Advances in Addiction & Recovery (Winter 2020) by NAADAC, the Association for Addiction Professionals

WINTER 2020 Vol. 8, No. 1

Substance Use Disorders in First Responders: The Vicious Cycle of Chronic Traumatic Stress Exposure and Sleep Deprivation as Contributing Factors By Sara G. Gilman, PsyD, LMFT

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WINTER 2020 Vol. 8 No. 1 Advances in Addiction & Recovery, the official publication of NAADAC, is focused on providing useful, innovative, and timely information on trends and best practices in the addiction profession that are beneficial for practitioners. NAADAC, the Association for Addiction Professionals, represents the professional interests of more than 100,000 addiction counselors, educators, and other addictionfocused health care professionals in the United States, Canada, and abroad. NAADAC’s members are addiction counselors, educators, and other addiction-focused health care professionals, who specialize in addiction prevention, treatment, recovery support, and education. Mailing Address 44 Canal Center Plaza, Suite 301 Alexandria, VA 22314 Telephone 703.741.7686 Email naadac@naadac.org Fax 703.741.7698 Managing Editor

■ F EAT UR ES 15 Stepped Alcohol Treatment Improves HIV and Alcohol Outcomes

By the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Staff

16 Substance Use Disorders in First Responders: The Vicious Cycle of Chronic Traumatic Stress Exposure and Sleep Deprivation as Contributing Factors By Sara G. Gilman, PsyD, LMFT

20 Tailoring Substance Use Treatment to Emerging Adults

By Randall Webber, MPH, CADC, Jessica Love Jordan-Banks, MHS, CADC, Fred Dyer, PhD, CADC, and Mark Sanders, LCSW, CADC

24 The New Front Lines: Using Peer Recovery Specialists to Address and Treat Substance Use Disorder By Christopher Freer, DO, FACEP

26 Trauma Treatment and Addictions: Results of the NAADAC Member Survey

By Tom Alexander, PhD, LPC, Mary Hoke, PhD, MAC, BC-TMH, Karlene Barrett, PhD, CASAC2 and Edward Cumella, PhD, CEDS

■ DEPA R T M EN TS 4 President’s Corner: Kindred Spirits in Kosovo

By Diane Sevening, EdD, LAC, MAC, NAADAC President

7 From The Executive Director: National Resolution for Addiction Counselors

Introduced in Congress By Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, NAADAC Executive Director

8 Certification: NCC AP Update: Continued Development

By Jerry Jenkins, MEd, MAC, NCC AP Immediate Past Chair

9 Certification: And the Psychologists said, “MAC Please!”

By Nancy A. Piotrowski, PhD, MAC, NCC AP Commissioner

11 Ethics: Walking the Tightrope: Maintaining Our Ethical Responsibilities to Our Clients, Our Profession, and Ourselves By Mita Johnson, EdD, LAC, MAC, SAP, NAADAC Ethics Committee Chair

12 Conference: NAADAC 2019 Annual Conference Highlights

By Kristin Hamilton, JD, NAADAC Director of Communications

Kristin Hamilton, JD

Advisor

Jessica Gleason, JD

Features Editor

Samson Teklemariam, MA, LPC, CPTM

Graphic Designer

Austin Stahl

Editorial Advisory Committee

Kirk Bowden, PhD, MAC, NCC, LPC Rio Salado College EAC Chair

Kansas Cafferty, LMFT, MCA, CATC, NCAAC True North Recovery Services National Certification Commission for Addiction Professionals (NCC AP)

Deann Jepson, MS Advocates for Human Potential, Inc.

Roy Kammer, EdD, LADC, ADCR-MN, CPPR, LPC (CD), NCC Hazelden Betty Ford Graduate School of Addiction Studies James McKenna, MEd, LADC I McKenna Recovery Associates Donald P. Osborn, PhD, LCSW, LMFT, LCAC, MAC Indiana Wesleyan University Joseph Rosenfeld, PsyD, CRADC, HS-BCP Elgin Community College Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP NAADAC, the Association for Addiction Professionals Margaret Smith, EdD, MLADC Ottawa University & Keene State University Article Submission Guidelines We are interested in accepting any interesting and topical articles that address issues of interest to addiction-focused professionals. Please submit story ideas and/or articles to Features Editor, Samson Teklemariam at steklemariam@naadac.org. For more information on submitting articles for inclusion in Advances in A ddiction & Recovery, please visit www.naadac.org/advances-in-addiction-recovery. Disclaimer It is expressly understood that articles published in Advances in Addiction & Recovery do not necessarily represent the view of NAADAC. The views expressed and the accuracy of the information on which they are based are the responsibility of the author(s) and represent the wide diversity of thought and opinion within the addiction profession. Advertise With Us For more information on advertising, please contact Irina Vayner, NAADAC Marketing Manager, at ivayner@naadac.org. Advances in Addiction & Recovery The Official Publication of NAADAC, the Association for Addiction Professionals ISBN: 978-0-9885247-0-5 This publication was prepared by NAADAC, the Association for Addiction Professionals. Reproduction without written permission is prohibited. For more information on ob taining additional copies of this publication, call 703.741.7686 or visit www.naadac.org. Published March 2020

STAY CONNECTED

14 Advocacy: Advocacy for Addiction Professionals & Their Clients Tim Casey, Policy Advisor, Polsinelli

30 NAADAC CE Quiz 31 NAADAC Leadership

ALL IMAGES FROM SHUTTERSTOCK UNLESS OTHERWISE NOTED

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■ P R ESID ENT ’S CORN E R

Kindred Spirits in Kosovo By Diane Sevening, EdD, LAC, MAC, NAADAC President

Substance use disorders (SUD) and mental health disorders (MHD), including co-occurring or co-morbidity disorders, are not only a concern in North America but are also a concern throughout the world. As many of you know, NAADAC co-sponsored a professional exchange with National Council for Behavioral Health and World Learning in Kosovo on May 18–24, 2019. This trip provided opportunities for touring parts of Kosovo and meeting with the Minister of Health, the General Secretary of the Ministry, Director of the Mental Health Department, the Chief of the Minister’s Cabinet aide, the Director, Secretariat of Strategies, Ministry of Internal Affairs, the U.S. Ambassador, the Director of the Psychiatric Clinic and staff, the Executive Director of the Labyrinth Center, the Director of the Mental Health Center in Gjilan Municipality, and the Director of Streha Rehabilitation Center. The available treatment and treatment protocols for MHD and SUD in Kosovo differ from the available treatment and treatment protocols in the United States. There are three levels of care for MHD and SUD in Kosovo (primary, secondary, and tertiary), and the first point of contact for any patient with SUD and/or MHD in Kosovo is the family medicine doctor. Primary care includes the free family medicine centers; secondary care involves psychiatric wards and hospitals, integration homes, and the Center of Rehabilitation for Chronic Mental Health Disorders; and tertiary care includes the psychiatric clinics, the Center for Children and Adolescents, and forensics. Each of the levels of care works to improve health, reduce stigma, and allow patients to become self-sufficient. Currently, of patients diagnosed with addiction diseases, approximately 2% receive inpatient treatment at the psychiatric clinics. Marijuana and heroin are

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the predominantly used drugs in Kosovo, and methadone is the primary treatment provided for heroin addiction. Alcoholism is not believed to be a common problem, but this is not known for sure since it may be under reported due to the cultural norm of family members taking care of each other. Kosovo is planning to develop a center or institution for addiction diseases that can also provide an addiction diseases database. All government officials and healthcare providers with whom we met emphasized the importance of having highly educated and trained addiction professionals employed at this center of institution to provide treatment to the individuals who would receive treatment. All professionals providing therapeutic services are required to have at least a Master’s degree and be licensed in their respective profession. The main providers for SUD in Kosovo are medical doctors, psychiatrists, psychologists, and social workers. Currently, the universities do not provide any specific education for addiction professionals, but the professionals providing SUD services are increasingly recognizing the need for higher education specializing in addiction studies and addiction-specific licensure for addiction professionals. The individuals with whom we spoke consistently identified maintaining and funding appropriate treatment facilities, addressing the workforce shortage, and professional development as some of the key challenges that they face. While in Kosovo, we had the opportunity to visit the Labyrinth Center, an outpatient facility,

