dependence or abuse of heroin doubled from 214,000 in 2002 to 467,000 in 201210. ●● When teens were surveyed to find out why they started using drugs in the first place, 55 percent replied that it was due to pressure from their friends. They wanted to be cool and popular. ●● Heroin accounts for 18 percent of the admissions for drug and alcohol treatment in the United States. ●● An estimated 9.2 million-use heroin worldwide. The U.S. Drug Enforcement Agency (DEA) 2013 National Drug Threat Assessment Summary found that heroin smuggling is increasing across the United States border from Mexico and Mexican cartels, called Transnational Criminal Organizations (TCOs) by the DEA7. The summary noted, “The availability of heroin continued to increase in 2012, likely due to high levels of heroin production in Mexico and

Mexican traffickers expanding into white powder heroin markets in the eastern and Midwest United States.” Previous to 2012, heroin from Mexico was predominantly west of the Mississippi River with heroin from Asia coming through the major airports east of the Mississippi River. Some heroin from South America is smuggled through Mexico to the United States. The DEA report noted a steady decrease in cocaine trafficking from Mexico to the U.S. during this time period and theorizes that the increase in heroin trafficking may be a push by the Mexican TCOs to make up for the loss of cocaine profits. The DEA 2013 National Drug Threat Assessment Report includes the following7: ●● The availability of white powder heroin continued to increase in 2012 due to an increase in Mexican heroin production and trafficking which expanded into the Eastern and Midwest markets. ●● There was an increased level of smuggling of both Mexicanproduced heroin and South-American-produced heroin, which was smuggled through Mexico into the United States in 2012. ●● According to National Seizure System (NSS) data from January 15, 2013, the amount of heroin seized each year at the Southwest Border increased 232 percent from 2008 (558.8 kilograms) to 2012 (1,855 kilograms). ●● The increase in Southwest Border seizures appears to correspond with increasing levels of production of Mexican heroin and the expansion of Mexican heroin traffickers into new US markets. ●● Heroin-related overdoses and deaths are increasing in certain areas, possibly due to high-purity heroin on the streets and increasing numbers of heroin abusers at a younger age because it can be smoked or inhaled. Inexperienced abusers, such as teens, college students, and those who would normally not inject a substance start by smoking or inhaling. Law enforcement officials reported an increase of high-purity heroin available at the street level. ●● People are switching from abusing prescription drugs to abusing heroin. Law enforcement and treatment officials throughout the country report that many heroin abusers began using the drug after having first abused prescription opioids. These abusers turned to heroin because it was cheaper and/or more easily obtained than prescription drugs and because heroin provides a high similar to that of prescription opioids. ●● According to treatment providers, many opioid addicts will use whichever drug is cheaper and/or available to them at the time. Several treatment providers report the majority of opioid addicts will eventually end up abusing heroin and will not switch back to another drug, because heroin is highly addictive, relatively inexpensive, and more readily available. Those abusers who have recently switched to heroin are at higher risk for accidental overdose. ●● Unlike prescription drugs, heroin purity and dosage amounts vary, and heroin is often cut with other substances, all of which could cause inexperienced abusers to accidentally overdose.

Etiology of heroin addiction: Physical effects on the brain The thorough study of the effects of heroin on the brain would require a separate course, but it is important to include an outline of the effects of heroin on the brain that lead to addiction. Whether heroin is smoked, snorted, or injected, it is rapidly absorbed and crosses the blood brain barrier. Addiction occurs due to specific effects on the brain caused by the drug that interfere with normal brain function in the following ways4: ●● Addiction affects the transmission of neurons within the parts of the brain that control motivation and reward. These parts include the basal forebrain amygdala and the anterior cingulate cortex. This part of the brain affects the individual’s ability to conduct routine behaviors related to healthcare, motivation, and normal reward-seeking behavior. ●● Addiction interferes with cortical and hippocampal interactions that affect reward; memory of reward; and control of physical, SocialWork.EliteCME.com

mental, and behavioral response to stimuli that drives individuals’ drug cravings and drug-related behaviors. These behaviors may include lack of judgment and impulse control, inability to delay gratification, poor decision-making and repeated inability to react appropriately despite patterns of repeated negative consequences. ●● Addictive behaviors are exacerbated when younger individuals, whose brain systems have not fully matured, use heroin. ●● Addiction causes changes in brain chemistry and function, which results in physical changes to the nerve cells that transmit messages in the brain. Damage to neuron transmission in the nerve cells may disrupt signals and cues that communicate a variety of messages affecting learning, perception, memory, impulse control, motivation, pleasure/pain sensations, and more critically, central nervous system function that controls breathing responses and heart rate.

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Factors influencing addiction Psychological factors Individuals may have psychological disorders or mental illness that interfere with their ability to function normally. They may use heroin and other substances to deal with their psychological issues, which may be the only coping mechanism they know. Their self-medication to escape their negative feelings turns to addiction, which may mask an undiagnosed mental disorder. As the heroin addiction progresses, the underlying issues will be complicated by increasing psychological and physical changes cause by the damaging effects of the drug. Genetic factors Though genetics factors do not cause an addiction to heroin, they can indicate addictive behavior and were found to be significant in about 50 percent of addictions.8 One or more immediate family members with

an addictive disorder may be an indicator that the individual addicted to heroin has a genetic predisposition. Social and environmental influences may determine the impact of genetic factors on addiction. The individual’s sense of security, stability, personality, motivation, emotional and mental well-being are influenced by their role models, early experiences, culture, health and behavior patterns as they mature. These factors can influence whether genetic indicators of addiction come into play. Environmental factors Environmental factors include a complex set of interacting variables and may be difficult to measure initially. Issues related to the individual’s upbringing, family dynamics, belief systems, educational level, peer group influences, cultural or religious beliefs, stress, trauma, community values, and group affiliations may influence an individual’s decision to try heroin.

Screening The two main ways to identify the presence of heroin is in either the blood or urine of a user. The analytical methods used are gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-mass spectrometry (LC-MS)11. Both methods do the same thing, which is to separate a mixture of compounds present in the sample prepared from the urine or blood, followed by the detection of those compounds. The separation step allows for detection of any substance that has been used in combination with heroin. The urine is screened for 6-acetylmorphine (6-AM) by immunoassay and confirming the results by GC-MS analysis, which can take four to five days to complete. Heroin can be detected for one to two days after use. Heroin metabolizes into 6-AM, and this differentiates the use of heroin from other drugs such as codeine, morphine, and other prescription opiate drugs. Since October 1, 2010, the Substance Abuse and Mental Health Services Administration (SAMHSA) established mandatory guidelines that require 6-AM screening as part of the required screening for all federally mandated drug testing in the workplace12. The 6-AM screening

can be done in house and one version can deliver results in 11 minutes with 98 percent accuracy when compared with GC-MS. The Supreme Court has approved this test as defensible technology11. In addition to the tests above, medical history, criminal records, and physical health/appearance typically identify chronic users. Chronic heroin abusers commonly have a lengthy arrest record for drug possession or theft; they may have overdosed one or more times and were brought to the hospital; and they will typically have “track marks” over the veins in their arms, which are small areas of contusions from injecting the drugs; along with other indicators of chronic use. Track marks may be found on any part of the body if larger veins are destroyed by repeated injection. A very lengthy, expensive way to identify chronic users would be hair analysis for the accumulation of small amounts of the drug. Extracting drugs from hair is extremely expensive and time consuming. The low amounts of the drugs that are present in the hair require highly sensitive instrumentation, and those techniques would typically not be done by a lab13.

Signs and symptoms of heroin addiction No two individuals who are addicted to heroin will present with the same signs and symptoms, which will vary due to the method of use, level of tolerance, dependency, addiction, frequency of use, form of the drug, and secondary illness and disease. HIV/AIDS is often the consequence of injecting heroin. Common signs and symptoms of heroin use can be divided into the following categories8: Psychological indicators ●● Hallucinations, delusions. ●● Paranoia. ●● Depression. ●● Disorientation. ●● Sudden changes in behavior. ●● Slurred, forced, or incoherent speech. ●● Negative school or work performance. ●● Distractibility. ●● Frequent comments indicating low self-esteem, negativity. ●● Insomnia or excessive sleep. ●● Euphoria. ●● Blaming others for their issues. ●● Withdrawal from friends and family, association with new, unknown friends. ●● Constant runny nose or bloody nose. ●● Avoiding eye contact. ●● Mood swings. ●● Anxiety. ●● Apathy, lack of motivation in interests and regular activities. ●● Fatigue/exhaustion. ●● Hostility toward others, agitation, and irritability. ●● Lying about drug use. ●● Stealing. ●● Avoiding loved ones and others.

Physical indicators ●● Cuts, contusions, bruises, and needle marks on the body, not just arms. ●● Weight loss. ●● Scabs or bruises as the result of picking at the skin. ●● Decreased attention to personal hygiene and appearance. ●● Shortness of breath. ●● Frequent respiratory infections. ●● Dry mouth, loss of teeth. ●● Skin infections and abscesses. ●● Warm, flushed skin. ●● Drooping heavy extremities. ●● Constricted pupils. ●● Hyperactivity or hyper alertness followed by lethargy. ●● Extreme itching. ●● Loss of menstruation. ●● Miscarriage. Other indicators7 ●● Possession of burned spoons. ●● Needles or syringes. ●● Items to use as tourniquet such as a shoelaces or rubber bands. ●● Evidence of drug residue in baggies or foil. ●● Foil, straws or gum wrappers with burn marks. ●● Glass pipes or water pipes. ●● Wearing long pants and shirts, even in warm weather. ●● Repeated borrowing of money, missing valuable items. ●● Criminal activity.

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Short-term effects of heroin Every addict will present with different side effects due to the type, amount, and frequency of heroin use, other substances used, coexisting physical and mental disorders, and pre-existing conditions. In addition to the initial “rush” or feeling of euphoria, short-term side effects of heroin use include3: ●● Dry mouth. ●● Flushed skin. ●● Poisoning due to contaminants or adulterants. ●● Vomiting. ●● Itching externally and feeling itchy sensation internally, picking at skin.

●● ●● ●● ●● ●● ●● ●● ●● ●●

Nausea. Breathing that is slow, shallow, or irregular. Slurred speech. “Nodding out,” “crashing,” lethargy, sleep/alert cycles. Confused cognition. Decreased sensations of pain, physical and emotional “numbness.” Constipation. Stomach cramps. Overdose/death.

●● ●● ●● ●● ●●

Seizures. Miscarriage. Birth defects.* Diseases and infections from sharing needles. Overdose/death.

Long-term effects of heroin Chronic abuse of heroin leads to severe medical complications, many irreversible, and may lead to death3: ●● Heart problems such as infection of heart lining, infection of the heart’s surface called endocarditis, valve prolapse, blockage, myocardial infarction and arrhythmia, congestive heart failure. ●● Infectious diseases transmitted through needles (HIV/AIDS and Hepatitis B and C). ●● Chronic pneumonia, pulmonary diseases. ●● Collapsed veins, vascular blockages, clots, resulting tissue death due to lack of blood supply. ●● Bacterial infections. ●● Liver and kidney disease. ●● Immune disorders. ●● Pulmonary edema. ●● Coma. ●● Paralysis. ●● Cognitive disorder.

In addition to miscarriage, babies born to mothers using heroin suffer problems associated with malnutrition, drug toxicity, infection. These problems include low birth weight, developmental delays, prematurity, birth defects, failure to thrive, drug dependence, or addiction known as neonatal abstinence syndrome (NAS). NAS is drug withdrawal that the baby must endure under strict medical care in the hospital. Studies have shown that pregnant mothers with heroin addiction can be treated in the hospital with the drug buprenorphine, which treats the mother and baby and reduces their withdrawal symptoms. Heroin addicted mothers will often lose custody of their baby and many are charged with child neglect or abuse. Addicted mothers often abandon their babies after birth.

Heroin withdrawal Heroin withdrawal symptoms can occur within an hour after the last drug dose, based on the level of abuse. Withdrawal symptoms may include4: ●● Severe heroin cravings. ●● Sweating. ●● Severe muscle and bone aches. ●● Nausea and vomiting. ●● Heavy extremities. ●● Muscle cramping. ●● Crying. ●● Insomnia.

●● ●● ●● ●● ●● ●●

Edema. Chills. Runny nose. Diarrhea. Fever. Death.

Addicts facing withdrawal must receive medical care in a clinic, rehabilitation facility, or hospital from providers who are specifically trained to treat patients for heroin withdrawal. They should never attempt withdrawal alone.

Signs and symptoms of multiple substance abuse Among persons with heroin addiction, multiple substance addiction is common. Cocaine and alcohol are the substances most often abused with heroin14. A trained professional should assess for abuse of other substances and determine the effects of the overlapping substances. The American Psychiatric Association (APA) suggests the following four approaches for assessing heroin dependent people for other substances:

●● Screening instruments: MAST, DAST, CAGE-AID, AUDIT. ●● Clinical assessments using interview with the patient, family of significant others. ●● Structured interviews: DSM-V SCID-1, Structured Clinical Interview for DSM-V Axis 1 Disorders. ●● Laboratory tests: Urine samples done onsite for immediate results that can be addressed with the patient.

Heroin addiction and co-occurring disorders As with other substance abuse addictions, individuals with heroin addiction often have co-occurring mental disorders. Since psychological and emotional causative factors for heroin addiction exist, it may be critical to determine the primary and secondary disorder in planning a long-term treatment plan. Of course, chronic addiction to heroin and the physical ravages of the disease must be addressed immediately, which will require medical care and monitoring. Patients must be screened for suicide ideation and selfSocialWork.EliteCME.com

harm tendencies, which are often part of the heroin addict’s coping or escape mechanism. The following co-occurring mental disorders are commonly seen among heroin addicts on the street and those in rehabilitation programs4: ●● Depressive and/or anxiety disorder. ●● Addiction to other drugs and/or alcohol. ●● Personality disorder. ●● Cutting, self-harm behaviors. Page 38

●● Bipolar disorder. ●● Eating disorders. ●● Post traumatic stress disorder.

●● Schizophrenia. ●● Conduct disorder. ●● Psychosis.

Treating heroin overdose A new and controversial medication to reverse the effects of heroin overdose has been approved and released for sale by prescription by the Federal Food and Drug Administration (FDA) in April 201415. Naxalone comes in the form of a hand-held device, injection, or nasal spray, and is being hailed by government and health care leaders as a ground-breaking tool to address the epidemic of heroin overdoses across the nation. The states of New York and New Jersey are already mandating its use by first responders, and after training, the drug was saving lives in the first weeks of use.

Evzio works like an Epipen, which counteracts anaphylactic shock, and can go into the muscle or the skin. New Jersey has approved the use of naloxone for law enforcement officers. “We think greater availability of immediate treatments like naloxone are important as New Jersey confronts this crisis in heroin and opioid overdoses,” said Aline Holmes, a registered nurse and senior vice president of clinical affairs at the New Jersey Hospital Association16. In May 2013, New Jersey signed the Overdose Protection Act, which gives legal immunity to anyone using the drug to save a life.

The drug, also known as Narcan, is marketed under the name of Evzio15. A single dose of the drug, which acts as an antidote to heroin, has been successful in bringing back overdose victims from death due to respiratory failure and lack of blood pressure. Naloxone works by reversing the suppressive effects of heroin on the opioid receptors that signal respiration to bring back consciousness and normal breathing. The drug is not new and has been used by emergency medical personnel on the street and in the hospital for over 40 years in injectable form. The release of the drug is controversial, because some, like Maine Governor Paul LePage, believe it will give addicts a false sense of confidence that they can continue to use much heroin as they want and the drug will save them from death from overdose. Many also object on the grounds that it will drive up insurance costs. Proponents of the drug do not believe addicts will purposely take enough drugs to overdose just because the drug is available and feel the FDA has addressed a life threatening public health crisis that has reached epidemic proportions.

The state of New York has also approved the use of the drug by all law enforcement agents, and 17 other states have followed suit, with some allowing prescriptions to family and friends of the addict. It comes in a nasal spray or injectable form and can be used by anyone without advanced training in an emergency situation. It is suggested for use after calling 911 and checking for breathing, though additional training is advisable. One drawback of the drug is that if the heroin is adulterated with fentanyl, patients will need a larger dose over a longer period of time to combat longer-acting drug combinations, which may cause them to sink back into respiratory distress. Patients will also require emergency medical care and/ or hospitalization despite receiving the drug and being revived. The CDC reports local and state health departments fund the drug and provide it to hospitals and community-based clinics free of charge22. San Francisco’s Drug Overdose Prevention and Education Project and Massachusetts’ Overdose Education and Naloxone Distribution Program are examples of two community-based programs using the drug15.

Moving from withdrawal to treatment The American Society for Addiction Medicine (ASAM) provides a wealth of information about the changes faced by the person who is withdrawing or has withdrawn from addiction. Addiction by definition includes periods of withdrawal and relapse, and the journey will be different for each individual. It is important to remember that unlike the feelings of early heroin use, as time goes by, the euphoria, pleasure or “reward” felt when the individual gets high does not continue to escalate with each subsequent use. As outlined previously, users need more heroin to achieve the same high and actually builds tolerance to the “high.” However, they continue to experience deeper and more painful “lows” as their addiction progresses. As explained by ASAM4: Persons with addiction compulsively use even though it may not make them feel good and in some cases long after the pursuit of “rewards” is not resulting in pleasurable feelings. Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition. Addiction is classified as a chronic brain disorder or disease and not a behavioral one, which is important to remember when working with a person in recovery. As in any chronic disease there will be

periods of relapse which will vary by frequency, duration or amount of use but ASAM points out that, “the return to drug use or pathological pursuit of reward is not inevitable4.” They provide the following information about the recovery process: ●● Clinical interventions can help to alter the course of addiction. ●● Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. ●● Engagement in health promotion activities that encourage personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. ●● The patient must be monitored and managed over time to decrease the frequency and intensity of relapses, to sustain remission and optimize functioning, and to minimize episodes of relapse and their impact. ●● Medication management can improve treatment outcomes. Integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. ●● Recovery is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.

Treatment and recovery The ultimate goal of treatment is recovery, because the person addicted to heroin has so many levels of life that have been damaged or destroyed. Some individuals have co-occurring mental disorders that may have preceded the addiction or occurred during drug use. Knowing that the individual is ready to enter treatment to move toward recovery, and developing a treatment plan to support them in reaching their goal are the first steps in the process. The recovering patients may face unresolved issues that initially led to their drug use. Therefore, patients may need to make total life changes with the assistance from

their treatment team. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), “Recovery from Mental Disorders and Substance Use Disorders” is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential17. SAMHSA has delineated four major dimensions that support a life in recovery: ●● Health: Overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way. ●● Home: A stable and safe place to live.

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●● Purpose: Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society. ●● Community: Relationships and social networks that provide support, friendship, love, and hope. Heroin addiction is a chronic disease that cannot be treated easily or quickly since it has been prevalent since the late 1880s . Scientific research and treatment trials conducted over decades have yielded the following guiding principals for treatment18: ●● Addiction is a complex but treatable disease that affects brain function and behavior. ●● No single treatment works for everyone. ●● Treatment needs to be readily available. ●● Effective treatment attends to multiple needs of patients, not just their drug abuse. ●● Remaining in treatment for an adequate period of time is critical, sometimes continuing for years. ●● Counseling, individual and/or group, along with behavioral therapies are the most commonly used forms of drug abuse treatment. ●● Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

●● Patients’ treatment and services plan must be assessed continually and modified as necessary to ensure that it meets their changing needs. ●● Many drug-addicted individuals also have other mental disorders, which must be addressed. ●● Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. ●● Treatment does not need to be voluntary to be effective. ●● Drug use during treatment must be monitored continuously, as lapses during treatment do occur. ●● Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk for contracting or spreading infectious diseases. After the patient is stabilized and makes the decision to enter treatment, a long-term treatment plan is developed. There is no single method that works for all individuals, but practitioners need to review a variety of programs available in the vicinity of the patient and match the program to the patient’s needs. This course outlines some current programs and provides resources for free training materials and program guides.

Therapeutic communities for residential treatment For individuals with severe drug and addiction problems, therapeutic communities (TC) are the next step after hospital or medical management of their withdrawal symptoms.18 These programs provide a highly structured, strictly monitored program to meet the medical and psychological needs of patients. Patients may live in the facility for up to a year and receive treatment for their addiction as well as other therapy and services needed for recovery. They receive support and treatment to address behavior issues, including criminal behavior, social,

communication and family issues. Specialized centers can accommodate pregnant women, children, and adolescents. The goal of the therapeutic community is to provide the treatment and skills necessary for individuals to return to the community as healthy, drug-free individuals who can successfully when re-enter society and live productive lives. After care will continue through outpatient or support services in the community following successful release from residential care.

Pharmacological treatment Heroin addiction changes the structure and function of specific parts of the brain, so for medication to be effective, it must work despite changes that occur in the short and long term. In the beginning stages of withdrawal, medication must curb the strong cravings for heroin and lessen the painful side effects of withdrawal to avoid a relapse. In later stages of recovery, individuals need medication to help them think clearly, gain control, make decisions, and focus on goals and skills for a healthy new life. Pharmacological treatment of heroin addiction has proven to be successful by increasing time in treatment, decreasing rates of relapse, and reducing rates of infectious disease and illegal drugseeking behaviors. Medications such as buprenorphine, methadone, and naltrexone can help people to escape the grip of heroin, because it reduces their cravings by blocking the euphoric effect. The medications used in this treatment work in the same manner as heroin by impacting the opioid receptors, but they do not cause the dangerous side effects or lead to addiction. The three types of medications interact with the opioid receptors in different ways as follows19: 1. Agonist medication such as Methadone, also known as Dolophine and Methadose, activates receptors by gradually reaching the brain slowly, preventing the euphoric feeling, and preventing withdrawal symptoms. These drugs are appropriate for use by certified physicians in outpatient treatment programs and are given to the patient orally each day. An estimated 200,000 people in correctional facilities each year are addicted to heroin. Therapy such as methadone maintenance treatment has been effective in prison populations and shown to increase time in treatment and diminish criminal activity if continued in the community upon release, because it eliminates the need to commit crime to buy heroin. 2. Partial agonists, such as Buprenorphine, also called Subutex, produce a small response in the brain, which relieves cravings with SocialWork.EliteCME.com

no euphoria or side effects when taken orally. The FDA approved buprenorphine in 2002 for prescription by certified physicians in their office, which extends the availability of this drug to a wider population of patients and makes it more accessible. Some critics theorize that the ease of obtaining this drug will encourage more individuals to enter and stay in pharmacologic treatment. In 2013, the FDA approved two generic forms of Suboxone, which is buprenorphine that contains naloxone, in 201315. This drug prevents attempts to get high by causing severe withdrawal symptoms if injected but no negative effects when taken orally as directed. Buprenorphine can be used effectively with prisoners and could be implemented through collaboration with health professionals and the juvenile justice system. Many governmental agencies are working together to address the heroin addiction epidemic. An example of one partnership, known as the Blending Initiative20, combines the efforts of SAMHSA and NIDA to fund and conduct research and clinical trials on a variety of therapies that can effectively treat heroin addiction. Currently, they are developing and disseminating protocols to educate multidisciplinary treatment professionals about buprenorphine. Information can be found at (http://www.ctndisseminationlibrary. org/display/85.htm). This information contains the following goals: Blending teams of NIDA researchers, treatment practitioners, and trainers have completed two buprenorphine training packets21: ■■ To increase overall awareness of buprenorphine therapy. ■■ To instruct physicians and treatment practitioners in implementing a 13-day detoxification intervention for opiate-dependent patients. ■■ To change the mindset of many community treatment providers previously unwilling to consider the use of medications to treat drug addiction. Page 40

■■ To expand the programs now regularly use buprenorphine to assist in opiate detoxification and treatment maintenance. ■■ To work with SAMHSA’s Addiction Technology Transfer Centers (ATTC), State Directors, and other stakeholders, to spread the word about buprenorphine to more proactively address the urgent needs of drug addiction. ■■ To continue clinical tests on the safety and efficacy of buprenorphine in other affected populations, including pregnant women, adolescents, and patients addicted to opiate analgesics. ■■ To increase the use of this and other addiction medications in different settings and locales, including in the U.S. criminal justice system and in countries where injection drug use is still a primary mode of HIV transmission21. Additional information on buprenorphine can be found at http://www.ctndisseminationlibrary.org/ display/85.htm 3. Antagonists, such as Naltrexone, also known as Depade and Revia, block opioid receptors that send pleasure signals, thus blocking the “high.” They doo not cause dependence, addiction, or sedation. Patients must take this drug daily, but the FDA recently approved a long-acting form called Vivitrol that can be administered once a month, which may increase compliance. Naltrexone does not

suppress all drug craving, and many patients cannot remain abstinent and relapse in six months. According to Dr. George22, “Drug abusers are notoriously ambivalent and just because they decide to quit using heroin one week doesn’t mean they’ll be motivated to quit a week later.” Extended-release forms like Vivitrol can provide long-lasting protection over time, which can help patients in their resolve to stay drug-free. Patients taking a daily oral dose of naltrexone must make a daily decision to remain drug-free. Patients using Vivitrol will receive a sustained dose each month, so they have more time in treatment and recovery between doses and do not face a daily decision to use heroin when the naltrexone tapers every 24 hours. Clinical trials are being conducted on patients in Russia with extended release implants that last up to two months and can be refilled without having to be removed22. Early trials of these implants are proving to be three times more effective in some patients than the daily dose pill in preventing relapse. Dr. Woody continues, “Methadone and buprenorphine have helped hundreds of thousands of people around the world who are drug dependent, and they have helped reduce the spread of HIV.” “The new injectable and implantable naltrexone formulations are really the new kids on the block, but they’re offering us more options in an area where we really need a lot of help.”

Urine testing for compliance Treatment programs that include medication are only effective if they include strict monitoring to make sure patients comply with the program and have not relapsed. This is done through urine testing, patient interview, observation, and input from family and other significant parties in the patient’s life. Drug treatment programs that are administered through outpatient or doctor’s office settings may have limited contact with the patient and must rely on tightly controlled drug monitoring protocols. These testing protocols must contain the following components12: ●● Location A decision must be made about whether testing will be on site or off site. There are advantages to each setting, depending on the person’s needs. On- site testing will give immediate, affirming results if positive. The sample will require less handling, and the patient may feel this testing is more confidential because it is kept on site.

If the results are negative, the therapist can immediately address the issue with the person. In both cases, the samples may have to be confirmed off site depending on the lab, and additional tests may be required if the result is negative. Off-site testing allows for more comprehensive testing; a higher level of expertise among personnel, which may yield higher rates of accuracy; and admissibility in court. ●● Type of test Different types of tests provide different levels of information. Immunoassay can test for heroin and other natural opioids, and it provides almost immediate results. Methadone is a synthetic opioid but specific immunoassay tests have been developed for this drug. Immunoassay tests will not detect the presence of other synthetic opioids, like fentanyl and buprenorphine, so it is not as comprehensive as other tests. Laboratory tests such, as GS-MS, will detect all types of opioids but take four to five days11.

Current research in pharmacology new medications NIDA is committed to new treatments for heroin addiction, which include improved medication and other forms of therapy. When combined, they have proven to raise recovery rates. The NIDA is working to improve treatment for heroin addiction that they can implement to large numbers of patients across the country. A new drug

called Probuphine is producing positive results in clinical trials. It is a long-acting form of buprenorphine that is administered as an implant under the skin to provide medication over a six-month period23. This drug is more convenient for the patient and eliminates daily dosing which increases adherence to treatment goals.

The heroin vaccine Another exciting NIDA clinical trial currently underway is vaccine research that can effectively block addiction to heroin and other drugs. Dr. Ronald Crystal and Dr. George Koob and Dr. Kim Janda are among the many researchers around the world conducting research and clinical trials to develop a vaccine to address heroin addiction24. The vaccine acts to combat the effects of heroin as it enters the bloodstream before it reaches the brain and the opioid receptors so the euphoric or reward sensation is not released. The medication would be part of a treatment plan that would increase the chance of recovery by lowering the risk of relapse. The vaccine works by interfering with the immune system’s ability to conduct the action of heroin on the brain. The antibodies in the vaccine identify and attach to molecules of heroin and the together they are too big to cross the blood brain barrier to enter the brain. When the drug does not enter the brain, it cannot reach the opioid receptor and signal the pleasurable sensation that drivers the need for the drug.

Two parts must be present in the vaccine to accomplish this action24. The first is a protein that causes the immune system to produce sufficient antibodies to overtake the total molecules in the amount of heroin taken so they do not reach the brain. The second part of the drug, hapten, has molecules that are similar to heroin in structure. Hapten serves as the schematic for the development of the antibodies that identify and combine with the heroin molecules. Each person’s immune system responds differently, and the system is often compromised from heroin addiction. The drug trials focus on identifying the effective combinations of the parts of the vaccine to illicit the immune response necessary to block the action of the heroin in the bloodstream. Several concurrent trials are underway for the vaccine, which are in the early stages of development and have not yet been tested on humans. Researchers agree that vaccine treatment should be part of a comprehensive therapy plan.24 Dr. Janda and Dr. Crystal note, “People

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have the misconception that a single vaccine can protect patients from substance abuse, that’s not true.” Dr. Crystal states, “A patient who has attained abstinence could be vaccinated to block the effects of the drug, thereby preventing relapse. Dr. Janda notes, “Our vaccine will not alleviate craving, but it could help patients maintain abstinence

in weak moments.” “The vaccine approach provides an alternative strategy for treating drug addiction,” says Dr. Nora Chiang of NIDA’s Division of Pharmacotherapies and Medical Consequences of Drug Abuse. “There is much more work to be done on these vaccines, but the results so far are promising25.”

Treatment for adolescents Many biological factors, such as immature brain development in the frontal cortex, social and environmental factors, influence drug abuse and addiction in adolescents. Government health agencies, through their initiatives to blend the fields of study that research addiction, have combined neurobiology and social sciences to develop prevention and treatment programs that address the multiple and overlapping factors that influence heroin addiction in adolescents. NIDA explains this process as follows: The resulting social neuroscience initiative will help us better understand how neurobiological mechanisms and responses, genetic, hormonal, and physiological, underlie, motivate, and guide social behaviors related to abuse and addiction. This perspective may help us understand adolescents’ heightened sensitivity to social influences and decreased sensitivity to negative consequences, for example, that make them particularly vulnerable to drug abuse20. Pharmacology None of the medications used with adults to treat addiction have been approved by the FDA for use with children and adolescents. At this time, clinical trials for additional medications are in development. Behavioral treatment Behavioral therapies are effective with children and adolescents and follow the same procedures noted in the section on therapy for adults. Contingencies and incentives help to motivate youth, and cognitive behavioral strategies work effectively when they are structured to meet the child’s needs, age, developmental and maturity level. Any healthcare provider trained and certified to provide services to young clients can deliver behavioral treatment. Family therapy Children and adolescents can benefit from treatment using family therapy approaches, which include all significant people in their lives, including parents, guardians, mentors, siblings, and peers. Family therapy can address all areas of children’s lives and increase communication and address problems in family dynamics, which may add to the stress of recovery. Therapy can build a wide circle of support for adolescents and help them gain confidence and self-esteem as they fight their addiction. Involving the family is a critical part of adolescent substance abuse treatment. The following evidence-based family treatments programs work effectively to treat adolescent substance abuse26. Brief strategic family therapy (BSFT) BSFT focuses on unhealthy family interactions that contribute to the young person’s drug problem. The therapist works to establish rapport with each family member, while observing how each member interacts, to identify problem areas and strategies. During the course of 12–16 sessions, the therapist will work to address problems and guide the family members to work together to resolve them. This approach can target any family issue and can be conducted in any setting. Family behavior therapy (FBT) FBT includes strategies from behavioral therapy, including behavior contracts that include contingencies to motivate the young person, and build impulse control and appropriate behaviors. The therapist works

with the adolescent and parent to develop behavior goals, treatment plans, behavior strategies, and treatment interventions. The therapist writes a contact based on the goals and treatment plan, with contingencies based on measurable behaviors. The adolescent and parent work together to practice new behaviors and skills in the home, school, and community. Therapists and adolescents review the contract on a schedule that is appropriate for the child’s age and maturity level to motivate and reinforce behavior. Professionals should reinforce appropriate behavior and goal mastery frequently in order for the program to work effectively. Functional family therapy (FFT) FFT is based on the premise that problem behaviors stem from dysfunctional family interactions. Therapy uses behavioral strategies to resolve conflict by improving skills for parenting, communication, and problem solving within the family involving all family members. Program goals include engaging and motivating all family members to work together to change their patterns of interaction through techniques of behavior therapy. Multidimensional family therapy (MDFT) The MDFT approach combines treatment components from all programs addicted youths encounters as a result of their addiction or conduct. At-risk or addicted youths can benefit from techniques of family therapy combined with treatment at school, juvenile justice, child protective services, clinics, family court, or other community agencies involved in their treatment plans. Often adolescents abusing drugs exhibited at-risk behavior, conduct disorder, family problems, or illegal behavior in the past that brought them in contact with special services in a number of organizations. MDFT goals work toward pooling resources and developing consistency and collaboration among all agencies involved in the child’s care. Representatives from these agencies meet together with the adolescent and family to plan and implement goals and strategies consistently and hold the young person accountable on all fronts. According to NIDA, the MDFT program has been effective with severe substance-use disorders and can facilitate the reintegration of juvenile detainees into the community. Multisystemic therapy (MST) Similar to MDFT, this therapy uses a multidimensional approach that combines family therapy approaches with treatment strategies from a variety of treatment programs in the community. This approach is a natural out-growth of treatment for adolescents involved in severe drug addictions, violent behavior, and illegal activity. MST focuses on adolescents’ personality, attitude, behavior, emotions, and peer influences related to their addiction and behavior. The second component includes a review of family interactions such as discipline, parenting skills, communication, and history of substance abuse among family members, and attitudes and values that influence them. The last variable looks to adolescents’ performance and attitudes in the community at school, on the street, and membership in gangs or other groups in the community. The therapist works with the youth individually, with the family and youth together, and they coordinate and lead meetings with community agencies to coordinate services and build program consistency.

Recovery support for adolescents If addiction treatment and recovery programs work effectively, there must be support services for aftercare to avoid relapse and support adolescents as they develop and apply skills to maintain a healthy, drug-free lifestyle. NIDA notes the following programs in clinical SocialWork.EliteCME.com

trials show promise in supporting recovery and lowering relapse among adolescent addicts26. Assertive continuing care (ACC). ACC is a home-based continuingcare approach delivered by trained clinicians to prevent relapse, and Page 42

is typically used after an adolescent completes therapy utilizing the Adolescent Community Reinforcement Approach (A-CRA). ACC combines A-CRA, behavior therapy, and assertive case management services using a multidisciplinary team of professionals, round-the-clock coverage, and assertive outreach to help adolescents and their caregivers acquire the skills needed to engage in positive social activities. Peer recovery support services. Peer recovery support services connect youth with groups and individuals who have experienced addiction and recovery and act as peer mentors. They help individuals, based on their specific needs, support and coach the individual through treatment, and help them connect with community support groups and resources. More

importantly, these services can provide new social connections so the adolescent can build positive social interactions with sober peers. Recovery high schools. Recovery high schools can take different forms, but they are designed to meet the specific needs of students recovering from drug abuse. Students may attend a separate school or be part of a community school, but initially, they attend classes in a separate area with students who share their specific experiences and needs. The high school program may run concurrently with other treatment programs. Students benefit from specially trained teachers and counselors who support their treatment plan, which may address mental disorders as well as substance abuse. Students participate with peers who have experienced similar issues in a structured setting that promotes recovery.

