Hi, my name is Tina Nadeau and I'm the Chief Justice at the New Hampshire Superior Court. I was fortunate enough to be in Reno with some specialists on addiction psychiatry and other judges and we had a chance to get together and talk about the nature of addiction and how we need to be understanding it and addressing it in our courtrooms. And together with Dr. Sevarino, we made a presentation in Reno at the National Judicial College about risk assessment and substance use disorder assessments. Now some of you won't have assessment tools at your fingertips, but it's important for you to know what an assessment does and how to use it. Maybe your pretrial services program uses assessment tools, maybe you have a drug court that uses assessment tools, or maybe you will have a probation report that has provided the assessment for a defendant. So what we need to understand is what is the severity of someone's substance use disorder and/or mental health condition, and how can we as judges respond to those issues by issuing appropriate sentences and by considering what level of supervision is required for each person. For example somebody who can stop using substances on their own without a whole lot of help doesn't necessarily need the same level of treatment as somebody who has a deeply ingrained substance use disorder. So these assessment tools are designed to help you make those decisions. Even if you weren't using them in the courtroom, you'll be able to understand why they're important and what other agencies might be able to use them and giving you information for sentencing. Welcome everybody. We're gonna be discussing today how clinicians assess clients for substance use disorders, but I'm gonna be describing why that is actually an important thing to do with persons that are involved in the judicial system. My name's Kevin Sevarino. I'm a consulting psychiatrist with Gaylord Hospital, which is a small hospital that specializes in traumatic brain injury and spinal cord injuries. I've also for many years been a consultant for group disability for Liberty Mutual, which is now known as Lincoln Financial. And I'm an Associate Clinical Professor at Yale University School of Medicine. So thank you for having me. On the next slide, just by way of disclosure, I initially adapted this presentation from Dr. Blevins, with a lecture called Screening, Assessment and Treatment Initiation for Substance Use Disorders. That's now on the Provider Clinical Support System in something called the SUD 101 Core Curriculum if you wanted to see the original presentation. I do not have any relevant financial relationships with an ACGME recognized commercial interest. And I'm not gonna be talking about any off-label or investigative drug uses today. I just wanted to reiterate, this is an initiative made possible in part by a grant from SAMHSA, which is now best known as the Opioid Response Network. Next slide. So what are we gonna be doing today? First, I wanted to focus a little on why detection of substance use disorders in judicial populations would be important. Talk about some of the clinical features that identify somebody at being at elevated risk for having a substance use disorder. And then talk about some of the screening tools that were developed from those clinical features for substance use disorders. Then I wanna talk about how, if you identify somebody at risk, how you'd go on and confirm whether they have the diagnosis of a substance use disorder, what's involved in a complete SUD assessment. And then a little bit about the benefits of early detection of an SUD. Next slide please. So what are the goals of screening for a substance use disorder? Why do we screen for one as opposed to going right on to looking at one right away? So the next slide. I'd like to emphasize that in fact, if we took everybody that was involved in a population, and in this case those involved in the justice system, and did a full assessment on them for mental health and substance use disorders, we'd quickly overwhelm the resources we had. So what we need to try to do is be more efficient with our resources by first identifying those at risk and then doing full assessments on those people. It's important in the judicial system because chronic drug users, and those are defined as people that have used an illicit substance for four or more days in the prior month account for an astoundingly high 97% of heroin use and 89% of the cocaine consumed in the United States. So you can see that it's a fairly small number of high utilizers that use a lot of these illicit substances in the country. And that unfortunately these are the people that are often very involved in the justice system. Greater than 50% of those chronic drug users are arrested every year. On average about one and a half arrests per person. So if we were to reduce drug use in arrestees, we'd have a disproportionately high effect on overall drug consumption in the United States. And as well as you've heard in other talks that if we were to reduce substance use disorder, we'd reduce the burdens on the justice system overall. Next slide please. So the goals of substance use screening, first as I said before, to make the most efficient use of resources. And we want our screening tools to identify the subpopulation of people that we come in contact with that are in increased risk of a substance use disorder. They need to be universally applied. In other words we don't wanna use any prejudicial feeling, this one may have at that one may not. Because in the clinical world for example, somebody's grandmother could actually