WRNMMC, Bethesda, MD  –   Preventing suicides and treatment of people with Substance Use Disorders (SUDs) top discussion during the Annual Substance Use Disorder Symposium, hosted by the National Capital Region Pain Initiative (NCRPI) at Walter Reed National Military Medical Center, Sept. 21.
The symposium, in its sixth year, virtually brought together clinicians, researchers and other health-care practitioners from around the globe to present their work focused on identifying, preventing and treating SUDs.
Dr. Christopher Spevak, a pain medicine specialist and board-certified anesthesiologist who directs the NCRPI at WRNMMC, explained that a multifaceted approach including education, research, intervention and clinical care is necessary to prevent, identify and treat SUDs. He added that this is why the annual symposium includes speakers from a variety of medical specialties and disciplines.
Amy Osik, senior program manager for the NCRPI and Tele-Pain Program, said the symposium focuses on sharing best practices, evidenced-based research, and learning integrative approaches for treating pain management and SUDs for better patient outcomes.

Preventing suicide

Keynote speaker for the symposium, Dr. Hilary Connery, discussed preventing suicide in people with opioid use disorder.
“Suicide risks are elevated for both prescription and illicit opioid misuse, as well as for opioid use disorders and persons living with moderate-severe chronic pain,” said Connery, assistant professor of psychiatry at Harvard Medical School who also serves as the clinical director for McLean Hospital’s Division of Alcohol, Drugs, and Addiction. “Among suicide poisonings, those involving opioids have the highest lethality,” she added.
Connery explained there are psychological and social risk factors commonly experienced by SUD patients which should be considered when applying personalized suicide prevention planning approaches. She added a SUD includes “the three Cs” occurring over a 12-month period. The Cs standing for: Control (Is substance use self-moderated in a safe and appropriate way? If not, this is a criteria for SUD); Craving (Does the person anticipate substance use with an urgency that is disproportionate to other drives? If yes, this is a core criteria for SUD); and Consequences (Substance use is observed to be associated with negative health and/or social outcomes).
Spevak explained that throughout the Military Health System there appears to be a decreasing amount of opioids prescribed, but opioid misuse and other substance misuse remain a concern in military medicine. “Mirroring the civilian population, we’re seeing an uptick in risky behaviors, including alcohol use and misuse,” he added.
Alcohol-use disorder and opioid-use disorder are the two use disorders most highly associated with suicide risk, Connery furthered. “These have 10 to 15 times higher rates of suicide deaths when compared to the general population. People with SUD have elevated suicide risk even during abstinence and remission from substance use.”
Connery explained suicide warning signs can be direct or indirect. Those that are direct require immediate actions for safety, and the signs may include:
• Communication of a desire or plan to die
• Seeking the means to die (internet searches; purchase of a firearm or another weapon; stockpiling pills)
• Making “final arrangements” (saying goodbye to others; giving away possessions)
Indirect warning signs for suicide may include:
• A marked shift in mood/anxiety or behavior
• Severe, persistent insomnia
• A relapse following stability
• Agitation or rage
• Isolation, hopelessness, feeling like “not belonging”
• Feeling like a burden to others
• Family/significant other states “not him/herself”
• Recklessness
Connery added there are biological and social determinates of health that serve as protective factors against suicide.
Biological determinates include:
• Abstinence, recovery care for all mental health disorders
• Sleep hygiene
• Pain relief
Social determinates include:
• Security of food, housing, safety, economics
• Community alliances: social connections and belonging
• Positive, shared spiritual beliefs and connections
• No firearm in home; no substances in home
Connery said safety planning includes identifying the risk (ongoing screening, assessment and means reduction); identifying the personal patterns (thoughts, behaviors, mood, sleep, and common triggers such as people, places and things); and enhancing positive coping (abstinence, self-assessment, reasons to live, connections to others, medication adherence, physical and spiritual self-care).
She recommended people use the National Institute of Mental Health suicide-risk screening tool, Ask Suicide-Screening Questions (ASQ), located at the site https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials. In addition, she encourages people carry naloxone for emergency use in opioid overdose.
Also, the National Suicide Prevention Lifeline can be reached at 1-800-273-TALK (8255).

Military, first responder care

John Rodolico, Ph.D., a psychologist at McLean Hospital who also serves as an assistant professor of psychology in the Department of Psychiatry at Harvard Medical School, discussed military and first responder care in relations to SUDs. As an Army reservist, Rodolico deployed twice to Iraq as the executive officer of a combat stress medical company.
SUDs affect readiness, Rodolico stated. He added the U.S. military has made great progress with illicit drug use, but still lags with respect to alcohol use. “Binge drinking has increased manifold. 43 percent of active duty military indulge in binge drinking, and of these binge drinkers, 70 percent were heavy drinkers. Drinking in many respect is part of the culture, a culture that the military is trying to change.”
Influencing factors in substance use among military and first responder members, Rodolico explained, include: social (drinking to “fit in” with peers and to be part of the team); pain management; and access to prescription drugs (particularly among emergency medical services personnel).
Rodolico also discussed the overlap between suicide and alcohol, which he described as “a perfect storm.” He explained that with the increase in behavioral health issues, such as depression and post-traumatic stress disorder, and/or traumatic brain injury, there can be an increase in drug and alcohol use, thereby possibly creating the perfect storm and increasing the chance for suicide.
He added the Army’s Commander's Ready and Resilient Council (CR2C), a combination of the SUD program, resiliency, military sexual abuse prevention, suicide prevention, behavioral health and fitness, is designed to enhance and support the resiliency and readiness of service members.
Organizational prevention programs geared toward SUDs need for be supported and endorsed by senior staff and employee unions, Rodolico emphasized. He said that everyone has a responsibility in suicide and SUDs prevention, and identify red flags for SUDs and suicide risk. He said this is the foundation of the military’s battle buddy and shipmate concepts.