and Streha Rehabilitation Center, an all-male residential facility. Both facilities took unique approaches to treatment, education, and sustainability, and both facilities face a common problem that we also see in the United States: difficulty in finding qualified professional SUD staff. The Labyrinth Center, established in 2002, deals with the prevention of drug and alcohol abuse, the treatment of addiction to drugs and alcohol, and the reduction of drug-related damages. Labyrinth has three centers across Kosovo in Prishtina, Gjilan, and Prizren. This outpatient program employs professionals in the fields of medicine and psychology and provides counseling, psychotherapy, pharmacotherapy, methadone holding therapy, ambulatory opiate drug detoxification, and rapid tests for drug detection in the body. The facilities also provide information and education for drug users as well as for the general public, with a special focus on young people, about drugs and the risks accompanying their use and/or abuse. The Labyrinth Center facilities are currently treating approximately 2,300 patients, though qualified SUD professionals are difficult to find, creating a workforce shortage in providing competent and necessary care. Streha Rehabilitation Center is a professional rehabilitation center for people addicted to narcotic substances. Established in 2007 to create a peaceful and convenient environment for all people in need, its goal is to care for people addicted to drugs, train them for a free and independent life, and integrate them back into social life. The facility is located in a beautiful rural setting in Gjilan and offers a home environment with therapeutic conversations, various lessons, practical work, leisure, sports, music, art, and other activities. Streha therapy is done without medication and can last approximately 12 to 18 months. They currently have six beds for males aged 18 and over and their average patient is 35 years old. All residents are expected to join in farming the land, and the vegetables, fruits, and herbs that are harvested are shipped to various regions in Kosovo and other surrounding countries to fund the program. Streha’s leadership would like to expand the program and recognize the need to have a similar program for women but the inability to find and hire sufficient qualified SUD professionals is a barrier to adding beds and growing the program. The individuals in this delegation represented different areas of the United States with diverse backgrounds and professional expertise. It was exciting to get to know each other and share our professional and personal experiences realizing our common goal is providing the best care possible for the patients and constituents we serve through education, intervention, prevention, and treatment. It was equally gratifying

to engage with our counterparts from the other side of the world and learn that we face many of the same challenges and many of the same goals. This was a very memorable experience for me and wish to thank NAADAC for providing this opportunity to continue and develop international relationships. Diane Sevening, EdD, LAC, MAC, is an Assistant Professor at the University of South Dakota (USD) School of Health Sciences Addiction Counseling and Prevention Department (ACP), has over 35 years of teaching experience, and is a faculty advisor to CASPPA. In addition to serving as NAADAC President, Sevening is also a member of the South Dakota Board of Addiction and Prevention Professionals (BAPP) and Treasurer of the International Coalition for Addiction Studies Education (INCASE). Her clinical experience involves 7 years as the Prevention and Treatment Coordinator Student Health Services at USD, Family Therapist at St. Luke’s Addiction Center in Sioux City, IA for 1 year, and 2 years as clinical supervisor for the USD Counseling Center. Sevening has been the Regional Vice President for NAADAC North Central Region, the Chair of the Student Committee for NAADAC, and an evaluator for the National Addiction Studies Accreditation Commission (NASAC), and is currently a member of the NASAC board of commissioners.

NAADAC is leading a delegation to Greece on March 7-13, 2020! Led by NAADAC Executive Director Cynthia Moreno Tuohy, and Chuck Ingolia, President and CEO of the National Council for Behavioral Health, participants will have a unique opportunity to learn about the state of addiction and mental health programs in the Mediterranean region of Europe. Learn more at www. naadac.org/greece-professional-exchange. Stay tuned for the next opportunity to travel and learn with NAADAC.

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44 Canal Center Plaza, Suite 301 Alexandria, VA 22314 P: 703.741.7686 F: 703.741.7698 E: naadac@naadac.org

■ F R O M T H E E X E C U T I VE DI RE C TOR

National Resolution for Addiction Counselors Introduced in Congress By Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, NAADAC Executive Director A resolution recognizing addiction professionals was introduced in the U.S. House of Representatives by Representative Dave Joyce (R-OH14 and NAADAC’s Legislator of the Year in 2018) and supported by Representative Tim Ryan (D-OH-13) on June 4, 2019. The bipartisan resolution acknowledges the contributions of addiction professionals across the country who deliver quality, effective care to their patients and supports evidenced-based care for those working to overcome addition. “As a representative from one of the states hit hardest by the opioid crisis, I know how critical it is for our communities to have access to the full range of treatment and recovery services needed to effectively tackle addiction,” said Representative Joyce. “I’m proud to introduce this resolution alongside my good friend and fellow Buckeye, Congressman Tim Ryan, to not only raise awareness about all that addiction professionals do to provide life-saving treatment to their patients, but also to help build a workforce that can mitigate the threats addiction continues to pose in our communities.” (Congressman Dave Joyce, 2019) “As the Co-Chair of the Addiction, Treatment and Recovery Caucus, I have a keen understanding of the devastation caused by substance [use disorder], especially the opioid epidemic, which has ravaged too many lives, families and communities across the country. And it’s our addiction professionals who are on the front lines providing high quality, evidencedbased care to those affected by this public health crisis. I am proud to join Congressman Dave Joyce in honoring and recognizing America’s addiction professionals whose unwavering commitment and tireless dedication to their patients are saving lives every day,” said Congressman Ryan. The addiction professional workforce represents more than 100,000 counselors, educators and other addiction-focused health care professionals. By recognizing their critical contributions, this resolution not only increases awareness about recovery services, but also supports the knowledge, training, competencies, and credentials needed to deliver quality, life-saving care to those struggling with addiction. Our communities need and deserve access to the most effective treatment and recovery services available to meet the complex issues of substance use disorders. This resolution acknowledges the key role addiction professionals play in delivering comprehensive care for individuals with addiction and substance use disorders. Recognizing the requisite knowledge, training, competencies, and credentials for delivering quality, effective substance use disorder counseling is critical in recruiting the next generation of addiction professionals. As the national professional association representing the interests of addiction counselors, educators, and addiction-focused health professionals, NAADAC proudly supports the resolution and commends its authors for their commitment to improving the nation’s treatment and recovery services for individuals, families and communities. It is incumbent on us to continue to work to build the addiction workforce, and this Resolution is an important step to securing the recognition of the important role that addiction professionals play. One major obstacle that we face in building the workforce is the lack of funding allocated in

the bills introduced to support the workforce. NAADAC has tirelessly petitioned the Health Resources and Services Administration (HRSA) for additional support workforce development. HRSA is obligated to follow the directives of Congress, so passing this resolution will be an important step on the path to increasing our professions’ visibility and to strengthening our efforts to secure the support that we need. NAADAC will follow the National Resolution by asking you, our constitutes, to respond to our “Call to Action” to contact your legislators to support the resolution and sign on to the resolution. We also encourage you to use this Resolution as a template for your own State Resolution in Support of Addiction Professionals. We want states to recognize the importance of addiction counselors and their role in society. NAADAC’s long-term public policy goal continues to be the recognition, reimbursement and acceptance of nationally recognized credentials and the acceptance of a clear scopes of practice for the addiction profession. Currently, the confusion created by the large variety of credentials that are used throughout the country puts our profession and professionals in a position of disparity in insurance and Medicaid reimbursement compared with other counseling disciplines. Together, we can make a difference in the recognition of our contribution to close the gap on the addiction crisis in America! Let’s do it! REFERENCES Congressman Dave Joyce. (2019, June 4). Joyce, Ryan Introduce Resolution to Recognize the Life-Saving Work of Addiction Professionals [Press Release]. Retrieved from https://joyce. house.gov/press-releases/joyce-ryan-introduce-resolution-to-recognize-the-lifesavingwork-of-addiction-professionals/ Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, is the Executive Director of NAADAC, the Association for Addiction Professionals, and has worked as an addiction professional for over 35 years. She has been a trainer in Domestic Violence/Anger Management and Conflict Resolution for over 25 years as well as an international, national and state trainer in a variety of topics. Moreno Tuohy is also a curriculum writer in addiction screening and evaluation, counseling methods, conflict resolution, co-occurring disorders, and medicated assisted treatment and recovery, and has written articles published in national and other trade magazines. She holds a Bachelor’s degree in Social Work and is certified both nationally and in the State of Washington.

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■ CER T IF IC AT I ON

NCC AP Update: Continued Development By Jerry Jenkins, MEd, MAC, NCC AP Immediate Past Chair Much has been happening with the National Certification Commission for Addiction Professionals (NCC AP)! NCC AP has progressed with modernizing the scopes of practice and the materials associated with credentials, on boarding new commissioners, and preparing for a leadership change – all while monitoring national trends and collaborating nationally and internationally. The national standards set by NCC AP reflect a consensus of the current scope of practice for each credential the NCC AP offers. I consider developing these scopes of practice the toughest, most detailed, and most important challenge for NCC AP. Scopes of practice are not static for the respective credentials. They define the core competencies a professional should be knowledgeable in and able to do. Each individual holding the respective credential is responsible for determining his or her competencies and capabilities within these scopes of practice based on training and experience.