be addicted to opioid pain medicines. So the screening tool should be universally applied to avoid missing cases at risk. But if we're gonna apply them to everybody, they need to be fast and easy to administer, easy to score and have a good what we call positive and negative predictive value. What that means in non-technical terms is that if somebody does have a substance use disorder, you want the screening tool to identify that person. But if they don't have a substance use disorder, you want to have the screening tool accurately rule out that they have the substance use disorder. Next slide. A screening tool doesn't establish a diagnosis. So what's important is you may screen for something, but that doesn't mean you have the disorder and that's why we need then to go on and do a full assessment. A screening tool is no good if it's ignored or over interpreted. When I worked in the VA and I'll talk about the VA a lot because I worked there for 17 years, sometimes you would see somebody that had a screening tool applied, which was mandatory for some screenings every six months, and yet it was positive and then nobody reacted to it. So it's important that we don't ignore a positive or we don't interpret what it means. And then finally, the goal of screening is to identify the potential therapeutic opportunity and reduce the harms of substance use misuse and having an SUD as well as reducing the burden on the judicial system. Next slide. I'd like to emphasize that even though today I'm gonna be talking about what we call addiction or a substance use disorder, actually use occurs along a continuum. So if you don't or you use very little of a substance, that's called no use. But at risk use, for example the National Institutes of Alcohol and Alcohol use disorders, NIAAA would say that if a male drank in the past year over five drinks at one sitting, he had quotes, at-risk use. All that meant was he was at risk for a substance use disorder, not that he had one because there was no documented harmful consequence. If in fact though somebody say drank just once, but unfortunately got into a car accident because of the intoxication and suffered a life altering events, such as a spinal cord injury that left them say without the use of their legs, that would be now an adverse consequences and that would be harmful use, but they really only used once, they didn't use compulsively or whatnot. So they don't meet the definition of a substance use disorder. The reason why I bring all this up is I'm, talking about screening tools that look for substance use disorders, but many times it's important to keep in mind that harmful use also can result in severe consequences for somebody. So say for the first time a teen becomes intoxicated and becomes involved in a very serious altercation and is arrested, they will be in the judicial system, they will have suffered a consequence because of alcohol use, but they wouldn't have met criteria for assumptions use disorder, which I'll describe a little more in the next few slides. Next slide. So first of all clinically, what have we learned about what puts somebody at an increased risk for a substance use disorder? The next slide shows us that in fact, first of all we have to pay attention to genetics. What is somebody's family history? So what does this mean? This is looking at numbers from 0.4 to 0.7. You can see cocaine is like 0.75, hallucinogens on the low end of the spectrum is just under 0.4. What does that mean? If you take identical twins, so they are monozygotic twins, they have identical genetic systems or a genetic sequence and then they're adopted away to completely different environments. That's the way we measure the genetic component of a heritability, as opposed to the environmental impact, such as parental influence, as you were being raised in what environment you were being raised in. And based on those adopted away twin studies, you actually see a very high degree of heritability of substance use disorders. This is higher than for example say heritability for hypertension, high blood pressure or for diabetes. So these are high degrees of heritability. For cocaine, if one identical twin is living in Sweden and another identical twin got adopted away and is living in, I don't know, Ohio, if the first twin had a cocaine use disorder, more than 70% of the variability of that second twin developing a cocaine use disorder is explained by the genetics. And you can see these are high heritabilities. And even 0.4 is a very high heritability for diseases because those diseases are very multifactorial. If we look at the next slide, these are individual characteristics that we've come to know make one more at risk for developing a substance use disorder. Even in kids, you can see kids that are very risk averse and very conservative, and then kids that are high risk takers or they're novelty seeking. That tends to go along with poor emotional control and impulsive behavior. You also see deficient interpersonal relatedness, people that do not develop strong bonds, especially within the family or having an avoidant personalities are at increased risk for developing substance use disorder. And then something I'll talk about a lot today, those with any other cycle pathology are at increased risk of a substance use disorder. So at the bottom you see SUD, early continuous smokers. The earlier one develops one substance use disorder. For example starting to smoke at age nine, risk is much higher than say you started smoking at age 17 or 18. So an early smoker is an increased risk of developing later alcohol use