Incentives for SUD treatment

Dr. Dominick DePhilippis, a clinical psychologist who serves as the VA deputy national mental health director for the U.S. Department of Veterans Affairs (VA) in New Jersey, discussed incentives in the treatment of substance use disorder, also called contingency management (CM).
He explained recovery from SUD presents a number of challenges, including neurophysiological, time, attrition, and cognitive-behavioral hurdles.
Regarding the neurophysiological challenge, DePhilippis explained that “brain reward” (dopamine) increases in response to natural rewards, such as food, music and sex. “When cocaine is taken, dopamine increases are exaggerated, and communication is altered [presenting the neurophysiological challenge].”
The time challenge regarding recovery is that it takes prolonged abstinence for the brain to recover from the SUD.
Concerning the attrition challenge, DePhilippis stated, “SUDs are chronic illnesses that respond best to continuing care. Yet traditional treatment attendance is often sporadic. Attrition rates range from 50 to 60 percent among inpatients, to more than 70 percent after just four sessions of outpatient treatment.”
The cognitive-behavioral challenge of recovery from SUD, which DePhilippis described as a “daunting challenge of decision-making,” is that on one hand, substance use presents an opportunity for immediate gratification despite the consequences for the user, whereas abstinence from substance use presents the user the opportunity for delayed gratification and possible recovery, but not the immediate gratification.
“Contingency management helps meet that challenge,” DePhilippis explained. He described CM as “based on the most fundamental learning principles that govern the acquisition of behavior.” The treatment is called contingency management because the incentives are contingent on staying abstinent. “CM brings immediate, reliable reinforcement for engaging in recovery-supportive behaviors, e.g. abstaining from substances. CM engages patients in treatment and gives their brains a chance to heal.”
DePhilippis describes CM as not a bribe nor “paying someone not to use,” but as “positive reinforcement to strengthen recovery.” He added CM also “withholds reinforcement when the target behavior does not occur.”

12 steps of recovery

Psychologist Dr. Christine Timko, from the VA Palo Alto Health Care System in California, discussed the 12-step facilitation for adults with SUDs.
“People with addictions who participate in 12-step mutual-help groups are more likely to experience recovery,” Timko said. She added evidence-based practices help providers facilitate 12-step group participation. “These groups meet on line as well as in person.”
She explained the 12 steps help with:
• Self-governance, narcissism, feelings of omnipotence
• Acceptance of feelings of powerlessness over alcohol or substances
• Recognizing that achieving abstinence and recovery can’t be done alone (“You need a higher power.”)
• Realizing your behavior affects others
• Treating other people better
• Finding meaning in life
• Relinquishing negative self-focus by helping other people
Timko said use of mutual-help groups, such as Alcohol Anonymous (AA) and Narcotics Anonymous (NA) are used by a number of people for help in their recoveries. “About 10 percent of adults in the U.S. have been to an AA meeting. About 80 percent of adults who seek professional help for alcohol use disorders participate in AA. AA has about 1.3 million members and 59,000 groups in the U.S., and about 2.1 million members and 120,000 groups worldwide. NA has about 70,000 weekly meetings in 144 countries. Al-Anon has about 24,000 groups in 130 countries.”
She added there’s a strong association between participation in 12-step mutual-help groups and better substance-use outcomes, with attendance associated with abstinence.
“[In a recent study,] among 515 veterans, at 18 months post-treatment, abstinence rates were 50 percent among 12-step attendees versus 25 percent among non-attendees,” Timko added.

Workshops

Workshops during the symposium covered motivational interviewing for SUD; going beyond the diagnosis of SUD; the latest research concerning SUD; and integrative medicine for SUD (East Asian medicine techniques).
Air Force Maj. Rosemary Estevez Burns, a clinical psychologist, led the workshop focusing on motivational interviewing for SUD. She explained the counseling approach is designed to help individuals “explore, reflect on, and resolve ambivalence about change” for better outcomes in SUD treatment.
Lynne Vance, an integrative medicine nurse at WRNMMC who is also a licensed acupuncturist, led the integrative medicine for SUD workshop. She explained that East Asian medicine (EAM) offers a number of evidence-based practices beneficial for treatment of SUDs. EAM providers use therapeutic and self-care interventions, such as acupuncture, Tai Chi and Qigong, which support behavior change and therapeutic benefit between treatments.
Psychologist Dr. Harold Wain, Army Lt. Col. Shannon Ford, clinical psychologist fellowship director for the National Capital Consortium (NCC), and Army Lt. Col. Rohul, program director for the NCC Psychiatry Residency Program, presented the beyond the diagnosis of SUD workshop. They explained that going beyond the obvious diagnosis and understanding the variables contributing to each patient’s SUD diagnosis may be different and produce better results. The workshop addressed the myriad of biopsychosocial components contributing to each individual’s diagnosis for better treatment outcomes.
Dr. Ilene Robeck, an internal medicine specialist, discussed the latest research in SUD, including adolescent substance use and overdose risk reduction.