Job Task Analysis As detailed in previous articles, a job task analysis (JTA) was completed in 2018 for the NCAC I, NCAC II, and Master Addiction Counselor (MAC) credentials. The JTA demonstrated shifts in priorities of tasks and inclusion of new technologies, including an increased emphasis in assessment skills, assessment instruments and the areas to be assessed. Conversely, psychopharmacology shrank compared to previous JTAs. The most recent JTA revealed the following core areas to be priorities: (1) screening and orientation to the treatment process; (2) assessment; (3) ongoing treatment planning and implementation; (4) addiction counseling practices and skills; and (5) professional practices. These core areas further included 177 skills/knowledge areas currently considered critical for credentialed professionals. They also reflect the tenets of TAP 21, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice published by SAMHSA and last updated in 2017 (Center for Substance Abuse Treatment, 2006).

Qualified Addiction Professional & 1115 Substance Use Disorder Waiver Recently, I was introduced to the term Qualified Addiction Professional (QAP). The Centers for Medicare and Medicaid Services (CMS) included the term in the scope of practice literature related to the 1115 Substance Use Disorder Waiver recently approved for the Alaska waiver. It states, “Individuals presenting for any Medicaid-funded service in any setting (i.e., primary care, behavioral health care) will receive an AUDIT and a DAST. If the number of “yes” answers indicate the need for further assessment based on quantified scoring criteria, the screener will refer the Medicaid recipient to a behavioral health provider for an integrated, comprehensive clinical assessment conducted by a qualified addiction professional” (State of Alaska Department of Health and Human Services, 2018). Who is a QAP? Alaska, for example, has defined “substance use disorder counselor” as a qualified addiction professional, and holding an NCC AP credential meets the specified criteria (State of Alaska Department of 8

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Health and Human Services, 2019). As a result, persons can apply for the corresponding national credential once they meet the national criteria for training and experience for the level at which they tested. The 1115 waiver process for SUD services requires the use of standards set forth by the American Society of Addiction Medicine (ASAM). In April 2017, the Medicaid Innovation Accelerator Program published “Overview of Substance Use Disorder (SUD) Care Clinical Guidelines: A Resource for States Developing SUD Delivery System Reforms.” This document established the tenets of the ASAM’s “Treatment Criteria for Addiction Substance-Related, and Co-Occurring Conditions” as the industry standard for states to use in the 1115 SUD demonstration waiver process (IAP: Medicaid Innovation Accelerator Program, 2017).

New Commissioners Let me conclude by introducing our new Commissioners, Dr. Nancy Piotrowski, Dr. Gary Ferguson, and Michael Kemp, and NCC AP’s new Chair, Kansas Cafferty. Please visit www.naadac.org/about-the-ncc-ap to learn more about our Commissioners. It has been a true honor to serve as the NCCAP chair for the past three years. I now hand the reins to my distinguished colleague, Kansas Cafferty. I am confident that Kansas will do a wonderful job as Commissioner. We continue to recruit with an eye on diversity of credentials as well as experience and geography. Please visit the NCC AP website if you are interested in being considered. (www.naadac.org/about-the-ncc-ap ) Thank you for your professionalism and what you do to help people, families and communities recover from substance use disorders whether practicing in the US or somewhere else in the world. REFERENCES Alaska Commission for Behavioral Health Certification. (2017, February 13). Application for CDC II Certification. https://akcertification.org/wp-content/uploads/documents/New-CDCII-Application-2-28-17.pdf Center for Substance Abuse Treatment. Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice. Technical Assistance Publication (TAP) Series 21. HHS Publication No. (SMA) 15-4171. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006. IAP: Medicaid Innovation Accelerator Program. (April 2017). Overview of Substance Use Disorder (SUD) Care Clinical Guidelines: A Resource for States Developing SUD Delivery System Reforms. https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/reducing-substance-use-disorders/asam-resource-guide.pdf State of Alaska Department of Health and Human Services. (2018, January 31). Medicaid Section 1115 Behavioral Health Demonstration Application. https://www.medicaid.gov/ Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ak/behavioralhealth/ak-behavioral-health-demo-pa.pdf State of Alaska Department of Health and Human Services. (2019, April 30). Proposed Changes to Regulations: Medicaid Coverage, Behavioral Health Services, Revised Requirements for Behavioral Health Providers. https://aws.state.ak.us/OnlinePublicNotices/ Notices/Attachment.aspx?id=117675 Jerry A. Jenkins, MEd, LADAC, MAC, is the Immediate Past Chair of the National Certification Commission for Addiction Professionals (NCC AP). He has over 35 years of experience in treating substance use disorders and mental illness and has been a member of NAADAC since the late 1980s. He has worked in and managed community based, outpatient, halfway and residential treatment services. He is an advocate for recovery as the expectation for behavioral health care with an emphasis on being trauma informed and substance use disorder treatment counselors having credentials to demonstrate having specialized training, experience and skills.

And the Psychologist said, “MAC Please!” By Nancy A. Piotrowski, PhD, MAC, NCC AP Commissioner It is no surprise to anyone reading this magazine that NAADAC is committed to upholding high ethical and practice standards for addictions care. This is achieved through care providers receiving education, testing, and recognition through certification and credentials. What you might not realize however, is that a sister organization in addictions also has a long history of doing the same thing. Between 2001 and February 2018, the American Psychological Association (APA) through its practice organization (APAPO), was doing this same kind of work for psychologists working in addiction. Through a mechanism called a Certificate of Proficiency, licensed psychologists with relevant training experiences were eligible to sit for an exam to demonstrate their competency to work in the area of substance use treatment. Historically, in line with older versions of diagnostic nosology, it was called a Certificate of Proficiency in the Treatment of Alcohol and Other Psychoactive Substance Use Disorders. Efforts to establish such credentials were created to assist psychologists with meeting demands to document their competency to state agencies, third-party payers, referral sources, and consumers looking for ways to understand provider knowledge and skills to treat addiction. But to get a certificate, there was a step in between. Someone had to officially define what it meant to be proficient! As such, leaders in the Society of Addiction Psychology (SOAP; https://addictionpsychology. org), also known as APA Division 50, sponsored the establishment of such a definition. SOAP leaders worked with co-sponsors in APA Division 28, which focuses on Psychopharmacology and Substance Abuse, along with some other interested parties. And together, psychologists working in addiction wrote a report describing the core psychological knowledge and skills necessary for such proficiency, as well as specific methods for how psychologists gain such experience. Once defined by the sponsors, they presented the report to the APA Committee on the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP). CRSPPP defines the criteria for recognizing specialties and proficiencies and makes recommendations to the larger body of APA on such decisions. Once approved, proficiency definitions have to be reviewed and reaffirmed approximately every seven years through a renewal process. In its last revision, the Proficiency in the Treatment of Alcohol and Other Psychoactive Substance Use Disorders was updated to be the Proficiency of Addiction Psychology. It now renewed through 2024. A brief description of it is online (https://www.apa.org/ed/graduate/specialize/alcohol). But here is what has changed: the shared history in parallel is now merged for the process of certification. Changes at APA created an

opportunity to bring the certification process to NAADAC. During 2018, the APAPO Certificate of Proficiency in the Treatment of Alcohol and Other Psychoactive Substance Use Disorders transitioned to the National Certification Commission for Addiction Professionals (NCC AP) Master Addiction Counselor (MAC). And so, while NAADAC had previously had psychologists with a MAC, several hundred more are now present. Going forward, SOAP has the responsibility to maintain the definitions of the proficiency with CRSPPP in APA. Additionally, efforts will be made to look for opportunities to strengthen the MAC in ways that bring benefit for the many different types of professionals who hold it, including licensed psychologists. To this end, NCC AP has added a commissioner who is a licensed psychologist with a MAC, and I am serving in this role. A benefit with this transition for psychologists is that the MAC has great recognition nationally across a larger number of states that surpasses what was achieved by the prior certificate of proficiency. And while psychologists’ scope of practice typically covers work in addictions, so long as it is supported by appropriate preparation and experience, the MAC provides the added benefit of easy recognition by consumers, for referrals, and by third party payers. In March 2019, Cynthia Moreno Tuohy, NAADAC Executive Director, and I attended the annual APA Practice Leadership Convention (PLC) in Washington, DC to talk to psychologists about the MAC. We also held a roundtable discussion with varied state leaders about addictions credentials and other addictions issues. We anticipate continuing these conversations to identify additional opportunities to enhance the value of the MAC for psychologists and to look for more ways to bolster this very strong, shared tradition of continuously raising the quality of addictions treatment services through excellence in training and practice. REFERENCES Proficiency of Addiction Psychology, American Psychological Association Committee on the Recognition of Specialties and Proficiencies in Professional Psychology, https://www. apa.org/ed/graduate/specialize/alcohol Society of Addiction Psychology, American Psychological Association Division 50, https:// addictionpsychology.org/ Nancy A. Piotrowski, PhD, MAC, is a clinical psychologist with more than 35 years of experience working in addictions. Piotrowski is a past president of the Society of Addiction Psychology (SOAP) and division Federal Advocacy Coordinator in SOAP’s work with the American Psychological Association (APA). She maintains an active consultancy, teaches for University of California – Berkeley Extension, and serves as Core Faculty at Capella University in the Department of Psychology, where she is Lead Faculty in Addiction Psychology. Piotrowski also serves as a NCC AP Commissioner.