disorder, cannabis use disorder and all the other drug use disorders. But as well you're at increased risk if you have what we call the externalizing personality syndromes, such as the antisocial syndromes, conduct disorder, antisocial personality disorder, aggressiveness, those with attention deficit hyperactivity disorder, especially those kids that also have conduct disorder, the mood disorders, bipolar disorder, and major depression and anxiety disorders such as panic disorder. Any of those put you at at least double the risk of developing a substance use disorder compared to individuals that do not have those. Next slide. This gives you a sense of the numbers. On the pure blue on the right, adults with a mental illness, but not a substance use disorder. On the left is the yellow, those with a substance use disorder, but no mental illness. And then look at in the middle, the green, which I guess is a combination of blue and yellow. The green are adults that have both substance use disorders and mental illnesses. You see that it's 45% or so of all those that have a substance use disorder. And in fact, this is from the National Survey of Drug Use and Health, 2018. And if you just Google that, you can always get the latest up to date figures with all sorts of wonderful graphs on it right on the internet. But what this is, is an epidemiological study reaching out to people in the community and having them report back on their symptoms and then showing who meets criteria for what. These are not treatment seekers in other words. In those with a substance use disorder seeking treatment, it's well over 50% have a comorbid serious mental illness. Next slide. And the National Survey of Drug Use and Health, this is through SAMHSA, the Substance Abuse and Mental Health Services Administration has focused mainly on the occurrence of major depressive episodes in adolescents. And you could see for pretty much all drugs of abuse, if you've had a major depressive episode in the last year, and you were between the ages of 12 and 17, you were two times or more greater likely to also meet criteria for a substance use disorder. That includes cigarette smoking, includes alcohol, and it includes all illicit drugs. So it's very important when we screen for substance use disorders to be aware that there's very likely going to be a comorbid other mental illnesses as well. Next slide. Some of the developmental characteristics, in other words, what was in somebody's background in childhood and upbringing, family factors are of course very critical for these people, whether the parents had a substance use disorder plays in not only the genetics, but environmentally. Whether there's other mental illnesses within the parents. Parental personality factors, especially absent parents or abusive parents. The relationship of the parents and the offspring. The more distant that relationship, the less protective it is. And of course sibling influences, what your brothers and sisters do. If you go outside of the family, similarly the influence is peer influence. And then finally marital status, occupational, educational status. That's pretty much general across the board for mental illness and substance abuse in general. Being married is protective, being a full-time worker is protective, and having a higher socioeconomic status is protective. The next slide. And then contextual characteristics. Irrespective of what your environment was like being raised and irrespective of your genetics, if you're in impoverished environment, if you're in an environment that has high drug availability or alcohol availability, if they're strong gang influences and concurrent with that social and familial disorganization. And finally if you have the perception that you are being discriminated against or alienated from society, these are all high risk factors for developing a substance use disorder. And you look at that list and you realize that also put you at very great risk for involvement in the justice system. So that's partly why those with substance use disorders are unfortunately as we would say enriched in the judicial population. If we go to the next slide, I think we're gonna get into the screening tools now. So the reason why I told you all those risk factors is that's what basically, when people started to develop screening tools, they started to ask about. Do you have a family history for the substance use disorder? Did you start smoking when you were younger, et cetera? So let's go over some of the common screening tools. If you go to the next slide, we see that the National Institutes of Drug Abuse, one of the subgroups of the National Institutes of Health has a very quick screen called the Quick Screen V1. In the past year, single question, how often have you used alcohol with five or more drinks in one day, or for women four or more drinks in a day? And actually this has been verified also for those over 65, four or more drinks in a day. And I'll explain to you why that's a very important, it turns out to be single question, but very important one. Have you used tobacco products at all in the last year? Have you used prescription drugs for non-medical reasons in the past year? Have you used any illicit illegal drugs in the past year? If you answered yes to any of these, you go on to something I'm gonna show you in a second called the NIDA-ASSIST, which then takes much longer. But you can see that this could be done very quickly by anybody trained to use it. It doesn't have to be a social worker or somebody certified as an addiction counselor. Let's go on to the next slide though. In