Behavioral therapies Outpatient behavioral treatment provides therapy through individual and group settings based on the program that best meets the needs of the person. It can be designed to meet the needs of youth and adults and is often combines with pharmacological treatment to increase efficacy. The NIDA outlines the following types of outpatient behavioral treatment programs27: ●● Cognitive–behavioral therapy aims to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs. ●● Motivational interviewing capitalizes on the readiness of individuals to change their behavior and enter treatment. ●● Motivational incentives and contingency management uses positive reinforcement to encourage abstinence from drugs. Contingency programs and cognitive-behavioral therapy are commonly used forms of therapy to help patients take control and responsibility for their behavior and build coping and life skills to move toward

long-term recovery and health. Behavior therapy uses strategies to address unwanted behaviors using learning theory, conditioning, and reinforcement with the focus on the present and addicts’ ownership and responsibility for their behavior. Therapy focuses on targeted behaviors to change and strategies to identify the triggers, or antecedents, and consequences of the behavior. The addict identifies behavior patterns to change and works toward healthy replacement behaviors. The therapist and client work to identify goals and barriers to those goals that may include habits, obsessions, compulsions, denial, procrastination, fear, depression, anxiety, dysfunctional inter-personal relationships, communication issues, and any other negative thought and behavior patterns. They work through these barriers together to build the client’s awareness of the former thoughts, feelings, and behaviors that have a negative impact on recovery and must be changed. Behavior therapy has been around for decades, and many forms have proven effective with addiction. In the case of heroin addiction, this therapy works best when combined with pharmacological therapy.

Motivational incentives for enhanced drug abuse recovery: Promoting awareness of motivational incentives The National Institute on Drug Abuse (NIDA) a division of the Substance Abuse and Mental Health Services Administration (SAMHSA) noted the challenge of helping patients avoid relapse while in a treatment program. They conducted research and clinical trials to develop an evidence-based approach called Promoting Awareness of Motivational Incentives (PAMI) to train other organizations to use incentive techniques, sometimes called contingencies, in programs to maintain abstinence from drug and alcohol use30. After testing the program, they developed a package of tools and training resources to replicate the program and share evidence-based research data behind the clinical use of motivational incentives. The strategies of the approach used low-cost incentives with patients that were successful in maintaining abstinence and program compliance to avoid relapse during treatment. PAMI is based on positive research outcomes from the NIDA Clinical Trials Network (CTN) study, Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR), and uses strategies from Dr. Nancy Petry’s Fishbowl Method of incentives31. “We use rewards as a clinical tool not as by bribery but for recognition; the really profound will come later.” The researchers used motivational incentives because they lead to higher rates of retention in treatment and abstinence from drug abuse. They found incentives that were motivating, low cost, and supported the patient’s treatment plan included prices, vouchers, and clinic privileges. The patients earned reinforcers on the results of their onsite urine screening and completion of treatment goals. The study noted that patients who participated in incentive programs were more likely to submit urine samples that were negative than patients not receiving incentives. The average cost of incentives was $120 per patient32. PAMI is designed to build awareness of motivational incentives as a researchbased therapeutic strategy for addiction treatment. The package, which is free of charge, reviews the research, provides support materials and

resources along with suggestions for implementation, data collection, training and replication of the program and includes a video, Successful Treatment Outcomes Using Motivational Incentives. The NIDA31 reported data showing that approximately 25 percent of samples from both study groups tested negative for stimulants and alcohol at the first study visit. Overall, participants in the incentive group (54.4 percent) were significantly more likely to submit target drug-negative samples than were participants in the usual care group (38.7 percent). The motivational incentives and interviewing techniques address patients’ feelings and barriers about stopping drug use. Motivational interviewing is a therapeutic approach to help patients in recovery, and the incentives help patients modify and change specific behaviors. The incentives acted as a supplement to therapy were effective in the treatment of substance-use disorders. The study noted that the incentives improved therapeutic climate because they were based on positive, affirming, and celebratory strategies. Positive reinforcement incentives will be effective if they are valuable to the person and motivate them to work to change target behaviors. Patients received a menu of incentives to choose from, and therapists were consistent in the distribution of the incentives earned. Intermittent schedules of reinforcement were the most powerful, and the Fishbowl Method used this schedule to deliver low or no-cost incentives, such as coupons, vouchers, and privileges. Patients had a chance to earn and win prizes when they drew from the fishbowl. Target behaviors must be observable and measurable, and they should include abstinence and the successful completion of goals from the patient’s treatment plan. The PAMI program outlines seven core principles of motivational incentive programs30.

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Seven core principles of motivational incentive programs: 1. Identification of target behavior. 2. Choice of target population. 3. Choice of reinforcer. 4. Incentive magnitude. 5. Frequency of incentive distribution. 6. Timing of the incentive. 7. Duration of the incentive.

The PAMI program materials include all the information needed to replicate the program and include supplemental software to track information about patients’ participation and progress in the program. Information on these programs, and others to address the heroin addiction epidemic, can be obtained from the Motivational Incentives Web-Portal: www.bettertxoutcomes.org; National Institute on Drug Abuse: http://www.drugabuse.gov/blending-initiative; and SAMHSA ATTC: http://www.attcnetwork.org/blendinginitiative

Prevention Prevention programs to address heroin addiction have been researched for over 20 years, which is not very long, considering the heroin addiction goes back to the late 1800s. To find a solution to the complex, epidemic disease of heroin addiction, the process must include the following components: ●● Identification and definition of heroin addiction. ●● Determine the scope of the problem, sequence of events and factors that lead to addiction. ●● Review evidence-based programs proven to effectively break the cycle of addiction including prevention and treatment. ●● Matching prevention and treatment programs to the individual needs of the individual and community. There is a rush to implement these steps because of the public’s awareness of the problem of heroin addiction and the number of overdose deaths in every community, large or small. For those in the field of medical and mental health, the work to eradicate this complex problem has been in progress for decades. It is clear to all who work in this field that there is no easy and quick solution because the predictors or heroin addiction are varied and there is no definitive “test” to determine who will become addicted. Instead, many factors overlap to increase the chance that a person will become addicted. Biology, genetics, age at onset of use, environment, personality, and social influences are a few of the factors that contribute to addiction but are impossible to unravel or measure. Researchers, therapists, medical personnel, school staff, and families know that addiction to the substance may take hold quickly, but addiction is a developmental disease that begins long before the person becomes addicted to heroin. NIDA research shows that in some cases, the signs were there in childhood and adolescence while the brain is rapidly developing and changing. Brain research shows that the prefrontal cortex develops last, and that is the part of the brain that controls decisions and judgments, which explains why adolescents often engage in at risk behaviors. These factors correlate with statistics that show heroin addiction is rising among young people because they are open to experimentation with drugs, and therefore, vulnerable to heroin addiction. These facts, established from evidence-based research, conclude that for prevention programs to work, they must begin early in order to address all the factors that lead to addiction, which often begin in childhood. NIDA identifies the following factors that can be addresses to prevent addiction at an early age33: ●● Mental illness. ●● Neurobiology. ●● Physical or sexual abuse. ●● Aggressive behavior. ●● Academic problems. ●● Poor social skills. ●● Lack of motivation. ●● Peer influences. ●● Poor parent-child relations. Effective prevention programs must have a multidimensional approach involving family, school staff, community health agencies, media, and other social and cultural modes of communicating prevention education, information, and early intervention. Because heroin addiction crosses all boundaries and excludes no one, community prevention outreach programs must speak directly to the intended SocialWork.EliteCME.com

audience in a way they can understand; therefore, the programs must encompass all languages, cultures, and educational levels. Community education for prevention must also address the relationship between at-risk behavior, addiction and the spread of HIV/AIDS, which is part of the heroin addiction epidemic. The NIDA and other federal research organizations have included prevention as a primary goal. The principles outlined in this section focus on numerous, long-term, evidence-based studies of addiction behavior and combined concepts from many successful prevention programs. The prevention principles target children through young adults across the country with the goal of implementation at the community level. Prevention programs are geared to specific settings and specific needs of the participants and address the needs of all youth, whether they are drugfree, at-risk, or already experimenting with drugs. These principles can be implemented at home, school, community or all three. The entire list and specific details on each principle, including research information, can be obtained on the NIDA website Prevention section at http://www.drugabuse.gov/publications/preventing-drug-use-amongchildren-adolescents. The following information and principles can guide the development of prevention programs for children and youth:35 NIDA’s prevention research program focuses on risks for drug abuse and other problem behaviors that occur throughout a child’s development, from pregnancy through young adulthood. Research funded by NIDA and other federal research organizations – such as the National Institute of Mental Health and the Centers for Disease Control and Prevention – shows that early intervention can prevent many adolescent risk behaviors.

Principle 1 - Prevention programs should enhance protective factors and reverse or reduce risk factors. The risk of becoming a drug abuser involves the relationship among the number and type of risk factors, deviant attitudes and behaviors, and protective factors. Specific risk and protective factors change with age and stage of development. For example, risk factors within the family have greater impact on a younger child, while association with drug-abusing peers may be a more significant risk factor for an adolescent. Early intervention with risk factors, such as aggressive behavior and poor self-control, often has a greater impact than later intervention by changing a child’s life path away from problems and toward positive behaviors. These factors can have a different effect depending on a person’s age, gender, ethnicity, culture, and environment. Principle 2 - Prevention programs should address all forms of drug abuse, alone or in combination, including the underage use of legal drugs and substances and the use of illegal drugs. Principle 3 - Prevention programs should address the type of drug abuse problem in the local community, target modifiable risk factors, and strengthen identified protective factors. Principle 4 - Prevention programs should address risks specific to population or audience characteristics, such as age, gender, and ethnicity, to improve program effectiveness. Principle 5 - Family-based prevention programs should enhance family bonding and relationships including parenting skills and training in drug education and information. Family bonding is the bedrock of the relationship between parents and children. Family bonding can Page 44

strengthen through skills training on parent supportiveness of children, parent-child communication, and parental involvement. Parental monitoring and supervision are critical for drug abuse prevention. Training on rule-setting; techniques for monitoring activities; praise for appropriate behavior; and moderate, consistent discipline that enforces defined family rules should be included. Drug education and information for parents or caregivers reinforces what children learn about the effects of drugs and opens opportunities for family discussions about the abuse of legal and illegal substances. Brief, family-focused interventions for the general population can positively change specific parenting behavior and reduce children’s later risks of drug abuse.

Principle 9 - Prevention programs aimed at general populations at key transition points, such as the transition to middle school, can produce beneficial effects even among high-risk families and children.

Principle 6 - Prevention programs can be designed to intervene as early as infancy to address risk factors for drug abuse, such as aggressive behavior, poor social skills, and academic difficulties.

Principle 12 - When communities adapt intervention programs to match their needs, community norms, or differing cultural requirements, they should retain core elements, which include the structure, content, and delivery of the program.

Principle 7 - Prevention programs for elementary school children should target academic and social-emotional skills to address risk factors for drug abuse. Education should focus on the following skills: ●● Self-control. ●● Emotional awareness. ●● Communication. ●● Social problem solving. ●● Academic support, especially in reading. Principle 8 - Prevention programs for middle or junior high and high school students should increase academic and social competence with the following skills: ●● Study habits and academic support. ●● Communication. ●● Peer relationships. ●● Self-efficacy and assertiveness. ●● Drug resistance skills. ●● Reinforcement of anti-drug attitudes. ●● Strengthening of personal commitments against drug abuse.

Principle 10 - Community prevention programs that combine two or more effective programs, such as family-based and school-based programs, can be more effective than a single program. Principle 11 - Community prevention programs reaching populations in multiple settings such as schools, clubs, faith-based organizations, and the media, are most effective when they present consistent, community-wide messages in each setting.

Principle 13 - Prevention programs should be long-term with repeated interventions to reinforce the original prevention goals. Benefits from middle school prevention programs diminish without follow-up programs in high school. Principle 14 - Prevention programs should include teacher training on good classroom management practices, such as rewarding appropriate student behavior to foster students’ positive behavior, achievement, academic motivation, and school bonding. Principle 15 - Prevention programs work most effectively when they use interactive techniques, such as peer discussion groups and parent role-playing. Principle 16 - Research-based prevention programs can be costeffective. Research shows that for each dollar invested in prevention, a savings of up to $10 in treatment for alcohol or other substance abuse28.

The community youth development study This NIDA program offers assessment tools and technical trainings to communities so they can more accurately identify risk and protective factors for youth drug use and related behavior problems. This system

allows communities to select appropriate evidence-based prevention programs based on their particular needs29.

Future trends In addition to the pharmacological and therapeutic models in clinical trials previously reviewed, additional research studies may prove effective in the identification, prevention, and treatment of heroin addiction. High-resolution mapping of targeted brain areas. Research is currently underway that will increase knowledge of the brain systems and pathways taken by drugs and their effects on centers of the brain that influence drug-related behaviors involved in motivation, impulse control, pleasure, reward, compulsions, addiction, and relapse34. With this information, advances can be made to identify medications that interfere and block these drug behaviors to prevent drug addiction in persons at risk or assist in recovery and relapse prevention. Blending initiative Research and clinical trials are of no use if the results languish in a government publication and remain unused. The goal of the Blending

Initiative of 200120 was to address this problem of disseminating research-based addiction treatment information so that it could be implemented in clinical practice. NIDA explains the process as follow: NIDA and the Substance Abuse and Mental Health Services Administration (SAMHSA) joined together to create the Blending Initiative in 2001 to reduce the gap that exists between the publication of research results and impact on treatment delivery. This initiative incorporates collaboration between clinicians, scientists, and experienced trainers to catalyze the creation of user-friendly treatment tools and products and facilitate the adoption of research-based interventions into front-line clinical settings. Through this initiative, NIDA and SAMHSA’s Addiction Technology Transfer Centers (ATTC) disseminate treatment and training products based on results from studies conducted by the National Drug Abuse Clinical Trials Network (CTN) as well as other NIDA-supported research.

Conclusion It is the responsibility of all health care professional to advocate for their clients and promote access to health care for everyone. The disease of heroin addiction impacts all ages in all communities, so health professionals today must work to bring heroin addiction out of the shadows. They must educate others to remove the stigma and address heroin addiction as a brain disease that can affect anyone. As with

many diseases, such as HIV/AIDS, heroin addiction causes fear and is widely misunderstood in the community. Scientists and researchers are collaborating on better screening, treatment, and prevention techniques, health professionals and the general public should be educated about what they can do in their daily lives to prevent heroin addiction from spreading. This course points to the need for a multiple disciplinary

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approach that must start early in life to address the complex factors that lead to at-risk behaviors that may lead to drug experimentation. Environmental, social, genetic, physical, and mental health factors that contribute to addiction have been identified and are critical in developing effective treatment and prevention programs. Addressing these factors among youth at an early age may be the only way to control the epidemic, while law enforcement tries to eradicate the source of the drug from Mexico, South America, and Asia. Prevention begins by educating parents, teachers, and healthcare staff about early identification of risk factors in childhood as well as the early the signs and symptoms of drug use. Health care professionals, school staff, and community resource agencies can identify and refer at-risk individuals and struggling families to social services for prevention and treatment programs. Once identified, these families can benefit from early intervention programs, including, health care, counseling, assistance with parenting, and discipline to support healthy family interaction. Health care professionals must participate in prevention and treatment programs in the community through fundraising activities, lobbying local officials and state legislators, conducting community outreach activities to identify

and offer services to young people and adults at risk, educating the public about the disease, and working with the media to develop effective campaigns to combat negative cultural influences. By moving forward through a multi-disciplinary approach, health care professionals can close the heroin treatment gap and increase prevention efforts. As advocates, health professionals, government agencies, and politicians must collaborate to write policies and increase funding for heroin addiction prevention and treatment to stop the escalating cycle of addiction and relapse. NIDA research has demonstrated that prevention is cost effective in lowering expenditure in areas such as residential treatment, hospital and health care, incarceration, crime, and the justice system. Funds are necessary to increase the accessibility and ease of treatment to encourage families and individuals to seek help to stop the cycle of addiction and prevent it in the future. There is no way to put a price on the mounting death toll from this epidemic, and health care professionals are the front line of defense. The epidemic of heroin addiction is a massive problem that requires effort on the part of every health care professional to identify what they can do today to break the cycle of addiction in their community.

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Addiction Severity Index. Provides a structured clinical interview designed to collect information about substance use and functioning in life areas from adult clients seeking drug abuse treatment. triweb.tresearch.org/index.php/tools/download-asiinstruments-manuals. Blending Teams Web site at nida.nih.gov/blending. drugabuse.gov/blending-initiative. Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services (SAMHSA) Center for Substance Abuse Treatment; Substance Abuse and Mental Health Services Administration( SAMHSA). www.samhsa.gov/about/csat.aspx. http://www.samhsa.gov/data/ NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm. Treatment Locator: 1-800-662-HELP or search www.findtreatment.samhsa.gov. SAMHSA’s Store has a wide range of products Web site: store.samhsa.gov Clinical Trials. For more information on federally and privately supported clinical trials, please visit clinicaltrials.gov. Drugs, Brains, and Behavior: The Science of Addiction (Reprinted 2010). This publication provides an overview of the science behind the disease of addiction. Publication #NIH 10-5605. Available online at drugabuse.gov/publications/science-addiction. Complete NSDUH findings are available at National Institute for Drug Addiction drugabuse.gov. National Institute of Drug Addiction. Web site: www.drugabuse.gov NIDA Public Information Office: 301-443-1124. The National Institute of Justice. The research agency of the Department of Justice. For information contact the National Criminal Justice Reference Service at 800-851-3420 or 301-519-5500; or visit www.nij.gov. National Institute of Mental Health nimh.nih.gov. The National Registry of Evidence-Based Programs and Practices. This database of interventions for the prevention and treatment of mental and substance use disorders is maintained by SAMHSA and can be accessed at nrepp.samhsa.gov.

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NIDA DrugFacts: Treatment Approaches for Drug Addiction (Revised 2009). This is a fact sheet covering research findings on effective treatment approaches for drug abuse and addiction. Available online at drugabuse.gov/publications/drugfacts/treatment-approaches-drugaddiction. NIDA DrugPubs Research Dissemination Center. NIDA publications and treatment materials are available from this information source. Staff provide assistance in English and Spanish, and have TTY/TDD capability. Phone: 877-NIDA-NIH (877-643-2644); TTY/TDD: 240-645-0228; fax: 240645-0227; e-mail: [email protected]; Web site: drugpubs.drugabuse.gov. Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders– Second Edition. This booklet lists over 20 examples of effective research-based drug abuse prevention programs and is available free on NIDA’s website. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide. NIH Publication No.: 11-5316. Available online at nida.nih.gov/PODAT_CJ. Research Report Series: Therapeutic Community This report provides information on the role of residential drug-free settings and their role in the treatment process. NIH Publication #02-4877. Available online at NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) drugabuse.gov/CTN/Index.htm. Seeking Drug Abuse Treatment: Know What To Ask NIDA Publication #12-7764. Available online at drugabuse.gov/publications/seeking-drug-abuse-treatment. The “Find A Physician” feature on the American Society of Addiction Medicine (ASAM) Web site: http://community.asam.org/search/default.asp?m=basic Patient Referral Program on the American Academy of Addiction Psychiatry Web site: http://www.aaap.org/patient-referral-program. The Child and Adolescent Psychiatrist Finder on the American Academy of Child and Adolescent Psychiatry Web site: http://www.aacap.org/cs/root/child_and_adolescent_psychiatrist_finder/ child_and_adolescent_psychiatrist_finder

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14. 15. 16.

Foundation for a Drug-Free World. (2014). Retrieved from http://www.drugfreeworld.org/drugfacts/ heroin.html What is Heroin and What is it For? (2014). Retrieved from http://www.drugabuse.gov/publications/ research-reports/heroin/what-heroin Drugs, Brains, and Behavior: The Science of Addiction (2014). Retrieved from http://www. drugabuse.gov/publications/science-addiction The Definition of Addiction (2011). Retrieved from http://www.asam.org/advocacy/find-a-policystatement/view-policy-statement/public-policy-statements/2011/12/15/the-definition-of-addiction Panell, I. (2014). The Horrific Toll of America’s Heroin Epidemic. BBC News Magazine. Chicago. Retrieved from http://www.bbc.com/news/magazine-26672422 National Survey on Drug Use and Health: Summary of National Findings (2012). Retrieved from http://www.drugabuse.gov/publications/research-reports/heroin/scope-heroin-use-in-united-states The U.S. Drug Enforcement Administration (2012) National Drug Threat Assessment Report (FULL) Retrieved from http://www.justice.gov/dea/resource-center/DIR-017-13%20NDTA%20Summary%20 final.pdf Heroin Addiction. (2013). Retrieved from http://report.nih.gov/nihfactsheets/viewfactsheet. aspx?csid=123 Data, Outcomes and Quality (2012). Retrieved from http://www.samhsa.gov/data/ American Psychiatric Association (2013). Substance-Related and Addictive Disorders, in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: American Psychiatric Publishing, 540–550, and 2013. Mardis, C. (2011). Increased Opiate Use and the Need for Onsite Heroin Screening. Retrieved from http://www.nadcp.org/sites/default/files/nadcp/Final%206AM%20Brief.pdf Department of Health and Human Services (2010). Mandatory Guidelines for Federal Workplace Drug Testing Programs. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2010-04-30/pdf/201010118.pdf Harrison, L .D., Martin, S. S., Enev, T., Harrington, D. (2007). Comparing Drug Testing and SelfReport of Drug Use among Youths and Young Adults in the General Population Department of Health and Human Services Substance Abuse and Mental Health Services Administration Office of Applied Studies. Retrieved from http://www.samhsa.gov/data/nsduh/drugtest.pdf Symptoms and Signs of Poly-substance Abuse (2014). Retrieved from http://www.buppractice.com/ howto/screen/polysubstance U.S. Foods and Drug Administration (2014). FDA Approves New Hand-Held Auto-Injector to Reverse Opioid Overdose. FDA News Release. April 3, 2014. Retrieved from http://www.fda.gov/ NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm. O’Brien, R. (2014) FDA Approves Potential Lifesaver in Heroin Epidemic: April 4, 2014. Retrieved from http://www.northjersey.com/news/fda-approves-potential-lifesaver-in-heroin-epidemic1.841414?page=all

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17. SAMHSA Announces a Working Definition of “Recovery” from Mental Disorders and Substance Use Disorders. Retrieved from http://www.samhsa.gov/newsroom/advisories/1112223420.aspx 18. Principles of Drug Addiction Treatment: A Research-Based Guide, Third Edition (2012). Retrieved from http://www.drugabuse.gov/publications/principles-drug-addiction-treatment 19. Neuropsychopharmacology. (2012) 2012 Apr; 37(5): 1083-91. doi: 10.1038/npp.2011.200. Epub 2011 Sep 14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21918504. 20. Topics in Brief: NIDA’s Blending Initiative: Accelerating Research-Based Treatments into Practice (2007). Retrieved from http://www.drugabuse.gov/publications/topics-in-brief/nidas-blendinginitiative-accelerating-research-based-treatments-practice 21. National Institute on Drug Abuse(2006) Buprenorphine: Treatment for Opiate Addiction Right in the Doctor’s Office Retrieved from http://www.drugabuse.gov/publications/topics-in-brief/ buprenorphine-treatment-opiate-addiction-right-in-doctors-office 22. Krupitsky, E.; Zvartau, E.; Blokhina, E.; Verbitskaya, E.; Wahlgren, V.; Tsoy-Podosenin, M.; Bushara, N.; Burakov, A.; Masalov, D.; Romanova, T.; Tyurina, A.; Palatkin, V.; Slavina, T.; Pecoraro, A.; Woody, G. E. (2013). Naltrexone Implant Outperforms Daily Pill in Russian Trial: Randomized Trial of Long-Acting Naltrexone Implant vs Oral Naltrexone or Placebo for Preventing Relapse to Opioid Dependence. Archives of General Psychiatry 69(9): 973–981, 2012. Retrieved from http:// www.drugabuse.gov/news-events/nida-notes/2013/11/naltrexone-implant-outperforms-daily-pill-inrussian-trial 23. CDC (2002). Methadone Maintenance Treatment. Retrieved from http://www.cdc.gov/idu/facts/ MethadoneFin.pdf 24. Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings (2012) NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Retrieved from http://www.drugabuse.gov/publications/research-reports/ heroin/scope-heroin-use-in-united-states 25. Wee, S., Hicks MJ, De BP, Rosenberg JB, Moreno AY, Kaminsky SM, Janda KD, Crystal RG, Koob GF. (2011). Novel Cocaine Vaccine Linked to a Disrupted Adenovirus Transfer Vector Blocks Cocaine Psychostimulant and Reinforcing Effects. Neuropsychopharmacology. Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/21918504 26. Division of Pharmacotherapies and Medical Consequences of Drug Abuse (DPMCDA) (2011). Retrieved from http://www.drugabuse.gov/about-nida/organization/divisions/divisionpharmacotherapies-medical-consequences-drug-abuse-dpmcda/research-programs#ATDP 27. Family Based Approach (2014). Retrieved from http://www.drugabuse.gov/publications/principlesadolescent-substance-use-disorder-treatment-research-based-guide/evidence-based-approaches-totreating-adolescent-substance-use-disorders/family-based-approaches 28. Behavioral Therapies (2012). Retrieved from http://www.drugabuse.gov/publications/principles-drugaddiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies

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29. Mark TL, Woody GE, Juday T, Kleber HD. (2001) The Economic Costs of Heroin Addiction in the United States. Drug Alcohol Dependency. 2001; 61:195–206. Retrieved from http://www.ncbi.nlm. nih.gov/pubmed/11137285 30. Community Youth Development Study (2009). Retrieved from www.drugabuse.gov/sites/default/ files/nnvol23n4.pdf 31. Promoting Awareness of Motivational Incentives NIDA (2006). Retrieved from http://www. drugabuse.gov/sites/default/files/files/PAMI_Factsheet.pdf 32. Petry, N. M., & Bohn, M. J. (2003). Fishbowls and candy bars: Using low-cost incentives to increase treatment retention. NIDA Science & Practice Perspectives, 2(1), 55–61. PDF] Successful Treatment Outcomes Motivational Incentives: Positive Reinforces to Enhance http://www.drugabuse.gov/sites/ default/files/files/MI-PRESTO_Factsheet.pdf 33. Kellogg, S. H., Burns, M., Coleman, P., Stitzer, M., Wale, J. B., & Kreek, M. J. (2005). Something of Value: The Introduction of Contingency Management Interventions into the New York City

Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment, 28, 57–65. Retrieved from http://www.drugabuse.gov/sites/default/files/files/MI-PRESTO_Factsheet.pdf 34. Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide (2014). Retrieved from http://www.drugabuse.gov/publications/principles-adolescent-substance-use-disordertreatment-research-based-guide/principles-adolescent-substance-use-disorder-treatment 35. High Resolution Brain Spectrum Imaging in a Clinical Substance Abuse Practice (2010). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20648911 J Psychoactive Drugs. 2010 Jun; 42(2): 153-60. 36. National Institute on Drug Abuse Preventing Drug Use among Children and Adolescents: A ResearchBased Guide for Parents, Educators, and Community Leaders, Second Edition booklet. (2003). NIH Pub Number: 04-4212(A) Published: January 1997Revised: October 2003: Retrieved from http:// www.drugabuse.gov/publications/preventing-drug-use-among-children-adolescents

The Heroin Epidemic in America: Identification, Treatment and Prevention Final Examination Questions

Select the best answer for each question and proceed to SocialWork.EliteCME.com to complete your final examination. 31. Heroin and morphine, along with codeine, hydrocodone, oxycodone, and oxymorphone are similar in structure because of the following: a. They all bind to the opioid receptor. b. They are all benzodiazepines. c. They are inexpensive. d. They are easily accessible 32. White powder heroin is a salt form known as diacetylmorphine hydrochloride, and even though white heroin is the purest form the following statement is correct. a. It cannot be cut. b. It will still contain lethal contaminants. c. It is not very powerful. d. It is 12 times as powerful as brown heroin. 33. A chronic, relapsing disease, characterized by compulsive drug seeking and use accompanied by neurochemical and molecular changes in the brain is the definition of which term below? a. Dependence. b. Tolerance. c. Addiction. d. Drug abuse. 34. An opioid receptor antagonist that rapidly binds to opioid, blocking heroin from activating them is which of the following? a. Morphine. b. Methadone. c. Naloxone. d. Oxycodone. 35. When heroin from the mother passes through the placenta into the baby’s bloodstream during pregnancy it is called________. a. Infant addiction. b. Maternal addiction. c. Neonatal addiction symptoms. d. Neonatal abstinence syndrome.

36. Young people who would never inject a drug can now find heroin that can be smoked or inhaled. As a result which of the following occurs? a. Heroin seems easier, safer, and more desirable, thus increasing their willingness to try the drug. b. Young people will not try the drug because of anti smoking campaigns. c. There is no difference in the use of the drug. d. Youth will only inject the drug as a last resort. 37. A combination of Mexican black tar heroin and cold medicine obtained over the counter is called which of the following? a. Cold tar. b. Cheese heroin. c. Brown heroin. d. China jade. 38. Those abusers who have recently switched to heroin are at higher risk for which of the following? a. Accidental overdose. b. Sudden death. c. Blood diseases. d. Chronic renal failure. 39. Choose the correct statement. a. Addiction causes changes in brain blood volume. b. Addiction causes changes in brain mass. c. Addiction causes changes in brain chemistry and function. d. Addiction causes changes in brain stabilization. 40. Though genetics factors do not cause an addiction to heroin, they can indicate which of the following? a. The person is prone to alcoholism. b. Addictive behavior and were found to be significant in about 50 percent of addictions. c. Addiction is 85% likely to occur. d. Addiction occurs more often in certain minority groups.

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41. Negative school or work performance is which of the following? a. A common denominator. b. A psychological factor. c. A coincidence. d. An insignificant sign. 42. Breathing that is slow, shallow or irregular may be __________. a. A short term side effect. b. A long term side effect. c. Insignificant to note. d. Easily treatable. 43. Severe muscle and bone aches may indicate which of the following? a. Over exertion. b. A withdrawal symptom. c. Hepatitis. d. An elderly client and not related to drug use. 44. The state of New York has also approved the use of the drug Naloxone by all law enforcement agents. Which of the following statements are correct about the use of Naloxone? a. New York is the only state using the drug. b. Seventeen other states have followed suit, with some allowing prescriptions to family and friends of the addict. c. Only law enforcement agents can use it in the United States. d. All states use it now. 45. Choose the correct statement. a. Addiction is a behavioral disorder. b. Addiction is a culture driven disorder. c. Addiction is classified as a chronic brain disorder or disease and not a behavioral one. d. Addiction is a genetic disorder. 46. Which is correct about treatment of heroine addiction? a. Medication does not work in these cases for long term positive outcomes. b. Only behavioral therapy will work to provide lasting results. c. There is no effective treatment known. d. Integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. 47. When treating a client_____________________. a. Treatment must be voluntary to work. b. Treatment does not have to be voluntary to be effective. c. Treatment must be court ordered. d. Treatment must include electro shock. 48. Agonist medication such as methadone, also known as Dolophine and Methadose work in what way? a. They activate receptors quickly and stop cravings. b. They over enhance euphoria which causes sickness. c. They activate receptors by gradually reaching the brain slowly, preventing the euphoric feeling. d. They de-activate receptors to stop the euphoria.

49. Partial agonists, such as buprenorphine, also called Subutex, produce which of the following? a. A large response in the brain to stop cravings when injected. b. A small response in the brain, which relieves cravings with no euphoria or side effects when taken orally. c. A slow response that causes minimal euphoria that can be diminished over time. d. A quick response that is unpleasant but stops cravings. 50. Which type of therapy uses positive reinforcement? a. Contingency management uses positive reinforcement to encourage abstinence from drugs. b. Pharmacological therapy with reality therapy. c. All forms of therapy. d. Cultural/social therapy. 51. Brain research shows that the prefrontal cortex develops last, and that is the part of the brain that controls what functions? a. Breathing and heartbeats. b. Blood flow. c. Decisions and judgments. d. Circulation 52. NIDA identifies the following factors that can be addresses to prevent addiction at an early age. a. Neurobiology. b. Culture. c. IQ. d. Ethnicity. 53. Which is correct about prevention programs? a. There are no prevention programs that are effective. b. Prevention programs can be designed to intervene as early as infancy to address risk factors for drug abuse. c. Prevention programs should start with the parents before they have children. d. Prevention with drugs and behavior therapy work for those children at risk by age four. 54. This NIDA program offers assessment tools and technical trainings to communities so they can more accurately identify risk and protective factors for youth drug use and related behavior problems. a. The Teacher Training for Youth Safety Program. b. The Youth at Risk Program. c. The Community Youth Development Study. d. Stop Addiction Now! 55. The Blending Initiative of 2001 was developed to _____________. a. Blend all therapeutic efforts together in therapy. b. Educate the public to work together to stop addiction. c. Reduce the gap that exists between the publication of research results and impact on treatment delivery. d. To blend mental health and law enforcement efforts to stop addiction.

SWPA04HE17 SocialWork.EliteCME.com

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Chapter 4:

Medication Management of Opioid Dependence 5 Contact Hours

By: Kathryn Brohl, MA, LMFT

Learning objectives ŠŠ ŠŠ ŠŠ ŠŠ

Define opioid dependence. Understand the diagnosis of opioid dependence. Describe opioid withdrawal. Understand the history of opioid use in the United States and related legal implications. ŠŠ Understand what opioid-dependent populations benefit from methadone and buprenorphine medical management.

ŠŠ Understand why methadone provides effective medical management for opioid dependence. ŠŠ Understand why methadone can be used with pregnant women. ŠŠ Understand how buprenorphine is used with opioid dependence. ŠŠ Understand different research that validates medical management for opioid dependence. ŠŠ Provide treatment information in early recovery with health care and counseling professionals.

Jeff’s story Jeff was the third child born to professionals who adored their son. A rambunctious and curious child from birth, Jeff was not an A-student, but he was exceedingly bright, with interests in music and literature as well as a love for baseball. Sports came easily to him, and at the age of 10 he was the lead pitcher on a traveling baseball team. Jeff’s dream was to get into the Major League and play for the Mets. His parents were diligent supporters and often traveled with the team, lending their support and encouragement. Sadly, a shoulder injury sidelined the young man at age 16, and he was told an operation could fix the problem. Jeff, with his usual straight-ahead attitude, went for it. The operation proved to be more painful than the teen had anticipated, but the doctor prescribed pain medication, OxyContin, and it greatly helped Jeff’s discomfort. As a matter of fact, it actually made Jeff feel good, so good, in fact, that when it came time to wean himself off the meds, he was not willing. He’d never experienced this feeling before, and while he told his parents he’d stopped his use, it continued after he returned to playing baseball. Jeff didn’t have any trouble getting the painkillers; there were plenty of people selling them. The once well-intended, benign use to relieve pain began to turn into abuse and then an addiction/ dependence. Jeff became more concerned about getting the medication than getting to school on time, or practicing baseball, and he felt terribly guilty. A couple times he tried to stop, but then he would get sick, and sought the pills to feel better. His addiction was turning into a nightmare, and he was ashamed to tell his parents. They came upon the truth when they learned

that Jeff had taken all of the money out of his savings account, but not before he began to behave erratically. Jeff’s folks had a difficult time thinking that their son could have a drug problem because they thought they had done everything to prevent it from occurring. They watched him carefully throughout his childhood and adolescence, and never failed to mention the danger of using drugs. Yet, the idea of pain medication as an addiction had never entered their minds. Didn’t young people generally smoke marijuana, drink alcohol, or take ecstasy, they wondered? After several days and much questioning, Jeff finally admitted to his addiction/dependence, and with even greater trepidation, his parents guiltily admitted him into a detox unit at local hospital. But while Jeff was getting medical attention and counseling during this time, his parents and he still had to decide what he was going to do when he was released from detox. The physician at the facility suggested that Jeff might have a very difficult time in early recovery without some form of medication management, coupled with counseling, and a suggested methadone maintenance regimen. He also referred him to a licensed mental health professional. At this point, Jeff and his parents thought that this would simply extend his addiction, but the doctor told them that with careful supervision and counseling, Jeff’s chances of sobriety long-term were good.

Introduction In recent years, opiate dependence has become a catastrophic problem in the United States, causing thousands, especially younger people, to lose their lives, and leaving loved ones behind to question these senseless losses. People included in this grave epidemic come from the full spectrum of socio-economic backgrounds. Sadly, approximately 9 percent of the population is believed to misuse opiates over the course of their lifetimes, including illegal drugs like heroin and prescription pain medications such as Oxycontin. (Opiate drugs include heroin, morphine, codeine, Oxycontin, Dilaudid, methadone, and others.) It is an addiction, where, truly, no one gets left behind.