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For more information, please visit www.naadac.org/specialty-online-trainings.

■ E T H ICS

Walking the Tightrope: Maintaining Our Ethical Responsibilities to Our Clients, Our Profession, and Ourselves By Mita Johnson, EdD, LAC, MAC, SAP, NAADAC Ethics Committee Chair When it comes to addressing ethical and/or legal breaches, we have clear obligations not only to our clients, but also to our profession and to ourselves. We also have to ensure that we are not falling into the trap of providing an expert opinion or recommending the filing of a grievance based solely on limited information such as the client’s self-report without collateral information such as case notes/records or discussion with the therapist in question. It is important to be as objective as possible, factoring for our theoretical biases and personal opinions regarding therapeutic boundaries. We often are providing a professional opinion based solely on the client’s self-report, without accounting for professional bias. We cannot define a colleague’s attitudes or practices unethical or illegal just because the colleague used a different therapeutic approach, methodology or intervention than we would have. There is a difference between choosing a different clinical approach to an issue presented by the client and deeming such intervention as substandard care. We want to make sure we have a professional basis for forming an opinion about a colleague’s choice of methodology or intervention. As professionals, we recognize that we are not to put ourselves in the role of investigator or facts-find; as professionals, we must also recognize that we are not to put ourselves in the role of judge or jury. Prior to recommending that a client file a grievance against another therapist, it is important that we ask ourselves several important questions. Are we basing our professional opinion solely on the client’s self-report, knowing that there are two sides to every story? Is there any chance that the client’s report is false, incomplete, inaccurate, or invalid? Is our assessment of the colleague based on our theoretical or other biases? Are our boundaries of professional behavior inflexible, narrow, or misinformed? Are we informed about the standards of practice and evidence-based modalities specific to the presenting issues the client took to the other therapist? Do we have a pre-existing negative opinion of the colleague? Is the situation unethical and/or illegal versus being a situation where we disagree with the other therapist and his or her assessment and technique? Is there any chance that we are taking on a savior-rescuer role with the client? We have an unwavering duty to protect clients and the profession from incompetent, predatory, and harmful therapists. There are therapists who cross professional lines and exploit or harm their clients. We also have an ethical and professional obligation to not make assumptions or form premature or unsubstantiated conclusions without further discussion with the client and our clinical supervisor or consultant. Just because a therapist approaches the same clinical issue differently does not make them wrong. Each clinician has their own scope of competency, and the benchmark will always be “do no harm” and how that is defined. We recognize that there are standards of practice that we are measured against. Situations such as sexual misconduct have clear benchmarks – there are

no circumstances where this behavior is acceptable. Situations involving differences of opinion related to theoretical modalities and tools used are not so clear. It is important that we are reflective and thoughtful about concerns we might have about another therapist’s practices. We must at least consider seeking clinical supervision and/or consultation prior to directing a client to file a grievance against a clinician. In cases of harm, we might recommend that the client seek legal counsel to determine the best course of action. The NAADAC Code of Ethics call us to be advocates for our clients and often times we begin that advocacy by seeking supervision and consultation. We are not only called to reflect on the behaviors of others, but also on our own behavior. In the process of holding other professionals accountable, we hold ourselves accountable as well. Mita Johnson, EdD, LPC, MAC, SAP, has degrees in biology, counseling, and counselor education and supervision. Johnson is a faculty member at Walden University’s School of Counseling MS Program. Johnson teaches, trains, and speaks nationally and internationally on psychopharmacology, ethics, and the science of addictions. She became interested in the field of addictions when she realized that most of her clients were dealing with co-occurring mental health and substance misuse or other behavioral addictions. Johnson is passionate about understanding how drugs influence the body homeostasis systemically. Johnson is an Executive Committee and Board Member of NAADAC as President-Elect and is NAADAC’s Ethics Chair.

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■ CO NF ER EN C E

NAADAC 2019 Annual Conference Highlights By Kristin Hamilton, JD, NAADAC Director of Communications With over 1,000 participants, 100 exhibitors, and 90 presentations, the NAADAC 2019 Annual Conference: Navigating the Addiction Profession in Orlando, Florida, from September 28 – October 2 was a huge success! NAADAC members and other addiction professionals from across the country received up-todate information from the top industry experts on the latest trends, practices, and critical issues that impact addiction professionals, built their businesses and networks, and had fun! NAADAC would like to extend its gratitude to all of the presenters, speakers, sponsors, and partners who contributed to make this year’s conference a success.

Missed Orlando? You can still learn from the best of the best on your own time! Materials and handouts from sessions are available at www.naadac.org/ ac19-schedule.

Hope to See You in Washington, DC! The 2020 NAADAC Annual Conference: Learn, Connect, Advocate, Succeed will take place at the Gaylord National Resort & Convention Center from September 25–30, 2020, including pre-conference training sessions on September 25, post-conference training sessions on September 29–30, and a Hill Day on September 29. Regular conference sessions will take place September 26–28. For more information, please visit https://www.naadac.org/ annualconference. We look forward to seeing you in Washington, DC! Kristin Hamilton, JD, is the Director of Communications for NAADAC, the Association for Addiction Professionals. She works on NAADAC public relations, communications, and digital media, including the NAADAC website and social media, is editor of NAADAC’s two ePublications, the bi-weekly Addiction & Recovery eNews and weekly Professional eUpdate, and is the managing editor for NAADAC’s magazine, Advances in Addiction and Recovery. She also contributes to the planning, organization, and administration of communication campaigns, administers the PhD Candidate Survey Program, and serves as the affiliate liaison for the Communications Department. Hamilton joined NAADAC in December 2015. She holds a Juris Doctorate from Northeastern University School of Law in Boston, MA, and a Bachelor of Science degree in Biology and Chemistry from Roger Williams University in Bristol, RI.

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■ A D V O C AC Y

Advocacy for Addiction Professionals & Their Clients: 2019 in Review By Tim Casey, Policy Advisor, Polsinelli It was a busy 2019 in Washington, D.C. for NAADAC. Our efforts yielded important progress and generated a flurry of activity on Capitol Hill around key issues impacting you and your clients. Despite a tense atmosphere in our nation’s capital, we managed to raise the profession’s profile among lawmakers and make significant progress on critical policy priorities, including the following:

Congressional Resolution Recognizing Addiction Professionals (H.Res.419) NAADAC worked closely with the co-chairs of the Congressional Addiction, Treatment and Recovery Caucus to introduce language in the House of Representatives acknowledging the critical contributions of Addiction Professionals in the delivery of quality, evidence-based SUD treatment and recovery services. Representatives Dave Joyce (R-OH) and Tim Ryan (D-OH) introduced H.Res.419 in the spring, along with original cosponsors Representatives Bill Johnson (R-OH), Paul Tonko (D-NY), James Sensenbrenner (R-WI), and Ann Kuster (D-NH). NAADAC is grateful to our Congressional champions for raising awareness about the role of addiction professionals and honoring your vital contributions. NAADAC has been busy building cosponsors for the resolution, but we need your continued help! Be sure to contact your Representative and urge him or her to cosponsor and support H.Res.419.

The Addiction Treatment Access Act (S. 2412) NAADAC helped identify and address a critical gap in Medicare coverage for treatment and recovery services. Working closely with Senators Tester (D-MT), Sullivan (R-AK), Shaheen (D-NH), and Murkowski (R-AK), NAADAC helped shape legislation that would provide coverage of addiction counselor services under Medicare Part B. NAADAC was pleased to support introduction of the Addiction Treatment Access Act (S. 2412) and commends these Senators for their leadership on this critical SUD treatment issue. Recognizing the education, training, and competencies of addiction counselors under Medicare Part B represents a critical point of access to services for so many in need. NAADAC continues to build support among Senators for the legislation and is working to cement champions in the House for a companion measure. Medicare beneficiaries in your community deserve access to the treatment and recovery services they need, and you deserve to be reimbursed for providing them. Contact your Members of Congress today, and urge them to support this important legislation.

Bolstering the Workforce In 2019, we successfully advocated for funding for critical access and workforce programs including the National Health Service Corps, the 14

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Minority Fellowship Program (MFP), the newly authorized Loan Repayment Program for the Substance Use Disorder Treatment Workforce, and a number of other important programs impacting you and your clients.