alcohol, this is where we have our most developed screens. And the reason why I focus a lot on alcohol is I think in this day and age of the rise in methamphetamine and what we've just been through, the opioid epidemic, we've forgotten that there's a huge amount of societal harm and justice system involvement that occurs still because of alcohol. So alcohol use is much more prevalent than that of illicit drugs. So how do we screen for alcohol? Well first of all we need to define what a standard drink is, because the questions I'm gonna show you in the screenings say a certain number of drinks a day or a certain number of drinks a week. When I would see in the VA veterans who would tell me while they'd have a single drink of vodka at night before going to bed, I'd have a picture next to me, and this was taught to me by a psychologist who ran a substance abuse program, a picture next to me and I'd fill it and I'd say, "Okay, fill your glass to how high that vodka drink is." It should actually be a single shot of alcohol is a standard drink. Sometimes they would fill a regular table drinking glass, half full of the vodka, which would be something like five standard drinks. So when we say a drink, we need to be able to define what it is. Similarly some people don't consider beer a drink. But in fact a standard beer, one beer, a 12 ounce beer is a standard drink. So what's in one beer, what's in a glass of wine, what's in a single shot of hard spirits, like 40% alcohol, that is a standard drink. And for any of these graphs if you want to print them and stick them up on your wall or whatnot, because you don't have any wallpaper, you can always Google with the NIAAA, Rethinking Drinking, which is a nice brochure. So using that standard definition of a drink, what are some of the screenings we use? The best one I think is called the AUDIT-C, which is the Alcohol Use Disorders Identification Test, and C as the abbreviated version. It's just the first three questions of what's called the full audit and I'll show you that. In fact the AUDIT-C is what's used in the VA and Department of Defense. In the VA all patients have this as a standard screener every year and in some VAs every six months. The CAGE is one many of you have probably heard of before, which is a four item, very quick screener, but in fact, it doesn't detect risky drinking. It only detects those with an alcohol use disorder. So the AUDIT-C is really a better screening tool and it is one that can be pretty quickly done. I think that's on the next slide. Yep. Here we go the AUDIT-C. And the AUDIT-C asks you to score from zero to four, a, how often do you have a drink of alcohol and that's frequency. Two, how many standard drinks containing alcohol do you have on a standard, do you have on a typical day? And so those two things allow you to really come up with kind of an average use over the month. And then finally, how often do you have six or more drinks on one occasion? So this was actually done before that NIAAA criteria, I'll tell you about, about five drinks for men and four drinks for women. They used six drinks here. And if you score this and you come up with greater than equal to four for men or greater than an equal to three for women, that's a positive screen, which says you then need to go on and do a further assessment because this person is at increased risk for having an alcohol use disorder. So if we'd go to the next slide. This is the CAGE, which is a far older one. Have you ever felt you needed to cut down? Have people annoyed you by criticizing your drinking? Have you ever felt guilty about your drinking? And then finally the one that's probably the most predictive, do you need an eye-opener to steady your nerves? If that one's a positive, you usually have somebody that has at least physiological dependence to alcohol. And a positive screen for the CAGE is two plus. Next slide I think shows you where people-- No, okay. This is the NIAAA, the National Institutes of Alcohol and Alcohol Abuse disorders, or it's actually National Institutes of Alcohol and Alcoholism, which asks for the pattern of your drinking. So this is in this pamphlet, Rethinking Drinking. What's your pattern of drinking? Three questions. On any day in the past year, did you ever have more than four standard drinks for men or three standard drinks for women? Then in a typical week, how many days per week do you drink? And on a typical day, how many drinks do you have? So that allows you to look at two criteria. Did you ever exceed that binge drinking standard, four drinks for men, three drinks for women? And then on average, two and three, number two allows you to calculate on average, how many drinks do you have in a week. And the cutoff is 14 or more for men, seven or more for women are kind of the danger thresholds. Now I realize that for some college students, this kind of binge drinking is fairly lightweight, but that doesn't mean that those college students aren't at increased risk for developing an alcohol use disorder. It's just that they've tended to normalize how much they're drinking. So where do people stand in America on terms of these kinds of criteria? If we look at the next slide, you can see in the top, 9% actually exceed thresholds for both, the binge drinking standard and the weekly limits. And those people are at 50%. In other words, one out of two of those people will, if you then do a further assessment meet criteria for an alcohol use disorder. So that's very high. If you exceed either of those two limits, the single day limit or the weekly limit, you're at about a 20% risk