Drug abuse and addiction/dependence changes the way the brain works, resulting in compulsive behavior focused on drug seeking and use, despite often devastating consequence. These behaviors are the essence of addiction. Consequently, drug abuse/addiction treatment must address these brain changes, both in the short and long term. When people addicted to opioids first stop, they undergo withdrawal symptoms, which may be severe pain, diarrhea, nausea and vomiting. (Note: Throughout this course, “ addiction” and “dependence” will be used interchangeably to describe the same condition.)

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Prescription and OTC drugs and the brain Taken as intended, prescription and OTC drugs safely treat specific mental or physical symptoms. But when taken in different quantities or when such symptoms aren’t present, they may affect the brain in ways very similar to illicit drugs. For example, stimulants such as Ritalin increase alertness, attention, and energy the same way cocaine does – by boosting the amount of the neurotransmitter dopamine. Opioid pain relievers like OxyContin attach to the same cell receptors targeted by illegal opioids like heroin. Prescription depressants produce sedating or calming effects in the same manner as the club drugs GHB and rohypnol by enhancing the actions of the neurotransmitter GABA (gamma-aminobutyric acid). When taken in very high doses, dextromethorphan acts on the same glutamate receptors as PCP or ketamine, producing similar out-of-body experiences. When abused, all of these classes of drugs directly or indirectly cause a pleasurable increase in the amount of dopamine in the brain’s reward pathway. Repeatedly seeking to experience that feeling can lead to addiction. Opioids can produce drowsiness, cause constipation, and depending upon the amount taken, depress breathing. The latter effect makes opioids particularly dangerous, especially when they are snorted or injected or combined with other drugs or alcohol. CNS depressants slow down brain activity and can cause sleepiness and loss of coordination. Continued use can lead to physical dependence and withdrawal symptoms if discontinuing use. Dextromethorphan can cause impaired motor function, numbness, nausea or vomiting, and increased heart rate and blood pressure. On rare occasions, hypoxic brain damage – caused by severe respiratory depression and a lack of oxygen to the brain – has occurred from the combination of dextromethorphan with decongestants often found in the medication. Deaths from opioid pain relievers exceed those from illegal drugs. Opioid pain relievers have the potential for addiction, and this risk is amplified when they are abused. Also, as with other drugs, abuse of prescription and OTC drugs can alter a person’s judgment and decision making, leading to dangerous behaviors such as unsafe sex and drugged driving. Medications can be helpful in this detoxification stage to ease craving and other physical symptoms, which often prompt relapse. However, this is just the first step in treatment. Medications may also become an essential component of an ongoing treatment plan, enabling opioidaddicted persons to regain control of their health and their lives.

Medications developed to treat opioid addiction work through the same receptors as the addictive drug, but are safer and less likely to produce the harmful behaviors that characterize addiction. Three types include: 1. Agonists that activate opioid receptors. 2. Partial agonists that also activate opioid receptors but produce a diminished response. 3. Antagonists that block the receptor and interfere with the rewarding effects of opioids. Physicians prescribe a particular medication based on a patient’s specific medical needs and other factors. Effective medications include: ●● Methadone (Dolophine or Methadose), a slow-acting, opioid agonist. Methadone is taken orally, so that it reaches the brain slowly, dampening the “high” that occurs with other routes of administration while preventing withdrawal symptoms. Methadone has been in use since the 1960s to treat heroin addiction and is still an excellent treatment option, particularly for patients who do not respond well to other medications; however, it is only available through approved outpatient treatment programs, where it is dispensed to patients on a daily basis. ●● Buprenorphine (Subutex, Suboxone), a partial opioid agonist. Buprenorphine relieves drug cravings without producing the “high” or dangerous side effects of other opioids. Suboxone is a novel formulation taken orally that combines buprenorphine with naloxone (an opioid antagonist) to ward off attempts to get high by injecting the medication. If an addicted patient were to inject Suboxone, the naloxone would induce withdrawal symptoms, which are averted when taken orally as prescribed. The FDA approved buprenorphine in 2002, making it the first medication eligible to be prescribed by certified physicians through the Drug Addiction Treatment Act. This approval eliminates the need to visit specialized treatment clinics, expanding treatment access. ●● Naltrexone (Depade, Revia) an opioid antagonist. Naltrexone is not addictive or sedating and does not result in physical dependence; however, poor patient compliance has limited its effectiveness. Recently an injectable long-acting formulation of naltrexone called Vivitrol received FDA approval for treating opioid addiction. Given as a monthly injection, Vivitrol should improve compliance by eliminating the need for daily dosing. To avoid withdrawal symptoms, Vivitrol should be used only after a patient has undergone detoxification. Vivitrol provides an effective alternative for individuals who are unable to or choose not to engage in agonist-assisted treatment.

Benefits of medication-assisted treatment Scientific research has established that medication-assisted treatment of opioid addiction increases patient retention and decreases drug use, infectious disease transmission, and criminal activity. For example, studies among criminal offenders, many of whom enter the prison system with drug abuse problems, showed that methadone treatment begun in prison and continued in the community upon release extended the time parolees remained in treatment, reduced further drug use, and produced a three-fold reduction in criminal activity. Research has also demonstrated that methadone maintenance treatment is beneficial to society, cost-effective, and pays for itself in basic economic terms. A study of the cost benefits of methadone maintenance treatment showed that the costs to society of the criminal activities related to active heroin use can run as high as four times more than the costs for methadone maintenance treatment (Harwood et al., 1988).

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Through the New York State Department of Substance Abuse Services, NIDA researchers have estimated the yearly costs to maintain an opioid addict in New York are: ●● Untreated and on the street ($43,000). ●● In prison ($34,000). ●● In a residential drug-free program ($11,000). ●● In methadone maintenance treatment ($2,400). (New York State Committee of Methadone Program Administrators, 1991.) As early as the 1960s, methadone gained recognition as an effective treatment for heroin addiction. Naltrexone, an opioid receptor blocker, joined the medications treatment inventory in 1984. It proved to be highly effective in reversing the effects of opiate overdose, but poor treatment adherence has hampered its utility to promote abstinence. Buprenorphine, the newest medication, is a long-acting partial agonist that acts on the same receptors as heroin and morphine, relieving drug cravings without producing the same intense “high” or dangerous side Page 50

effects. These medications, along with effective behavioral treatments and outreach efforts, have not only reduced injection drug use in this country, but have also helped reduce the spread of HIV/AIDS from a peak of more than 25,000 new cases in 1993 to fewer than 10,000 cases in 2003.

This course will focus on medication maintenance treatment for substance abuse and addiction, as well as its medication management and treatment implications. Related, validating research on its use for opioid addiction will further be described. An additional section of the course will explain why methadone is used successfully with pregnant women, a seemingly counter-intuitive medication management intervention.

UNDERSTANDING THE CLASS OF DRUGS KNOWN AS OPIOIDS Heroin, morphine, and some prescription painkillers (e.g., OxyContin, Vicodin, and Fentanyl) belong to the class of drugs known as opiates. They act on specific (opiate) receptors in the brain, which also interact with naturally produced substances known as endorphins or enkephalins, which are important in regulating pain and emotion. And while prescription painkillers are highly beneficial medications when used as prescribed, opiates as a general class of drugs have

significant abuse liability. Currently, approximately 1 million people in the United States are addicted to heroin (Office of National Drug Control Policy, 2000), and more than 3 million people over the age of 12 have used heroin at least once (National Survey on Drug Use and Health, NSDUH, 2004). And an estimated 1.4 million people are dependent on or abusing other opiate drugs, including prescription painkillers (NSDUH, Ibid).

Opioid dependence Opioid dependence falls under the DSM-IV-TR Criteria for Substance Dependence (American Psychiatric Association, 2000). DSM-IV-TR It is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for withdrawal from the specific substances). b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 3. The substance is often taken in larger amounts or over a longer period than was intended. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use. 7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption). ICD-10 Clinical Description (World Health Organization, 2006) A cluster of physiological, behavioral, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviors that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals (World Health Organization, 2006). A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

●● A strong desire or sense of compulsion to take the substance. ●● Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use. ●● A physiological withdrawal state when substance use has ceased or been reduced, as evidenced by the characteristic withdrawal syndrome for the substance or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms. ●● Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill non-tolerant users). ●● Progressive neglect of alternative pleasures or interests because of psychoactive substance use and increased amount of time necessary to obtain or take the substance or to recover from its effects. ●● Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm. ICD-10 Diagnostic Criteria for Research (World Health Organization, 2006) Three or more of the following manifestations should have occurred together for at least one month or, if persisting for periods of less than one month, should have occurred together repeatedly within a 12-month period: ●● A strong desire or sense of compulsion to take the substance. ●● Impaired capacity to control substance-taking behavior in terms of its onset, termination, or levels of use, as evidenced by the substance often being taken in larger amounts or over a longer period than intended, or by a persistent desire or unsuccessful efforts to reduce or control substance use. ●● A physiological withdrawal state when substance use is reduced or ceased, as evidenced by the characteristic withdrawal syndrome for the substance or by use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms. ●● Evidence of tolerance to the effects of the substance, such that there is a need for significantly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of the substance.

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●● Preoccupation with substance use, as manifested by important alternative pleasures or interests being given up or reduced because of substance use; or a great deal of time being spent in activities necessary to obtain, take, or recover from the effects of the substance. ●● Persistent substance use despite clear evidence of harmful consequences, as evidenced by continued use when the individual is actually aware, or may be expected to be aware, of the nature and extent of harm.

The spectrum of prescription drug abuse includes: 1. Taking someone else’s prescription to self-medicate. 2. Taking a prescription medication in a way other than prescribed. 3. Taking a medication to get high.

A brief history of opioid addiction 1860-1910 – Although opioids have been used as pain medications and anti-anxiety drugs throughout recorded history, it was not until the U.S. Civil War of 1861-1865 that widespread prevalence of opioid addiction was documented in the United States (Hentoff, 1965). The synthesis of heroin in 1874 and its commercial marketing as a “wonder drug” contributed to a pattern of iatrogenic addiction that continued into the early 1900s, with physicians, pharmacists, and patent medicine salesmen dispensing narcotics freely to patients who were primarily middle-aged, middle-class women (Courtwright, 1992; United Nations Department of Social Affairs, 1953; Acker, 2002). The Institute of Medicine estimated that by 1900, perhaps 300,000 Americans were addicted to opiates (Courtwright, 1992). 1910-1950 – Between 1910 and 1950, opioid addiction was rarely prevalent among U.S. patients inadvertently addicted to a medical cure. The Institute of Medicine describes how successive waves of immigration and urbanization contributed to a population of opioid abusers who were in their teens or early 20s, unmarried, poor, primarily male, ethnic minorities who experimented with drugs for nonmedical purposes (Courtwright, 1992).

1950-Present – Intravenous use of heroin intensified in the United States after WWII, reaching epidemic proportions in urban centers during the 1950s and 1960s (Joseph, Stancliff, and Langrod, 2000). In 1967, the National Survey on Drug Use and Health (NSDUH) began collecting data on heroin use. The survey documents dramatic increases in the initiation of heroin use during the early 1970s and between 1995 and 2002 (Substance Abuse and Mental Health Services Administration, 2005), when the annual number of new heroin users ranged from 121,000 to 164,000. The National Institute on Drug Abuse (NIDA) reports that, during this period, most new users were age 18 or older (on average, 75 percent) and most were male (National Institute on Drug Abuse, 2005a). The 2003 NSDUH found that an estimated 3.7 million Americans had used heroin at some time in their lives and 314,000 in the past year. The group that represented the highest number of those users was age 26 or older (National Institute on Drug Abuse, 2005a). NIDA also reports that heroin use in 2003 was stable at low levels (National Institute on Drug Abuse, 2005b).

Opiates create physical dependence People rely on the drug to prevent symptoms of withdrawal. Over time, greater amounts of the drug become necessary to produce the same effect. And the time it takes to become physically dependent varies with each individual. Prescription and OTC drugs may be abused in one or more of the following ways: ●● Taking a medication that has been prescribed for somebody else. Unaware of the dangers of sharing medications, people often unknowingly contribute to this form of abuse by sharing their unused pain relievers with their family members. Most teenagers who abuse prescription drugs are given them for free by a friend or relative. ●● Taking a drug in a higher quantity or in another manner than prescribed. Most prescription drugs are dispensed orally in tablets, but abusers sometimes crush the tablets and snort or inject the powder. This hastens the entry of the drug into the bloodstream and the brain and amplifies its effects. ●● Taking a drug for another purpose than prescribed. All of the drug types mentioned can produce pleasurable effects at sufficient quantities, so taking them for the purpose of getting high is one of the main reasons people abuse them. ADHD drugs like Adderall are also often abused by students for their effects in promoting alertness and concentration.

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Opioid intoxication Opioid intoxication is a condition caused by use of opioid-based drugs, which include morphine, heroin, oxycodone, and the synthetic opioid narcotics. Prescription opioids are used to treat pain. Intoxication or overdose can lead to a loss of alertness, or unconsciousness. Symptoms of opioid intoxication can include breathing problems, and breathing may stop; extreme sleepiness or loss of alertness, and small pupils. Some people even withdraw from opiates after being given such drugs for pain while in the hospital without realizing what is happening to them. They think they have the flu, and because they don’t know that opiates would fix the problem, they don’t crave the drugs. The opioid-dependent person generally uses opioids several times each day. Each use causes an elevation in mood, and the user feels “high.” This high is followed by a rapid decline in mood and functional state. The user no longer feels high and may begin to feel sick. At the end of the day, or in the morning, the user feels quite sick as a result of opioid withdrawal. Overall, a typical day includes several cycles of elevated and depressed mood and function state. As an opioid dependent person uses opioids for a period of time – weeks or months – the person’s level of physical dependence makes it less likely that he or she will experience the “high.” Continued drug use results from a desire to avoid the depressions and physical symptoms associated with opioid withdrawal. In the story shared earlier about Jeff, he was literally unable to stop his opioid use on his own because of this withdrawal cycle. Page 52

Opiate withdrawal refers to the wide range of symptoms that occur after stopping or dramatically reducing opiate drugs after heavy and prolonged use (several weeks or more). When the person stops taking the drugs, the body needs time to recover, and withdrawal symptoms result. Withdrawal from opiates can occur whenever any chronic use is discontinued or reduced. Early symptoms of withdrawal include: ●● Anxiety. ●● Muscle aches. ●● Increased tearing. ●● Insomnia.

●● ●● ●● ●●

Runny nose. Sweating. Yawning. Agitation.

Late symptoms of withdrawal include: ●● Abdominal cramping. ●● Diarrhea. ●● Dilated pupils. ●● Goose bumps. ●● Nausea. ●● Vomiting.

Prescription opioids (abuse): Hydrocodone, oxycodone, codeine Health effects Acute.

Pain relief, drowsiness, nausea, constipation, euphoria in some. When taken by routes other than as prescribed (e.g., snorted, injected), increased risk of depressed respiration, leading to coma, death. CDC reports marked increases in unintentional poisoning deaths since late the 1990s, due mainly to opioid pain reliever overdose (often in combination with alcohol or other drugs).

Long-term.

Tolerance, addiction.

In combination with alcohol.

Dangerous slowing of heart rate and respiration, coma, or death.

Withdrawal symptoms.

Restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”), and leg movements. Associated special vulnerabilities/populations

Youth.

8-10 percent of high school seniors have used Vicodin non-medically in the past year; ~5 percent have abused OxyContin.

Pregnancy.

Spontaneous abortions; low birth weight.

Older adults.

The higher prevalence of pain in this population renders a greater number of prescriptions written for opioid medications. Unintentional misuse or abuse could have more serious health consequences for elderly patients because of comorbid illnesses (and multiple prescriptions), potential for drug interactions, and agerelated changes in drug metabolism. Treatment options

Medications.

●● Methadone. ●● Buprenorphine. ●● Naltrexone (short and long-acting).

Behavioral therapies.

Behavioral therapies that have proven effective for treating addiction to illicit opioid drugs, such as heroin, may be useful in addressing prescription opioid addiction.

Opioid withdrawal reactions are very uncomfortable but are not, in general, life-threatening. Symptoms usually start within 12 hours of last heroin usage and within 30 hours of last methadone exposure. The Addiction Severity Index (ASI) (McLellan, Kushner, Metzger, et al., 1992) is an instrument designed to assess the impact of a patient’s addiction on his or her function. Although this instrument is typically used in research, it has been adapted for clinical use and illustrates the various aspects of a patient’s life that should be assessed at each patient visit to determine the impact of active addiction or the benefits of abstinence. The ASI evaluates patient function in the areas of: ●● Drug use. ●● Alcohol use. ●● Psychiatric function. ●● Medical function. ●● Employment.

●● Social/family functioning. ●● Legal problems. In addition to patient self-report, urine testing can be a useful practice in monitoring patient progress in treatment. In some countries, urine testing is mandated as part of the treatment plan. A variety of substances can be detected in urine testing. Testing can occur for naturally occurring opioids (e.g., codeine, morphine) or synthetic or semi-synthetic opioids (e.g., oxycodone, methadone). Testing also can occur for benzodiazepines, cocaine, marijuana, or other drugs that are used and abused by the patient population. The period of detection of each of these substances varies with the laboratory technique that is used, and the extent of drug use and can range from days to weeks.

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METHADONE MAINTENANCE TREATMENT U.S. opiate addiction regulations and methadone maintenance treatment U.S. regulations about treatment for heroin addiction have evolved from strict prohibition of medical prescription of heroin to treat addiction, which began in 1914 and continued into the 1960s. Initial pilot studies testing methadone maintenance treatment for heroin addiction began in 1964, and methadone maintenance treatment was formally approved in 1972. Scientific advances prompted major reviews of Federal regulations by the Institute of Medicine in 1995 (Substance Abuse and Mental Health Services Administration, 2000b) made significant changes in U.S. regulations about treatment for heroin addiction, reducing Federal regulations and paving the way for new pharmacotherapies to treat heroin addiction. 1860-1909: Minimal government involvement - The Institute of Medicine documents U.S. narcotics policies from the 19th century through 1992, (Courtwright, 1992). In the first years following widespread use of heroin in the United States, there were no Federal regulations about the manufacture, distribution, or use of heroin, and the few State or municipal laws that existed were enforced sporadically. Physicians, pharmacists, and opportunists were free to prescribe opioids–and treat subsequent opioid addiction–in whatever manner they chose, which contributed to widespread addiction and sometimes unscrupulous practices. Inadvertent addiction to early over-the-counter medications prompted enactment of the 1906 Pure Food and Drug Act, which first authorized Federal regulations on any medication. 1909-1924: Increasing federal government role - In the United States, heroin was first placed under Federal control by the 1914 Harrison Narcotic Act, which required anyone who sold or distributed narcotics–importers, manufacturers, wholesale and retail druggists, and physicians–to register with the Federal Government and pay an excise tax. The United Nations Bulletin on Narcotics documents early international efforts to address opioid addiction (United Nations Department of Social Affairs, 1953). The United States was among the organizers of the 1909 International Opium Commission in Shanghai, China, and a signatory of the 1912 Hague Opium Convention, the first international treaty to make heroin a controlled substance.

1924-1960: Criminalization of narcotics use - Between 1924 and 1960, the United States approved a series of progressively stiffer narcotics policies, first establishing mandatory sentences for possession and sale of opioids in 1951 (Courtwright, 1992). Internationally, the United States was a signatory to two more international treaties to limit the manufacture of narcotics: the Geneva Convention of 1925 and the Limitation Convention of 1931 (United Nations Department of Social Affairs, 1953). 1960-Present: Combined medical-criminal approach - Scientific advances in the 20th century revolutionized our understanding of addiction and contributed to a medical approach to drug abuse treatment coupled with criminal sanctions for drug traffickers. The 1962 White House Conference on Narcotic Drug Abuse first recommended more flexible sentencing, wider latitude in medical treatment, and more emphasis on rehabilitation and research. By 1971, the Special Action Office of Drug Abuse Prevention (SAODAP), established within the White House, was responsible for drug treatment and rehabilitation, prevention, education, training, and research. Currently, heroin is regulated under the Controlled Substances Act. Federal policies and regulations about heroin are coordinated by the following agencies: ●● The Office of National Drug Control Policy (ONDCP) operates within the White House to establish policies, priorities, and objectives for the Nation’s drug control program. ●● The U.S. Department of Health and Human Services to promote and regulate addiction treatment services. ●● The Drug Enforcement Administration (DEA) operates within the Department of Justice to prevent diversion and illicit use of controlled substances and administer criminal sanctions for drug traffickers. In 2004, the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC), and the Joint United Nations Program on HIV/AIDS (UNAIDS) adopted a joint position paper on substitution maintenance therapy for opioid dependence, calling substitution maintenance therapy one of the most effective treatment options.

Law and methadone maintenance From 1914 through 1972, although heroin became a controlled substance under the Harrison Act of 1914, the law did not expressly prohibit the medical prescription of heroin to treat addiction. The U.S. Government concluded that the Harrison Act intended to prohibit such medical uses of controlled substances, prosecuting individual doctors who prescribed the drugs. In 1919, the U.S. Supreme Court upheld the Government’s position in Webb v. United States. In response, about 40 localities opened municipal narcotic clinics to treat addiction using a variety of methods, including medical prescription of narcotics, but by the mid-1920s, these clinics had all been closed by the Federal Government (Joseph, Stancliff, and Langrod, 2000). After 1972 until 2000, Methadone maintenance treatment for heroin addiction was first approved by the U.S. Food and Drug Administration in 1972, subject to three levels of Federal regulation: ●● Food and Drug Administration rules that pertained to all prescription drugs. ●● Drug Enforcement Administration rules that governed all controlled substances. ●● Unique Department of Health and Human Services rules limiting methadone maintenance treatment to strictly controlled opioid

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treatment programs, which also were subject to additional State or local rules. Methadone was approved for office-based dispensing by the Food and Drug Administration in 2002. Administered daily, methadone treatment is currently regulated so that only specialized clinics can provide it. Methadone maintenance programs must go through an accreditation process in order to operate. The Substance Abuse and Mental Health Services Administration address each critical legal, clinical, safety, and program management area related to the treatment of patients using methadone maintenance therapy. All accredited methadone programs operate under the authority of the Drug Enforcement Agency (DEA) regulations that govern the dispensing of controlled substances. The DEA regulations (www. deadiversion.usdoj.gov/pubs/manuals/narcotic/narcotic.pdf) stipulate requirements for the type of registration required, qualifications for physicians who dispense methadone, and rules for physician recordkeeping.

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Methadone treatment dosage Patients’ illicit opioid use declines, often dramatically, during methadone maintenance treatment. However, adequate methadone dosage and basic psychosocial services are essential for treatment effectiveness. Methadone is provided in various forms, including diskettes, tablets, oral solution, liquid concentrate, and powder. In the United States, methadone used in medically assisted treatment is almost always administered orally in liquid form. Parenteral administration is prohibited in opioid treatment programs. Parenteral abuse of methadone is not widespread, and people rarely inject the methadone dispensed in U.S. programs because it is mixed with substances (e.g., flavored drinks) that make injection unattractive (Treatment Improvement Protocol 43, Chapter 3: http://www.ncbi.nlm.nih.gov/ books/NBK25695/#A82783). The acceptable initial dose for methadone treatment is 30 mg daily, unless a reason for a higher dose can be evidenced, which could increase the initial dose to no more than 40 mg a day. Based on the

judgment of the program physician and careful observation of the patient, dosing can go up to 60 mg a day prior to stabilization (http:// dpt.samhsa.gov/pdf/draft_accred_guidelines.pdf) (267KB). In the Ball and Ross studies (1991), patients reduced their use of injected heroin by 71 percent compared with preadmission levels. Illicit opioid use was directly related to methadone dosage: in patients on doses above 71 mg per day, no heroin use was detected, whereas patients on doses below 46 mg per day were 5.16 times more likely to use heroin than those receiving higher doses. The impact of methadone dose has been demonstrated consistently across studies and countries. Higher (e.g., greater than 50 mg) doses of methadone are associated with better treatment retention and decreased illicit drug use (Faggiano, Vigna-Taglianti, Versino, et al., 2003). A meta-analysis (Faggiano et al., 2003) of 21 studies concluded that methadone dosages ranging from 60 to 100 mg per day were more effective than lower dosages in retaining patients and in reducing use of heroin and cocaine during treatment.

Research and methadone treatment Methadone is a rigorously well-tested medication that has been safely used to treat opioid addiction in the United States for more than 40 years. Methadone: ●● Suppresses the symptoms of opioid withdrawal for 24 to 36 hours. ●● Blocks the effects of administered heroin. ●● Does not cause euphoria, intoxication, or sedation. ●● Blocks the craving for opioids that is a major factor in relapse. For 40 years, methadone maintenance treatment has been used successfully to treat heroin addiction in the United States. From the first pilot project in 1964, when Drs. Vincent P. Dole and Marie E. Nyswander established that methadone maintenance treatment was an effective medical intervention for heroin addiction, rigorous scientific research has documented the safety and effectiveness of methadone maintenance to treat heroin addiction. Through the extensive research grant programs administered by the National Institutes of Health, the Federal Government funds most major medical research conducted in the United States, including research on methadone maintenance treatment. In addition, some of the research on methadone maintenance treatment has been conducted by the Federal Government itself at research facilities like the U.S. Public Health Service Hospital in Lexington, Kentucky, where methadone was first shown to be effective in treating the symptoms of heroin withdrawal. Research has demonstrated that methadone maintenance treatment is an effective treatment for heroin and prescription narcotic addiction when measured by: ●● Reduction in the use of illicit drugs. ●● Reduction in criminal activity. ●● Reduction in needle sharing. ●● Reduction in HIV infection rates and transmission. ●● Cost-effectiveness. ●● Reduction in commercial sex work. ●● Reduction in the number of reports of multiple sex partners. ●● Improvements in social health and productivity. ●● Improvements in health conditions. ●● Retention in addiction treatment. ●● Reduction in suicide. ●● Reduction in lethal overdose. For example the following research demonstrates the efficacy methadone treatment: ●● Recent meta-analyses have supported the efficacy of methadone for the treatment of opioid dependence. These studies have demonstrated across countries and populations that methadone can

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be effective in improving treatment retention, criminal activity, and heroin use (Marsch, 1998). An overview of 5 meta-analyses and systematic reviews, summarizing results from 52 studies and 12,075 opioid-dependent participants, found that when methadone maintenance treatment was compared with methadone detoxification treatment, no treatment, different dosages of methadone, buprenorphine maintenance treatment, heroin maintenance treatment, and L-aacetylmethadol (LAAM) maintenance treatment, methadone maintenance treatment was more effective than detoxification, no treatment, buprenorphine, LAAM, and heroin plus methadone. High doses of methadone are more effective than medium and low doses (Amato, Davoli, Perucci, et al., 2005). Patients receiving methadone maintenance treatment exhibit reductions in illicit opioid use that are directly related to methadone dose, the amount of psychosocial counseling, and the period of time that patients stay in treatment. Patients receiving methadone doses of 80 to 100 mg have improved treatment retention and decreased illicit drug use compared with patients receiving 50 mg of methadone (Simpson, 1993). A systematic review conducted on 28 studies involving 7,900 patients has demonstrated significant reductions in HIV risk behaviors in patients receiving methadone maintenance (Metzger, Woody, McLellan, et al., 1993). A randomized clinical trial in Bangkok, Thailand, included 240 heroin-dependent patients, all of whom had previously undergone at least 6 detoxification episodes. The patients were randomly assigned to methadone maintenance versus 45-day methadone detoxification. The study found that the methadone maintenance patients were more likely to complete 45 days of treatment, less likely to have used heroin during treatment, and less likely to have used heroin on the 45th day of treatment (Vanichseni, Wongsuwan, Choopanya, et al., 1991). In the Treatment Outcome Prospective Study (TOPS), methadone maintenance patients who remained in treatment for at least 3 months experienced dramatic improvements during treatment with regard to daily illicit opioid use, cocaine use, and predatory crime. These improvements persisted for 3 to 5 years following treatment, but at reduced levels (Hubbard, Marsden, Rachal, et al., 1989). In a study of 933 heroin-dependent patients in methadone maintenance treatment programs, during episodes of methadone maintenance, there were (1) decreases in narcotic use, arrests, criminality, and drug dealing; (2) increases employment and marriage; and (3) diminished improvements in areas such as

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narcotic use, arrest, criminality, drug dealing, and employment for patients who relapsed (Powers and Anglin, 1993). ●● In a 2.5-year follow up study of 150 opioid-dependent patients, participation in methadone maintenance treatment resulted in a substantial improvement along several relatively independent dimensions, including medical, social, psychological, legal, and employment problems (Kosten, Rounsaville, and Kleber, 1987). ●● A study that compared ongoing methadone maintenance with 6 months of methadone maintenance followed by detoxification

demonstrated that methadone maintenance resulted in greater treatment retention (median, 438.5 vs. 174.0 days) and lower heroin use rates than did detoxification. Methadone maintenance therapy resulted in a lower rate of drug-related (mean [SD] at 12 months, 2.17 [3.88] vs. 3.73 [6.86]) but not sex-related HIV risk behaviors and a lower score in legal status (mean [SD] at 12 months, 0.05 [0.13] vs. 0.13 [0.19]) (Sees, Delucchi, Masson, et al., 2000).

Patient status before and after methadone maintenance treatment A study by McGlothlin and Anglin (1981) examined patients from three methadone maintenance treatment programs. All three program results illustrate that methadone maintenance treatment is effective in improving patients’; lives in terms of time spent (1) using narcotics daily, (2) unemployed, (3) involved in crime, (4) dealing drugs, and (5) incarcerated. The percentage of time using daily narcotics was much greater before methadone maintenance treatment than after. The percentage of time unemployed decreased after methadone

maintenance treatment. The percentage of days the patient was involved in crime decreased after methadone maintenance treatment. The percentage of time dealing drugs decreased after methadone maintenance treatment. The percentage of time incarcerated decreased after methadone maintenance treatment (McGlothlin and Anglin, 1981). A single oral dose of methadone in the morning promotes a relatively steady state of mood and function.

Treatment duration and outcomes There is a relationship between reduction in illicit opioid use in recovery and treatment duration. And there is a relationship between how long patients remain in treatment and how well they function after treatment. The length of treatment is, in general, associated with abstinence from illicit drug use and an absence of crime. The longer patients stay in treatment, the more likely they are to remain crime free. For example, those who remained in methadone maintenance treatment for the entire 18-month study period, 3.5 percent became infected with HIV. However, among those who remained out of treatment, 22 percent became infected with HIV (Metzger et al., 1993). In a 3-year field study of methadone maintenance treatment programs in New York, NY, Philadelphia, PA, and Baltimore, MD, methadone maintenance treatment was found to be effective in reducing injection

drug use and needle sharing by most heroin addicts. Of 388 patients who remained in treatment for 1 year or more, 71 percent had stopped injection drug use. Conversely, 82 percent of the 105 patients who left treatment relapsed rapidly to injection drug use (Ball et al., 1988). In one study, 82 percent of 105 patients who discontinued methadone relapsed to intravenous drug use within 12 months (Payte and Khuri, 1993). And, Drug abuse reduction program studies of opioiddependent patients 12 years following admission to treatment showed that illicit opioid use declined progressively over time until year 6, when it stabilized at about 40 percent for “any” use and 25 percent for “daily” use (Simpson, Joe, Lehman, et al., 1986). In studies, of long treatment duration was the strongest predictor of reduced heroin use among methadone maintenance patients.

HIV and methadone maintenance The daily oral administration of adequate dosages of methadone reduces the need for opioid-dependent individuals to inject drugs. By decreasing injection drug use, methadone maintenance treatment helps reduce the spread of diseases transmitted through needle sharing, such as human immunodeficiency virus (HIV) infection, hepatitis C virus (HCV), and other bloodborne infections (Sullivan, Metzger, Fudala, et al., 2005; Gowing, Farrell, Bornemann, et al., in press). Research demonstrates decreased in HIV risk behaviors among methadone maintenance patients A systematic review of 23 studies of 7,900 patients in diverse countries and settings reported significant decreases in the following HIV risk behaviors among patients receiving methadone maintenance treatment: (1) the proportion of opioid-dependent injection drugs, (2) the reported frequency of injection, (3) levels of sharing of injection equipment, (4) illicit opioid use, (5) reduction in the proportion of opioid-dependent injection drug users reporting multiple sex partners or exchanges of sex for drugs or money, and (6) reductions in cases of HIV infection among opioid-dependent injection drug users. However, it should be noted that methadone treatment had little or no effect on the use of condoms. The authors concluded that the provision of agonist treatment for opioid dependence should be supported in countries with emerging HIV and injection drug use problems as well as in countries with established populations of injection drug users (Gowing, Farrell, Bornemann, et al., 2004). These results support an earlier meta-analysis of 11 studies that found a consistent, statistically significant relationship between methadone maintenance treatment and the reduction of HIV risk behaviors. This meta-analysis found that methadone maintenance treatment had a SocialWork.EliteCME.com

small-to-moderate effect in reducing HIV risk behaviors (Marsch, 1998). ●● A study that evaluated HIV risk behavior in patients receiving ongoing methadone maintenance compared with patients receiving 6 months of methadone maintenance followed by detoxification demonstrated that those patients who received ongoing methadone maintenance treatment reported lower HIV drug (but not sex) risk behaviors after 6 and 12 months of treatment (Sees, Delucchi, Masson, et al., 2000). ●● In New Haven, CT, 107 methadone-maintained injection drug users who were not in treatment were surveyed regarding their risk behaviors. The frequency of injections was found to be 50 to 65 percent (p < .001) higher among the out-of-treatment subjects (Meandzija, O’Connor, Fitzgerald, et al., 1994). ●● In a 3-year field study of methadone maintenance treatment programs in New York, NY, Philadelphia, PA, and Baltimore, MD, treatment was found to be effective in reducing injection drug use and needle sharing by most heroin addicts. Of 388 patients who remained in treatment for 1 year or more, 71 percent had stopped injection drug use. Conversely, 82 percent of patients who left treatment relapsed rapidly to injection drug use (Ball, Lang, Meyers, et al., 1988). ●● Abdul-Quader, Friedman, Des Jarlais, et al. (1987) reported that both the frequency of drug injection and the frequency of drug injection in shooting galleries were significantly reduced by the amount of time spent in methadone maintenance treatment. ●● A study by Serpelloni, Carrieri, Rezza, et al. (1994) examined the effect of methadone maintenance treatment on HIV infection incidence among injection drug users. The study found that the Page 56

amount of time spent in methadone maintenance treatment was the major determinant in remaining HIV-free, which confirms the effectiveness of long-term programs in reducing the risk of HIV infection. Indeed, the risk of HIV infection increased 1.5 times for every 3 months spent out of methadone treatment in the past 12 months immediately preceding seroconversion. The study noted that higher daily methadone doses were associated with a reduction in HIV infection. ●● A study by Weber, Ledergerber, Opravil, et al. (1990) examined the role of methadone maintenance treatment in reducing the progression of HIV infection among 297 current and former injection drug users with asymptomatic HIV infection. The study showed that HIV infection progresses significantly more slowly in those who receive methadone maintenance treatment and those who are drug free than in active injection drug users. ●● In Philadelphia, PA, a longitudinal study of HIV infection and risk behaviors among 152 injection drug users in methadone maintenance treatment and 103 out-of-treatment injection drug users found significantly lower rates of risk behavior, including needle sharing, injection frequency, shooting gallery use, and visits to crack houses among the methadone-maintained users. While 70 percent of the out-of-treatment cohort reported sharing needles during the 6 months before entry into the study, only 30 percent of those in treatment reported sharing needles during this same interval.