Protecting Privacy We also worked tirelessly to combat harmful policies, including ongoing efforts to align 42 CFR Part 2 with HIPAA standards in comprehensive SUD legislation, as this policy risks compromising confidentiality and could discourage those in need from seeking treatment.

Raising NAADAC’s Profile We’ve crisscrossed Capitol Hill over the past year, including all together at NAADAC’s annual Advocacy in Action Conference. We have dramatically expanded NAADAC’s Congressional network and are increasingly fielding calls from lawmakers seeking feedback on proposals across a widerange of topics, including reimbursement, SUD treatment and recovery services, housing, workforce and loan repayment, childhood trauma and foster care, and many other issues impacting addiction professionals. NAADAC’s Advocacy in Action conferences have provided great visibility for the profession on Capitol Hill and with the agencies. The conferences included a full day of training and guest speakers, followed by a slate of meetings with prominent lawmakers and staff on Capitol Hill. We also hosted two Congressional briefings, where we engaged in meaningful discussions with Congressional staff and stakeholders in the Capitol and House Cannon Building, respectively.

Your Voice Counts These are critical times for our profession and for our nation. Your elected officials can help support addiction professionals and the clients who count on you in communities across the country. Please stay tuned as we provide updates on these important developments, and be sure to share the feedback you receive from your elected officials with NAADAC. With your support, we will build on these successes in 2020 and continue positively shaping federal policies impacting you and your clients. Tim Casey is a policy advisor at Polsinelli. He has a proven record of leadership in advancing the federal priorities of national associations, corporations, consumer organizations, and nonprofits. On Capitol Hill, Casey is a trusted resource to Members of Congress and their staff. Casey’s experience in the House and Senate combined with his time as a senior lobbyist for prominent health care organizations offers clients sound policy advice, strategic political counsel, and a keen instinct for delivering on key priorities before Congress and the Administration.

Stepped Alcohol Treatment Improves HIV and Alcohol Outcomes By National Institute on Alcohol Abuse and Alcoholism (NIAAA) Staff

ncreasing the intensity of treatment for alcohol use disorder (AUD) over the time course of treatment reduces alcohol consumption among people living with human immunodeficiency virus (HIV) and AUD, according to new clinical research supported by NIAAA. In the study, led by researchers at Yale University, this stepped approach to AUD treatment also reduced viral load (amount of HIV present in the blood) and improved other HIV-related disease measures in this patient population. A report of the study appears in The Lancet HIV. “These research findings demonstrate the potential of integrated treatment for AUD and HIV to improve health outcomes and provide support for integrating AUD treatment in HIV and other healthcare settings,” says NIAAA Director George F. Koob, PhD. Alcohol misuse can increase risky behaviors that increase the likelihood of acquiring HIV, speed the progression of the disease, and make it harder to follow medication regimens. Previous studies have linked drinking, even at low levels, to greater risk of death for people with HIV. In the present study, E. Jennifer Edelman, MD, MHS, and her colleagues at Yale studied five U.S. Department of Veterans Affairs–based HIV clinics with 128 people who were HIV-positive and had AUD.

They investigated integrated stepped alcohol treatment (ISAT)—an approach that involves consecutive steps of increasing the intensity of AUD treatment if lower-intensity treatment does not produce desired results. Although no differences in drinks per week consumed or HIV outcomes were found between the ISAT group and control group at 6 months, at the 12-month followup, individuals receiving ISAT were found to have fared better—reporting fewer drinks consumed per drinking day and a greater percentage of days abstinent. “Importantly, we also observed that participants randomized to stepped AUD treatment were more likely to achieve an undetectable HIV viral load,” says Dr. Edelman. “We believe that with decreased alcohol consumption, participants in the ISAT group were more likely to take their HIV medications consistently, translating into improved HIV viral control.” REFERENCE Edelman, E.J.; Maisto, S.A.; Hansen, N.B.; Cutter, C.J.; Dziura, J.; Deng, Y.; Fiellin, L.E.; O’Connor, P.G.; Bedimo, R.; Gibert, C.L.; Marconi, V.C.; Rimland, D.; Rodriguez- Barradas, M.C.; Simberkoff, M.S.; Tate, J.P.; Justice, A.C.; Bryant, K.J.; and Fiellin, D.A. Integrated stepped alcohol treatment for patients with HIV and alcohol use disorder: A randomised controlled trial. The Lancet HIV 6(8):e509–e517, 2019. PMID: 31109915

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Substance Use Disorders in First Responders The Vicious Cycle of Chronic Traumatic Stress Exposure and Sleep Deprivation as Contributing Factors By Sara G. Gilman, PsyD, LMFT

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reaking the silence about substance use disorders in public safety professionals is the first step in addressing the stigma that having a substance-related or mental health problem is a sign of weakness. Cumulative exposure to traumatic stress has negatively affected the first responder workforce for decades. For many, turning to substance use to manage the internal turmoil is a way to escape. In time, this vicious cycle of coping becomes the greater problem as addictive patterns take hold. Emergency first responders (police officers, firefighters, emergency medical technicians, paramedics, 911 dispatchers, emergency room personnel, rescue workers) are public safety professionals who respond to emergency situations every day. They are expected to consistently respond with rapid and competent judgments amid hazardous situations. Over time, these routine calls take toll on their physical and psychological health while they continue to be exposed to additional traumatic events during their career (Haugen & Weiss, 2012). The rates of posttraumatic stress disorder (PTSD) in first responders have remained higher than the rates in the civilian population for the past decade, suggesting the negative impact of their unique occupational stress. Additionally, there is growing evidence that first responders exhibit ongoing symptoms of distress such as depression, heavy alcohol consumption, anxiety, hyperarousal, and sleep disturbances. These symptoms significantly impact the first responder’s overall health and sense of well-being, but they rarely receive a diagnosis of PTSD (Bergen-Cico, 2015; Utzon-Frank, 2014). The average career of a firefighter, police officer or 911 dispatcher can vary. Staying physically and mentally fit throughout these years is an imperative, yet challenging job requirement. Chronic exposure to graphic human tragedy such as mangled bodies from vehicle accidents; hearing a mother screaming while trying to revive her baby; an elderly person injured, scared and alone; caring for a child who has suffered terrible neglect; young adults who have died due to drug over dose or suicide; seeing heinous violence; or going into a burning structure in hopes to save those inside; can breakdown even the most resilient people. Like any human, the first responder takes in these experiences through all their senses. Due to their extensive training, they have learned to override emotionally reacting in order to make split second decisions in the urgency of the incident. So, where does all of this ‘data’ go when it is downloaded into the first responders’ brain and nervous system day after day, year after year?

Prevalence The prevalence of alcohol abuse in first responders can range from 16%40% (Milligan–Saville, et al., 2017; Jones, S., 2017; Utzon-Frank, N., et al., 2014). Research literature documents terms such as binge drinking or hazardous levels of drinking and notes that peer encouragement is a strong factor in drinking behavior. Alcohol consumption, tobacco chewing, and smoking are the primary substances used, along with overuse of pain killers. Like the general public, first responders can begin using pain medications following an injury and then the insidious over usage quickly evolves. In the Ruderman White Paper on Mental Health and Suicide of First Responders (2018), one research team examined drinking among female firefighters and found that 40% reported binge drinking during the previous month, and 16.5% of female firefighters who used alcohol

screened positive for problem drinking behaviors (Haddock, et al., 2017). Another study included both male and female firefighters and found even higher rates of binge and hazardous drinking – 58% and 14%, respectively (Carey, et al., 2011). The presence of SUD diagnostic criteria as a potential indicator for mismanaged trauma builds off studies, including Jahnke’s 2014 study, that suggest substance abuse exacerbates PTSD symptoms and increases with the severity of psychological trauma (Jahnke, 2014).

Inherent On-Duty Experiences Contribute to Substance Use, Abuse and Addiction Chronic traumatic stress exposure and other occupational hazards such as fearing for one’s own life creates an over-taxed system and hypervigilance. The shock of each tragic and violent event has a cumulative physical and mental strain that, for some, is temporarily relieved by drinking alcohol or taking pain medication. This cumulative exposure to traumatic stress throughout the first responder’s career causes ongoing distress, often referred to as sub-threshold posttraumatic stress disorder (S-PTSD). S-PTSD symptoms include irritability, sleep disruption, fatigue, anger, detachment, isolation, alcohol use increase, hypervigilance, startling, physical aches & pains, headaches and anxiety (Chopko & Schwartz, 2012). Diminished quality of life can be ongoing and can contribute to a higher incidence of delayed-onset PTSD (Haugen & Weiss, 2012). These symptoms are often not acknowledged, and many first responders suffer in silence buying into the stigma that trauma is part of the job. Left unaddressed, symptoms related to chronic traumatic stress rarely improve or dissipate. Proactively addressing stress management and self care are vital components to the first responder understanding normal stress responses to cumulative exposure and recommended steps towards treatment.