of meeting criteria for an alcohol use disorder, which ends up being three to four times the average populations risk. And then the other two groups are what we consider low-risk. So the AUDIT-C I think is something that, and this NIAAA screenings are both very good ways of trying to identify those that are at risk for alcohol use disorders. Next slide. So now go into what we call the illicit drugs. And actually when I say illicit, not in all states is cannabis now considered illicit, but many of these screeners actually did consider cannabis illicit when they were developed. A positive screen as I said with that NIDA Version one screener is positive answer to non-medical use of a medication. So either overusing your opioid or using your Adderall to get high. Use of illicit drugs or tobacco. So yes, they said tobacco. Just being a smoker puts you at increased risk of having an illicit substance use disorder. And then use of other substances for example huffing gasoline or using whippets in the reddi whip cans. Two of the screeners that are commonly used. One is called the Drug Abuse Screening Test or the DAST-10. It's a 10 item, very quickly administered test, which actually is self-reported. In other words, you can hand a sheet to somebody and that they give you the answer to that. If you look up the DAST it'll show you ways to try to screen, a, where you are, high-risk or low-risk zone of use, and then what you should do. And it scores it, these are no problem, low level, moderate level, substantial level, and severe level related to the drug abuse. The CRAFFT is a nine item score, which is, have you ever ridden in a car driven by somebody, including yourself who was high or intoxicated? Have you ever used drugs or alcohol to relax? Have you ever used alcohol or drugs when you're alone? Do you ever forget things while you're using the substances? Do family or friends tell you you should cut down? And have you ever gotten into trouble while you were using alcohol or drugs? The CRAFFT is actually one that is better verified for adolescents and it's a very good one for adolescents because they may consider some of those behaviors to be typical behavior because their friends do it, but it puts them at increased risk of actually meeting criteria for a substance use disorder. Next slide. Now remember I told you that screener, that Version one NIDA screener was positive and that included even things as simple as just smoking, what could you do then? This is actually takes a little longer to do and actually probably you wouldn't find many counselors for example or peers comfortable to doing it. It's called the Version two or the Modified NIDA ASSIST. They want you to ask for each substance in the past three months, have you used a substance say cannabis? How strong is your desire to use? And how often has it led to adverse consequences? And then six, seven, and eight are, have friends express concern about it? Have you tried to cut down and failed? And have you ever used drug by injection? The scoring is a little complicated, but if you look on the bottom URL there, you can see the that's how the level of risk is calculated. Next slide. These are some of the other addiction risk tools that we use in the clinic. You'll see three of them, the SOAPP, the ORT and the PDUQ are all geared toward opioids. Do you especially misuse your opioid pain medicines? Which ends up being very important, not in clinically, not only you determining whether somebody has a problem, but in terms of determining their risk if you're gonna prescribe them opioids. And some of the other ones are the STAR, which is a screening tool for addiction risk and the screening instrument for substance abuse potential. That's very important for primary care doctors in terms of easing their level of concern when prescribing a controlled substance. And in corrections that where that kind of treatment is being offered, those would also be important tools. So in the next slide, I show you the SOAPP, which is the Screener for Opioid Assessment for Patients with Pain. And you can see that they're all not on face value, things that you think you'd ask. How often do you have mood swings? How often do you smoke a cigarette within an hour after you wake up? Which is kind of, that's a good first question in terms of how dependent somebody is on nicotine. And how often have you had legal problems? Only questions three and four really directly pertained to the use of opioids. Three, how often have you taken a medication other than the way it was prescribed? Which usually refers to the opioids. And how often have you used illegal drugs? Which would include heroin, fentanyl, et cetera. And for the SOAPP, if you score a four or positive, that person is at increased risk of developing an opioid use disorder, if they were to be prescribed an opioid. You look at the next slide. So let's say you use these screening tools, and the easiest way within the judicial system, I would say is first to determine if screening tools are already being used, because just like prescribers are most comfortable with drugs they've already prescribed, if a tool is already in place, you've probably already had some training on it and people are comfortable with it. If a tool isn't in place, it wouldn't take long to use the clinical resources within your system or within the community to determine what screening tool you think might make sense for your personnel. For free localized education and training designed to meet your needs, contact the Opioid Response Network.

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