●● At entry into this study, 18 percent of the out-of-treatment subjects and 11 percent of the methadone-maintained clients tested positive for antibodies to HIV. After 18 months of study, 33 percent of the out-of-treatment cohort were infected, whereas 15 percent of the methadone clients tested positive (p < 0.01). The incidence of new infection was strongly associated with the level of participation in methadone treatment. Among those who remained in methadone treatment for the entire 18-month study period, 3.5 percent became infected. Among those who remained out of treatment, 22 percent became infected with HIV (Metzger, Woody, McLellan, et al., 1993). ●● Another study of HIV seroconversion followed 56 patients who were continuously enrolled in methadone maintenance and compared them with 42 patients who had intermittent methadone treatment. Subjects in continuous treatment had a seroconversion rate of 0.7 per 100 person years (95 percent CI = 0.1, 5.3), and those with interrupted treatment had a rate of 4.3 per 100 person years (95 percent CI = 2.2, 8.6) (Williams, McNelly, Williams, et al., 1992). ●● A relatively short-term study of methadone maintenance versus control in a prison system in Australia found reductions in opioid use but no changes in HIV or HCV incidence (Dolan, Shearer, MacDonald, 2003).

Methadone maintenance and criminal activity Patients are less likely to become involved in criminal activity while in methadone maintenance treatment. ●● Patients who remain in methadone maintenance treatment for long periods of time are less likely to be involved in criminal activity than patients in treatment for short periods. ●● The availability of methadone maintenance treatment in a community is associated with a decrease in that community’s criminal activity, particularly theft. Research ●● In a meta-analysis of 24 studies, results indicate an overall smallto-medium effect of r = -0.25 (un-weighted) of the impact of methadone maintenance on criminal activity. A large effect size of r = 0.70 (un-weighted) was seen in those studies that investigated the efficacy of methadone maintenance treatment in reducing drugrelated criminal behaviors. A small-to-moderate effect of r = 0.23 (un-weighted) was obtained when both drug and property-related criminal activities were evaluated. Finally, a small effect of r = 0.17 (un-weighted) was demonstrated when drug- and nondrugrelated criminal behaviors were combined (Marsch, 1998). ●● In the Treatment Outcome Perspective Study (TOPS), 32 percent of the methadone maintenance patients acknowledged committing one or more predatory crimes in the year before treatment, but only 10 percent continued these activities during treatment. By 3 to 5 years after leaving treatment, only 16 percent of the patients reported predatory criminal activity–a reduction of one-half the pretreatment level (Hubbard, Marsden, Rachal, et al., 1989). ●● Among the 617 patients studied by Ball and Ross (1991), there was a 70.8-percent decline in crime-days within the 4-month methadone maintenance treatment period. This decline was followed by continuing, but less dramatic, declines in mean crimedays among those in treatment for 1 to 3 years. Those in treatment for 6 or more years had the lowest rate of crime-days per year (14.5). ●● The Powers and Anglin (1993) retrospective study of 933 heroin addicts demonstrated that rates of criminality, arrests, and drug

dealing decreased during episodes of methadone maintenance treatment when compared with addicts not in treatment. ●● In the National Treatment Outcome Research Study, acquisitive criminal behavior decreased in the majority of the 333 patients except those (n = 88) who were felt to have a poor treatment response. In these patients, there was no change in this type of criminal activity (Gossop, Marsden, Stewart, et al., 2000). ●● The meta-analysis by Mattick, Breen, Kimber, et al. (2003) revealed that criminal activity declined in consort with reductions in heroin use, although the advantage for methadone beyond control in reducing criminal activity was not statistically significant (3 studies, 363 patients: RR = 0.39, 95 percent CI: 0.121.25). The effects of methadone maintenance treatment on crime-days Ball and Ross study (1991) of 617 patients demonstrated that methadone maintenance treatment is associated with a dramatic decline in the average number of crime-days per year. The study revealed that the average number of crime days per year before treatment was 237. During the 4-month initial methadone maintenance treatment, the average number of crime days per years was 69. This represents about a 71 percent decline. The decline was followed by continuing, but less dramatic, declines in the average number of crime days among those in methadone maintenance treatment for one to three years. Patients who remained in methadone maintenance treatment for 6 or more years reported only 14.5 crime days per year, representing a 94 percent decline in average number of crime days. Ball and Ross (1991) also found a dramatic decline in crime when comparing pretreatment crime-days per year and the number of crime-days per year after 6 months or more in methadone maintenance treatment. Although there are differences among programs, the dramatic decrease in crime days before and during methadone maintenance treatment occurs for all six programs. The average reduction in crime for those in methadone maintenance treatment was just over 91 percent.

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Methadone maintenance and employment Methadone maintenance has been associated with significant increases in full-time employment. Research ●● In an early study of 100 chronic heroin users who were admitted to methadone maintenance treatment, the employment rate increased from 21 percent at admission to 65 percent 1 year later (Maddux and Desmond, 1979). ●● A study of 92 males admitted to methadone maintenance treatment programs from 1971 through 1973 demonstrated that, following methadone maintenance treatment, employment increased about 18 percent (Harlow and Anglin, 1984). ●● In a 10-year followup study, 95 chronic opioid users who spent at least 1 cumulative year in methadone maintenance treatment were compared with 77 chronic opioid users who spent less than 1 cumulative year in methadone maintenance treatment. Those who were on methadone maintenance treatment for more than 1 year had a higher average time employed (mean of 42 months)

than those who were in treatment for less than 1 year (mean of 35 months) (Maddux and Desmond, 1992). ●● The Powers and Anglin (1993) study of 933 heroin addicts in methadone maintenance treatment demonstrated that rates of employment (and marriage) increased during treatment. ●● Methadone maintenance patients in the Treatment Outcome Perspective Studies (TOPS) had small changes in employment rates during and following treatment compared with pretreatment rates. Although 24 percent of the patients reported full-time employment in the year before admission, this rate did not increase significantly during treatment. It declined abruptly in the 3 months following discharge, improved to 29 percent by year 2, and dropped off again to less than pretreatment rates by years 3 to 5 following treatment (Hubbard, Marsden, Rachal, et al., 1989). ●● In a study that compared ongoing methadone maintenance with 6 months of methadone maintenance followed by detoxification, no difference was seen in employment, although nearly 50 percent of patients were employed at entry into the study (McLellan, Arndt, Metzger, et al., 1993).

Methadone maintenance treatment and general drug abuse Research outcomes are mixed regarding the effect of methadone maintenance treatment on the use of illicit drugs other than opioids. In other words, some research indicates that methadone maintenance treatment is associated with decreases in the use of alcohol, cocaine, and marijuana; other research indicates increases in the use of these drugs. It is important to note that the medication methadone has no direct effect and is not intended to have an effect on rates of alcohol and other drug use. Patients receiving methadone maintenance who disengage from interactions with others who are actively using drugs are less likely to engage in these behaviors. In addition, reductions in alcohol and drug use result from the counseling services included in methadone maintenance treatment. When these services are specifically designed to reduce alcohol and other drug use, such reductions are likely. Research ●● In the Drug Abuse Reporting Program (DARP) studies, there were reductions in non-opioid drug use (except marijuana) among 895 methadone maintenance patients, comparing the 2-month period before admission and the year following discharge. The reduction in non-opioid use was 13 percent–from 54 percent of patients who reported any use before admission to 41 percent at the 1-year follow-up point (Simpson and Sells, 1982). ●● In the 12-year DARP follow-up study, “heavy drinking” was reported by 21 percent of the sample in the month before treatment; it rose to 31 percent during the first year afterward and then declined to 22 percent by year 12. One-half of the patients reported substituting alcohol for opioids after stopping daily illicit opioid use (Lehman, Barrett, and Simpson, 1990). ●● In a study comparing buprenorphine maintenance with methadone maintenance for patients with opioid dependence and cocaine abuse, both treatments resulted in significant declines in opioid use but were indistinguishable in terms of their effect on comorbid cocaine use (Schottenfeld, Pakes, Oliveto, et al., 1997).

Among three cohorts of new-admission patients in methadone maintenance treatment, Ball and Ross (1991) found that the use of all illicit drugs, except marijuana, decreased markedly in relation to time in treatment. These three cohorts had been in treatment 6 months, 4.5 years, or more than 4.5 years. In the Treatment Outcome Perspective Study (TOPS), 90 percent of methadone maintenance treatment patients who reported drug use at intake reported a reduction in use during the first 3 months of treatment. For 80 percent, this reduction is large. In the year before treatment, less than 10 percent of methadone maintenance treatment patients were minimal drug users. During treatment, more than 50 percent of the patients were minimal drug users. During the 3 to 5 years after discharge, less than 32.5 percent were minimal drug users (Hubbard, Marsden, Rachal, et al., 1989). In the National Treatment Outcome Research Study (NTORS), of 333 patients receiving methadone maintenance in the United Kingdom, overall declines were seen in the use of heroin, barbiturates, amphetamines, cocaine, and crack cocaine among patients receiving methadone maintenance. Alcohol use, however, did not change over time (Gossop, Marsden, Stewart, et al., 2000). In another evaluation of 513 heroin users in methadone treatment in TOPS, a decline was observed in the use of cocaine, amphetamines, illegal methadone, tranquilizers, and marijuana, but not alcohol (Fairbank, Dunteman, and Condelli, 1993). The Powers and Anglin study (1993) of 933 heroin addicts in methadone maintenance programs demonstrated that during episodes of methadone maintenance treatment, illicit opioid use decreased, but alcohol and marijuana levels increased moderately. Kreek (1991) observed that by 1990, alcoholism was identified in 40 or 50 percent of new admissions to methadone maintenance treatment programs, and cocaine abuse was found in 70 to 90 percent. She also estimated that 20 to 46 percent of patients in effective methadone maintenance treatment programs continue using cocaine, and 15 to 20 percent of methadone maintenance treatment patients regularly inject cocaine.

Methadone maintenance treatment and cocaine use Among the TOPS patients who remained in methadone maintenance treatment at least 3 months, 26.4 percent had used cocaine regularly the year before treatment. This rate fell to 10 percent during the first 3 months of treatment but returned to 16 percent by 3 to 5 years after discharge. Altogether, 40 percent of methadone maintenance treatment SocialWork.EliteCME.com

patients who regularly used cocaine before treatment and stayed in treatment for at least 3 months abstained from cocaine use in the year after treatment (Hubbard et al., 1989). In the TOPS studies, although 70 percent of heroin abusers had frequently used cocaine the year before treatment, it was the primary Page 58

drug of choice for only 2 percent of methadone maintenance treatment patients (Hubbard et al., 1989).

percent vs. 62.4 percent and 67.1 percent, respectively; p < 0.05) (Strain, Stitzer, Liebson, et al., 1993).

In the new admissions group of a six-program study (n = 345), 46.8 percent of 126 patients had used cocaine in the past 30 days. Among the average-stay group (up to 4.5 years in treatment), 27.5 percent still used cocaine; this rate dropped to 17.2 percent among the long-term group of 146 patients who had been in continuous treatment for more than 4.5 years (Ball and Ross, 1991).

A systematic review examined the impact of methadone dose on cocaine use and found three studies that addressed the question. Results from the one study in which cocaine use was based on selfreported use showed no significant excess of use of cocaine among subjects treated with higher doses compared with subjects treated with lower doses. Pooled results from the two studies that used urine analysis and looked at an abstinence period longer than 3 weeks showed that higher methadone doses increased the probability that patients would stay abstinent from cocaine, compared with lower doses (RR = 1.81 [1.15, 2.85]) (Faggiano, Vigna-Taglianti, Versino, et al., 2003).

A study evaluating the effect of methadone dose on treatment outcomes noted that patients receiving 50 mg of methadone, compared with those receiving 20 mg or 0 mg, had a reduced rate of opioidpositive urine samples (56.4 percent vs. 67.6 percent and 73.6 percent, respectively; p < 0.05) and cocaine-positive urine samples (52.6

Methadone maintenance and marijuana use Among TOPS subjects, marijuana use was common: 55 percent of methadone maintenance patients who stayed in treatment for 3 months reported regular use in the year before admission. This decreased to 47 percent during the first 3 months of treatment, continued to decline immediately posttreatment, and decreased even more to 36.4 percent in the 3- to 5-year period after discharge. However, marijuana use appeared more resistant to change than other illicit substances (Hubbard et al., 1989). It should be considered that the treatment programs likely did not clinically address marijuana or other drug use.

Ball and Ross (1991) found that marijuana continued to be used quite regularly (an average of 13 to 16 days per month) by high percentages of all patient groups in methadone maintenance treatment: 48.4 percent of the new admissions, 47.7 percent of the average-stay group, and 37.2 percent of the patients in treatment more than 4.5 years. In one study of 132 opioid addicts participating in methadone maintenance treatment programs, it was noted that during episodes of methadone maintenance treatment, levels of alcohol and marijuana use increased modestly (Powers and Anglin, 1993).

Methadone maintenance and the non-medical use of prescription drugs In the TOPS studies, the regular nonmedical use of psychoactive prescription drugs by methadone maintenance treatment patients during the first post-treatment year decreased by one-third from the pretreatment period. Although 30.3 percent of this methadone maintenance group reported regular nonmedical use of prescription drugs (i.e., barbiturates, amphetamines, tranquilizers, sedatives, and hypnotics), nonmedical prescription drug use was a primary problem for only 1.9 percent of these patients at admission (Hubbard et al., 1989). In the NTORS study, a decline was seen in the use of benzodiazepines among patients receiving methadone maintenance (Gossop et al.,

2000). In the TOPS studies, nonmedical prescription drug use declined during methadone maintenance treatment, increased immediately following discharge, and declined again to 10 percent of patients 3 to 5 years following discharge (Hubbard et al., 1989). Ball and Ross (1991) found that although the nonmedical use of sedatives other than barbiturates was acknowledged by 31.8 percent of new admissions to methadone maintenance treatment, the percentage of sedative-using patients who had been in treatment for more than 4.5 years was less than half that of the new admission group (14.5 percent).

Methadone maintenance treatment and alcohol and other drug use In the TOPS studies, improvements in the use of illicit and nonprescription drugs follow a pattern of (1) a dramatic reduction during treatment, (2) a sharp increase immediately after discharge, and (3) a leveling off at an impressively reduced rate for up to 5 years of follow-up contacts (Hubbard et al., 1989). In the TOPS study of 4,184 patients, methadone maintenance treatment was associated with reductions in: 1. Any illicit opioid use 2. Any cocaine use 3. Any

marijuana use, and 4. Alcohol abuse. (Hubbard et al., 1989) “Any opioid use” declined from 63 percent pretreatment to 17 percent 1 year post-treatment. This was the most dramatic decline. “Any cocaine use” declined from 26 percent to 18 percent. “ Any marijuana use” declined from 55 percent pretreatment to 46 percent 1 year post-treatment. Alcohol abuse remained almost steady, declining slightly from 25 percent to 24 percent.

Women and methadone maintenance Since the earliest methadone maintenance treatment programs in the United States, women have been treated successfully with methadone through all phases of their lives, including pregnancy. There is consensus that the major outcomes of the effectiveness of methadone maintenance treatment, especially cessation of illicit drug use and lifestyle stabilization, apply to both men and women. However, gender-specific issues, which are often related to the social status of women, are important to treatment effectiveness for female injection drug users. Compared with men, women are more likely to: ●● Have total responsibility for child care. ●● Have lower socioeconomic status. ●● Encounter greater barriers to treatment entry, retention in treatment, and economic independence.

●● Have different psychological, counseling, and vocational training needs. ●● Have difficulty with transportation to treatment. Research ●● In the past, little emphasis was placed on gender-specific biopsychosocial problems in drug treatment. One reason was the predominance of drug-addicted men, estimated in the United States to be three males to every female. Although mild forms of psychoactive substance use show converging usage rates and patterns for males and females, opioid addiction and other forms of chemical dependency continue to show a male predominance (Kandel, 1992). ●● Drug Abuse Reporting Program (DARP) studies showed that 19 to 28 percent of admissions to drug treatment programs from 1969 to 1973 were women. In 12 years of follow-up of 84 females and

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91 males in methadone maintenance, there were no differences between men and women in overall reduction of opioid use. Women required more government financial assistance and had lower rates of employment than men. Compared with men, women were more likely to enter treatment for health reasons (Marsh and Simpson, 1986). ●● A study of 567 methadone-maintained patients in California found overall shorter duration of time from first entry to first discharge from treatment for women compared with men (Murphy and Irwin, 1992). ●● A study of white, Latina, and African American women in methadone maintenance found that, in general, Latinas were more likely to report familial influences and to display evidence of low self-esteem and self-efficacy, inconsistent condom use, and highrisk injection behavior. White women reported the highest levels of regular condom use at follow-up; however, they were the least likely to report safer injection practices. African American women expressed the highest levels of self-esteem, yet they reported more alcohol use at intake and crack cocaine use both before and after treatment entry. African American women showed the greatest gains in adopting safer injection practices and were the least likely to report multiple sex partners after treatment entry (Grella, Annon, and Anglin, 1995). ●● Drug-using women are likely to experience clinical depression, anxiety disorders, and low self-esteem to a much greater degree than their male counterparts. Women entering treatment have experienced unique gender-specific life events. In particular, female drug users often have been abused physically, sexually, and emotionally. Experiences of sexual violence, especially during childhood, have profound, lifelong psychological effects and often underlie addiction, complicating successful recovery. Methadone maintenance treatment of women requires awareness of these issues and appropriate counseling. Confrontational styles of therapy and counseling are not effective for most women in treatment (Hartel, 1989/1990). Therefore, key treatment issues include: ○○ Social isolation. ○○ Poor self esteem. ○○ Clinical depression and anxiety disorders. ○○ Physical and sexual abuse. There is a strong need for: ●● Child care. ●● Transportation to treatment. ●● Non-confrontational therapy and counseling. ●● Vocational job skills training and education designed specifically for women. In research conducted in New York, NY, among 452 methadonerecruited injection drug users early in the HIV epidemic, having an injection drug user as a sex partner was associated with HIV infection status independent of or in addition to injection risk behavior. In this same study, women reported a higher level of sexual risk behavior than men: 57 percent of women compared with 45 percent of men reported one or more injection drug users as sex partners since 1978. In addition, women were more likely than men to have engaged in sex work: 23 percent of women compared with 5 percent of men (Schoenbaum, Hartel, Selwyn, et al., 1989). Research Since the early 1970s, methadone maintenance treatment has been used successfully with pregnant women. There is consensus that methadone can be safely administered during pregnancy with little risk to mother and infant. Maintenance on methadone is necessary to prevent relapse to illicit opioid use and thus to maintain optimal health during pregnancy.

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A systematic review revealed that randomized controlled studies of methadone treatment in pregnancy demonstrate an approximate threefold reduction in heroin use and a threefold increase in retention in treatment relative to non-pharmacologic treatment (Rayburn and Bogenschutz, 2004). ●● All drug-using women are considered to be at higher-than-normal risk for medical and obstetrical complications. Methadonemaintained women show a far greater improvement in obstetrical health than untreated women. Hepatitis types A, B, and C and other sexually transmitted diseases; bacterial endocarditis; septicemia; and cellulites are common among active injection drug users, particularly those who share needles. Women maintained on methadone who have stopped illicit drug use and injection before pregnancy are less likely to experience these and other medical complications during pregnancy. Obstetrical complications such as spontaneous abortion, placental insufficiency, and other conditions also occur at a lower rate among methadone-maintained women than among opioid-dependent women not enrolled in treatment. When compared with opioid-addicted women not in treatment, women in methadone maintenance treatment have been observed to maintain better overall health and nutritional status during pregnancy because of stability provided through treatment. In addition, methadone clinics can provide onsite prenatal services or link patients to these services in nearby clinics, coordinating addiction treatment and prenatal care to optimize both (Kaltenbach, Silverman, and Wapner, 1993). ●● Some women in methadone maintenance treatment are infected with HIV before pregnancy. Treatment programs that link women to appropriate medical care during pregnancy may reduce the burden of illness suffered by HIV-infected women. In a study of 191 methadone-maintained women in a New York City clinic with extensive medical linkages, medical and obstetrical complications did not differ among women with and without HIV infection. HIV infection occurred among 37 percent of women, most of whom were asymptomatic for HIV disease and AIDS before pregnancy. Adverse birth outcomes were relatively infrequent and occurred at approximately the same rates as observed in studies of methadone-maintained women before the HIV epidemic (Selwyn, Schoenbaum, Davenny, et al., 1989). ●● U.S. research in the 1970s demonstrated that methadone does cross the placenta. Passive exposure to methadone in utero can result in neonatal abstinence syndrome among exposed infants. The syndrome varies considerably and depends on a number of factors, including the use of other drugs during pregnancy, anesthesia during delivery, the maturational and nutritional status of the infant, and other aspects of maternal health that affect the fetal environment. The relationship of maternal methadone dose in the last trimester of pregnancy has been explored in a number of studies, but results have not consistently delineated a doseresponse relationship between maternal dose and severity of infant abstinence syndrome. For those neonates experiencing withdrawal, the length and severity of the withdrawal vary greatly; however, pharmacotherapy for neonatal methadone abstinence syndrome is simple and effective. Methadone maintenance treatment affords protection of the fetus from erratic maternal opioid levels and repeated episodes of withdrawal typically seen in users of illicit opioids (Finnegan, 1991). ●● The majority of infants exposed to methadone in utero are healthy and have fewer adverse outcomes than infants exposed to heroin and other illicit drugs. Methadone maintenance treatment for pregnant women can reduce in utero growth retardation and neonatal morbidity and mortality, in comparison with women not in treatment (Kaltenbach and Finnegan, 1984). A review of the literature on methadone and lactation reveals that the amount of methadone in breast milk is very small and depends

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on the dose of methadone that a mother is receiving. The amount of methadone received by an infant from breast milk is not enough to prevent neonatal abstinence syndrome. Therefore, even though

a mother is receiving methadone, her infant may require additional opiate treatment of neonatal abstinence syndrome (Jansson, Velez, and Harrow, 2004).

Methadone safety for pregnant women and their infants Methadone for pregnant women and their infants: ●● Reduces adverse pregnancy outcomes. ●● Reduces adverse birth outcomes. ●● Infant withdrawal is treatable. ●● Shows no long-term adverse neurobehavioral consequences to in utero exposure. Women have been safely maintained on stable methadone dosage during pregnancy without adverse long-term effects on their health and the health of their infants. Withdrawal of medication during pregnancy leads to opioid abstinence syndrome, which is harmful to the pregnancy and often leads to relapse to illicit drug use. Dosage change in pregnancy must be carefully evaluated on an individual basis. Some women experience lowered blood levels of the methadone during pregnancy and may need an increase in dosage or split (e.g., twice daily) dosing. It is important to determine the relapse risk for each woman when considering a dosage change because a woman steadily maintained on methadone is more likely to have a healthy pregnancy and infant than a woman who uses alcohol and other drugs. The intermittent periods of withdrawal that typically occur with illicit opioid use and can adversely affect the fetus do not occur when methadone is individually determined and properly administered. Research ●● Optimal methadone dosage for pregnant women in methadone maintenance treatment should be based on careful consideration of risks and benefits to both mother and fetus on an individual basis. Individual dose should be evaluated, taking into account the stage of pregnancy, the relapse risk potential of the mother, pre-pregnancy methadone dose, previous experience with methadone, and history of addiction recovery. When the mother does not relapse to illicit drug use, short-term reductions in

maternal dose have been effectively administered during the last stage of pregnancy. However, many women in treatment have been successfully maintained on a constant dose and, in some cases, on an increased dose to keep blood levels stable throughout pregnancy (Finnegan, 1991). ●● Some women in treatment experience decreased blood levels of methadone during pregnancy, causing withdrawal symptoms. This decrease in blood levels of methadone during pregnancy can be accounted for by an increased fluid space, a large tissue reservoir that can store methadone, and drug metabolism by both the placenta and the fetus. Pregnant women in treatment with low blood levels of methadone frequently experience a high level of discomfort, withdrawal symptoms, and drug craving and anxiety and may be at high risk of relapse to opioid use and treatment dropout. Determination of methadone blood levels and possibly raising the methadone dosage to maintain sufficient blood levels may be warranted in such cases but must be carefully evaluated. Dosages should be evaluated in conjunction with ongoing medical monitoring of the pregnancy. Since the greatest risks to maternal and infant health occur when women in treatment relapse to illicit drug use, it is important to promote methadone dosage stability during and after pregnancy to optimize both maternal and child health (Kreek, Schecter, Gutjahr, et al., 1974; Pond, Kreek, Tong, et al., 1985). Methadone dosage adjustment during pregnancy Three main considerations regarding dosage for pregnant women in methadone maintenance treatment: ●● Pregnancy can lower methadone blood levels. ●● Lower blood methadone levels can increase relapse-risk. ●● Dosage levels should be evaluated and individually tailored to reduce risk of relapse and to stabilize both mother and fetus.

Long-term administration of methadone Studies of the long-term administration of methadone confirm that it is a medically safe drug. Long-term methadone maintenance treatment at doses of 80 to 120 mg per day is not toxic or dangerous to any organ system after continuous treatment for 10 to 14 years in adults and 5 to 7 years in adolescents. Research ●● Methadone has few adverse biological effects. There appear to be no dangerous or troubling psychological effects from long-term administration (Verdejo, Toribio, Orozco, et al., 2005). ●● Methadone sometimes causes minor side effects, such as sweating, constipation, temporary skin rashes, weight gain, water retention, and changes in sleep and appetite (Lowinson et al., 1992). ●● Methadone prescribed in high doses for a long period of time has no toxic effects and only minimal side effects for adult patients maintained in treatment for up to 14 years and for adolescent patients treated for up to 5 years (Kreek, 1978). ●● Although early studies demonstrated no persisting abnormalities directly attributable to methadone in the functioning of five organ systems (pulmonary, cardiovascular, renal, ophthalmologic, and liver) (Krantz, Lewkowiez, Hays, et al., 2002). ●● Patients maintained on methadone have no impairment in driving and have no more frequent motor vehicle accidents than people not receiving methadone maintenance treatment (Schindler, Ortner, Peternell, et al., 2004). ●● The most common and enduring complaints after 6 months to 3 years of continuous methadone treatment are sweating, constipation, abnormalities in libido and sexual functioning,

sleep abnormalities (insomnia and nightmares), and altered appetite (mild anorexia, weight gain) (Kreek, 1979). A study of 92 methadone-maintained patients found that the rate of global sexual dysfunction in methadone-treated men was similar to the general population but that orgasm dysfunction may respond to methadone dose reduction. ●● Although euphoria and drowsiness, with occasional nausea and vomiting, can occur before tolerance develops, these side effects are most noticeable when doses are increased too rapidly. Conversely, if a heroin habit has been particularly heavy, initial methadone doses may be too low to prevent the onset of early withdrawal symptoms (Kreek, 1979). ●● Life-threatening interactions of methadone with other drugs have not been identified. Drugs found to affect the metabolism of methadone include phenytoin (Dilantin) and rifampin. Opioid antagonists such as pentazocine (Talwin) and buprenorphine can cause withdrawal symptoms in methadone patients and should not be prescribed (Kreek, 1978). Methadone maintenance patients, in the early stages of treatment, can experience several minor side effects that include: constipations, organism abnormalities, alternations of sexual interest, alternations of sleep and appetite, nausea, drowsiness, nervousness, headaches, body aches and pains, and chills. Many of these side effects almost disappear with long-term, high-dose methadone maintenance treatment (Hartel, 1989/1990).

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Patient characteristics associated with treatment success include the following: ●● Age. ●● Age of first heroin use. ●● Overall drug-use history. ●● Severity and duration of drug use.

●● ●● ●● ●● ●●

Emotional health. Psychiatric health. Social health. Vocational stability. Criminal history.

Methadone maintenance retention in treatment Retention in methadone is related to the dose of methadone but not the provision of ancillary services. In a study of 351 daily or weekly heroin users who were admitted to 1 of 17 publicly funded methadone treatment programs, predictors of retention in methadone maintenance treatment programs included (1) positive patient evaluations of the quality of social services received during the first month after admission (e.g., family, legal, educational, employment, financial services); (2) positive patient ratings of how easily accessible the program was; and (3) participation in programs that informed patients of their methadone dosage levels (Condelli, 1993). Mandated

methadone maintenance treatment (being forced to attend treatment by the criminal justice system) is as effective as voluntary treatment. Patients who are legally coerced into methadone maintenance treatment experience treatment success at about the same rate as patients who participate voluntarily in treatment. A study by 36) had moderate legal pressure to participate in methadone maintenance treatment (medium coercion). A third group had mild legal pressure to participate in methadone maintenance treatment (low coercion).

Methadone abuse Methadone can be diverted for oral or intravenous use (Fiellin and Lintzeris, 2003; Green, James, Gilbert, et al., 2000). Some diverted methadone can result in fatal overdoses; however, the rate of overdose among patients enrolled in methadone maintenance is low. A metaanalysis revealed a relative risk of death of 0.25 (95 percent CI: 0.190.33) for patients receiving methadone maintenance (Capelhorn et al., 1996). A study of nearly 10,000 individuals inducted onto methadone determined that the mortality rate was 7.1 deaths per 10,000 inductions (95 percent CI: 1.8± 12.4). In this same study, 51 percent of methadone-related deaths occurred in people who were not registered in methadone maintenance (Zador and Sunjic, 2002). In addition, while methadone may be detected in drug-related deaths, it is often not the causative agent. In one study in the west of Scotland, during the period 1991–2001, methadone alone was judged to be the causative agent in only 29 percent (56) of drug-related deaths (Seymour, Black, Jay, et al., 2003). Similarly, with the increased use of methadone as a treatment for chronic pain, the majority of methadone-related deaths in Australia and the United States are believed to be associated with the use of this medication for pain treatment instead of treatment of opioid dependence (Center for Substance Abuse Treatment, 2004).

Both methadone and buprenorphine can be diverted from their intended recipients. This diversion occurs in countries that provide these medications via supervised dispensing (e.g., pharmacies) and by prescription. Oftentimes, this diversion is by individuals who are seeking a therapeutic benefit (e.g., unobserved treatment). Other times, this diversion results in abuse. The extent of these two types of diversion varies, although most studies note that the benefits of providing the treatment outweigh the risks associated with diversion. For instance, the efficacy of methadone has been demonstrated over the past 40 years (O’Connor and Fiellin, 2000). The provision of methadone and buprenorphine treatment was associated with a 75-percent decrease in fatal heroin overdoses in France (Lepere, Gourarier, Sanchez, et al., 2001; Auriacombe, Fatseas, Dubernet, et al., 2004). In studies that have compared death rates from heroin overdose among those who are untreated and those who receive methadone, deaths are higher among untreated opioid-dependent individuals (Capelhorn, Dalton, Haldar, et al., 1996,; Zanis and Woody, 1998).

BUPRENOrPHINE AND BUPRENOrPHINE/NALOXONE MEDICATION MANAGEMENT NIDA-supported basic and clinical research led to the development of buprenorphine, which culminated in a large NIDA-sponsored, multisite clinical trial demonstrating its effectiveness. The trial showed that, alone or in combination with naloxone, buprenorphine significantly reduced opiate drug abuse and cravings and was a safe and acceptable addiction treatment (figure).

Buprenorphine and Buprenorphine/Naloxone Help Patients Quit Opiate Abuse 25%

20.7 20

17.8

15 10

5.8 5 0

Bup

Bup/Nal

Placebo

Treatment Group Fudala, et al. New England J Medicine 349(10):949-958, 2003.

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While these products were being developed in concert with industry partners, Congress passed the Drug Addiction Treatment Act (DATA 2000) permitting qualified physicians to prescribe narcotic medications (Schedules III to V) for the treatment of opioid addiction. This legislation created a major paradigm shift by allowing access to opiate treatment in a medical setting rather than limiting it to federally approved Opioid Treatment Programs. The FDA approved Subutex (buprenorphine) and Suboxone tablets (buprenorphine/naloxone) in October 2002, making them the first medications to be eligible for prescribing under the DATA 2000. To date, nearly 10,000 physicians have taken the training needed to prescribe these two medications, and nearly 7,000 have registered as potential providers. Buprenorphine is approved for use in the treatment of opioid dependence in a large number of countries, including Australia, Belgium, Canada, Croatia, Germany, Iran, England, France, the United Kingdom, and the United States. Buprenorphine is a partial agonist at the opioid receptor, as opposed to a full agonist such as methadone or heroin. This means that buprenorphine has a unique pharmacologic profile leading to a lower likelihood of overdose or respiratory depression. Like methadone, buprenorphine has the ability to suppress opioid craving and withdrawal, block the effects of self-administered opioids, retain patients in treatment, and decrease illicit opioid use. Because it is a partial agonist, buprenorphine maintains patients in a milder degree of physical dependence and is associated with milder withdrawal syndrome following cessation. Clinical trials comparing the efficacy of buprenorphine to methadone on the outcomes of retention and illicit opioid use have demonstrated similar results when compared with low doses of methadone (20 to 30 mg) (Kosten, Schottenfeld, Ziedonis, et al., 1993).

Patients receiving buprenorphine can be either (1) discontinued without significant withdrawal, (2) maintained, or (3) transferred to opioid antagonist treatment, such as naltrexone. Patients with a higher level of physical dependence and whose needs cannot be met by buprenorphine can be transferred to an opioid agonist, such as methadone or L-alpha-acetyl-methadol, (LAAM). Research ●● Mello and Mendelson showed that buprenorphine suppresses heroin self-administration by opioid-dependent primates and humans (Mello, Bree, and Mendelson, 1983). ●● Findings from a subsequent dose-ranging study at the Los Angeles Addiction Treatment Research Center (LAATRC) suggest that the median doses of buprenorphine for adequate clinical stabilization may be in the 12- to 16-mg range (Compton, Ling, Charuvastra, et al., in press). ●● A NIDA-sponsored, 12-site LAATRC/Veterans Administration/ NIDA multicenter study compared doses of 1, 4, 8, and 16 mg of buprenorphine in 631 patients. The primary comparison between the 8-mg and the 1-mg groups shows that the 8-mg group used fewer illicit opioids and remained in treatment longer (Ling, Charvastra, Collins, et al., 1998). ●● A clinical trial comparing buprenorphine, the buprenorphine/ naloxone combination, and placebo was terminated early because buprenorphine and naloxone in combination and buprenorphine alone were found to have greater efficacy than placebo. Opioidnegative urine samples were found more frequently in the buprenorphine and buprenorphine/naloxone groups (17.8 percent and 20.7 percent, respectively) than in the placebo group (5.8 percent, p < 0.001 for both comparisons) (Fudala, Bridge, Herbert, et al., 2003).

Potential benefits of buprenorphine Research on buprenorphine has shown that it has the potential to be a feasible alternative to methadone maintenance treatment. One potential benefit of buprenorphine compared with methadone that needs further investigation is a lower prevalence of medication interactions between buprenorphine and highly active antiretroviral treatment used to treat patients with HIV. Potential benefits of buprenorphine include:

●● ●● ●● ●● ●●

Low abuse potential. Relatively mild withdrawal symptoms. May facilitate transfer to opioid antagonist treatment. High safety profile. May attract broader range of addicts.

Buprenorphine abuse As a partial agonist, buprenorphine has less potential for abuse than most full agonists. However, there is a reinforcing effect that subjects can experience with buprenorphine administration, especially via the injection route. This reinforcement is less likely if the subject has recently used a full agonist compound; in fact, buprenorphine can lead to a painful and uncomfortable precipitated withdrawal under this scenario. In addition, the development of a tablet that combines buprenorphine with naloxone, in a 4 to 1 ratio, has demonstrated decreased abuse potential and the ability to precipitate withdrawal in

patients who are receiving a full opioid agonist (Mendelson, Jones, Welm, et al., 1999). When the buprenorphine/naloxone combination tablet is taken sublingually, as prescribed, naloxone is poorly absorbed, and the patient receives a buprenorphine effect. However, if the tablet is dissolved and injected, the naloxone will antagonize the buprenorphine, resulting in a range of reactions, including blockade of opioid effects and precipitation of an immediate withdrawal. In this way, the combination gives the therapeutic benefit but greatly reduces opportunities for abuse by injection.