Working Long Hours Is Not a Badge of Honor; It Is Fuel for Self-Destruction Sleep deprivation is a significant contributing factor to health problems for first responders. Extended working hours and disrupted sleep patterns can cause a first responders’ system to become dysregulated over time (Haddock, et al., 2017). This disruption in the natural circadian rhythms also interrupts invaluable sleep patterns known as REM sleep (Rapid Eye Movement). Chronic disruption to REM sleep, as a result of chronic stress negatively affects the way memories are stored. The result is long-term problems with the hypervigilant nervous system and additional symptoms related to posttraumatic stress injury. Until recently there has not been adequate attention on how to rebalance the system to restore quality sleep, nor was there much education about the serious negative consequences that sleep deprivation can cause, such as impairments in judgement and decision making. Within first responder culture, many use alcohol or sleep medications off-duty to aide in falling asleep (Chopko & Schwartz, 2012). While the negative effects of sleep deprivation have been known for a long time, organizations still appear slow to implement positive change. For example, in 2007 there was a thorough report put out by the International Association of Fire Chiefs and collaborative partners about the fatigue related problems that occur on the job. Recommendations were made to improve the problem (Toomey, J. & Toomey, S., 2018). In 2018 (eleven years later), an excellent article was published in the Fire Engineering magazine by Jacqueline and Sean Toomey titled “Addicted to Awake: Sleep Deprivation in the Fire Service.” Once again, W I N T E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 17

statistics confirm the industry-wide impact of sleep deprivation amongst first responders. In a study of over 6,900 firefighters, 40% presented with symptoms that should earn a diagnosis of sleep apnea, insomnia and work shift disorder. However, 80% of those presenting with diagnosable conditions had no history of receiving a diagnosis (Toomey, J. & Toomey, S., 2018). Without an accurate diagnosis, first responders were unaware and treated with mismatched interventions, leading to further destructive coping strategies such as excess alcohol consumption. Fortunately, Toomey & Toomey’s research suggests making cultural changes in discussing sleep hygiene and provides ways to implement department changes in training first responders on sleep recovery practices.

Stigma & Breaking the Silence Continual problems related to substance use remains hidden in a work culture where de-stressing with alcohol and comradery is normal. There are internal barriers and legacy-driven norms impeding progress. Some examples include not talking about traumatic experiences, believing that an inability to compartmentalize on-the-job experiences as a sign of inability to work as a first responder, and fear of appearing weak or unfit for duty. Often the result of a first responder talking about a traumatic experience is decreased trust amongst peers, less confidence in decision-making, and risk of job loss. While this stigma is currently being confronted, and broken down in many departments, it is still prevalent. Peer Support Programs that include Chaplains and Mental Health Professionals are beginning to emerge in many departments. Psychoeducation on the neurobiology of stress is needed to help normalize stress responses, along with stress management skills training to develop healthy coping strategies. Since substance use disorders are treatable, and research shows that on-duty stress is a contributing factor, then the industry must acknowledge the value of addressing, treating and building a clear path to return to work. If SUDs were treated like other types of on-the-job injuries, first responder culture will improve over time. However, the judgmental responses to this type of injury run deep and often employees are dealt with in a punitive manner and shamed.

Importance of Peers in Recovery Reaching the first responder in need can be difficult, but successful approaches leverage concerned peers in early intervention. A first responder in recovery can be a vital voice heard in the silence of suffering – whether that person is a peer or an addiction counselor. Two first responders share their experience of suffering with substance use disorder and their recovery. With 33 years in the Fire Service, an anonymous first responder openly shares a personal story and example of how Peer Support Team members can help: “During my career, I have seen a lot of changes for the way we fight fires to the way we deal with stress. Over the years call-volume has increased, and the number of major incidents has increased. When I first started in the fire service, I was told to never talk about feelings and never show that calls affected you, suck it up and move on. The way for many of us to cope was to go out after the shift and have a beer. At the beginning, this seemed to work but over years and years, many peoples’ drinking increased and started to affect careers and home life. Many of us still would not talk about the effects the job had on our 18

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lives and how we were using alcohol as a short-term fix to mask the pain. For many firefighters, this is still working today, or so they think. There is a major increase of abusing alcohol and drugs, because we are still scared of what our peers will think if we show any feelings or any vulnerability. So, we minimize it and hide our truth. For me, after I hit what I hope was the worst day of my life, the day my kids told me “Dad, you need to get help and stop drinking or we don’t want to be around you anymore.” This was my wake-up call, but many of us never get that and end up considering or committing suicide because the inner pain, nightmares, flashbacks and the thought of more human tragedy ahead, is just too overwhelming. I finally asked a friend, a fellow firefighter, for help; he had been sober for 6 years at that point. I had to let my Department know what I planned to do to get myself better. I was scared that they were going to fire me, but to my surprise, they fully supported me and bent over backwards to help me. I started to work with my friend and checked into a 28-day in-patient rehab facility. After I finished the inpatient program, I returned to work worried what people thought and said about me. I was showing weakness! But again, to my surprise, I found out that I was not alone. That there was a larger group of us that were in recovery; it wasn’t something that everyone had known about but if someone in the group heard of a possible employee with a problem or just starting their recovery, someone would reach out to them. The people in the group know who is in the group, but no one advertises the group. We all check on each other. We are all involved in a recovery program, and I have to say, it is nice to have a group of people in recovery that does the same job I do because we all have walked in that pair of shoes. As part of my recovery, I have become very involved with my department’s Substance Assists Program. I have talked to people, taken some to treatment facilities and sat with them as they tried to figure things out. As most firefighters are “Type-A” personality, and don’t ask for help, it is nice to know there are people just like you in the fire service and in your department. Especially as people begin their recovery to know that you are not alone. For me, it is an honor to help my brothers and sisters in the fire service because I am giving back to a family I love. To those that may be struggling with substance [use disorder], please reach out. Trust me there is a hand of one of your brothers or sisters that will help you.”

The first personal story is a reminder that there is a sub-culture in the first responder family of those in recovery. First responders in recovery can be instrumental in not only getting the help needed, but also in healing the guilt and shame that accompanies the one who has been struggling alone. Another anonymous first responder shares a different experience. The next story comes from a former narcotics detective who later became an addiction counselor. This highly recognized police officer and detective loved work, friends, family and identified co-workers as a second family. Eventually, this story ends with an untreated substance use disorder related to prescribed pain medication from numerous injuries and ultimately resulted in loss of the life and career once cherished. The message to counselors who want to work with first responders is to continue building an empathic understanding of the intense barrier of cultural stigma, and the shame that accompanies officers who suffer with SUDs: “The stigma of asking for help, specifically amongst law enforcement, keeps many suffering in silence. It is not a job; it is an honor

and duty to bond together to help others. We vow the oath to serve and protect. Subsequently, seeing first-hand the horrors of violence, tragedy, and innocence lost, many don’t feel safe to speak of their inner anguish and emotional wounds experienced as a result. Turning to substance use seems a valid solution to escape the internal turmoil. How do we expect first responders to seek help if they are living in fear of the stigma of addiction and mental health disorders? The stigma is drilled into them since starting the academy. Addiction counselors can especially help if they have experience with first responders and understand the complex nature of this population. Counselors need to be ethical and introduced through trusted sources. Counselors also need to have a passion for counseling first responders, and be motivated to learn, firsthand, what first responders are dealing with.”