Buprenorphine’s pioneering contributions to addiction treatment ●● Buprenorphine’s novel formulation with naloxone, an opioid antagonist, limits abuse and diversion potential. Scientific breakthroughs led to this formulation, which produces severe withdrawal symptoms in those who inject it to get “high” but no adverse effects when taken orally, as prescribed. ●● Buprenorphine represents a health services delivery innovation. The development of buprenorphine and its authorized use in

physicians’ offices gives opiate-addicted patients more medical options and extends the reach of addiction medication to remote populations. Its accessibility may even prompt earlier attempts to obtain treatment.

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Outreach SAMHSA, NIDA is developing and disseminating protocols to educate multidisciplinary treatment professionals about buprenorphine (http://www.ctndisseminationlibrary.org/ display/85.htmExternal link, please review our disclaimer.). Blending Teams of NIDA researchers, treatment practitioners, and trainers have completed two buprenorphine training packets: ●● To increase overall awareness of buprenorphine therapy; and

●● To instruct physicians and treatment practitioners in implementing a 13-day detoxification intervention for opiate-dependent patients. Through these efforts, buprenorphine has helped change the mindset of many community treatment providers previously unwilling to consider the use of medications to treat drug addiction. Some of these programs now regularly use buprenorphine to assist in opiate detoxification and treatment maintenance.

Next steps ●● NIDA will continue to test the safety and efficacy of buprenorphine in other affected populations, including pregnant women, adolescents, and patients addicted to opiate analgesics. ●● Working with SAMHSA’s Addiction Technology Transfer Centers (ATTCs), State Directors, and other stakeholders, these agencies are continuing to spread the word about buprenorphine to more proactively address the urgent needs of drug addiction. They are striving to increase the use of this and other addiction medications

in different settings and locales, including in the U.S. criminal justice system and in countries where injection drug use is still a primary mode of HIV transmission. NIDA continues to be committed to supporting research to improve opioid addiction treatment, including behavioral therapies, which can be an important component of long-term recovery. Equally important is ensuring that these improvements reach all affected communities.

Improved medications Probuphine is a long-acting version of buprenorphine that is showing promise in clinical trials. An implant inserted under the skin, Probuphine can deliver medication continuously for 6 months. Like

Vivitrol, it aims to prevent abuse and diversion and increase treatment adherence by eliminating the need for daily dosing.

Vaccine research Vaccines are being developed to help combat a variety of addictions including heroin. A heroin vaccine, currently under development, would corral heroin in the bloodstream and prevent it from reaching the brain and exerting its euphoric effects. This approach could guard against relapse and be an effective addition to a comprehensive treatment plan for heroin addiction.

This brief intervention gives patients a chance to learn about their drug use – especially as it pertains to their health – from an objective third party with medical training. It relies on the premise that advice from an expert has been shown to promote change.11,12

TREATMENT Research validates the use of both health care and counseling predicts better outcomes for sustaining sobriety and engagement with longterm recovery. The mental health professional will, in general, first meet their prospective opioid dependent client, shortly after he or she has

been examined by a health care provider and started the medication induction process. Often, the first contact will include a brief introduction and handing the client written information pertaining to opioid recovery treatment.

The role of the health care provider The health care provider will measure and monitor the patient’s vital signs, including temperature, pulse, breathing rate, and blood pressure. Symptoms will be treated as appropriate. The patient may receive: ●● Breathing support. ●● Tube placed through the mouth into the lungs (endotracheal intubation). ●● Medicine called naloxone, which helps block the effect of the drug on the central nervous system (such medicine is called a narcotic antagonist). ●● Toxicology screening. In most cases, the health care team will monitor the patient for 4 to 6 hours in the emergency room, although the optimal observation time after opioid intoxication has not been defined for most opioids. Those with moderate-to-severe intoxications will likely be admitted to the hospital for 24 to 48 hours. The health care provider may also indicate a psychiatric evaluation is needed for all exposures with suicidal intent. For example, a new analysis of data from a trial in which “intensive case management” or (ICM) outperformed usual care among women receiving welfare indicates that comorbid depression played a significant role in the outcomes. Dr. Alexis Kuerbis and colleagues at Columbia SocialWork.EliteCME.com

UniversityExternal link, please review our disclaimer. found that both assignment to ICM and the presence of high levels of depression symptoms independently enhanced participants’ likelihood of engaging in substance abuse treatment and attending more treatment sessions during the 2-year study. Surprisingly, ICM proved to be more effective among depressed participants than among non-depressed ones in improving two outcomes: treatment engagement and reducing alcohol consumption. A higher level of depression symptoms at the start of the study also predicted more days of abstinence over a 2-year period. The researchers had hypothesized that ICM would be less, rather than more, effective for depressed women, as it did not include any specialized focus on comorbid psychiatric disorders. To explain their contrary findings, the researchers note previous research that showed that depression increases readiness to change. They suggest that ICM participants’ copious ongoing contact with case managers and help in overcoming practical barriers to treatment capitalizes on such readiness. Complications from withdrawal include vomiting and breathing in stomach contents into the lungs. This is called aspiration, and can cause lung infection. Vomiting and diarrhea can cause dehydration and body chemical and mineral (electrolyte) disturbances.

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The biggest complication is return to drug use. Most opiate overdose deaths occur in people who have just withdrawn or detoxed. Because withdrawal reduces a person’s tolerance to the drug, those who have

just gone through withdrawal can overdose on a much smaller dose than they used to take.

Exams, tests and long-term health care maintenance A doctor can often diagnose opiate withdrawal after performing a physical exam and asking questions about your medical history and drug use.

Patient progress should be monitored via clinical evaluation (e.g., patient self-report) and objective measures (e.g., urine toxicology testing).

Urine or blood tests to screen for drugs will be utilized.

The Addiction Severity Index (ASI) (McLellan, Kushner, Metzger, et al., 1992), mentioned earlier in this course, is an instrument designed to assess the impact of a patient’s addiction on his or her function. Although this instrument is typically used in research, it has been adapted for clinical use and illustrates the various aspects of a patient’s life that should be assessed at each patient visit to determine the impact of active addiction or the benefits of abstinence. The ASI evaluates patient function in the areas of: ●● Drug use. ●● Alcohol use. ●● Psychiatric function. ●● Medical function. ●● Employment. ●● Social/family functioning. ●● Legal problems.

Treatment involves supportive care and medications. The most commonly used medication, clonidine, primarily reduces anxiety, agitation, muscle aches, sweating, runny nose, and cramping. Other medications can treat vomiting and diarrhea. Buprenorphine (Subutex) has been shown to work better than other medications for treating withdrawal from opiates, and it can shorten the length of detox. It may also be used for long-term maintenance like methadone. People withdrawing from methadone may be placed on longterm maintenance. This involves slowly decreasing the dosage of methadone over time. This helps reduce the intensity of withdrawal symptoms. Some drug treatment programs have widely advertised treatments for opiate withdrawal called detox under anesthesia or rapid opiate detox. Such programs involve placing you under anesthesia and injecting large doses of opiate-blocking drugs, with hopes that this will speed up the return the body to normal opioid system function. There is no evidence that these programs actually reduce the time spent in withdrawal. In some cases, they may reduce the intensity of symptoms. However, there have been several deaths associated with the procedures, particularly when it is done outside a hospital. Because opiate withdrawal produces vomiting, and vomiting during anesthesia significantly increases death risk, many specialists think the risks of this procedure significantly outweigh the potential (and unproven) benefits.

Stated earlier, in addition to patient self-report, urine testing can be a useful practice in monitoring patient progress in treatment. In some countries, urine testing is mandated as part of the treatment plan. A variety of substances can be detected in urine testing. Testing can occur for naturally occurring opioids (e.g., codeine, morphine) or synthetic or semi-synthetic opioids (e.g., oxycodone, methadone). Testing also can occur for benzodiazepines, cocaine, marijuana, or other drugs that are used and/or abused by the patient population. The period of detection of each of these substances varies with the laboratory technique that is used and the extent of drug use and can range from days to weeks.

Mental health professional intervention The mental health professional’s role, often includes “case management” jobs, and in general, includes: ●● Advising the client about drug use. ●● Assessing client’s readiness to quit. ●● Facilitating client changes. ●● Arranging other types of treatment or follow-up care. Providers should be aware that many States mandate reporting of drug use during pregnancy and that failure to do so may be a prosecutable offense. Mental health professionals, during the course of their initial sessions will assess their clients’ readiness to quit opioid use while establishing

a therapeutic alliance. The professional wears many hats during this process by utilizing the ASI, checking in with the client’s healthcare professional, and informing clients about medical management, and possible side effects, and normal withdrawal cycles. It is important to establish rapport by: ●● Avoiding a tone that your client might think is judgmental or confrontational. ●● Show an interest in your client’s life. ●● Acknowledge your client’s current view of his/her drug use. ●● Signal to the client that having mixed feelings about a drug use problem is normal. ●● Highlight client’s confidentiality (and its limitations).

Utilizing the ASI results When administering and reporting on the ASI results begin by reviewing screening results with the client by: ●● Asking permission to have a short discussion about the screening results. ●● Report back the types and amounts of use reported: ○○ Allow the client to correct omissions so you get the full picture of use. ○○ Prompt the patient: “Tell me more about your use of drug X and Y” (for each drug the patient reported).

Reminder: The ASI screen is only one indicator of a client’s potential drug use problem. It is not a substitute for clinical judgment, which you should use to determine when an intervention is warranted. When appropriate, educate clients on the following: ○○ Use of even small amounts of drugs or tobacco may negatively impact health and performance (e.g., driving or operating machinery). ○○ Because drug intoxication can lead to impaired judgment and risky behaviors, refer all sexually active clients for confidential testing for HIV and other sexually transmitted diseases or provide an onsite testing opportunity, if they do not know their

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status or have not been tested recently. Encourage all clients to practice safe sex. ○○ Refer all clients with past or current injection drug use for HIV and Hepatitis B/C testing if they have not been tested twice over a 6-month span following their last injection. ●● Make referrals to evaluate suspected co-occurring conditions (e.g., psychiatric consultation for depressed, inattentive, or anxious clients or pain specialist consultation for patients seeking narcotic prescriptions for chronic nonmalignant pain). ●● Provide recommendations based on risk level that includes: High risk - A strong recommendation to change substance use is essential. Consider making a statement such as: “Based on the screening results, you are at high risk of having or developing a substance use disorder. It is medically in your best interest to stop your use of (insert specific drugs here). I am concerned that if you do not make a change quickly, the consequences to your health and wellbeing may be serious.” Include a referral for additional assessment (the NIDA-Modified ASSIST provides a risk level, but not a diagnosis of abuse or dependence). Let the client know that the assessment will determine whether they have a diagnosis of substance abuse or dependence and if substance abuse treatment is indicated. Whether to attend treatment will be the patient’s decision. ●● Specific examples of harm for different problem drug categories may be helpful. ●● Emphasize that there are many ways to change substance use behavior (e.g., community treatment programs, self-help groups, medications, etc.). ●● Emphasize that treatment is often on an outpatient basis and programs are often accommodating of concerns like maintaining employment, insurance reimbursement, child care, etc., depending on the patient’s concerns. Moderate risk - Consider beginning the discussion by saying, “Based on the screening results, you are at moderate risk of having or developing a substance use disorder. It is medically in your best interest to change your use of (insert specific drugs here).” ●● Add information that is specific to the drugs the client uses. ●● Express your concern about specific ways drugs might negatively impact your patient’s life (e.g., health, relationships, work, etc.). ●● Emphasize that there are many ways to change substance use behavior (e.g., community treatment programs, self-help groups, medications, etc.).

Lower risk - Consider having a discussion about acceptable levels of use and the potential for future problems. You may begin the discussion by saying, “Your screening results show you are unlikely to have a substance use disorder. However, people with any history of substance use can be at some risk of adverse consequences and developing a disorder especially in times of stress or if they have just started to use recently. It is impossible to know in advance whether or not a person will become addicted. As your physician I encourage you to only use alcohol moderately and responsibly and to avoid using other substances.” ●● Intervention duration may be minimal. ●● Use your clinical judgment based on the medical status of the patient and drug being used. For example, pregnant women,* youth, people with histories of substance use disorders, and others for whom any drug use could potentially pose a serious risk may benefit from a complete intervention regardless of apparent risk level. At follow-up, make targeted recommendations to moderate-, high- and select lower-risk clients accordingly: High risk – targeted recommendations: ●● Determine whether the client followed through with the referral. ●● Offer additional brief intervention for clients who did not attend the referral. ●● Make additional referrals for clients who missed referral. ●● Obtain records of assessment and/or treatment for clients who attended referral and/or treatment. ●● Discuss ways to help support recommendations of referral source. Moderate risk – targeted recommendations: ●● Determine whether the client reduced or abstained from use. ●● For clients who did not make progress with change efforts, acknowledge change is hard, repeat brief intervention, and discuss additional ways to support the clients’ efforts. ●● For clients who have made changes, reinforce efforts and encourage additional goal-setting. ●● Follow up at subsequent visits. Lower risk – targeted recommendations: ●● If the client indicated that he/she wanted to make a change, ask what, if anything, the client decided to do about substance use. ●● Encourage abstinence from tobacco and illicit drugs and advise low-risk alcohol users to remain within acceptable drinking levels. ●● On evidence of escalation of use, conduct brief intervention.

Assessing client’s readiness to quit When assessing your client’s readiness to quite consider these suggestions: ●● Have a conversation about whether the client is ready to quit. For example, you might say something like, “Given what we’ve talked about, do you want to change your drug use?” ●● If the client is unwilling to quit, raise awareness about drugs as a health problem. Let clients who are not ready know that you will

revisit the issue at future visits and have resources available when he/she decides to pursue making a change. ●● If the client is ready to quit, reinforce current efforts and then assist client in their efforts to make changes that will help them reduce and/or quit their drug use.

Facilitating your client’s change ●● Jointly complete a progress note form with the client to document the screening results and create a follow-up plan. ●● Help set concrete (and reasonable) goals for making a change: ○○ Ask interested clients to complete a change plan during session. ○○ Make a copy without their name or the name of your office on it, give it to them to take home, and tell them you will check in on their progress at the next visit. ○○ For clients who do not complete a change plan, schedule a second appointment to continue the discussion and to complete the change plan. You may provide a blank copy for them to take home and ask them to return with it, but some clients SocialWork.EliteCME.com

may need to start again with a fresh copy during their second session. ○○ For clients not interested in completing a change plan, encourage them to set a few brief change goals (e.g., cutting back, trying a self-help group); record the goals to check progress at the next visit. Longer-term treatment is recommended for most people following withdrawal. This can include self-help groups, like Narcotics Anonymous or SMART Recovery, outpatient counseling, intensive outpatient treatment (day hospitalization), or inpatient treatment.

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Professional counseling is strongly recommended, particularly in early recovery. Those withdrawing from opiates should be checked for depression and other mental illnesses. Appropriate treatment of such disorders can reduce the risk of relapse. Antidepressant medications should NOT be withheld under the assumption that the depression is only related to withdrawal, and not a pre-existing condition.

Treatment goals should be discussed with the patient and recommendations for care made accordingly. If a person continues to withdraw repeatedly, methadone maintenance is strongly recommended.

Follow-up As a licensed mental health professional it is necessary to evaluate your strengths when counseling substance abuse clients; specifically opioid dependent persons. Continue to assess your client for need for additional services such as specialty assessments, residential drug treatment, and long-term care. Remember to: ●● Refer clients as appropriate. Support groups - Support groups, such as Narcotics Anonymous and SMART Recovery, can be enormously helpful to people addicted to opiates. ●● Schedule follow-up on a consistent basis. ●● Offer continuing support at follow-up with regard to additional book recommendations, materials, blogs, etc. ●● Because the screening does not provide a diagnosis of abuse or dependence, refer high-risk clients for a full assessment. For moderate-risk clients and low-risk patients with special concerns (e.g., pregnant women, past injection drug users), use clinical

judgment to determine whether additional assessment is necessary. Use SAMHSA’s treatment locator (see additional resources, http:// findtreatment.samhsa.gov/) or NIDA’s National Drug Abuse Treatment Clinical Trials Network List of Associated Community Treatment Programs (see additional resources, www.drugabuse. gov/about-nida/organization/cctn/ctn) to locate assessment resources. ○○ If nearby treatment resources are not available, consider providing support group contact information and self-change materials, as well as other counseling resources – clergy or mental couples counselors. ○○ Obtain a written information release to send the screening results to all providers who will receive referrals. ●● Schedule a follow-up session within 1–2 weeks for moderate and high-risk clients and low-risk clients in certain groups. ●● Offer continuing support at follow-up sessions. ○○ Annual rescreening is indicated for clients who report any drug use at baseline (even with scores of 0–3) and for any other clients about whom you remain concerned. For moderate- and high-risk patients, rescreen at next appointment.

Treatment benefits Many benefits of medication management combined with counseling for opioid dependence have been discussed in this course. But in addition, intensive case management (ICM) can help substanceabusing women who receive welfare benefits stay off drugs and make strides in employment, report Dr. Jon Morgenstern and colleagues at Columbia University. In a study of 302 applicants for Temporary Assistance for Needy Families in New Jersey, the researchers assigned roughly half to an ICM intervention that included weekly visits from a case manager, help in overcoming treatment barriers, assistance in identifying and meeting other patient service needs, and voucher incentives for remaining in treatment. The rest of the trial participants received the care welfare agencies typically provide to substanceabusing clients, which consists of screening and referral for treatment.

When interviewed after 24 months, 47 percent of the women receiving ICM had been abstinent from drugs for the past 30 days, compared with 24 percent of those in the usual care group. At that same time, 22 percent of the women in the ICM group – but only 9 percent of those in the usual care group – were employed full-time. For comparison, the full-time employment rate was 34 percent among 150 female welfare recipients who did not abuse drugs. The researchers are now conducting a cost-benefit analysis of ICM. If their promising results are replicated in future evaluations, welfare agencies may have an effective tool to help some of their most vulnerable clients. (American Journal of Public Health 28(53):14372– 14378, 2008 (AbstractExternal link, please review our disclaimer.))

Preventing opioid dependence in the future Healthcare providers have long wrestled with how best to treat patients who suffer from chronic pain, roughly 116 million in this country. Their dilemma stems from the potential risks involved with longterm treatment, such as the development of drug tolerance (and the need for escalating doses), hyperalgesia (increased pain sensitivity), and addiction. Patients themselves may even be reluctant to take an opioid medication prescribed to them for fear of becoming addicted. Estimates of addiction among chronic pain patients vary widely from about 3 percent to 40 percent. This variability is the result of differences in treatment duration, insufficient research on long-term outcomes, and disparate study populations and measures used to assess abuse or addiction. To mitigate addiction risk, physicians should screen patients for potential risk factors, including personal or family history of drug

abuse or mental illness. Monitoring patients for signs of abuse is also crucial, and yet some indicators can signify multiple conditions, making accurate assessment challenging. Early or frequent requests for prescription pain medication refills, for example, could represent illness progression, the development of drug tolerance, or the emergence of a drug problem. The development of effective, non-addicting pain medications is a public health priority. A growing elderly population and an increasing number of injured military only add to the urgency of this issue. Researchers are exploring alternative medications that can alleviate pain but have less abuse potential. More research is needed to better understand effective chronic pain management, including identifying factors that predispose some patients to addiction and developing measures to prevent abuse.

Summary Taken as intended, prescription and OTC drugs safely treat specific mental or physical symptoms. But when taken in different quantities or when such symptoms aren’t present, they may affect the brain in ways

very similar to illicit drugs. For example, stimulants such as Ritalin increase alertness, attention, and energy the same way cocaine does – by boosting the amount of the neurotransmitter dopamine.

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Drug abuse and dependence changes the way the brain works, resulting in compulsive behavior focused on drug seeking and use, despite often devastating consequence. These behaviors are the essence of addiction. Consequently, drug abuse/addiction treatment must address these brain changes, both in the short and long term. When people addicted to opioids first stop, they undergo withdrawal symptoms, which may be severe pain, diarrhea, nausea and vomiting. Medications can be helpful in this detoxification stage to ease craving and other physical symptoms, which often prompt relapse. However, this is just the first step in treatment. Medications may also become an essential component of an ongoing treatment plan, enabling opioidaddicted persons to regain control of their health and their lives. Physicians prescribe a particular medication based on a patient’s specific medical needs and other factors. Effective medications include: Methadone (Dolophine or Methadose), a slow-acting, opioid agonist. Methadone is taken orally, so that it reaches the brain slowly,

dampening the “high” that occurs with other routes of administration while preventing withdrawal symptoms. Since the earliest methadone maintenance treatment programs in the United States, women have been treated successfully with methadone through all phases of their lives, including pregnancy. Buprenorphine (Subutex, Suboxone), a partial opioid agonist. Buprenorphine relieves drug cravings without producing the “high” or dangerous side effects of other opioids. Suboxone is a novel formulation, taken orally, that combines buprenorphine with naloxone (an opioid antagonist) to ward off attempts to get high by injecting the medication. Naltrexone (Depade, Revia) an opioid antagonist. Naltrexone is not addictive or sedating and does not result in physical dependence; however, poor patient compliance has limited its effectiveness. Research validates the use of both health care and counseling predicts better outcomes for sustaining sobriety and engagement with long-term recovery with opioid dependent persons.

References ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ

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Methadone dose and heroin use during maintenance treatment.Addiction 1993;88:119-24. Capelhorn JRM, Bell J. Methadone dosage and retention of patients in maintenance treatment. The Medical Journal of Australia 1991;154:195-99. Center for Substance Abuse Treatment. Methadone-Associated Mortality: Report of a National Assessment, May 8-9, 2003. CSAT Publication No. 28-03. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2004. Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention. Methadone Maintenance Treatment. Atlanta, GA: CDC, 2000. Available online at: www.cdc.gov/ idu/facts/MethadoneFin.pdf. [Accessed March 23, 2006.] Compton P, Ling W, Charuvastra C, Wesson DR. Buprenorphine as a pharmacotherapy for opioid addiction: what dose provides a therapeutic response? American Journal of the Addictions, in press. Condelli WS, Dunteman GH. Exposure to methadone programs and heroin use. American Journal of Drug and Alcohol Abuse 1993;19:65-78. Courtwright D. A century of American narcotic policy. In: Institute of Medicine. Treating Drug Problems: Volume 2. Washington, DC: IOM, 1992, pp. 1-62. Available online at: books.nap.edu/ openbook.php?isbn=0309043964. [Accessed March 23, 2006.] Dolan KA, Shearer J, MacDonald M, Mattick RP, Hall W, Wodak AD. A randomized controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system. Drug & Alcohol Dependence2003;72(1):59-65. Dole VP, Nyswander ME, Kreek MJ. Narcotic blockade. Archives of Internal Medicine 1966;118:304-09. Faggiano F, Vigna-Taglianti F, Versino E, Lemma P. Methadone maintenance at different dosages for opioid dependence. The Cochrane Database of Systematic Reviews, Issue 3, 2003. Fairbank JA, Dunteman GH, Condelli WS. Do methadone patients substitute other drugs for heroin? Predicting substance use at 1-year follow-up. American Journal of Drug & Alcohol Abuse 1993;19(4):465-74. Fiellin DA, Lintzeris N. Methadone syrup injection in Australia: a sentinel finding? Addiction 2003;98:385-386. Finnegan L. Treatment issues for opioid-dependent women during the perinatal period. Journal of Psychoactive Drugs 1991;23:191-201. Fudala PJ, Bridge TP, Herbert S, Williford WO, Chiang CN, Jones K, et al. Buprenorphine/ Naloxone Collaborative Study Group. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. New England Journal of Medicine 2003;349(10):949-58. Gossop M, Marsden J, Stewart D, Rolfe A. Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study. Drug & Alcohol Dependence 2000;60(3):275-86. Gowing L, Farrell M, Bornemann R, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection. The Cochrane Database of Systematic Reviews, Issue 4, 2004. Gowing LR, Farrell M, Bornemann R, Sullivan L, Ali, R. Methadone treatment of injecting opioid users for prevention of HIV infection. Journal of General Internal Medicine, in press. Green H, James RA, Gilbert JD, Harpas P, Byard RW. Methadone maintenance programs–a twoedged sword?American Journal of Forensic Medicine & Pathology 2000;21(4):359-61.

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Grella CE, Annon JJ, Anglin MD. Ethnic differences in HIV risk behaviors, self-perceptions, and treatment outcomes among women in methadone maintenance treatment. Journal of Psychoactive Drugs 1995;27(4):421-33. Harlow LL, Anglin MD. Time series design to evaluate effectiveness of methadone maintenance intervention.Journal of Drug Education 1984;14(1):53-72. Hartel D. Cocaine use, inadequate methadone does increase risk of AIDS for IV drug users in treatment. NIDA Notes 1989/1990;5(1). Hentoff N. The treatment of patients - I. The New Yorker 1965;June 26:32-77. Hubbard RL, Marsden ME, Rachal JV, Harwood HJ, Cavanaugh ER, Ginzburg HM. Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill: University of North Carolina Press, 1989. Hubbard RL, Marsden ME, Rachal JV, Harwood HJ, Cavanaugh ER, Ginzburg HM. Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill: University of North Carolina Press, 1989. Jaffe JHl, Martin WR. Opioid analgesics and antagonists. In: Goodman & Gilman’s the Pharmacological Basis of Therapeutics. New York: Pergamon Press, 1985. Jansson LM, Velez M, Harrow C. Methadone maintenance and lactation: a review of the literature and current management guidelines. Journal of Human Lactation 2004;20(1):62-71. Johnson RE, Jaffe JH, Fudala JP. A controlled trial of buprenorphine treatment for opioid dependence. JAMA1992;267(20):2750-55. Joseph H, Stancliff S, Langrod J. Methadone maintenance treatment (MMT): a review of historical and clinical issues. The Mount Sinai Journal of Medicine 2000;67(5 & 6):347-64. Available online at: http://mountsinai.site-ym.com/?page=Journal_of_Medicine/67/6756.shtml. [Accessed March 23, 2006.] Journal of Studies on Alcohol and Drugs 72(2):297–307, 2011. Abstract AvailableExternal link, please review our disclaimer. Kaltenbach K, Finnegan L. Developmental outcome of children born to methadone maintained women: a review of longitudinal studies. Neurobehavioral Toxicology and Teratology 1984;6:27175. Kaltenbach K, Silverman N, Wapner R. Methadone maintenance during pregnancy. In: State Methadone Treatment Guidelines. Rockville MD: U.S. Department of Health and Human Services, 1993. Kandel D. Epidemiological trends and implications for understanding the nature of addiction. In: O’Brien D, Jaffe J (eds.). Addictive States. New York: Raven Press, 1992. Kleber HD, Mezritz M, Slobetz F. Medical Evaluation of Long-Term Methadone-Maintained Clients. Rockville, MD: National Institute on Drug Abuse, 1980. Kosten TR, Rounsaville BJ, Kleber, HD. Multidimensionality and prediction of treatment outcome in opioid addicts: a 2.5-year follow-up. Comprehensive Psychiatry 1987;28:3-13. Kosten TR, Schottenfeld R, Ziedonis D, Falcioni J. Buprenorphine versus methadone maintenance for opioid dependence. Journal of Nervous and Mental Disease 1993;181(6):358-64. Kraft KM, Rothbard AB, Hadley TR, McLellan AT, Asch DA. Are supplementary services provided during methadone maintenance really cost-effective? American Journal of Psychiatry 1997;154:1214-19. Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, Robertson AD, Mehler PS. Torsade de pointes associated with very-high-dose methadone. Annals of Internal Medicine 2002;137(6):501-04. Kreek M, Schecter A, Gutjahr C, Bowen D, Field F, Queenan J, et al. Analyses of methadone and other drugs in maternal and neonatal body fluids: use in evaluation of symptoms in a neonate of mother maintained on methadone. American Journal of Drug and Alcohol Abuse 1974;1:409. Kreek MJ. Medical complications in methadone patients. Annals of the New York Academy of Science1978;311(29):110-34. Kreek MJ. Methadone in treatment: physiological and pharmacological issues. In: DuPont RL, Goldstein A, O’Donnell J, Brown B (eds.). Handbook on Drug Abuse. Rockville, MD: National Institute on Drug Abuse, 1979. Kreek MJ. Using methadone effectively: achieving goals by application of laboratory, clinical, and evaluation research and by developing of innovative programs. In: Pickens RW, Leukefeld CG, Schuster CR (eds.). Improving Drug Abuse Treatment. NIDA Research Monograph Series 196. Rockville, MD: National Institute on Drug Abuse, 1991. Lehman WEK, Barrett ME, Simpson DD. Alcohol use by heroin addicts 12 years after drug abuse treatment. Journal of Studies in Alcohol 1990;51(3):233-44. Lenne MG, Dietze P, Rumbold GR, Redman JR, Triggs TJ. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving. Drug & Alcohol Dependence2003;72(3):271-78. Lepere B, Gourarier L, Sanchez M, Adda C, Peyret E, Nordmann F, et al. Reduction in the number of lethal heroin overdoses in France since 1994. Focus on substitution treatments. Annales de Medecine Interne 2001;152:5-12. Ling W, Charuvastra C, Collins JF, Batki S, Brown LS, Kintaudi P, et al. Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial. Addiction 1998;93(4):475-86.

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Ling W, Wesson DR, Charuvastra C, Klett CJ. A controlled trial comparing buprenorphine and methadone maintenance in opioid dependence. Archives of General Psychiatry 1996;53(5):401-47. Lowinson JH, Marion IJ, Joseph H, Dole VP. Methadone maintenance. In: Lowinson JH, Ruiz P, Millman RB (eds.).Substance Abuse: A Comprehensive Textbook. Second Edition. Baltimore, MD: Williams & Wilkins, 1992. Maddux JF, Desmond DP. Crime and treatment of heroin users. The International Journal of the Addictions1979;14(7):891-904. Maddux JF, Desmond DP. Ten-year follow-up after admission to methadone maintenance. American Journal of Drug and Alcohol Abuse 1992;18(3):289-303. Maddux JF, McDonald LK. Status of 100 San Antonio addicts one year after admission to methadone maintenance.Drug Forum 1973;2:239-52. Maddux JF, Williams TR, Ziegler JA. Driving records before and during methadone maintenance. American Journal of Drug and Alcohol Abuse 1977;4(1):91-100. Marion IJ. Methadone treatment at forty. NIDA Science & Practice Perspectives 2005;3(1):25-31. Available online at: http://archives.drugabuse.gov/perspectives/vol3no1.html. [Accessed March 23, 2006.] Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis. Addiction 1998;93(4):515-32. Marsh J, Miller N. Female clients in substance abuse treatment. International Journal of the Addictions 1985;20:995-1019. Marsh K, Simpson D. Sex differences in opioid addiction careers. American Journal of Drug and Alcohol Abuse1986;12:309-29. Martell BA, Arnsten JH, Krantz MJ, Gourevitch MN. Impact of methadone treatment on cardiac repolarization and conduction in opioid users. American Journal of Cardiology 2005;95(7):915-18. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews, Issue 2, 2003. McGlothlin WH, Anglin MD. Shutting off methadone: cost and benefits. Archives of General Psychiatry 1981;38:885-92. McLellan AT, Arndt IO, Metzger DS, Woody GE, O’Brien CP. The effects of psychosocial services in substance abuse treatment. JAMA 1993;269(15):1953-59. McLellan AT, Kushner H, Metzger D, Peters R, Smith I, Grissom G, et al. The Fifth Edition of the Addiction Severity Index. Journal of Substance Abuse Treatment 1992;9(3):199-213 Meandzija B, O’Connor PG, Fitzgerald B, Rounsaville BJ, Kosten TR. HIV infection and cocaine use in methadone maintained and untreated intravenous drug users. Drug & Alcohol Dependence 1994;36(2):109-13. Mello NK, Bree MP, Mendelson JH. Comparison of buprenorphine and methadone effects on opioid self-administration in primates. Journal of Pharmacological Experimental Therapy 1983;225:378-86. Mello NK, Mendelson JH, Kuehnle JC. Buprenorphine effects on human heroin self-administration: an operant analysis. Journal of Pharmacological Experimental Therapy 1982;223:30-39. Mello NK, Mendelson JH. Buprenorphine suppresses heroin use by heroin addicts. Science 1980;27:657-59. Mendelson J, Jones RT, Welm S, Baggott M, Fernandez I, Melby AK, et al. Buprenorphine and naloxone combinations: the effects of three dose ratios in morphine-stabilized, opiate-dependent volunteers.Psychopharmacology 1999;141(1):37-46. Metzger DS, Woody GE, McLellan AT, O’Brien CP, Druley P, Navaline H, et al. Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. Journal of Acquired Immune Deficiency Syndrome 1993;6:104956. Mondanaro J. Strategies for AIDS prevention: motivating health behavior in drug dependent women. Journal of Psychoactive Drugs 1987;19:143-49. Murphy S, Irwin J. Living with the dirty secret: problems of disclosure for methadone maintenance clients. Journal of Psychoactive Drugs 1992;24:257-64. National Institutes of Health. Effective Medical Treatment of Opiate Addiction: Consensus Development Conference Statement. Bethesda, MD: NIH, 1998. Available online at: http:// consensus.nih.gov/1997/1998TreatOpiateAddiction108html.htm. [Accessed March 22, 2006.] O’Connor PG, Fiellin DA. Pharmacologic treatment of heroin-dependent patients. Annals of Internal Medicine2000;133:40-54. Payte JT, Khuri ET. Treatment duration and patient retention. In: State Methadone Treatment Guidelines. Rockville, MD: Center for Substance Abuse Treatment, 1993. Pond S, Kreek M, Tong T, Raghunath J, Benowitz NL. Altered methadone pharmacokinetics in methadone-maintained pregnant women. Journal of Pharmacology and Experimental Therapeutics 1985;233:1-6 Powers KI, Anglin MD. Cumulative versus stabilizing effects of methadone maintenance. Evaluation Review1993;17(3):243-70 Rayburn WF, Bogenschutz MP. Pharmacotherapy for pregnant women with addictions. American Journal of Obstetrics & Gynecology 2004;191(6):1885-97. Rettig R, Yarmolinsky A (eds.). Federal Regulation of Methadone Treatment. Washington, DC: Institute of Medicine, 1995, pp. 1-16. Available online at: books.nap.edu/catalog.php?record_ id=4899. [Accessed March 22, 2006.] Rosenbaum M. Sex roles among deviants; the women addict. International Journal of the Addictions 1981;16,859-77.