The second personal story is a reminder that confusion, misinformation and stigmas in police culture makes it extremely difficult to maintain career and connections. When officers need help, the barriers perpetuated by stigma causes confusion on where to go for help. Peers in recovery can support the difficult first step of finding those who understand and identifying a path towards recovery. First responders in recovery can validate feelings of shame or personal disappointment for those seeking help. The potential barrier of violating public service oath becomes a relatable experience. Addressing stigma as a barrier, relatable experiences, and shame concurrently promotes successful treatment outcomes. Using evidence-based trauma-informed interventions is important but achieving cultural competence for this unique population of heroes, who continually risk their lives for others, is also critical. Beyond formal training, a counselor for first responders can leverage everyday experiences to continue learning in cultural competency. For example, request a ride-along with police and fire departments, sit-along with dispatchers, or volunteer shift in the ER. There is incredible learning value in achieving a live visual experience with first responders. Experiential continued learning also provides an opportunity to inquire about first responders’ day-to-day experience, which can build a counselor’s ability to build rapport, conceptualize unique cases, and provide more targeted treatment solutions. For continued learning and development, addiction treatment professionals should build skills in stress management techniques for anxiety such as breathing exercises, guided visualizations, mindfulness and heart rate variability training. Additionally, become trained in trauma-informed modalities such as Eye Movement Desensitization and Reprocessing (EMDR) and Trauma Informed-Cognitive Behavioral Therapy (TI-CBT). These therapies have specific protocols for people recovering from substance use disorders. It is imperative for the family of the first responder to be a part of the recovery and treatment process. The family has suffered alongside their loved one and would benefit from individual counseling, couples and family counseling, and support groups such as Al-Anon and ACA. There is strength in a collaborative treatment team who can work together to meet the needs of the first responder and their loved ones. Finding ways to support and encourage those in recovery to return to the career they love, while managing the impact of ongoing traumatic stress exposure is challenging, yet not impossible. Bringing together caring peers, passionate and well-trained counselors, using effective treatment

methods, along with human resource professionals who will support the recovery process and do their best to protect the first responders’ job, will create the best scenario for positive outcomes. Working together, all professional helpers can protect and serve those first responders in need of restoring the mind, body, and soul! REFERENCES Bergen-Cico, B., Lane, S., Wozny, S., Zajdel, M., & Noce, J. (2015). The impact of post-traumatic stress on first responders: analysis of cortisol, anxiety, depression, sleep impairment and pain. International Journal of Paramedic Practice, 5(3),78-87. doi:10.12968/ ippr.2015.5.3.78 Bhatia, K. M., & Pandit, N. (2017). Prevalence of Chronic Morbidity and Sociodemographic Profile of Police Personnel – A Study from Gujarat. Journal of Clinical and Diagnostic Research : JCDR, 11(9), LC06–LC09. http://doi.org/10.7860/JCDR/2017/27435.10586 Carey, M. G., Al-Zaiti, S. S., Dean, G. E., Sessanna, L., & Finnell, D. S. (2011). Sleep problems, depression, substance use, social bonding, and quality of life in professional firefighters. Journal of occupational and environmental medicine, 53(8), 928-33. Chopko, B. A., & Schwartz, R. C. (2012). Correlates of career traumatization and symptomatology among active-duty police officers. Criminal Justice Studies: A Critical Journal of Crime, Law & Society, 25(1), 83-95. http://dx.doi.org/10.1080/1478601X.2012.657905 Gilman, S., (2017). Doctoral Dissertation: “CHRONIC TRAUMATIC STRESS EXPOSURE IN EMERGENCY FIRST RESPONDERS: EMDR AS AN INTERVENTION., California Southern University, Costa Mesa, CA. Gilman S., Kerwood, R., (2018) Does Your Console Need a Reboot? EMDR Therapy for Healing Traumatic Stress & Self Care. In J. Marshall (Ed) The Resilient 9-1-1 Professional, A Comprehensive Guide to Surviving & Thriving in the 9-1-1 Center (pp.112-127). South of Heaven Press. Gilman, S., & Marshall J., (2015). Reaching the unseen first responder: treating 911 trauma in emergency telecommunicators. In M. Luber, (Ed), EMDR Scripted Protocols: Anxiety, Depression, and Stress=Related Issues (pp. 185-216). New York: Springer Publications Haddock, CK., Poston, W.S.C., et al., (2017) Alcohol Use and Problem Drinking among Women Firefighters Womens Health Issues. Nov - Dec;27(6):632-638. doi: 10.1016/j. whi.2017.07.003. Epub 2017 Aug 16. Haddock, C. K., Day, R. S., Poston, W. S. C., Jahnke, S. A., & Jitnarin, N. (2015). Alcohol Use and Caloric Intake From Alcohol in a National Cohort of U.S. Career Firefighters. Journal of Studies on Alcohol and Drugs, 76(3), 360–366. http://doi.org/10.15288/jsad.2015.76.360 Haugen, P. T., Evces, M., & Weiss, D. S. (2012). Treating posttraumatic stress disorder in first responders: A systematic review. Clinical Psychology Review, 32(5), 370. doi:10.1016/j. cpr.2012.04.001 Jahnke, S. A., Gist, R., Poston, W. S. C., & Haddock, C. K. (2014). Behavioral health interventions in the fire service: Stories from the firehouse. Journal of Workplace Behavioral Health, 29(2), 113-126. doi:10.1080/15555240.2014.898568 Jones, S., et al., (2018) Prevalence and correlates of psychiatric symptoms among first responders in a Southern State Archives of Psychiatric Nursing, Volume 0, Issue 0 https://doi. org/10.1016/j.apnu.2018.06.007 Milligan‐Saville, J. S., Paterson, H. M., Harkness, E. L., Marsh, A. M., Dobson, M. , Kemp, R. I., Bryant, R. A. and Harvey, S. B. (2017), The Amplification of Common Somatic Symptoms by Posttraumatic Stress Disorder in Firefighters. JOURNAL OF TRAUMATIC STRESS, 30: 142148. doi:10.1002/jts.22166 Toomey, J., Toomey, S., (2018). Addicted to Awake: Sleep Deprivation in the Fire Service. Fire Engineering Magazine. Rudermanfoundation.org, 2018, The Ruderman White Paper on Mental Health and Suicide of First Responders. Utzon-Frank, N., Breinegaard, N., Bertelsen, M., Borritz, M., Eller, N. H., Nordentott, M., . . . Bonde, J. P. (2014). Occurrence of delayed-onset post-traumatic stress disorder: A systematic review and meta-analysis of prospective studies. Scandinavian Journal of Work, Environment & Health, 40(3), 215-229. doi:10.5271/sjweh.3420 Sara G. Gilman, PsyD, LMFT, is a licensed Marriage & Family Therapist, with a Doctorate degree in Psychology. Her doctoral dissertation focused on the effects of cumulative traumatic stress exposure in first responders and the use of EMDR as an early intervention. She is the co-founder of Coherence Associates, a professional counseling corporation in San Diego, CA. As a former San Diego Rural Firefighter/EMT she served on the San Diego CISM Team and was awarded Fellowship status with the American Academy of Experts in Traumatic Stress for her work with first responders. She is past President of the EMDR International Association Board of Directors, contributing author in two books addressing treating trauma in 911-Telecommunicators. As a national speaker, consultant, and trainer, Gilman has a genuine passion to help people heal and grow, by creating a fun atmosphere to build resilience and promote long-term psychological wellbeing.

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Tailoring Substance Use Disorders Treatment for Emerging Adults By Randall Webber, MPH, CADC, Jessica Love Jordan-Banks, MHS, CADC, Fred Dyer, PhD, CADC, and Mark Sanders, LCSW, CADC

he National Institute on Drug Abuse reports that no single treatment is appropriate for everyone, that treatment needs will vary based on the type of substance used and characteristics of the patient, and that treatment settings and services should be appropriate to the individual’s age, gender, ethnicity, and culture (NIDA, 2018). Yet, substance use disorder (SUD) treatment is often provided in more of a one-size-fits-all type of modality. Such is widely the case with emerging adult populations (18 to 25 years old) seeking SUD treatment. Since the developmental changes that happen during emerging adulthood (18 to 25 years old) tend to be a more gradual process – a stark contrast to the dramatic changes that occur during child and adolescent development – early adulthood years are often devalued as a developmental period (Bonnie, 2015). Consequently, the need for population-specific SUD treatment practices for this age group is often unnoticed and underaddressed. Contrary to the misconception, emerging adulthood is a fundamental period of biological and psychological maturation, and an integral part of the transformation of adolescents into adults. For instance, recent research suggests that the frontal lobe area of the brain, which houses the prefrontal cortex, may not be fully developed until a person reaches their mid-thirties (Johnson, Blum & Giedd, 2009). The prefrontal cortex is the area of the brain that mediates an individual’s ability to carry out new and goal-directed behavior, sustained attention, short-term memory tasks, working memory, inhibitory control, delayed responding, and active problem solving; the executive functions of the prefrontal cortex are also closely linked to emotional regulation (Siddiqui, 20

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Chatterjee, Siddiqui & Goyal, 2008). Although the brain’s prefrontal executive processes may function at adult levels in emerging adulthood, the processes involved in monitoring behavior are still improving and continue to mature through young adulthood, which may affect decision making (Bonnie, 2015). As such, impairment or underdevelopment in these areas of executive functions often manifest in the form of impulsivity, poor planning behavior, poor decision making, poor strategy formation, and problem-solving. With such critical parts of the brain still developing through early adulthood, emerging adults are at increased risk for using impaired decision-making, as well as an increased risk for causing significant changes in brain development with exposure to psychoactive substances (NIDA, 2018). Taking these factors into consideration and giving equal attention to the nuances that are present within emerging adult culture, sub-cultures, developmental characteristics, and other biopsychosocial factors significant to this age group, specialized evidencebased treatment practices are necessary for enhancing treatment outcomes. The assimilation of emerging adults with either older or younger populations, in lieu of their own distinct group, is also reflected in the existing research on evidence-based SUD treatment practices. With the exception of studies examining substance use in college settings, a limited amount of research focuses on enhancing the understanding of and identifying effective treatment methods for emerging adult populations who engage in problematic substance use or have a diagnosable substance use disorder. As a result, a considerable number of emerging adults entering SUD treatment are at risk for being filtered through programming that may or may not be efficacious in addressing the special treatment needs

for this age group. Also, worth considering are the statistics that indicate emerging adult populations tend to have higher rates of current illicit drug use; while an increasing amount of evidence suggests that emerging adult populations tend to have worse treatment outcomes when compared to both adolescents and adults (Smith, Bahar, Cleeland & Davis, 2014). Lack of scientific evidence for efficacy is not tantamount to lack of efficacy, however. This disparity creates the question of whether existing methods that have showed efficacy in treating adolescent and/or adult populations, are equally efficacious when working with emerging adult populations in SUD treatment settings.