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Schindler SD, Ortner R, Peternell A, Eder H, Opgenoorth E, Fischer G. Maintenance therapy with synthetic opioids and driving aptitude. European Addiction Research 2004;10(2):80-87. Schottenfeld RS, Pakes JR, Oliveto A, Ziedonis D, Kosten TR. Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse. Archives of General Psychiatry 1997;54(8):713-20. Sees KL, Delucchi KL, Masson C, Rosen A, Clark HW, Robillard H, et al. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence. A randomized controlled trial. JAMA2000;283:1303-10. Sells SB, Simpson DD (eds.). The Effectiveness of Drug Abuse Treatment. Cambridge, MA: Ballinger, 1976. Selwyn P, Schoenbaum E, Davenny K, Robertson VJ, Feingold AR, Shulman JF, et al. Prospective study of human immunodeficiency virus infection and pregnancy outcomes in intravenous drug users. JAMA 1989;261:1289-94 Serpelloni G, Carrieri MP, Rezza G, Morganti S, Gomma M, Binkin N. Methadone treatment as a determinant of HIV risk reduction among injecting drug users: a nested case-control study. AIDS Care 1994;6:215-20. Seymour A, Black M, Jay J, Cooper G, Weir C, Oliver J. The role of methadone in drug related deaths in the west of Scotland. Addiction 2003;98(7):995-1002. Simpson DD, Joe GW, Lehman WEK, Sells SB. Addiction careers: etiology, treatment, and 12-year follow-up outcomes. Journal of Drug Issues 1986;16(1):107-21. Simpson DD, Sells SB (eds.). Opioid Addiction and Treatment: A 12-Year Follow-Up. Malabar, FL: Krieger Publishing Company, 1990. Simpson DD, Sells SB. Effectiveness of treatment for drug abuse: an overview of the DARP research program. Advances in Alcohol and Substance Abuse 1982;2(1):7-29 Simpson DD. Drug treatment evaluation research in the United States. Psychology of Addictive Behaviors1993;7(2):120-28. Simpson DD. Longitudinal outcome patterns. In: Simpson DD, Sells SB (eds.). Opioid Addiction and Treatment: A 12-Year Followup. Malabar, FL: Krieger Publishing, 1990 Strain EC, Bigelow GE, Liebson IA, Stitzer ML. Moderate- vs high-dose methadone in the treatment of opioid dependence. A randomized trial. JAMA 1999;281:1000-05. Strain EC, Stitzer ML, Liebson IA, Bigelow GE. Buprenorphine versus methadone in the treatment of opioid-dependent cocaine users. Psychopharmacology (Berl) 1994;116(4):401-06. Strain EC, Stitzer ML, Liebson IA, Bigelow GE. Dose-response effects of methadone in the treatment of opioid dependence. Annals of Internal Medicine 1993;119:23-37 Substance Abuse and Mental Health Services Administration. About Buprenorphine Therapy. Rockville, MD: SAMHSA, 2000a. Available online at: http://buprenorphine.samhsa.gov/about.html. [Accessed March 23, 2006.] Substance Abuse and Mental Health Services Administration. Drug Addiction Treatment Act of 2000. Rockville, MD: SAMHSA, 2000b. Available online at: http://buprenorphine.samhsa.gov/data. html. [Accessed March 23, 2006.] Substance Abuse and Mental Health Services Administration. Medication Assisted Treatment. Rockville, MD: SAMHSA, 2005. Available online at: www.dpt.samhsa.gov/404error. aspx?404;http://www.dpt.samhsa.gov /treatment.htm. [Accessed March 27, 2006. Sullivan LE, Fiellin DA. Buprenorphine: its role in preventing HIV transmission and improving the care of HIV infected patients with opioid dependence. Clinical Infectious Diseases 2005;41(6):89196 Sullivan LE, Metzger DS, Fudala PJ, Fiellin DA. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. Addiction 2005;100(2):150-58. Vanichseni S, Wongsuwan B, Choopanya K, Wongpanich K. A controlled trial of methadone maintenance in a population of intravenous drug users in Bangkok: implications for prevention of HIV. International Journal of the Addictions 1991;26(12):1313-20. 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Medication Management of Opioid Dependence Final Examination Questions

Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination. 56. Approximately _________ of the population is believed to misuse opiates over the course of their lifetime. a. 25 percent. b. 9 percent. c. 2 percent. d. 35 percent. 57. Opiate drugs include: a. Benzos, Xanax, anti-anxiety medications. b. Aspirin, non-prescription medication, inhalents. c. B and d. d. Heroin, morphine, codeine, methadone.

65. The spectrum of prescription drug abuse includes: a. Forgetting to take medication. b. Self-monitoring medication intake. c. Taking someone else’s prescription to self-medicate. d. All of the above. 66. Opioid intoxication is a condition caused by: a. Use of Xanax. b. Taking more than 10 mg. a day. c. Drinking alcohol. d. Use of opioid-based drugs.

58. Taken as intended, prescription and OTC drugs: a. Safely treat specific mental or physical symptoms. b. Rarely treat mental or physical symptoms. c. Occasionally treat mental or physical symptoms. d. Have been known to treat mental or physical symptoms.

67. Opiate withdrawal refers to the wide range of symptoms that occur after stopping or dramatically reducing opiate drugs after: a. Heavy short term use. b. Heavy and prolonged use. c. Moderate use. d. Prolonged light use.

59. Repeatedly seeking to experience that “high” feeling can lead to: a. Addiction. b. Vomiting. c. Loss of sleep. d. Feelings of depression.

68. The opioid dependent person generally uses opioids: a. Fewer than five times each day. b. At least once each day. c. Several times each day. d. None of the above.

60. As early as the _______ methadone gained recognition as an effective treatment for heroin addiction. a. 1930’s. b. 1940’s. c. 1960’s. d. 1970’s.

69. In addition to patient self-report _______ can be a useful practice in monitoring patient progress in treatment. a. Urine testing. b. Mouth swabbing. c. Eye exams. d. All of the above.

61. Deaths from opioid pain relievers exceed those: a. From illegal drugs. b. From excessive drug use. c. Car accidents. d. Heart disease.

70. Methadone was approved for office-based dispensing by the Food and Drug Administration in: a. 1978. b. 2010. c. 1995. d. 2002.

62. Scientific research has established that medication-assisted treatment of opioid addiction: a. Suppresses patient retention. b. Interrupts patient retention. c. Increases patient retention. d. Decreases patient retention. 63. Methadone (Dolophine or Methadose), is: a. Neural inhibitor. b. A slow-acting, opioid agonist. c. A fast-acting opioid agonist. d. A partial opioid agonist. 64. Buprenorphine (Subutex, Suboxone), is: a. A partial opioid agonist. b. A slow-acting opioid agonist. c. A fast-acting opioid. d. None of the above.

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71. Opioid withdrawal reactions are very uncomfortable but are not, in general: a. Addictive. b. Benign. c. Blatant. d. Life threatening. 72. The acceptable initial dose for methadone treatment is: a. 30 mg daily. b. 130 mg daily. c. 10 mg daily. d. None of the above. 73. Methadone: a. Suppresses the symptoms of opioid withdrawal for 24 to 36 hours. b. Blocks the effects of administered heroin. c. Does not cause euphoria, intoxication, or sedation. d. All of the above.

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74. Methadone maintenance has been associated with significant increases in: a. Unemployment rates. b. Costly over-time. c. Full-time employment. d. A decrease in worker productivity.

83. Complications from withdrawal include vomiting and breathing in stomach contents into the lungs. This is called: a. A seizure. b. Septic poisoning. c. Aspiration. d. None of the above.

75. The daily oral administration of adequate dosages of methadone reduces the need for opioid-dependent individuals: a. Take vitamins. b. To inject drugs. c. To release sugar into their systems. d. To take methadone for long period of time.

84. Providers should be aware that many states mandate reporting of drug use during pregnancy and that failure to do so may be: a. A sign of future problems for the mother and child. b. A problematic issue for the states. c. An ethics issue. d. A prosecutable offense.

76. Ball and Ross study (1991) of 617 patients demonstrated that methadone maintenance treatment is associated with a dramatic decline in the average number of: a. Days missed at work per year. b. Crime-days per year. c. Employee complaints. d. Days in treatment.

85. The mental health professional’s role, often includes “case management” jobs, and in general, includes: a. Advising the client about drug use. b. Assessing client’s readiness to quit. c. Facilitating client changes d. All of the above.

77. Since the early 1970s, methadone maintenance treatment has been used successfully with: a. The elder population. b. Adolescents. c. Athletes. d. Pregnant women. 78. All drug-using women are considered to be at higher-than-normal risk for: a. Medical and obstetrical complications. b. Respiratory complications. c. Heart problems. d. None of the above. 79. The longer patients stay in treatment, the more likely they are to remain: a. Free from heart disease. b. Crime free. c. Lacking in energy. d. Physically fit. 80. As a partial agonist, buprenorphine has: a. Less potential for abuse than addiction. b. Greater potential for abuse than most partial agonists. c. Less potential for abuse than most full agonists. d. None of the above. 81. Research on buprenorphine has shown that it has the potential to be a feasible alternative to: a. Methadone maintenance treatment. b. Residential care. c. Going cold turkey. d. Prescription medications. 82. The ASI screen is: a. The only proven indicator of a client’s potential drug use problem. b. Still being tested as a viable assessment instrument. c. A very long assessment instrument that takes several hours to complete. d. Only one indicator of a client’s potential drug use problem.

SWPA05MM17 Page 71 SocialWork.EliteCME.com

Chapter 5:

Obesity in Children 2 CE Hours

By: Rene’ Ledford, MSW, LCSW, BCBA and Kathryn Brohl, MA, LMFT

Learning objectives This workshop is designed to help you: ŠŠ Assess obesity statistics that drive current awareness of the obesity problem within the United States. ŠŠ Identify causes of obesity in children.

ŠŠ Describe effects of childhood obesity. ŠŠ Calculate body mass index (BMI). ŠŠ Recognize current initiatives and treatment for obesity in children.

Introduction Health care professionals within the United States and increasingly throughout the world are gravely concerned about the number of seriously overweight and obese children and youth. Recently, experts have confirmed that obesity, diabetes and heart disease, once thought to be afflictions of the affluent, are spreading to the developing world. Obesity has reached such epidemic proportions that world health officials have decided they need to take a more aggressive approach if they are to change a global explosion of obesity related diseases. After years of focusing on promoting healthy eating to dampen the demand for junk food, the World Health Organization is now examining what can be done on the supply side: enlisting the cooperation of food producers. Although the presence or development of obesity is a daunting problem, it should not be ignored by mental health professionals. In this course, mental health practitioners will learn: ●● What obesity is and why it does not have a DSM diagnosis. ●● Causal factors behind obesity.

●● Current trends and treatments to address the obesity epidemic within the United States. ●● The statistics cited here reflect the impact on the overall health and well-being of youngsters living within the United States. Juvenile obesity statistics: ●● Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years (National Center for Health Statistics, 2011). ●● The percentage of children aged 6–11 years in the United States who were obese increased from 7 percent in 1980 to nearly 18 percent in 2012. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5 percent to nearly 21 percent over the same period (National Center for Health Statistics, 2011). ●● In 2012, more than one third of children and adolescents were overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014).

Obesity reflects a changed society within the U.S. Children live in a society that has changed dramatically in the three decades in which the obesity epidemic has developed. Many of these changes will be further explored in this course and include both parents working outside the home, longer work hours by both parents, changes in school food environment, and more meals eaten outside of the home. These changes interface with changes in the physical design of communities that often affect what children eat, where they eat, how much they eat, and the amount of energy they expend in school and leisure time activities.

Other changes, such as the growing diversity of the population, influence cultural views and marketing patterns. Use of computers and video games, along with television viewing, often occupy a large percentage of children’s leisure time and potentially influence levels of physical activity for children as well as for adults. Many of the social and cultural characteristics that the U.S. population has accepted as a normal way of life may collectively contribute to the growing levels of childhood obesity as well.

Obesity – definition Obesity can be defined as an excessively high amount of body fat in relation to lean body mass. Obesity is a condition where weight gain has gotten to the point that it poses a serious threat to health and when calories consumed exceed the need. It also refers to increased body weight in relation to height, when compared to some standard of acceptable or desirable weight. Obesity is normally measured in terms of a person’s body mass index or BMI. BMI, therefore, is one important way of deriving desirable weight standards. According to the Centers for Disease Control and Prevention (2013), BMI uses a mathematical formula in which a person’s weight in pounds is divided by the square of the person’s height in inches. This result is then multiplied by 703. BMI is a ratio of weight to height that is calculated by weight in kilograms divided by height in meters squared, is used most commonly to define obesity operationally. BMI is strongly associated with adiposity and obesitySocialWork.EliteCME.com

related morbidity, and category thresholds have been established (BMI < 18.5 – underweight; BMI 18.5–24.9 – normal weight; BMI 25–29.9 – overweight; BMI > 30 – obese). For example, a 13-year-old boy who weighs 190 pounds and is 5 foot 5 inches tall would have a BMI = [190/(65)(65)] x 703 = 31.6. When infants are born, they have comparatively more fat and this is normal and appropriate. This relatively greater amount of fat provides the infant with some nutritional reserve when they are most vulnerable and adjusting to life outside the womb. The larger amount of fat decreases as the infant grows older. Around 5 years of age, children have the lowest amount of fat and have the lowest body mass index. If a child between the ages of 2 and 5 is overweight or obese, there is cause for worry. Page 72

It is interesting to note that as of 2013, the American Medical Association (AMA) has officially recognized obesity as a disease, joining a number of leading organizations that have previously made this classification, including the National Institutes of Health (1998), the Social Security Administration (1999), the Centers for Medicare and Medicaid Services (2004), The Obesity Society (2008) and the American Association for Clinical Endocrinology (2012). The passage of a new American Medical Association policy classifying obesity as a disease reinforces the science behind obesity prevention and

treatment. Obesity is considered a complex condition with numerous causes, many of which are largely beyond an individual’s control. The disease is a driver of much suffering, ill health and earlier mortality, and people affected are too often subject to enormous societal stigma and discrimination. This recognition of obesity as a disease can help to ensure more resources are dedicated to needed research, prevention and treatment; encourage healthcare professionals to recognize obesity treatment as a needed and respected vocation; and, reduce the stigma and discrimination experienced by the millions affected.

Children and BMI ●● A child’s BMI (body mass index) is calculated using the same method as for adults, but adult BMI figures must not be used to determine whether a child is overweight or obese. Specific ageadjusted charts are needed. ●● BMI is used differently for children. Though calculated the same way as for adults, it is then compared to typical values for other children of the same age. Instead of set thresholds for underweight and overweight, then, the BMI percentile allows comparison with children of the same gender and age. ●● A BMI that is less than the 5th percentile is considered underweight and above the 95th percentile is considered

overweight. Children with a BMI between the 85th and 95th percentile are considered to be at risk of becoming overweight. ●● The growth of children is usually documented against a BMImeasured growth chart. Obesity trends can be calculated from the difference between the child’s BMI and the BMI on the chart. ●● Clinical professionals should take into consideration the child’s body composition and defer to an appropriate technique such as densiometry since many children who are generally born or grow as an endomorph would be classed as obese.

Obesity is linked to human biology In the last 20 years, researchers have studied the intricate feedback system in which energy expenditure and food intake are balanced. For example, the brain responds to hormonal signals that maintain body weight by telling us when to start and stop eating, and how much food to consume. Leptin, a hormone produced by fat cells in the stomach, plays a role in suppressing appetite and stimulating energy expenditure. Other weight regulating hormones include ghrelin, an appetite stimulant; insulin; the orexins; and cholecystokinin. Neurotransmitters such as serotonin, norepinephrine and dopamine are also involved. Over time, even a slight imbalance in hormone regulation can prompt weight gain. For example, leptin levels in most obese humans are high and correlate with body fatness. In addition, nearly two dozen genes are known to control the production of these weight-regulating hormones, and weight is as inheritable as height. Consequently, obesity becomes a serious problem when the human evolutionary heritage expressed in the body’s control system interacts with modern social conditions because the environment in which bodies evolved were unpredictable when it came to food availability. At that time humans had to store energy beyond immediate need. Therefore, the body’s signals continue to erroneously tell us to eat when we can because there may be no food tomorrow. In addition, humans are especially attracted to sweet, fatty and salty tastes and textures that once indicated scarce essential nutrients. Research in mice and humans suggests that food high in fat, sugar and calories lowers the body’s response to chronic stress. In animal experiments, weight loss activates the stress responses. When stressed youngsters console themselves with foods high in fat, sugar and calories, they may be inadvertently contributing to lowering their body’s response to stress. Because obesity is often linked to poor health and subsequent depression and anxiety, research suggests that depressed persons are more likely to develop metabolic syndrome (insulin resistance, high cholesterol, excess abdominal fat, and high blood pressure) that frequently accompanies excess weight, especially if it’s deposited around the waist. And many scientists that investigate food cravings link overeating with addiction. Brain scans and animal experiments are suggesting that some of the same brain centers are active in both food addiction and drug addiction.

Additional Causal Factors 1. Genetics – Single gene animal models of obesity have led to the identification of several gene products that are associated with obesity. Of particular importance, the mutated gene products in animal models have human homologues that appear to have similar functions, suggesting that these proteins may also play roles in the development or maintenance of human obesity. ○○ Genes can directly cause obesity in disorders such as BardetBiedl syndrome and Prader-Willi syndrome. However genes do not always predict future health. Genes and behavior both contribute to excess weight. In some cases multiple genes may increase one’s susceptibility for obesity and require outside factors, such as abundant food supply or little physical activity. 2. Behavioral genetics – Behavioral genetics refers to the contribution of genetic variability to relevant behaviors such as eating and physical activity. Consequently behavioral factors such as dietary preference for fats, time between meals, calories eaten versus need, or even inclination to engage in physical activity can have strong genetic components. Therefore, genetically determined preferences may interact with environmental factors to yield conditioned eating patterns. Recognition of certain behaviors may have important implications for targeting behavior change in children. 3. Inherited traits – Inherited traits impact obesity and are an additional genetic effect. Studies have suggested that most of the familial resemblance for body mass index in adults is due to genetic influences rather than shared family environments. 4. Diet – Eating larger portions of higher calorie and energy dense foods significantly contributes to childhood obesity. In addition, many physicians are concerned that children’s bodies were not developed to take in the levels of processed foods they are now eating. And although there are many “foods” in children’s diets that contribute to excessive weight gain, one candidate is carbonated drinks. A single carbonated drink can add 10 percent to a child’s daily energy intake, so reducing solely the amount of soft drinks that a child consumes could cause a significant reduction in obesity risk. ○○ Several studies have indicated that in children and adolescents, sugar-sweetened beverage consumption as a percentage of total caloric intake has increased, while milk consumption has decreased over the last 20 years. The same studies found that sugar-sweetened beverages accounted for 5 percent to 10 percent of caloric intake among children age 2 to 16. In

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addition, quantities of milk consumed by youngsters decreased by 25 percent and sugar-sweetened beverage consumption increased almost threefold over a 10-year period. Soda consumption, but not the consumption of other beverages, predicted the greatest increase in body mass index. 5. Toxic environments – Toxic environments expose children to environmental risk factors that impact weight gain. They include: ○○ Sprawling urban areas. ○○ Availability and accessibility of convenience foods. ○○ Stressful home or school conditions. ○○ Larger food packaging. ○○ Atmospherics such as lighting, odor and noise. ○○ Stockpiled food. ○○ Cost of living food options. ○○ Food preparation. 6. Habitual consumption script – Habitual consumption scripts are formalized when repeated eating that associates certain stimuli with food intake becomes a pattern or script. 7. Behavior – Behavior increases a person’s risk for gaining weight. An anxious or depressed child may self-nurture or self-soothe with food for example. This can also be the case if parents are prompted to pacify children with food. Other behaviors include poor eating habits, extended inactivity through television or computer viewing, lack of exercise, and lack of sleep or rest. Socializing during food

intake and engaging in other distractions can also contribute to increased food consumption in children. 8. Culture – Western culture plays a role in obesity. Adolescent obesity increases among second – and third-generation immigrants to the U.S. as they adopt the American diet and lifestyle. The Western diet typically supplies more than 30 percent of its calories from fat. Sugar is also a problem. 9. Gender, race, ethnic, and socioeconomic factors – Between the second and third National Health and Nutrition Examination Surveys (NHANES II and III), the prevalence of overweight conditions and obesity increased in both genders, across all races and ethnicities and across all age groups. Disparities in overweight conditions and obesity prevalence exist in many segments of the population based on race and ethnicity, gender, age and socioeconomic status. Overweight conditions and obesity are particularly common among minority groups and those with a lower family income. ○○ In general, women who are members of racial and ethnic minority populations are more likely to be overweight or obese than are non-Hispanic white women. Among men, Mexican Americans are more likely to be overweight and obese than non-Hispanic whites or non-Hispanic blacks. For non-Hispanic men, the prevalence among whites is slightly greater than among blacks.

The question of metabolic efficiency Although genetic differences in metabolic efficiency are likely to exist, there is little evidence that low metabolic rate plays a major role in the development or maintenance of obesity for the vast majority of

overweight persons, suggesting that the development or maintenance of obesity is mediated by the consumption of a greater than normal amount of food. (APA, 2000)

Health consequences of childhood obesity In the past 10 years, there has been a tremendous increase in the number of studies examining the etiology and health effects of obesity in children. It would be no surprise then that physical health, quality of life and psychosocial functioning can be significantly impaired as a result of childhood obesity. The literature has presented well-documented links between obesity and increased mortality and morbidity due to hypertension, dyslipidemia, diabetes mellitus, coronary heart disease, congestive heart failure, stroke, gallstones, osteroarthritis, sleep apnea, certain types of cancer that include colon, breast, endometrial and gall bladder, menstrual abnormalities, impaired fertility and increased pregnancy risks in overweight people. When children become overweight, they risk early onset of many of these conditions. For example, the risk that an obese 5-year-old child remains obese as an adult is approximately 50 percent. This increases to more than 80 percent for an obese adolescent. On the other hand, the risk of a normal-weight child becoming obese as an adult is only 7 percent. Excess fat can manifest physically in two ways, each with its own adverse outcomes. An excess amount of fat cells tends to result in respiratory, gastrointestinal and or musculoskeletal problems. Quality of life and other measures of psychosocial functioning may be significantly impaired. Gastroesophageal reflux disease, which can lead to cancer in some cases, is also common, as are skeletal maladies owing to excess weight, particularly in children’s hips and knees. When fat cells are increased in size, metabolic and inflammatory conditions are often the result, with consequences for the heart, kidneys and liver. One study found that 19-30 percent of these obese children aged 5-11 had elevated blood pressure, with rates higher in boys than in girls, and higher in blacks than in whites. The obese children were also far more likely than normal weight children (11 percent versus 1-2 percent) to be diagnosed with hypertension as the result of three elevated blood pressure readings. Roughly half of obese children were found to have abnormalities of lipid factors. SocialWork.EliteCME.com

Endocrine issues such as insulin resistance, impaired glucose tolerance, and Type 2 diabetes are common in obese youth. These cardiovascular and metabolic problems can often result in the condition called metabolic syndrome. (Mentioned previously in this course.) According to researchers, metabolic syndrome may be what underlies much of the morbidity and mortality related to obesity. For example, in normal weight adolescents, it’s virtually nonexistent at 1 percent. In overweight adolescents, it’s about 10 percent, and in obese adolescents, it’s close to 30 percent. Liver and kidney abnormalities are also quite common in obese youngsters. These conditions can cause damage leading to increased risk of cancers later in life. The evidence is clear that obesity early in life can be devastating to short- and long-term health. In general, there are six health differences in overweight children, as compared to children with a healthy weight. They include: ●● High cholesterol. ●● Lipoprotein. ●● High blood pressure. ●● Blood lipid. ●● Insulin levels. Overall, juvenile obesity can cause: ●● Cancer. ●● Coronary heart disease. ●● Type 2 diabetes. ●● High blood pressure. ●● Osteoarthritis. ●● Hypertension. ●● Joint pain. ●● High cholesterol. ●● Asthma. ●● Hypothyroidism. ●● Hypoventilation. ●● Polycystic ovary syndrome. Page 74

●● Gallstones. ●● Sleep disorders.

●● Mood disorders. ●● Psychosocial problems.

More about type 2 diabetes Perhaps one of the most dramatic and disturbing findings in the past decade was the tremendous increase in the incidence of type 2 diabetes in children and adolescents. Previously, it was generally thought that type 2 diabetes was restricted to older age groups and largely did not affect children. However, the increased incidence of type 2 diabetes in

the pediatric population was shown by an examination of clinical cases that diagnosed diabetes. For example, in 10-19-year-olds, 33 percent of all cases of diabetes were identified as type 2. This translated to a tenfold increase in the incidence of type 2 diabetes between 1982 and 1994.

More about sleep disorders Due to an excess amount of fat cells, obstructive sleep apnea is a problem in obese youngsters and occurs in 15-20 percent of obese children, six times the rate of normal weight youngsters. A research study found that shorter sleep duration is associated with almost a twofold increased risk of being obese. The research suggested that those who sleep less have a greater increase in body mass index and waist circumference over time and a greater chance of becoming obese over time. The “epidemic’” of obesity is paralleled by a silent epidemic of reduced sleep duration, with short sleep duration linked to increased risk of obesity both in adults and in children. These trends are detectable in children as young as 5.

Short sleep duration may also lead to obesity through an increase of appetite because of hormonal changes. Hormonal changes are often caused by sleep deprivation. Lack of sleep produces ghrelin, among other effects. In addition, an abnormal eating pattern that exists most commonly in obese individuals has become known as the “night-eating syndrome.” First described in 1955, its key features are morning anorexia, evening hyperphagia, and insomnia. More recent clinical reports have suggested that many of these patients suffer from sleep disorders such as somnambulism, restless legs syndrome, and obstructive sleep apnea. Most of these people report some degree of amnesia for the eating episode. In addition, night eating syndrome is associated with nocturnal rise in leptin and melatonin and increased plasma cortisol.

Mental health issues Not long ago, it was commonly believed that overweight and obese people were compulsive eaters, anxious, depressed, under stress, or trying to compensate for emotional deficiencies in their lives. But today, experts are rejecting the theory that weight gain is rooted entirely in emotions. However, the psychological effects of obesity first occur with childhood obesity. Negative attitudes within Western societies toward obese youngsters are prevalent, not only among the general population, but also with health care providers. These negative attitudes translate into tangible disadvantages in several common areas, including social rejection and discrimination at school, and in the community at large. Consequently, mental health related issues are often present in overweight children. Obese children rated their quality of life with scores as low as those of young cancer patients on chemotherapy. Other self-reports include: ●● Perception of social discrimination. ●● Low self-esteem. ●● Teasing and bullying at school. ●● Difficulties playing sports.
 ●● Fatigue. ●● Sleep apnea.

It has been shown that obese adolescents have higher rates of poor self-esteem, and their negative self-image often carries over into adulthood. For example, by the time an obese child is 13 or 14, their self esteem is already significantly less than half that of normal-weight children. Increased rates of depression can occur in children who are overweight due to poor body image, and experience with inhibiting social pressures, such as changing clothes in front of other people. While obesity is connected to eating disorders recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM), obesity itself is not considered a mental health disorder and therefore does not appear in the DSM-5. Obesity is included in the International Classification of Diseases (ICD) as a general medical condition but does not appear in the DSM because it has not been established that it is consistently associated with a psychological or behavioral syndrome. However, when there is evidence that psychological factors are of importance in the etiology or course of a particular case of obesity, this can be indicated by noting the presence of psychological factors affecting medical condition.

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Binge eating There is one potential psychiatric diagnosis that is closely related to obesity. Binge eating disorder is defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control (APA, 2013). Someone with binge eating disorder may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months. Binge eating disorder was approved for inclusion in DSM-5 as its own category of eating disorder. In DSM-IV, binge-eating disorder was not recognized as a disorder but rather described in Appendix B: Criteria Sets and Axes Provided for Further Study and was diagnosable using only the catch-all category of “eating disorder not otherwise specified.”

This change is intended to increase awareness of the substantial differences between binge eating disorder and the common phenomenon of overeating. While overeating is a challenge for many Americans, recurrent binge eating is much less common, far more severe, and is associated with significant physical and psychological problems. Overeaters Anonymous (OA) has been established since 1960 to help people who engage in compulsive overeating and was apparently the first organization to term such patterns as compulsive overeating. Today, however, members may have any form of an eating disorder. The National Institute of Mental Health (NIMH) also notes bingeeating disorder as a troubling problem. It is noted that a pattern of binge-eating episodes accompanied by feelings of shame and guilt often lead to depression and distress over the eating pattern, which in turn can trigger more episodes of binge eating (2008).

Messages to girls versus boys Culture and the media send children powerful messages about body weight and shape cultural ideals. While gender has not been identified as a specific risk factor for obesity in children, the pressure upon girls to be thin may put them at greater risk for developing eating disordered

behaviors and/or related mood symptoms. Although society presents boys with a wider range of acceptable body images, they are still at risk for developing disordered eating and body image disturbances.

The impact of culture Some Western cultures discriminate against obese individuals. Within the United States it has been documented that obese females have lower acceptance rates for college than non-obese females with the same grades and standardized test scores. The National Longitudinal Survey

of Youth study noted that obese adolescent females as young adults had less education, less income, higher poverty rate and decreased rate of marriage as compared to non-obese adolescent females.

Childhood obesity prevention and intervention “Because it is so hard to treat obesity, we’ve tried to focus on preventing obesity from developing children, and we’re trying to do that through a variety of research and educational strategies. If you can prevent kids from becoming overweight and obese at a young age, then you’re much more likely to start to reduce the incidence of obesity in adults. I think there’s the potential that if we can successfully modify our environment to enable people to have a better diet or more physical activity, we can start to see some reductions in the growth of obesity in the next five to 10 years.” – Dr. Allen Dearry, National Institute of Environmental Health Sciences (NIEHS) The ultimate goal of childhood obesity prevention and intervention is to assist children to effectively prevent and deal with obesity. This includes assisting children in maintaining energy balance while protecting physical and mental health, growth and development, and nutritional status.

Addressing childhood obesity requires a wide-ranging action plan that includes a national public health priority with all government levels providing coordinated leadership, delineated healthy marketplace and media environment, healthy school and community environments, and research priorities. Research priorities should include evaluation of interventions, behavioral research on how to change dietary and physical activity habits, a community-based approach and best-practice protocols that address the mental health needs of overweight and obese youngsters. “It is difficult to promote healthier foods and healthy activity choices among all populations. The populations at most risk for obesity are those with the fewest resources, not only the fewest individual resources, but the neighborhoods in which they live that have lower resources as well. And so the challenge before us is to devise environmental solutions that will take the environmental and neighborhood factors into account.” – Dr. Adam Drewnowski, University of Washington

Treatment guidelines Mental health professionals can advocate for early identification and intervention with overweight children as soon as it can be appropriately addressed within the context of a therapeutic setting. Remember that unless a child is severely obese, weight loss is not recommended for the overweight school-age child. Severe caloric restriction could compromise growth, delay the onset of maturity and even enhance emotional overeating. The goal generally is to maintain weight or reduce the rate of gain. If weight is maintained while height increases, the percentage of body fat will decrease without compromising lean body mass and growth. When addressing a primary physical medical issue such as obesity, make sure that you receive recent medical information or refer your client for a medical examination. In addition to taking a psychosocial history, spend time on reviewing with parents the child’s diet and SocialWork.EliteCME.com

physical activity habits. The primary goals of obesity therapy should be healthful eating and activity, as well as addressing other causal factors such as stress, mood disorders, attachment and bonding, and habituated behaviors. As you begin to address obesity issues, assess the readiness of the child and family to engage in discussion about a weight-management program. Let parents know that they should be cautious about representing a realistic picture of the chances of weight-loss success. Success in terms of weight loss may be limited, but success in terms of enhancing emotional well-being, nutritional status and physical capability may be considerable. As a matter of ethics, remember that parents have a responsibility to care for and protect their children, even when it relates to food and nutrition. For example, a newer ethical question comes into focus Page 76

when mental health practitioners review the health and safety of their young clients if their parents do not address their children’s obesity.

The childhood obesity interventions mentioned here represent a holistic approach to working with obese youngsters and their families.

Behavior modification The most effective treatment for obese children and adolescents is behavior and lifestyle modification under the guidance of a physician, weight management specialist or mental health professional experienced in dealing with children and adolescents. Behavior and lifestyle modification involves the following: ●● Assessment of child and family eating habits. ●● Motivational interviewing. ●● Counseling to keep a food/activity diary. ●● Extensive family support. ●● Joining a weight loss group of peers. ●● Limiting the time and place of eating. ●● Limiting sedentary activities. ●● Recording food intake.

●● ●● ●● ●●

Recording physical activity. Self-monitoring progress. Slowing the rate of eating. Using rewards and incentives for desirable behaviors.

Motivational interviewing is used to interact effectively with young clients so that a mutually agreed upon set of achievable and incremental goals can be reached in order to support behavior change. Particularly effective are behaviorally based treatments that include problem-solving exercises in a parent-child behavioral program. Children in problem-solving groups, but not those in the behavioraltreatment only groups, significantly reduced percent overweight and maintained reduced weight for six months.

Parent coaching and family involvement Working with obese children involves engagement through parent and family coaching to make step-by-step permanent changes. Education about child and adult obesity as well as teaching nutrition and food preparation are part of coaching parents into wellness. Ongoing support for families after the initial weight-management program will help children maintain. You can make this information available to clients.

Tips for healthy eating: ●● Assess your dietary intake. ●● Monitor your portion sizes. ●● Modify food preparation if needed. Reduce the use of fats and sugars. ●● Use the Food Guide Pyramid as a guide for healthful eating. Basing meals and snacks on complex carbohydrates (breads, cereals, rice, pasta, grains). ●● Wait a few minutes before giving additional servings. A break allows time to determine if hunger is the issue.

Physical activity education Physical activity education and discussion is part of addressing childhood obesity with clients. It should be pointed out that overweight children do not experience psychological or physical benefits when they do not engage in regular exercise. Share these facts with your clients: ●● Increased physical activity can decrease or at least slow the increase in fatty tissues in obese youngsters. ●● Extended inactivity is not appropriate for normal, healthy children. In addition, inactivity in childhood has been linked to a sedentary adult lifestyle. ●● Time, intensity and variety are three important concepts to enhance the impact of physical activity on health, as well as the child’s interest in it. ●● Children should take part in at least 60 minutes of age- and developmentally appropriate activities every day. Activity periods

should last 10 to 15 minutes or more and include a range of intensities (moderate to vigorous). ●● Children should engage in a variety of physical activities of various levels of intensity. ●● Physically active parents and siblings serve as role models. They also provide good company for bike rides, walks or swims. Physical activity should be fun and make children feel good, not a chore they must do to lose weight. Adopting a formal exercise program, or simply becoming more active, is valuable to burn fat, increase energy expenditure, and maintain lost weight. Most studies have shown that exercise will be a successful strategy for weight loss when coupled with another intervention, such as nutrition education or behavior modification. Children’s body weight may not change following 50 minutes of aerobic exercise three times per week, but blood lipid profiles and blood pressure should improve.

Medical intervention treatment Although no drugs are specifically approved for pediatric weight loss, some physicians may prescribe them “off-label.” Because the side effects of these medications in children are unknown, children should not use adult weight loss drugs.

For extremely obese adolescents, surgical procedures called bariatric surgery may be performed, but only rarely. These procedures involve significant surgical alteration of the digestive tract and require substantial modification of diet after the surgery to much less than 1,000 calories per day. Weight loss surgery should only be performed on an adolescent as a last resort.

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Alternative treatment Alternatives for weight loss involve the use of ephedra-containing drugs or herbal preparation or the use of diuretics and laxatives. Both of these practices are unsafe, especially for children and adolescents. Because ephedra can cause severe cardiac side effects, the Food and Drug Administration has issued warnings against its use. Diuretics and laxatives can result in severe dehydration and improper absorption of nutrients.

Other alternative treatments include acupressure and acupuncture that may work to suppress food cravings. Visualization and meditation can create and reinforce a positive self-image that enhances the patient’s determination to lose weight. By improving physical strength, mental concentration and emotional serenity, yoga can provide similar benefits.

Public and private initiatives Special summer programs and therapeutic schools exist now to address childhood obesity. Much of these summer camp programs focus on healthy eating and exercise habits.

National public policy is evaluating science-based and best-practice protocols to address childhood obesity issues. Federally funded conferences are now held to continue to address this problem.

In addition, in early 2004, the first alternative school for overweight and obese children, which operates like other private and charter schools but with a focus on healthy weight loss and maintenance, was established. The Centers for Disease Control have recommended that schools establish policies that promote enjoyable, lifelong physical activity among young people. Their guidelines state, “Physical education should emphasize skills for lifetime physical activities, rather than those for competitive sports.” These experts also recommend that fitness-enhancing physical activities become an integral part of the American family’s lifestyle.

In addition, large private companies such as PepsiCo have recognized that there is tremendous business opportunity in offering consumers more nutritious, healthful products.

Many states are publicly and privately collaborating to focus on physical activity and healthy eating in order to address health risks in children and youth. Stakeholder groups, including businesses, schools, health care, faith-based groups and community organizations contribute to efforts within current and developing programs. Other community programs focus on time-based programs that address exercise, education, self-esteem, interactive workouts and evolving media attention.

Key terms: ●● Adipose tissue – Fat tissue. ●● Ghrelin – A peptide hormone secreted by cells in the lining of the stomach important in appetite regulation and maintaining the body’s energy balance. ●● Hyperlipidemia – A condition characterized by abnormally high levels of lipids in blood plasma. ●● Hyperplastic obesity – Excessive weight gain in childhood characterized by an increase in the number of new fat cells. ●● Hypertension – Abnormally high arterial blood pressure, which if left untreated can lead to heart disease and stroke. ●● Hypertrophic obesity – Excessive weight gain in adulthood, characterized by expansion of already existing fat cells. ●● Ideal weight – Weight corresponding to the lowest death rate for individuals of a specific height, gender and age. ●● Leptin – A protein hormone that affects feeding behavior and hunger in humans.

Conclusion Childhood obesity affects over 9 million children, making it the most common chronic disease of childhood. Today, more and more children are being diagnosed with diabetes, hypertension and other co-morbid conditions associated with obesity and morbid obesity. A child is defined as “overweight” if their weight-to-age percentile is greater than 95 percent. A child is defined as “at risk for overweight” if their weight-to-age percentile is greater than 85 percent and less than 95 percent.

Our biology and environment play major roles in shaping habits and perceptions in children. In addition, children are encompassed by environmental influences that demote the importance of physical activity, such as processed foods and urban sprawl. All of these factors contribute to sedentary lifestyles and ultimately to childhood obesity. Childhood obesity is now being addressed, both nationally and locally through a variety of initiatives and programs. Research on obesity is uncovering new links between the environment and our genes, and interventions are being studied to identify best-practice protocols.

References ŠŠ ŠŠ ŠŠ ŠŠ ŠŠ

American Psychological Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). i:10.1176/appi.books.doi9780890423349. American Psychological Association (2013). DSM-5: Diagnostic and Statistical Manual of Mental Disorders. Centers for Disease Control and Prevention (CDC). (2012a). Basics about childhood obesity. Retrieved from http://www.cdc.gov/obesity/childhood/basics.html Centers for Disease Control and Prevention (CDC). (2012b). Physical activity facts. Retrieved from http://www.cdc.gov/healthyyouth/physicalactivity/facts.htm Child Welfare League of America (2004). CWLA Issue Brief on Childhood Obesity: Defining Obesity in Children and Adolescents. Retrieved from http://www.kidsource.com

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Kendall, P., Wilken, K., & Serrano, E. (2007). Childhood obesity. Retrieved from http://www.ext.colostate.edu Marcus, L. & Baron, A. (2004). Childhood Obesity: The Effects on Physical and Mental Health. Retrieved from http://www.aboutourkids.org National Center for Health Statistics (2011) With Special Features on Socioeconomic Status and Health. Hyattsville, MD; U.S. Department of Health and Human Services. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association 2014;311(8):806-814. http://dx.doi.org/10.1001/jama.2014.732

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OBESITY IN CHILDREN Final Examination Questions

Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination. 86. Obesity can be defined as an excessively high amount of body fat in relation to __________. a. Height. b. Lean body mass. c. Amount of exercise. d. Daily caloric intake. 87. The passage of a new American Medical Association policy classifying obesity as a _______ reinforces the science behind obesity prevention and treatment. a. Mental health disorder. b. Scientific study. c. Disease. d. Proven theory. 88. A BMI that is less than the 5th percentile is considered underweight and above the ____ percentile is considered overweight. a. 80th. b. 85th. c. 90th. d. 95th. 89. _____, a hormone produced by fat cells in the stomach, plays a role in suppressing appetite and stimulating energy expenditure. a. Leptin. b. Serotonin. c. Ephedrine. d. Adrenaline. 90. Because obesity is often linked to poor health and subsequent depression and anxiety, research suggests that depressed persons are more likely to develop _________. a. Fisher syndrome. b. Pica syndrome. c. Metabolic syndrome. d. Serotonin syndrome. 91. ___________ are formalized when repeated eating that associates certain stimuli with food intake becomes a pattern or script. a. Cultural norms. b. Habitual consumption scripts. c. Addiction scripts. d. Behavioral standards. 92. Although _______ differences in metabolic efficiency are likely to exist, there is little evidence that low metabolic rate plays a major role in the development or maintenance of obesity. a. Gender. b. Genetic. c. Scientific. d. Strategic. 93. Endocrine issues such as ______ resistance, impaired glucose tolerance, and Type 2 diabetes are common in obese youth. a. Insulin. b. Neuron. c. Amoxicillin. d. Toxin.

94. Perhaps one of the most dramatic and disturbing findings in the past decade was the tremendous increase in the incidence of ___________ in children and adolescents. a. Anxiety. b. Binge eating. c. Type 2 diabetes. d. Depression. 95. Due to an excess amount of fat cells, __________ is a problem in obese youngsters and occurs in 15-20 percent of obese children, six times the rate of normal weight youngsters. a. Liver disease. b. Obstructive sleep apnea. c. Type 1 diabetes. d. Asthma. 96. While obesity is included in the ________________ as a general medical condition, it is not considered a mental health disorder and therefore does not appear in the DSM-5. a. International Classification of Diseases. b. Centers for Disease Control Manual. c. National Medical Index. d. Medical Condition Guidebook. 97. ____________ is defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. a. Bulimia nervosa. b. Anorexia nervosa. c. Binge eating disorder. d. Anxiety feeding disorder. 98. Research priorities should include evaluation of _________, behavioral research on how to change dietary and physical activity habits, a community-based approach and best-practice protocols that address the mental health needs of overweight and obese youngsters. a. Interventions. b. Educational exposure. c. Access to food. d. Parental involvement. 99. Severe caloric restriction could __________, delay the onset of maturity and even enhance emotional overeating. a. Reduce energy. b. Cause insomnia. c. Induce shock. d. Compromise growth. 100. _______________ is used to interact effectively with young clients so that a mutually agreed upon set of achievable and incremental goals can be reached in order to support behavior change. a. Action planning. b. Motivational interviewing. c. Group therapy. d. Family intervention.

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Chapter 6:

The Use of the Internet in Therapy: Guidelines and Best Practices 4 Contact Hours

By: Leah Walker, Ph.D., LMFT

Learning objectives ŠŠ Define the key areas of controversy over online therapy. ŠŠ List the major types of online therapy modalities. ŠŠ Explain the findings of at least two studies on the efficacy of online therapy. ŠŠ Identify the findings of two studies comparing outcomes of online to face-to-face therapy. ŠŠ List at least two benefits perceived by patients in online therapy settings. ŠŠ Describe two complaints that patients have had about online therapy. ŠŠ Discuss two benefits to online therapy as perceived by therapists. ŠŠ Explain the biggest frustration that therapists have regarding online therapy. ŠŠ Define the ways in which distance creates unique ethical dilemmas. ŠŠ List at least three ways therapists can protect clients and themselves in online situations. ŠŠ Be able to define at least three common themes in all the professional codes of ethics. ŠŠ Explain two suggestions for practice that can overcome some of the inherent issues in online therapy. Geneva Geneva is a 42-year-old woman who lives in a rural area of Montana. Geneva has been struggling with what she believes is depression for several months. She was crying frequently, had trouble sleeping, and lost her appetite. Her mother died recently, and this event, combined with her divorce 2 years ago, made life harder to manage recently. Geneva wanted to talk to a counselor, but the area in which she lives has only one counselor within 100 miles of her home. Her pastor had counseled her, but felt he is not able to help her further. At his suggestion, Geneva went on the internet and found a social worker who offered online counseling. Geneva decided it might be a good idea for her to try. She called and scheduled a telephone appointment with Craig, a licensed clinical social worker in the state capitol. Craig asked her numerous questions, and screened Geneva at length to ensure she was not suicidal. Geneva has been working with Craig in weekly online sessions, and has also been doing workbooks online for cognitive behavioral therapy (CBT) for depression. Geneva has begun to feel more in control of her depression over the last few weeks, and has recommended Craig to several friends. Craig felt that Geneva was an ideal candidate for this type of therapy. After carefully evaluating her for suicidality, psychosis, and other serious mental health issues, Craig determined that Geneva was

suffering through an adjustment disorder, in part triggered by the death of her mother. Craig has been pleased with Geneva’s progress and believes her case will soon be closed successfully. Bob Bob is a 36-year-old man on disability for a long history of alcoholism. Bob has been hospitalized seven times since the age of 18 for suicide attempts and severe depression. He has been noncompliant with several psychiatrists regarding medication over the years, and he tends to only go into counseling during times of acute crisis. Bob was having issues with transportation, as his license is suspended because of two DUIs. Bob had heard of Craig, a counselor who provided online therapy, and Bob thought that he wanted to try this type of therapy, so that he wouldn’t have to hassle with taking the bus to appointments. In addition, Bob had been feeling suicidal a great deal lately, and had made a plan to overdose on his mother’s pain medication. He wanted to talk to someone about feeling suicidal. Craig evaluated Bob, and did not agree to provide online therapy to him. Craig felt that Bob’s current suicidal ideations, which included having a plan to kill himself, combined with his history of noncompliance, numerous hospitalizations, and long mental health and substance abuse history, would be better served in face-to-face therapy in a local clinic specializing in treating dually diagnosed persons and those with long-term psychiatric issues. He arranged to have Bob taken to the local emergency center for an evaluation, based on his concerns about Bob’s suicidal thoughts and plans. Bob was admitted to the local crisis stabilization unit for 3 days, and followed up with the local clinic. These two cases represent two ends of the possible spectrum of people who seek to participate in online therapy. Obviously, they are the types of cases in which it is fairly clear if they can be treated through online services. Many of these cases, however, fall in between these two types of situations, and the appropriateness of participation in online therapy is less clear. Overall, the majority of therapists are not providing online services. Prabakhar (2012) noted that only about 2% of counseling professionals surveyed were providing the service. However 60% of counselors wanted more information about doing this type of work. So while there is a great interest in online therapy, most providers are unsure of how online therapy works, the effectiveness of the approach, especially as compared to face-to-face therapy, the benefits and drawbacks, the ethical situations involved with this form of therapy, and some of the best practices in the approach.

Controversy over online therapy It can be argued that Freud offered the first recorded incidence of distance therapy, through his exchanges of letters with patients. As noted by Prabakar (2012), beginning in the mid-1990s, a handful of therapists began experimenting with the idea of online therapy. Today, the definition that seems to fit most appropriately is, online therapy is a form of service delivery by ‘‘a licensed mental health care professional SocialWork.EliteCME.com

providing mental health services via email, video conferencing, virtual reality technology, chat technology, or any combination of these’’ (Manhal-Baugus, 2001). Barak, Hen, Boniel-Nissim, and Shapira (2008), published a metaanalysis of online therapy in which they explained the history and Page 80

practice of online therapy. The authors noted that online therapy has been described as cybertherapy, telehealth, ehealth, and internet therapy. Some therapy programs are self-help, web-based sites in which users can log in and complete exercises and workbooks. Other times, a provider and patient may exchange emails. Online therapy can be provided asynchronously, which means it occurs in a delayed fashion, such as a patient sending an email, and a therapist answering the email at a later time. Online therapy can also be provided in real-time, or synchronously, such as in the case of using a webcam, or instant messaging type of software program for the patient and therapist to interact. The authors note that historically, the implementation of this type of therapy was met with great resistance. The resistance can be divided into four broad categories: 1. Concern over the inability of the therapist to see body language, facial expressions and the like, as nonverbal communication was considered to be of extreme importance in therapy. 2. Concerns over privacy – including computer hacking of emails, webcam transmissions, and websites – that could expose an individual’s secrets, as well as concerns over the safety of patients in crisis. 3. Concerns that technology was outpacing both the law and the ethics of this type of therapy. Without a firm ethical understanding of online therapy, licensing and professional boards were concerned as to how to guide therapists into unknown territory, and there were no laws to govern such issues as crossing state lines for service delivery. 4. Concerns over the lack of qualifications and training for therapists providing online therapy. Other researchers voiced additional concerns, noting that the distance involved would make it easier for a client to terminate therapy. Furthermore, there were beliefs in the therapeutic community that the physical distance would also prevent the formation of transference from the client’s unconscious to the therapist, as well as countertransference from the therapist to the client (Ragusea & VandeCreek, 2003). Some studies also presented concerns about the technology itself, such as having the power going out in the middle of a critical point in a session, or dealing with poor video or audio

quality (Hamburger, et al., 2014). Kingsley and Henning (2015) noted that the unreliability of internet connections could force sessions to be canceled if the power or the internet was out, which could frustrate and upset the client. It is important to note that some types of clients may also not benefit from email interactions. People with low literacy and those who have limited access to the internet, such as low-income persons who have to use public access services may not have adequate privacy (FinfgeldConnett, 2006). In response to these types of criticisms, other researchers presented counter-arguments. Hamburger et al. (2014), noted that while there is certainly concern for the confidentiality and security of information, traditional face-to-face therapy has its own problems in this area, and breaches of confidentiality and improper releases of information occur in these settings as well. Furthermore, in relation to therapeutic relationships, it is suggested that an online therapeutic setting may actually lead to more openness and a faster therapeutic alliance as not having to be face-to-face with a therapist can actually reduce anxiety about disclosure (Amichai-Hamburger & Barak, 2009). Hamburger et al. note that the assessment and planning of how to handle a patient in crisis is not that different than it is in traditional settings. The authors argue that with the use of proper assessment, and taking steps to insure that therapists have client’s location information and information regarding resources where the client is located, the problem of suicide is not as hard to deal with as some researchers would claim. In issues of transference, Hamburger et al. (2014) make a persuasive argument that resistance occurs in online therapy and not just in faceto-face therapy. Furthermore, in citing the work of Scharff (2013), they note that transference, countertransference, and other aspects of the therapeutic relationship still occur in online settings. “Those welcoming etherapy believe that resistance in psychotherapy via the internet may take both similar and/or different forms from that of face to face psychotherapy. Examples of resistance may be forgetting to go online/call, speaking softly, not using a headset, moving away from the microphone, accepting other calls, and chatting as if on a social call, in addition to silence, hesitation, coughing, lateness, nonpayment, displacement, and so on” (p. 289).

How does online therapy work? Barak, Klein, & Proudfoot (2009) attempted to explain the different types of online therapy. They stated that “web-intervention” is the best term to use, as it incorporates a variety of service types. They described a web-based intervention as, “a primarily self-guided intervention program that is executed by means of a prescriptive online program operated through a website and used by consumers seeking health- and mental-health related assistance. The intervention program itself attempts to create positive change and or improve/ enhance knowledge, awareness, and understanding via the provision of sound health-related material and use of interactive web-based components” (p. 5). They further noted that web-based interventions can be subdivided into three categories: 1) Self-help, 2) self-guided, and 3) therapist-supported. Self-guided interventions utilize sophisticated software and some are highly interactive, providing multimedia applications and immediate feedback. The individualization provided varies depending on the complexity of the software used. Therapist-supported sites usually offer some form of interactive features. Overall, the main focus is on direct human interaction, whether it occurs from instant messaging, email, Skype, or webcams. The quickness of responses from the therapist can vary from immediate to days, depending on the format of the site. Other forms of interaction can include group chat rooms or group bulletin boards where users can post messages and receive replies from others as peer support. The amount of time spent interacting with the therapist varied from a few minutes to a few hours

per week. The authors noted an example of a highly interactive site, PTSD Online, which is a CBT program treating those persons with posttraumatic stress disorder (PTSD) in a format with a high level of therapist support and multimedia features that are highly interactive. The authors cite some recent research that indicates that overall, the therapist-supported online therapy may be more effective than the self-guided programs (Barak, Boniel-Nissim, & Shapira, 2008; Spek, et al., 2006). The approaches vary amongst the various models. For example, in one program for social phobia, which is self-guided, a user logs in and is directed to a “contact” module in which the therapist has left information about him/herself and invites the participant to contact him/her. The therapist responds within 3 days of receiving the email. Therapists were also required to send each client an email each week with motivating messages. Other parts of the program included an interactive guide with 57 different websites of five pages each. The progress through the programs is self-guided. The participants are free to repeat sessions as they wish. There is also a group area in which clients can share experiences with others in the program. It is designed to last 10 weeks. Participants are educated about social phobia and asked to complete such exercises as ranking how high their anxiety is during various activities. For example, if they were to be engaged in public speaking, how high would their anxiety be on a scale of 1 to 10? Throughout the program, assessment and exercises like these are used and feedback is

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given to the participants. The participants also keep a behavioral diary. They are encouraged to plan in vivo exposure exercises and follow through with them. Then participants report about the experience. The participants are then taught to decrease negative self-talk. Each section builds upon the next (Berger, Hohl, & Caspar, 2009).

For anyone who has provided this type of therapy, the steps are very familiar. The key difference is that it is done at a computer without the therapist sitting in the same room. However, the behavioral diary, the change of negative self-talk, and gradual exposure in vivo is the same format as regular CBT.

Does online therapy work? Early studies on the efficacy and satisfaction with online therapy produced mixed results. The authors noted that some studies found that online and face-to-face therapy were found to be very comparable in patient satisfaction and outcomes. There were some studies that found certain aspects of online therapy, such as the therapeutic alliance, to be inferior to face-to-face therapy. Some patients expressed concerns over privacy, but liked the convenience of not having to attend appointments. However, Barak et al. (2014) noted that the studies varied tremendously in how online therapy was evaluated. They observed that many of the studies focused only on one diagnosis, such as depression or anxiety, and many studies only examined one specific type of service delivery.

Another meta-analysis of internet CBT indicated that the approach was effective in working with anxiety disorders, as well as depression. The patients reported high levels of satisfaction, and the outcome of the reduction of symptoms was significant (Andrews et al., 2010).

There have been many studies examining the efficacy of online treatment for a variety of psychiatric diagnoses. One approach, selfguided CBT, has been studied extensively. Internet CBT has been found to be effective in persons with PTSD. Ivaarson et al. (2014) studied a group of Swedish adults who met the diagnostic criteria for PTSD. The participants were assessed and provided the internetbased treatment for PTSD. The participants did show significant improvement over the control group, both immediately after treatment, and at the 6-month follow-up evaluation.

In 2015, the American Psychological Association (APA) noted that online therapy is available for numerous conditions, including depression, anxiety, schizophrenia, smoking cessation, diabetes management, panic disorders, health promotion for weight loss, and adherence with antiretroviral medication. The APA refers consumers to the research studies regarding the effectiveness of these treatments and cites numerous articles outlining the efficacy of online therapy.

Online treatment has also been found to be effective with such diverse issues as social phobia. In a study conducted by Berger, Hohl, & Caspar (2009), adults were treated through online treatment with minimal phone contact provided by a therapist. In comparing outcomes with the control group, with the control group members being placed on a waiting list, those in the participation group had significantly better outcomes. This does at least show that online treatment was better than not having treatment.

Is face-to-face therapy more effective? The comparison of face-to-face and online therapy is still in the early stages of research. One of the most comprehensive studies to date, Olthuis, Watt, & Stewart, 2011, argued that there were simply not enough studies to effectively and fairly compare the two forms of treatment. However, the studies currently available have not found any real differences in the outcomes for patients (Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014). Another study of online CBT had similar findings. In this study, patients were treated for either PTSD or depression. The patients followed a manualized treatment program and aside from an initial telephone screening, they completed their assessments and workbooks online, and exchanged emails with their therapists. The outcomes over a period of several months were found to be comparable to another group of participants who received the same therapy in a clinic face-to-face with a therapist. Overall, about 80% of patients felt satisfied with the treatment and their therapists, and would recommend the online therapy to a friend. However, 30% of patients did state that they would have liked to have had face-to-face contact with the therapist. Andrews et al. (2010) noted that in comparing online therapy with face-to-face therapy using the CBT model for persons with anxiety and depression, there were no significant differences in outcome or patient satisfaction with the two types of treatment (Ruwaard, et al., 2012). In treating panic disorders, Kiropoulos et al. (2008) found that online therapy was just as effective as face-to-face therapy. O’Reilly et al. (2007) also compared video therapy to face-to-face therapy for a group of clients with a variety of psychiatric disorders. The study showed that the two groups were equivalent in both patient satisfaction and clinical outcomes.

behavioral health diagnoses. In therapeutic approaches, the authors did find support that CBT was the most effective form of online therapy. Furthermore, no differences were found in the efficacy of web-based interventions versus those approaches that used interactive approaches between patient and therapist. However, some recent studies have indicated that periodic phone contact with a therapist did not increase the adherence to the online treatment in any significant way (Berger et al., 2012). Other studies have shown than when used with a specific form of coaching, it increased adherence to online treatment and resulted in better outcomes (Mohr et al., 2013). Mohr and his fellow researchers found that in working with persons who had a diagnosis of major depressive disorder, their model, called TeleCoach, did show significantly lower rates of dropout than those not receiving TeleCoach. TeleCoach involved having a therapist make a weekly phone call to the program participant to develop a supportive relationship, reviewing goals for participation in the online program, positively reinforcing using the site, and encouraging the participants to stay with their goals. Therapists were also allowed to discuss the technical aspects of using the online program, but were not allowed to do any type of therapy over the phone to ensure that the actual therapy was only occurring online. However, as in the previously cited study by Berger et al. (2012), the improvement in symptoms did not differ between participants who had TeleCoach and those who did not. So it appears that while there is no difference in effectiveness of the treatment in this approach when the therapist provides telephone support, the program participants are more likely to finish their treatment with the telephone support.

Barak et al. (2007) in their meta-analysis of online therapy, noted that overall, in the numerous studies they reviewed, the effectiveness of online therapy was equal to face-to-face therapy for a variety of

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Perceived benefits by patients In addition to measurable outcomes of effectiveness using online therapy, it is also important to consider the patient’s perceptions of this form of therapy. Participants often note that convenience of therapy was a reason they liked online therapy. They stated that the ease of access made them more able to actually start working on their issues. One participant noted that in using MoodGym (an online self-help program for depression), “working with MoodGym, the best thing about it all was that I was doing something about it. You know, coming to these sessions every week, getting to talk, starting the next chapter. You know, the things I worked with did not suffice, but I felt good working with it. I felt sort of like I was getting out from getting back to normal.” The researchers noted the ability to start treatment quickly, rather than waiting for an office appointment, also kept participants motivated once they decided to start treatment (Lillevol et al., 2013). One recent study of college students noted that among the reasons they liked online therapy was the convenience and accessibility. Some admitted that if they had had to go to an office, they would have missed the sessions due to not wanting to get out of bed and feeling too stressed to leave home. This particular study examined an emailbased therapy approach, rather than a website where the participants logged in and thus, the participants developed an ongoing therapeutic relationship with a provider who exchanged emails with them. In addition to convenience, another added benefit for the college students was being able to receive ongoing support during spring break and Christmas break when they left campus and would not have been able to have attended therapy in a traditional setting (Mishna, Boggs & Sawyer, 2013). Other participants in the Mishna, Boggs and Sawyer study also noted that they felt more comfortable disclosing certain issues online that they might have otherwise have avoided discussing in a face-to-face setting. Some participants also felt that writing out their emotions and issues made it more real, noting that they would reread their emails and this made the situation more real to them, noting that in traditional therapy, they would speak and then forget about their issues after the session. One participant was quoted as saying, “cyber was very profound because it’s one thing to talk about it, but it’s almost like it doesn’t exist, it’s hypothetical. But when you’re reading something and it’s either on the screen or on the paper, which almost makes it more legitimate. You can’t run away from it, it’s like in your face kind of thing versus when you’re talking to someone and you can tune out, you can check out” (p. 174). The authors noted that as is common in younger people, college students may be particularly responsive to online therapy due to their constant use and familiarity with the internet and social media. Overall, participants stated they felt a strong emotional connection to their therapists, despite not having a face-to-face relationship. Of course, as these participants were college students who are more comfortable with the internet and are used to communicating with peers via social media and numerous chat applications, this may predispose them to feel a bond through a media connection. Therefore, it is somewhat difficult to assume that older people would feel the same way about online therapy, particularly if they do not use computers routinely. It may not be possible to generalize these findings to older adults who may not be used to such forms of communication on a routine basis (Mishna, Boggs, & Sawyer, 2013). Indeed, older people’s frustration with computers was noted in one recent study (Beattie, Shaw, Karr, & Kessler, 2009). The lack of face-to-face contact may not be a problem for some participants because of another factor. Bengtsson, Nordin, and Carlbring (2013) also noted that a reason clients may be happy with the therapeutic alliance in online therapy is due to a lack of comparison. A therapist is quoted as saying, “I experience that you get a stronger alliance in face-to-face, but at the same time I know

(laughs) that there are studies that show that it is not always that big a difference when you assess it, so it is simply relative, that . . . we who go for both parts, we might experience a greater difference than patients who only experience the one” (p. 475). Another important consideration of patient satisfaction with the online therapeutic bond is the patient themselves. The type of patients who want to participate in online therapy may be happier with the alliance that forms because the patient selects the online therapy (Bengtsson, Nordic, and Carlbring, 2015). Another plus is easier accessibility to services for clients with physical illnesses or disabilities that keep them from being able to leave home easily to attend traditional office-based services Hertlein, Blumer, & Mihaloliakos (2013). The APA also cited this as one of the major reasons that clients often prefer online therapy, as they do not have to worry about traveling to an office, missing work, and can just log on to a computer (APA,2016). Another group of people that prefer to seek online services may be those who have trouble leaving the home and getting to appointments due to their responsibilities with childcare and/ or eldercare (Pollock, 2006). There is a definite advantage for those who live in rural areas to participate in online therapy, as they have access to services that would not be available otherwise. As noted by the APA (2016), psychologists are relatively rare in remote areas, and patients may have to drive hours to reach the nearest provider, which simply is not feasible for everyone. In addition, even those who live in more populated areas may not have easy access to a specialist for their particular clinical needs, and through online therapy, they have access to specialized services without having to travel (Rummell & Joyce, 2010). Pollock (2006) also notes that gay and lesbian couples who live in rural or remote areas may also have difficulty finding a therapist open to treating gay couples. Furthermore, Shaw and Shaw (2006) noted that some who are reluctant to seek mental health services in person are more willing to engage in what they perceive as the safety of online therapy. Mishna, Boggs, & Sawyer (2013) noted that many of their participants cited that having some distance between themselves and the clinician made it more comfortable to discuss certain issues via email that they otherwise might have not spoken about face-to-face. This is also echoed in the study by Bengtsson, Nordin, and Carlbring (2013) in which a therapist noted in working with patients with social anxiety, “I think that many times, for some patients, it can be an advantage that you have not . . . met live because it feels a little more threatening and revealing to sit face-to-face and tell someone things that are shameful, anxious” (p. 475). Likewise, participants in another study noted that being somewhat anonymous helped increase their disclosure (Beattie, Shaw, Kaur, & Kessler, 2009). When looking at the perceived benefits of online therapy, it is also important to note how the expectations of online therapy met the experiences of those participants. One recent study explored what a patient initially expected of online CBT and how those expectations matched the outcomes of the actual process. A sample of expectations was: a. “I don’t think you would get the same feeling as if you were one-to-one in a room. You get more, you get to know the other person, so in a way you would. To me it would be like talking to a machine” (P21 Pre, female, 50–59, completer, 10 sessions). b. “It’s perhaps more difficult for them to offer the right advice because they’re not seeing you. I see that is perhaps the one disadvantage” (P19 Pre, male, 60–69, completer, 10 sessions). c. “I don’t know…I’ll be nervous…it’ll be strange…I suppose it’ll be just like talking to someone you don’t know…Well, people could not tell, say how they really feel. If you’re with someone oneto-one, say yeah, like now and I said something and you thought

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well, you could tell really if it was bothering me or if, if I just said that because I didn’t want to talk about things And maybe you encourage me to talk about it more, whereas maybe on-line I could just say, ‘Oh, I don’t want to think about that.’ And the person on the other end wouldn’t really, really know” (P20 Pre, female, 20–29, withdrew from therapy, 2 sessions). d. “There might be some issues of trust, with people feeling, you know, that they’re not really talking to a psychologist if they can’t see them” (P12 Pre, male, 30–39, completer, 10 sessions, no posttherapy interview). e. “I’m actually excited that there might be something that might do something for me, that I can actually commit to, because I can commit to it, if there’s nobody, if I don’t have to face someone then it’s easier to commit to, and it’s easier to be honest as well because you’re not, you know, if you say something to someone’s face and it’s something really personal that you care about, you know, whether you know you’re doing it or not, the way they react will probably frame and what you say afterwards. You might modify what you’re saying without knowing it” (P4 Pre, female, 40–49, withdrew from therapy, 1 session) (p. 50). After coming in for services, a posttreatment evaluation was completed. The participants noted that some of their fears were unfounded and they developed a relationship with their therapists, and others noted that not seeing the therapist made the process easier. However, some quit due to feeling that the process did not feel comfortable for them and they did not feel a bond with the therapist. a. “After a couple of sessions when it felt dry and then starting to feel that it was fluid, but I don’t think that’s to do with the medium, I think that’s actually just to do with communicating with someone there…We had built a relationship. It took a while but yeah, I was pleased with the way things were going at the end. Yes, it was a bit difficult at first because you know, it’s … you’re just communicating with a computer and you don’t know the person at the other end, who you’re communicating with... I was emailing, and I had a picture of somebody else in my mind and I was convinced I was talking to somebody else, so you know, you’ve got that potential, sort of trying to get over that sort of not knowing, but I guess, given the constraints and the fact that the persons not there, it was, it worked I would say, yeah” (P14 Post, male, 30–39, completer, 10 sessions). b. “I was surprised, I felt as though it was flowing quite well, which I didn’t think it would. And I warmed to him [psychologist], you know, straight away, you can do that over the internet…I think you could build up a good relationship over the internet, I was quite surprised” (P1 Post, female, 40–49, withdrew from therapy, 2 sessions).

c. “I don’t honestly think I could have sat down with someone and talked to them face-to-face, I don’t think I’d have had the confidence to do that. I’d talk to them but I think I’d have expressed what I express on a computer, having the therapy on there. So I don’t think it would have worked as well because I wouldn’t have been as honest with them” (P2 Post, male,30–39, completer, 9 sessions). d. “I enjoyed the anonymity. You know, I think it was, to start off with, but come the end, it didn’t worry me. It didn’t worry me, because I, I didn’t feel it was anonymity come the end. I thought I knew [psychologist’s name], I thought I knew the lady that I was talking to, you know, as if I was talking to her one-to-one, face-to-face, that’s what it felt like. I didn’t feel like I was typing things on a computer, you know, it didn’t feel like that at all, and I’ve never done that before on a computer; talked to anybody on, on a computer like that and yeah, it was, it was okay” (P16 Post, female, 40–49, completer, 10 sessions). e. “I’m not sure there was a relationship. And that, because of that, part of the reason for that was the lacking the face-to face, it’s like having a telephone conversation isn’t it? You don’t have the same closeness as you would meeting somebody round a table, it’s inevitable. And that, that’s got to impact on the benefit of the therapy…I didn’t build a relationship with him” (P19 Post, male, 60–69, completer, 10 sessions). f. “I didn’t feel comfortable with it. I think that what I need, or what I needed was to talk to someone one-on-one rather than talk through a machine…I could see the idea of it, and I think it’s a good idea but I personally didn’t feel comfortable with it…the idea I think is good. But it wasn’t for me” (P24 Post, male, 50–59, withdrew from therapy, 6 sessions). g. “I don’t know if it would have been the same if I’d been faceto-face with the same person. And that’s nothing against her [psychologist] it’s just sometimes you can’t always relate to everybody and I don’t know if it was that, or if it was the computer, I honestly don’t know” (P20 Post, female, 20–29, withdrew from therapy, 2 sessions). h. “Are they concentrating on what you’re saying? Are they focusing really on what you’re saying or are they doing something else… are they on the telephone, having a cigarette, maybe not taking me seriously” (P5 Post, female, 20–29, withdrew) (p. 51). In these cases, certainly some participants did not feel that online therapy was right for them. They were displeased with the process and usually chose to quit. So at times, there can be negative outcomes associated with online therapy.

Negative outcomes The use of online therapy is not recommended for all types of patients, and there have been a few studies that have examined negative outcomes for those who have participated in online therapy. Notably, Rozental, et al. (2015) did find that about 9% of participants reported negative experiences with online therapy. Some of the negative feelings about the experiences stemmed from frustration with technology. Failure to be able to easily log in and navigate the sites made patients feel incapable of handling a simple task, which reinforced the negative feelings they had about themselves. Others reported that their negative feelings resulted from not having therapeutic support adequate for their needs. Some stated that the program did not incorporate enough therapeutic support, and others stated that they felt the therapist who provided the support did not do an adequate job. The resulting frustrations resulted in greater feelings of sadness and distress than before beginning the treatment. However, the authors noted that it is impossible to tell if some of these negative feelings SocialWork.EliteCME.com

would also have occurred for these patients in a face-to-face treatment setting, based upon their particular needs and issues. Some patients got worse and some had other life events that complicated their treatment, but this is no different for online therapy than for any other treatment setting. The participants noted that some of their worsening feelings while participating in therapy were caused by various life events, and they did not ascribe their worsening symptoms or more negative feelings to the therapy. Some patients in the study also reported frustration with the rigid approach in the manualized treatment and felt pressured to complete the assignments too quickly. For some people, the pressure may be too much, and as the authors noted, this failure to complete the program in a timely fashion made them feel even more negative about themselves. One participant noted that he knew he could never finish in the allotted number of weeks, and this made him feel worse about his already problematic procrastination. The authors suggested that therapeutic support is a valuable tool to help patients feel supported, motivating them and encouraging them to finish if they Page 84

were procrastinating, and provided competent technical support to ensure clients could navigate the sites without feeling so frustrated. Beattie, Shaw, Karr, and Kessler (2009) also noted that for some depressed persons, some of the inherent issues in online therapy actually reinforce their depression, due to their tendency to go quickly into negative self-talk. When these patients could not visually see a therapist, they felt the therapist was lacking in commitment to their case. They complained about not being able to read the body language

of the therapist to ensure the therapist was really engaged in their treatment. During the lag time after their emails were sent and were being read by the therapist, these patients stated that they wondered what the therapist was actually doing. They wondered if the therapist was doing something else, or taking a break. Other patients reported that having to wait for a therapist to respond was wasted time and during the lag, they would lose focus or motivation to work on their issues.

The therapist’s perspective tost of the research regarding online therapy has been from the patient’s point of view. However, the therapist’s perspective is a vital aspect of the process. One recent study, Bengtsson, Nordin, and Carlbring (2013), focused specifically on the use of CBT and how therapists felt the experience of online therapy compared to doing CBT face-to-face. The therapists in this study provided therapy through email and the use of a manualized CBT approach. The patients they treated had diagnoses including PTSD, eating disorders, and depression. All therapists had extensive experience in CBT, both faceto-face and online, and were thus well qualified to compare the two types of service delivery. Several themes emerged from the qualitative study. Overall, therapists found that in some ways, online therapy was less frustrating, because they did not have to deal with clients cancelling sessions, as they did in face-to-face therapy. In addition, some of the therapists cited that faceto-face therapy often resulted in being more emotionally drained, and that online therapy freed them somewhat from this potentially negative outcome. One therapist noted, “I think that is has been both, well, fun and occasionally also very, like, demanding. You feel very much less burdened by (ICBT) than in regular outpatient care. It does not get as, like . . . heavy in the moment, as it can get when you are sitting with someone who become like that really sad or really angry or dissatisfied or – you become protected by the screen in some way” (p. 473). Other therapists felt that online therapy protected them from burnout as illustrated in this statement, “I think it is good that you, you are protected and you will last a little longer and you do not get tired and you will not, like, you will not be negatively impacted. Uh, you do not get run down. I think you will last longer as an internet therapist” (p. 474). The reasons given for the preference for online therapy also go beyond the positive effects that occur from the therapy itself. Other benefits of the online format include not having clients getting frustrated by having to coordinate hectic schedules, especially for those therapists who provide couple or family therapy involving multiple parties. Therapists also reported liking the ability to have more control over their schedules. They noted that the online therapy approach enabled them to choose when they wanted to work. For example, it was easy to rearrange their schedules as needed and check client’s progress at different times then they had originally planned. Some of the therapists who had family responsibilities noted that it was an advantage over face-to-face therapy if a child became ill, so instead of having to cancel a full day of booked clients, they could just log on later in the day. The online format also enabled the therapists to easily have a colleague take over cases in the event of an emergency. In addition, the website did some of the work for the therapists, which included

automated reminders for clients to complete assignments or email their therapists. Furthermore, the therapists felt they were also able to reach more people and provide more help than they could seeing all the patients face-to-face. Furthermore, counselors in other studies had noted that online therapy is easier to do with some patients. For some patients, email and written communication works better than face-to-face communication, such as in the case of clients who tend to not be very verbal (Fantus & Mishna, 2013). In terms of the negative feelings about online therapy, most of the therapists in the study by Bengtsson, Nordin, and Carlbring (2013) felt that the therapeutic alliance was not as strong for online therapy as face-to-face therapy. Their main concern was not being able to read body language, such as gestures and facial expressions. One therapist described this feeling, “in some way maybe it is easier (to create a working alliance), that is, when you are sitting in the room, because you have access to the body in some way. And then you have gestures and like . . . yes, but, facial expressions and gaze” (p. 474). Similar concerns were cited by other therapists in other studies as well. “Yeah, I felt more uncomfortable trying to gain control. Like it was harder for me to say, ‘Stop, let’s go back to this.’ I know that I feel more comfortable saying it face-to-face, because at least I would be able to show that I was more interested. But online, you know, that could come across that I was upset, or that I was being rude, or that I was, you know, just being different” (Haberstroh, et al., 2008, p. 465). Despite their feelings that the alliance was not as strong, Bengtsson, Nordin, and Carlbring (2013) noted that the therapists still felt that online therapy was just as beneficial for their patients. Some expressed surprise that the alliances formed were much stronger than they had originally expected before providing online therapy. Another positive finding in online therapy was the perception by the therapists that in online work, the focus really remained on the therapy itself. One therapist stated, “There is more focus on me, that is also... uh, could actually be a disadvantage in live therapy, that there is less focus on the therapy. Progress is also attributed more to me as therapist than to the therapy itself and what the patient does” (p. 473). Mishna, Boggs, and Sawyer (2013) noted in their study that social workers reported some frustration with the format of online therapy, stating that they felt they missed experiencing certain emotional events simultaneously with a client, which could cause a disconnect in their therapeutic alliance with the patient. One provider noted that she received an email detailing a very positive experience that a client had, and while she was happy for the client, she really wished she could have experienced the client’s feelings of satisfaction and happiness in the moment with the client, rather than reading about it later. It is interesting to note that the social workers in the study were masterlevel interns, and most were quite young, so their experiences might differ from those of more experienced therapists. Even though they lacked the experience of having done much face-to-face therapy and are more comfortable with computerized communication, they cited many of the same feelings about not having the face-to-face experience as older, more experienced therapists in other studies (Bengtsson, Nordin, and Carlbring, 2013).They did feel they were missing the

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chance to view body language and gestures, and worried they were missing something in the therapeutic alliance. On the positive side, the social workers liked to be able to reread emails from the patient and this helped them think more about which interventions were best, as well as reread their own responses to the patient. They felt this was a good learning tool for them as emerging clinicians. Another interesting finding was that while the social workers were concerned they did not feel as emotionally connected to the client, due to not seeing the client face-to-face, the client did not feel the same way. Therapists in other studies have expressed similar frustrations. In Haberstroh, et al., 2008, a therapist lamented that she could not see her patient in person saying, “I thought this was different, obviously, not to even know what she looks like. Just to have no idea. I mean, I do know that she is female and that’s about it. That’s all I know. I try to imagine someone I’m talking to. That was really hard, because I don’t want to do that, because I don’t want to stereotype what they look like. I challenge myself not to assume anything. I think I have a tendency to assume my client is more like me than different from me, if that makes sense. I do find myself wondering about her appearance, etc. When she’s telling her story” (p. 464-465).

Technology could also prove to be a frustration for therapists. In this same study, a therapist explained her experiences with a patient who had little computer knowledge and experience stating, “It hasn’t gone anywhere. I still feel like we’re on the first session. We had one full hour, before that it was sporadic. I still feel like we are on the first session. I feel like I really don’t know a lot about her. She called my cell number to tell me she couldn’t get on, and admitted to trying this project to help get better acquainted with the computer. It has been very frustrating to be there. Now she’s gone. Will she come back? Do I need to wait? I was trying last night to help her. I explained that AOL [America Online Service Provider] was not a good way to communicate, that explorer [Microsoft Internet Explorer] was better. She did get on for about 15 or so minutes. Got bumped and called again. We got nowhere” (p. 464). Overall, the therapists who were interviewed in these studies did feel a certain disconnect from their patients in the online setting, and did experience some frustration with technology. However, the therapists did feel a decrease in the burnout and stress they often felt in face-to-face therapy, and overall they felt their schedules were more manageable and they could reach more clients this way.

Online couples and family therapy Most of the information explored thus far pertains to individual counseling. Online couples and family counseling is an emerging field. Pollock (2006) was an early advocate for family and couples therapy being done online. She noted that one advantage of online therapy was the ability to bring together geographically separated family members into a therapy session that might be otherwise impossible. She noted that this can be done through videoconferencing, or through synchronous chat rooms, where all the members participate at once. She also believed that emails can be used effectively, especially with

communication being written down and read by everyone, creating less chance for family members to argue over who said what, as often occurs in live sessions. Furthermore, she found that practices such as email communication through a therapist can be a good alternative to live sessions for those who are too hostile to communicate face-to-face but who need to communicate with one another. She cites the example of two parents having custody issues as a situation in which the use of email can be effective.

Ethical concerns with online therapy Janet Janet has been a licensed clinical social worker for 18 years. She began providing services online 5 years ago. Janet carefully screens her clients and takes only those cases she feels qualified to treat. Janet has clear, written procedures explaining online therapy, its benefits, the potentially negative aspects of online therapy, and confidentiality. Janet worked with a web-hosting company that ensured her that her site was HIPAA compliant. Janet counsels her patients via email, instant messaging, and sometimes uses phone support. However, in all of her technical consultations, no one had ever advised Janet to have a series of passwords set up with clients to ensure the client was indeed the person on instant messaging or email Today, Janet received an email from John, a client she has been treating online for 3 months for an anxiety disorder. John discovered that last week, his wife, who was aware of the treatment he had been receiving, logged into his account and not only read the emails from Janet, but also exchanged instant messages with Janet, posing as him, to obtain more information about what, if anything, John was saying to Janet about their marriage. John is furious, and is threatening to complain to the state social worker about the breach of confidentiality. He is also threatening to sue Janet. Michael Michael is a marriage and family therapist who has been treating Marissa, a 19-year-old college student, through online therapy and phone therapy for 2 months. Marissa is from a very religious family and has been struggling with issues of sexual identity and whether or not she is a lesbian. Marissa pays Michael via a Paypal account. Michael has been careful to maintain privacy and has worked closely with a company to ensure his website is secure. He also makes clients uses a series of password and images to ensure no one is posing as his client. Michael has policies and procedures regarding safety, confidentiality, boundaries, and other important ethical and legal considerations that he has clients electronically sign. However, SocialWork.EliteCME.com

Michael never thought to verify that clients are really who they say they are. Today, he received an email from Marissa, who told him that she felt guilty about lying to him. Marissa admitted that she was only 16 years old and lied to Michael when she said she sought online therapy to avoid revealing her sexual issues to her family, which she was afraid Michael would do since she was a minor. Marissa is completely unaware of how much trouble Michael can now be in for providing services to a minor without the informed consent of a parent. Michael is panicking and called his attorney to ask how to proceed. Michael is furious with himself for not thinking to verify the client’s identity and believed he had covered all his bases related to ethics and regulations. Jackie Jackie is a professional counselor who has been providing online services for 2 years. She has been a counselor for 5 years. Jackie is 29 years old and like many people her age, she is savvy in social media, having accounts on Twitter, Instagram, and Facebook. Jackie is careful to keep her personal and professional accounts separate and labeled clearly. She has received consultation from IT specialists and feels that her site is confidential and HIPAA compliant. She has taken numerous workshops in the provision of online therapy. She also has clearly written policies and procedures to protect herself and her patients. Jackie has been treating Blake, a 28-year-old female. Despite what Blake has told her about her history with alcohol being very minimal, Jackie became suspicious that Blake was more of a partier than she was letting on. Jackie decided to look at Blake’s Facebook page, which Blake had not set up with privacy controls. Just as she suspected, Blake was in numerous pictures holding cocktails and looking intoxicated. Of course, Jackie is now faced with dilemma of having information about a client that she cannot confront her with, and she feels guilty about snooping, acknowledged it was a boundary violation, and promised herself to never do it again. Unfortunately, Jackie did Page 86

not know that while scrolling through the Facebook page, she had accidentally pushed the “like” button on one of Blake’s pictures. Blake noticed this and left Jackie an angry message, asking her why she had been spying on her. Blake told Jackie that she felt violated. She also asked Jackie if she was “being funny or sarcastic by liking the picture of me drinking?” Jackie is frantic and is calling her attorney for advice, but also is deeply worried that she will never be able to rebuild her trust and rapport with Blake and feels really awful about what she did. These vignettes illustrate the complexities of online therapy and potential pitfalls, even for therapists who are being careful and have sought technical and regulatory consultation. As the field develops, there will be unforeseen problems. Technology is rapidly growing and often outpaces ethical and regulatory oversight. In 1999, no governing board had to think about therapists lurking on a patient’s Facebook page as a boundary issue because there was no Facebook. Guidelines on how to ensure your client is really your client online could never have been predicted as a real ethical and legal dilemma in 1985. In 1985, therapy could not have been envisioned by most providers as something that occurs via computer. In 1985, few people owned home computers, and the ones that existed were nothing like we have today. There were no webcams, email accounts, or even an internet. Certainly, the last vignette with Jackie could occur with a provider who provides face-to-face therapy only and snoops on social media trying to glean information regarding clients. Thus, even for therapists who do not provide online services, the power of the medium cannot be ignored as a potential source of regulatory and ethical issues, and many therapists will at least use email with a client.

Boundaries are another issue that vary from online therapy to faceto-face therapy. Fantus and Mishna (2013) noted that due to the nontraditional atmosphere of online therapy, face-to-face boundaries of office hours no longer exist. As emails can be answered at any time, some patients may get upset if the provider does not respond right away, not realizing that even though an email can be sent late at night, it does not mean the therapist is working at that time. Boundaries and response times should be covered in the initial discussion between client and therapist. In addition, providers need to be aware that their own information is more accessible than ever before, and patients may become privy to details about the provider’s personal life through social media. Not only should providers ensure their accounts are private, but they also need to accept that patients will discover information about them that they may not be comfortable with patient’s knowing. The authors note that, “It is argued that practitioners cannot block certain aspects of their lives from patients, and they must learn to adapt to the new world that cyberspace has created” (Gabbard, Kassaw, and Perez-Garcia, 2011). The National Board of Certified Counselors (NBCC) has spent many years examining the role of internet therapy in the practice of counseling. The NBCC prefers the term “distance professional services” rather than online therapy, as they recognize that other modes of communication, such as phone calls, play in role in these types of therapeutic relationships.

Crisis management was the greatest concern, with the therapist being concerned about not knowing the location of a client who was suicidal to obtain emergency services. Therapists were also concerned about the security of the internet in general, how emails and chat transcripts might be hacked, and noted that they were unsure as to how long to keep these items. These therapists also were worried that the person on the phone or the computer may not be the person the therapist believed they were dealing with. For example, what if someone’s significant other somehow got into the correspondence between the patient and therapist and wrote emails to the therapist in hopes of gleaning confidential information regarding the patient’s issues. Several therapists developed special passwords and other security procedures to ensure this type of situation did not occur. Rummell and Joyce (2010) also expressed concerns that a counselor has no way to verify if the patient is actually a consenting adult. There is a possibility, for example, that an adolescent could be the patient and the counselor would be violating several laws by treating a minor without parental consent.

The organization has a detailed list of ethical considerations and some of the highlights summarized are: ●● Maintaining strict control over computer security and the appropriate backup to ensure that records are not lost in the event that a computer system fails. ●● Educating patients fully and clearly regarding the licensing and credentials of the counselor. ●● Explicit, written information explaining the process of distance professional services and the appropriateness of the interventions for the patient’s presenting issues. ●● Proper screening of clients for the appropriateness for distance professional services. ●● Taking extra caution to ensure that electronic information regarding a client is not accidentally sent to someone else. ●● Counselors must adhere to regulations in their home state, as well as the state in which the client lives and note this compliance in the record as appropriate. ●● Counselors must provide clients with detailed instructions on how to obtain emergency treatment in their community if it is needed. ●● Counselors shall create codes or passwords to ensure the client is really the one involved in distance professional services and have a written procedure as to how this will occur. ●● Counselors will provide information to clients on where to obtain internet service for free. ●● Copies of emails and other materials shall be kept and maintained for at least 5 years, unless otherwise indicated by state laws that the records should be kept longer. ●● Counselors shall ensure their personal social media accounts are carefully distinguished from their professional accounts and counselors should avoid interacting with patients in a personal manner on social media. ●● Counselors will respect the privacy of their patients on social media and will not view personal information on websites such as Facebook or Twitter.

Another potential risk that emerges in this form of therapy is, due to issues with email servers and programs and software, if a client inadvertently does not receive the therapist’s communication and then does not respond, the therapist may assume the client has dropped out of services and discharge them inappropriately. In addition, clients may have unrealistic expectations of response times and become upset when a therapist does not answer within a few quickly (Reamer, 2013).

The American Counseling Association (ACA) addresses similar issues in their code of ethics. In addition, they specify in section H.4.f. Communication Differences in Electronic Media, “Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of

Distance can create a real concern for safety and ethical practice in online therapy. One of the more complex issues surrounds the differences in state laws. Hertlein, Blumer, and Mihaloliakos (2013) cited the work of Derrig-Palumbo and Eversole (2011), who brought up an interesting dilemma. For example, duty-to-warn laws may differ substantially from the state where the therapist practices and the state in which the patient lives. Does the therapist follow the laws of his/her home state or that of the client? Hertlein, Blumer, and Mihaloliakos noted that the management of crisis, concerns for privacy, laws and regulations, training and education, and the quality of the therapeutic alliance remain the biggest ethical concerns for marriage and family therapists.

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visual cues and voice intonations when communicating electronically,” (American Counseling Association, 2014). The ACA also requires that counselors who maintain websites provide accessibility for those with disabilities and language translation when possible. The American Association of Marriage and Family Therapists (AAMFT) code of ethics covers several broad areas, but is not as detailed as those of the ACA or NBCC. The general areas covered under the Standard VI: Technology Assisted Professional Services include: “Therapy, supervision, and other professional services engaged in by marriage and family therapists take place over an increasing number of technological platforms. There are great benefits and responsibilities inherent in both the traditional therapeutic and supervision contexts, as well as in the utilization of technologically assisted professional services. This standard addresses basic ethical requirements of offering therapy, supervision, and related professional services using electronic means. 6.1 Technology assisted services Prior to commencing therapy or supervision services through electronic means (including but not limited to phone and internet), marriage and family therapists ensure they are compliant with all relevant laws for the delivery of such services. Additionally, marriage and family therapists must: (a) Determine that technology assisted services or supervision are appropriate for clients or supervisees, considering professional, intellectual, emotional, and physical needs; (b) inform clients or supervisees of the potential risks and benefits associated with technology assisted services; (c) ensure the security of their communication medium; and (d) only commence electronic therapy or supervision after appropriate education, training, or supervised experience using the relevant technology. 6.2 Consent to treat or supervise Clients and supervisees, whether contracting for services as individuals, dyads, families, or groups, must be made aware of the risks and responsibilities associated with technology assisted services. Therapists are to advise clients and supervisees in writing of these risks, and of both the therapist’s and clients’/supervisees’ responsibilities for minimizing such risks. 6.3 Confidentiality and professional responsibilities It is the therapist’s or supervisor’s responsibility to choose technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology. 6.4 Technology and documentation Therapists and supervisors are to ensure all documentation containing identifying or otherwise sensitive information that is electronically stored and/or transferred is done using technology that adheres to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology. 6.5 Location of services and practice Therapists and supervisors follow all applicable laws regarding location of practice and services and do not use technology assisted means for practicing outside of their allowed jurisdictions.

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6.6 Training and use of current technology Marriage and family therapists ensure they are well trained and competent in the use of all chosen technology assisted professional services. Careful choices of audio, video, and other options are made to optimize quality and security of services, and to adhere to standards of best practices for technology assisted services. Furthermore, such choices of technology are to be suitably advanced and current so as to best serve the professional needs of clients and supervises” (AAMFT, 2012). The National Association of Social Workers (NASW) Code of Ethics was last revised in 2008 and does contain a section specific to online therapy, or distance professional services. However, certain sections of the code cover some of the same areas addressed in other accrediting body’s more specific codes. While the sections below do not mention online service directly, the sections still cover important aspects of online therapy: b. Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques. c. When generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm (NASW, 2008). Sections of the Code of Ethics that address confidentiality also cover distance services: l. Social workers should protect the confidentiality of clients’ written and electronic records and other sensitive information. Social workers should take reasonable steps to ensure that clients’ records are stored in a secure location and that clients’ records are not available to others who are not authorized to have access. m. Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible (NASW, 2008). The American Psychological Association (APA) offers advice for those seeking online therapy and their tips for consumers offer important details for providers to consider as well. In general, they note that consumers should be aware of the following items: 1. Online therapy is not right for everyone in all situations. 2. Is the therapist or counselor actually licensed? Consumers are advised to investigate who the provider of the services actually is, and verify he/she is a qualified, licensed provider. 3. Check with your state licensing board to verify the provider is licensed where you live. Licensing is not across all 50 states. 4. For reasons of privacy and security, please make sure the website is HIPPA-compliant, there is a process in place to ensure you can verify the identity of the therapist, and there is a way to ensure the therapist can also verify your identity. 5. Check to make sure your insurance company will cover online therapy and, if not, you will need to pay for services yourself.

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Ethics and laws by state States vary in regulation and oversight of online therapy. The most comprehensive review to date (Haberstroh, Barney, Foster and Duffey, 2014) noted that no state boards prohibited online therapy for counselors or psychologists, but only half specifically allowed for the practice in regulations and laws. However, 32% of states offered no guidance on the practice of online therapy. Many states referred to the national organization’s code of ethics for guidance.

This lack of specific guidance at the state level is an issue that needs to be addressed as the practice of online therapy continues to grow. Some states, such as Oklahoma, have developed specific laws, noting that social work services provided to anyone living in Oklahoma, regardless of where the social worker is located or how the service is delivered, are to be regulated by the state of Oklahoma.

Suggestions for practice Sucala et al. (2013) suggested that having more than one mode of communication such as email, video chat, phone, etc. enabled a stronger therapeutic alliance to form. Fewer forms of communication available seemed to impact the therapeutic alliance negatively. In addition, more means of communication led to an easier ability to assess patients for suicidality. In overcoming some of the deficits of not being face-to-face, Barak, Klein, and Proudfoot (2009) suggested, “therapists should take special action, especially employing words and expressions that might not be used in face-to-face contact, to communicate empathy, care, concern, and warmth toward their clients. Similarly, clients have to be aware that their feelings are not as obvious and vivid as they would be in a face-to-face relationship. Therefore, clients have to communicate their emotions in more explicit ways, sometimes even describing what could easily have been visible (e.g., crying, sweating, laughing).” (p. 10) Clinicians who have provided online therapy successfully have important insight into what types of techniques work in these settings. One therapist noted: “It would be important that they [online counselors] could do a lot of reflecting and summarizing and that they can pull together the session that way, because I think it could get real fragmented if you don’t. And, so I think it’s real important to use that technique. I also think that, because it seems like you are a little limited in terms of what you can cover, it should be a little more action oriented, and even if it is insight oriented, taking action to increase insight. It’s funny because so many of the techniques you learn in school kind of need to be done in a face-to-face session. I think you can adapt a lot of them. It becomes almost a different technique,

I think, here on Web counseling. I think it’s really neat because I think it adds a different component to it. You can’t really express empathy or understanding nonverbally, and so I think it really helps me make sure I’m reflecting or summarizing rather than going straight to a question. So I kind of like that, and it kind of strengthens those skills. It seems like there’s some real specific techniques that can be effective for Web counseling, and it’s like we don’t know what those are yet. We’re defining those. I think some of those would be more homework stuff because it feels a little bit like you can’t cover as much ground in the same amount of time. So if you could have the client do something that they typed out, whether it’s a journal entry. . . something to process that week, or whatever. And then if the counselor reads it right at the beginning of the session, then I think that might be helpful. I guess that I was thinking about some theories that already have a lot of that in place. Like cognitive [theory] seems to have a lot of worksheets and charts and different stuff like that. So it seems like that would be real conducive to Web counseling, but I think that you could also adapt whatever theory it is that you go by and just whether it’s an assignment to explore this particular issue this week and write a little entry about it” (p.466, Haberstroh, et al., 2008). There are a few ideas regarding a set of best practices that are being developed, but it is not yet fully formulated. Some suggestions from NASW are: 1) Requiring pre-session information gathering from clients, 2) license practitioners in all states to allow for service delivery across state lines, 3) require that clients give therapists proof of their physical location and a list of emergency contacts, 4) provide clients with several means of electronic support, 5) make policies regarding payment, privacy, treatment outcomes, and such in plain language on the social worker’s website (NASW, 2007).

Future directions There is a definite need to have education and training in the field of online therapy. One recent survey showed that around 80% of marriage and family therapists reported that online or cyber issues had not been presented in their graduate training (Goldberg et al. 2008). Only 1.2% of all presentations at marriage and family therapy conferences were on cyber-related issues (Blumer et al. 2014a). Family therapists who responded to a survey regarding their interest in learning more about online therapy identified five key areas where they felt they were least knowledgeable and most in need of education. The areas were: 1. Ethical issues and legal advice. 2. Privacy and confidentiality. 3. General training in how to provide online clinical services. 4. Information on safety and security. 5. Evidence-based practices information for online services (Blumer, Hertlein, and VandenBosch, 2015). The field of online therapy is likely to continue to grow as the internet and other forms of electronic communication become part of our daily lives. The younger generation of people who have grown up with Facebook, email, and texting as a way of life are particularly likely to have an interest in online therapy. It is not likely to ever replace face-to-face therapy as the leading format of service delivery, but it is a

viable and growing option that cannot be ignored. The need is vast for more research concerning efficacy, particularly in comparing models of therapy for different needs. Regardless, any therapist or counselor seeking to provide these services should seek appropriate training under supervision of a knowledgeable practitioner. Furthermore, it is critical to seek ethical and legal guidance from governing bodies and professional associations. Client safety and confidentiality remain two major issues that need to be addressed by any provider of online therapy. If a therapist is planning to develop a website, this should only be undertaken with IT professionals who are experienced in cyber security and HPAA compliance for websites. A therapist should stay abreast of the constantly changing regulatory and ethical issues with online therapy. Certainly, the advantages are there: flexible schedules, low overhead, and the ability to reach more clients in a larger geographical area. However, not all practitioners will ever feel comfortable with this approach and the lack of face-to-face interaction with a patient, just as not all potential clients are satisfied with not seeing a therapist and instead working through electronic means. Nonetheless, the potential of online therapy cannot be ignored and providers should be aware of the growing trend in this area.

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References 1. 2. 3. 4. 5. 6. 7.

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American Association of Marriage and Family Therapy. (2012). Code of ethics. Retrieved from http://aamft.org/imis15/Documents/Final 2012 AAMFT Code of Ethics.pdf American Counseling Association. (2014). Code of ethics and standards of practice. Alexandria, VA: Author. American Psychological Association (2016). What you need to know before choosing online therapy. Washington, D.C. Author. Retrieved from: http://www.apa.org/helpcenter/online-therapy. aspx January 22, 2016. Amichai-Hamburger, Y., & Barak, A. (2009). Internet and well-being. In Y. Amichai-Hamburger (Ed.), Technology and well-being (pp. 34–76). Cambridge University Press. Andersson,G., Cuijpers, P., Carlbring, P., Riper,H.,& Hedman, E. (2014). Guided internet-based vs.Face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis. World Psychiatry, 13, 288–295. Andrews, P., Cuijpers, M.G., Craske, P., McEvoy, Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS ONE, 5(10), p. e13196. http://dx.doi.org/10.1371/journal.pone.0013196 Beattie, A., Shaw, A., Kaur, S., & Kessler, D. (2009). Primary-care patients’ expectations and experiences of online cognitive behavioural therapy for depression: A qualitative study. Health Expectations: An International Journal Of Public Participation In Health Care & Health Policy, 12(1), 45-59. Bendelin, N., Hesser, H., Dahl, J., Carlbring, P.,Nelson, K.Z., & Andersson, G. (2011). Experiences of guided internet-based cognitive-behavioural treatment for depression: A qualitative study. BMC Psychiatry, 11, 1-10. Bengtsson, J., Nordin, S., & Carlbring, P. (2015). Therapists’ experiences of conducting cognitive behavioural therapy online vis-à-vis face-to-face, Cognitive Behaviour Therapy, 44, 470-479. Berger T, Hammerli K, Gubser N, Andersson G, Caspar F (2011) Internet-based treatment of depression: a randomized controlled trial comparing guided with unguided self-help. Cognitive Behaviour Therapy, 40: 251–266. Blumer, M. L. C., Hertlein, K. M., Walker, L., & Koble, J. (2014b). MFTs’ education of online practices & online professional networking. Presented at the American Association for Marital and Family Therapy Annual Conference, October 18, 2014, Milwaukee, WI. Ivarsson, M. Blom, H. Hesser, P. Carlbring, P. Enderby, (2014). Guided internet-delivered cognitive behavior therapy for post-traumatic stress disorder: a randomized controlled trial Internet Interventions., 1 (2014), pp. 33–40. Derrig-Palumbo, K. A., & Eversole, L. N. (2011). Effective onlinetherapy with couples and families. Workshop presented at the Annual American Association for Marriage and Family Therapy. Conference, Dallas, Texas. Fantus, S., & Mishna, F. (2013). The ethical and clinical implications of utilizing cybercommunication in face-to-face therapy. Smith College Studies In Social Work, 83(4), 466-480. Finfgeld-Connett, D. (2006). Web-based treatment for problem drinking. Journal of Psychosocial Nursing & Mental Health Services, 44(9), 20-27. Gabbard, G. O., Kassaw, K. A. Perez-Garcia, G., (2011). Professional boundaries in the era of the Internet. Academic Psychiatry, 35, 168–174. Goldberg, P. D., Peterson, B. D., Rosen, K. H., & Sara, M. L. (2008). Cybersex: The impact of a contemporary problem on the practices of Marriage and Family Therapists (MFTs). Journal of Marital and Family Therapy, 34, 469–480. Haberstroh, S., Parr, G., Bradley, L., Morgan-Fleming, B., & Gee, R. (2008). Facilitating online counseling: Perspectives from counselors in training. Journal of Counseling & Development, 86(4), 460-470. Hertlein, K. M., Blumer, M. L., & Mihaloliakos, J. H. (2014). Marriage and family counselors’ perceived ethical issues related to online therapy. The Family Journal, 1066480714547184. Kiropoulos, L.A., Klein, B., Austin, D.W., Gilson, K., Pier, C., Mitchell, J., et al. (2008). Is internetbased CBT for panic disorder and agoraphobia as effective as face-to-face CBT? Journal of Anxiety Disorders, 22, 1273–1284.

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21. Lillevoll, K. R., Wilhelmsen, M., Kolstrup, N., Høifødt, R. S., Waterloo, K., Eisemann, M., & Risør, M. B. (2013). Patients’ experiences of helpfulness in guided Internet-based treatment for depression: Qualitative study of integrated therapeutic dimensions. Journal Of Medical Internet Research, 15(6), 172-183. doi:10.2196/jmir.2531 22. Manhal-Baugus (2001). E-therapy: Practical, ethical and legal issues. Cyberpsychology and Behavior, 4(5), 551–563. 23. Mishna, F., Bogo, M., & Sawyer, J. (2015). Cyber counseling: Illuminating benefits and challenges. Clinical Social Work Journal, 43(2), 169-178. 24. Mohr D.C., Duffecy J., Ho J., Kwasny M., Cai X., Burns M.N., Begale, M. (2013) A randomized controlled trial evaluating a manualized TeleCoaching protocol for improving adherence to a webbased intervention for the treatment of depression. PLoS One. 8(8):e70086. doi: 10.1371/journal. pone.0070086. 25. National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers. Washington, DC: Author. 26. National Assoication of Social Worker. (2007). Social Workers and e-Therapy. Washington, D.C: Author. 27. Olthuis, J., Watt, M., & Stewart, S. (2011).Therapist-delivered distance cognitive behavioural therapy for anxiety disorders in adults. The Cochrane Library, (3). 28. O’Reilley, R., Bishop, J., Maddox, K., Hutchinson, L., Fisman, M., &Takhar, J. (2007). Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatric Services, 58(6), 836-843. 29. Pollock, S. L. (2006). Internet Counseling and Its Feasibility for Marriage and Family Counseling. The Family Journal, 14(1), 65-70. 30. Prabhakar, E. (2013). E-Therapy: Ethical considerations of a changing healthcare communication environment. Pastoral Psychology, 62(2), 211-218. 31. Reamer, F. G. (2013). Social work in a digital age: Ethical and risk management challenges. Social Work, 58(2), 163-172. doi:10.1093/sw/swt003 32. Rozental, A., Boettcher, J., Andersson, G., Schmidt, B., & Carlbring, P. (2015). Negative effects of internet interventions: A qualitative content analysis of patients’ experiences with treatments delivered online. Cognitive Behaviour Therapy, 44(3), 223-236. 33. Rummell, C., & Joyce, N. (2010). ‘‘So wat do u want to wrk on 2day?’’: The ethical implications of online counseling. Ethics & Behavior, 20(6), 482–496. 34. Ruwaard, J., Lange, A., Schrieken, B., Dolan, C. V., & Emmelkamp, P. (2012). The effectiveness of online cognitive behavioral treatment in routine clinical practice. PLoS ONE, 7(7), e40089. 35. Scharff, J. S. (2013). Technology-assisted psychoanalysis. Journal of the American Psychoanalytic Association, 61(3), 491–510. 36. Shaw, H., & Shaw, S. (2006). Critical ethical issues in online counseling: Assessing current practices with an ethical intent checklist. Journal of Counseling & Development, 84(1), 41–53. Retrieved from http://www.plainlanguage.gov/index.cfm 37. Spek V, Cuipers P, Nyklicek I, Riper H, Keyzer J, Pop V., (2006). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychol Med. 37: 319-328. 38. Sucala, M., Schnur, J.B., Brackman, E.H., Constantino, M.J., & Montgomery, G.H. (2013). Clinicians’ attitudes toward therapeutic alliance in E-therapy. The Journal of General Psychology, 140, 282–293. doi:10.1080/00221309.2013.830590

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the use of the internet in therapy: GUIDELINES AND BEST PRACTICES Final Examination Questions

Select the best answer for each question and proceed to SocialWork.EliteCME.com to complet your final examination. 101. a. b. c. d.

________could be said to be the father of distance therapy. Freud. Einstein. Jung. Erikson.

110. a. b. c. d.

Lack of comparison is a factor in: Patient satisfaction with online counseling. Treatment efficacy. Therapeutic skills. Remission rates.

102. a. b. c. d.

Online therapy can be provided asynchronously, which means: Communication is provided in real time. Communication is provided at a later time. Communication is misunderstood. Communication is provided through text message.

111. a. b. c. d.

Responsibilities with childcare and elder care are part of: Patient outcomes. A reason to seek online therapy. Therapist burnout. Anxiety.

103. a. b. c. d.

Concerns about online therapy originally included the: Cost of the process. The fact that few people had computers. The technology stopping a critical point in therapy. Fraud.

112. a. b. c. d.

Frustration with technology: Was not a problem for most clients. Was a pervasive issue in online therapy. Resulted in negative feelings about the online process. Only happened with older adults.

104. Hamburger’s study noted that confidentiality was: a. A major problem in online therapy. b. Not at all a concern in online therapy for most people. c. Also a concern in in-person therapy and not exclusive to online therapy. d. The outcomes for online therapy were better than in person therapy for PTSD. 105. a. b. c. d.

Online CBT was found to be effective for: PTSD. Anxiety disorders. Depression. All the above.

106. a. b. c. d.

In one study what did 30% of client prefer in online therapy? Lower costs. Face to fact contact with therapist. More flexibility. More quality interventions.

107. Kiropoulos (2008) and O’Reily (2007) are authors of studies that found: a. Therapists did not understand their ethical obligations with online therapy. b. Therapists preferred face-to-face therapy. c. Online and face-to-face treatment comparisons had similar outcomes. d. Older persons disliked online therapy more than young adults. 108. a. b. c. d.

Telephone coaching, according to Mohr’s study, resulted in: Improved treatment outcomes. Improved treatment adherence. Greater rates of remission. No effect at all.

109. a. b. c. d.

Convenience, ease of accessibility, and easier disclosure are all: Perceived patient benefits from online counseling. Factors in treatment outcomes. Areas for key research questions. Terms used in CBT.

113. in: a. b. c. d.

In Rozental’s study, negative feelings about therapy occurred About 9% of clients. Young adults only. Only male clients. Only those persons with PTSD.

114. Not being able to see a therapist in person, for some patients, resulted in: a. A question of the therapist’s commitment. b. Wondering what the therapist was doing while the patient was waiting for a response. c. Increased negative feelings about the process. d. All of the above. 115. Increased schedule flexibility and _____________ were factors in therapists’ satisfaction with online therapy. a. Less emotional drain. b. Increased fee schedules. c. More evidence-based approaches. d. Improved patient outcomes. 116. Fantus and Mishna noted that for this type of patient, online therapy could be especially helpful. a. Nonverbal. b. Bipolar. c. Anxiety disorders. d. Females. 117. A frequently cited area of dissatisfaction for therapists in online therapy is: a. The lack of therapeutic alliance. b. Increased work load. c. Increased burnout. d. Increased paperwork. 118. a. b. c. d.

One surprising outcome of online therapy for therapists was: They made more money. It was more interesting than in person therapy. The interventions worked better in online therapy. The strength of the therapeutic alliance in online therapy.

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119. a. b. c. d.

Crisis management and internet security are: Two of the biggest concerns for patients in online therapy. Two of the biggest concerns for therapists in online therapy. Not a factor in online therapy. Two of the biggest variables in treatment adherence.

124. a. b. c. d.

120. a. b. c. d.

Proper screening of clients and internet security are: Two areas of ethical concern noted by the NBCC. Not a major factor in online therapy. Just as important in face-to-face as online therapy. Important for treatment outcomes.

125. on: a. b. c. d.

121. AAMFT recommends that __________________are given to clients in writing. a. Limitations and protections offered by technology. b. Fee schedules. c. Duty to warn information. d. Therapist’s licenses.

Licensing across all states is recommended by: Congress. NAMI. NASW. NBCC. 1.2% of training at marriage and family therapy conferences was Cyber-related issues. Domestic violence. Ethics. Confidentiality.

122. ___________ passed legislation that services provided electronically to anyone who lives in this state are subject to regulation by this state. a. Texas. b. New York. c. Florida. d. Oklahoma. 123. Describing verbally what is visible (crying, laughing) is recommended to clients in online therapy: a. Only in crisis. b. Never. c. To assist the therapist in understanding what he/she cannot see. d. If the client wants to.

SWPA\04IT17 SocialWork.EliteCME.com

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2017 CE Course for Pennsylvania Mental Health Professionals All 20 Hrs ONLINE ONLY

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Customer Information Three Easy Steps to Completing Your License Renewal Step 1: Complete your Elite continuing education courses: 99 Read the course materials and answer the test questions. 99 Complete the course evaluation. 99 Submit your final exams and course evaluation along with your payment to Elite online. Step 2: Receive your certificate of completion. 99 If submitting your course online you will be able to print your certificate immediately. Step 3: Once you have received your certificate of completion you can renew your license online at www.mylicense. state.pa.us, or mail in your renewal. In order to avoid late fees, your CE and license renewal must be completed by February 28, 2017. Board Contact Information: State Board of Social Workers, Marriage and Family Therapists and Professional Counselors P.O. Box 2649 Harrisburg, PA 17105-2649

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