Developmental Issues for Emerging Adults

the benefit of a skilled driver (Johnson, Blum, & Giedd, 2009). Many emerging adults feel this and find themselves in a sometimes-confusing state – what the psychologist Jeffery Arnett termed the “the age of in between” (Taber-Thomas & Pérez-Edgar 2015). In addition to psychosocial developmental tasks, emerging adults undergo specific neurological changes, like synaptic pruning, that propel them into adulthood. During synaptic pruning, excess synapses (structures that allow the transmission of neurotransmitters) are progressively eliminated to increase the efficiency of neural communication and overall brain functioning (Santos & Noggle, 2011). In general, the synaptic connections used most frequently are strengthened and retained, while those less used are weakened and ultimately undergo pruning. This elimination process, that appears to peak in emerging adulthood, has been linked to learning and environmental factors, meaning the more frequent exposure we have to the same experiences, the stronger the related synaptic connections become (Oberman & Pascual-Leone, 2013). Research has linked substance use in the developing brain, specifically the drug-induced release of dopamine in the brain’s reward pathway, to widespread long-lasting synaptic adaptations that may ultimately lead to addiction (Mameli & Luscher, 2011). This may be particularly true for emerging adults who have a genetic propensity for addiction, those under stress, and for whom substance use began in early adolescence (Yu & McEllan, 2016; Andersen & Teicher, 2009; Dennis & Scott, 2007). In contrast, substance misuse may terminate when individuals enter older adulthood, replaced by marriage, children and vocational aspirations. Those who are unable to mitigate their substance use may progress to a long-term pattern of addictive behavior.

From Erik Erikson’s psychosocial viewpoint, human development occurs in eight stages across the lifespan; each stage includes new challenges and opportunities to develop the skills needed to address them. For emerging adults, specific developmental tasks need to be accomplished before reaching maturity, which has led researchers to suggest that a ninth stage, “Later Adolescence” be added to Erik Erikson’s model. The tasks within the stage of later adolescence include autonomy from parents, greater self-awareness and emotional regulation capability, increased motivation, heightened empathy and social skills, the development of an internalized morality and determination of a career choice. Autonomy from parents does not represent rejection of or alienation from parents, but rather acquisition of unique skills, attitudes and capabilities that foster decisionmaking and goal-directed behavior in the absence of parental oversight. Such independence requires the exertion of internal, not externally imposed, behavioral control. During this time emerging adults also learn to appreciate the individuality between themselves and parents, experience increase in self-efficacy, and express opinions and beliefs that differ Developmentally Appropriate Treatment from their parents’. These changes are supported by enhanced cognitive When considering developmentally-appropriate treatment for emerging capability, such as problem solving and the evaluation of information adults with substance use issues, one approach might focus on the social from multiple sources. skills building, particularly for individuals whose social environments enAnother developmental milestone in emerging adulthood is acquiring a dorse substance use or misuse as a norm or “rite of passage”. Group therstronger level of self-motivation, in which the desire to accomplish is more apy and other social activities while in treatment can create opportunities so from a sense of agency and curiosity, for emerging adults develop and practice than parental expectations. As emerging healthy communication skills, unlearn social Contrary to the misconception, adults build more confidence of their role misconceptions, and connect to sober emerging adulthood is a ability to act effectively on their own and peers in meaningful ways. Higher quality use more abstract thinking, they develop support has been tied to greater refundamental period of biological and social a deeper sense of themselves as moral silience and success not only in mastering psychological maturation, and an beings whose actions have implications the developmental tasks of emerging adultfor the well-being of others. Part of the but also in those of later adulthood. integral part of the transformation hood, development of an internalized morality is As social recovery capital increases, so does of adolescents into adults. movement from pre-conventional reasonthe likelihood of continued participation in ing (fear of punishment) to conventional sober activities post-treatment, which can (conformity) and to post-conventional improve longer-term outcomes. Some pro(personal values) (Yilmaz, Bahçekapili & Sevi, 2019). grams working with emerging adults have found it helpful to host regular Although individuals are often considered to be fully adult when recovery celebrations to send the message that drugs and alcohol are not they reach the age of 18, newer research suggests that emerging adults necessary components to socializing or enjoyment. encounter changes in brain development, thinking and emotions before With the wide-ranging popularity and influence of the internet, social reaching maturity (Taber-Thomas & Pérez-Edgar 2015). Over time, media and smartphones, treatment providers must consider leveraging an integration of the brain’s emotional and cognitive processes occurs, technology to aid recovery. Studies have shown promising results among resulting in “emotional maturity” or the ability to regulate and interpret 12-25-year-old clients using daily text messaging as an adjunct to aftercare emotions. This integration is a gradual process, however, likening the following primary residential or outpatient treatment (Gonzales, Anglin socioemotional temporal gap to starting the engine of a car without & Glik, 2014). After at least one initial face-to-face session, distance W I N T E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 21

counseling may be another strategy that appeals to tech-savvy clients. Assigning clients to view videos on YouTube or “TED talks” and then discuss them with the counselor is recommended. Online check-in or ongoing assessment tools is used to provide clinicians with up-to-date information about changes in client needs and resources. Counselors are also using recovery apps post discharge from primary treatment. Recommended strategies include using recovery coaches with emerging adults to help with the fragility of early recovery. Relapse within the first 90 days of leaving treatment is not uncommon in emerging adult populations. The use of recovery coaches in their natural environment can prove critical towards long-term recovery. Increased autonomy is a developmental milestone of emerging adulthood. Therefore, to compliment the traditional introductory experience of 12-step groups, another age-appropriate intervention is to also introduce emerging adults to a variety of group recovery styles. Expanding their perspective of support is recommended, by including options such as Smart Recovery, Refuge Recovery, Celebrate Recovery, or Women for Sobriety. Selecting their own styles of recovery promotes increased autonomy, an important milestone for emerging adults and persons in recovery. Many emerging adults feel most comfortable in mutual aid communities with same-aged peers. Vocational and educational counseling is also an important focus of treatment for emerging adults. Increased educational recovery capital can help with recovery efforts, and meaningful work provides a sense of

purpose in recovery. While family therapy is an important part of recovery, clinicians who work with emerging adults and their family must be careful not to recreate the parent/teenager dynamic common in family therapy. A goal can include helping the emerging adult develop healthy boundaries in their family of origin and to develop greater autonomy and interdependent, rather than a dependent relationship. Treatment providers must also consider the increased prevalence of co-occurring mental health disorders. The peak incidence of many serious psychiatric problems occurs in the late teens to mid-twenties (Kessler, Amminger, Aguilar-Gaxiola, Alonzo, Lee, & Ustun 2007). Yet, only a small number of adolescents with psychiatric problems receive appropriate services. Thus, many emerging adults in SUD treatment have untreated or misdiagnosed disorders in need of updated assessment. Further, personality disorders can be first diagnosed as individuals enter the emerging adult stage. Coupled with the fact that many persons with substance use problems also have a psychiatric disorder (diagnosed or undiagnosed), the simultaneous occurrence of the two plays a prominent role in a targeted treatment plan for emerging adults.

Gender and Culturally Responsive Programming for Emerging Adults For professionals to continue developing gender and culturally responsive practice with substance using emerging adults, there are several

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assumptions which are useful. First, it is important for clinicians who work with emerging adults to have self-awareness. Self-awareness refers to insight into one’s identity with attention to race, ethnicity, gender socialization and identification, socioeconomic status, sexual orientation, religion, and abilities (Mallow, 2010; Williams-Gray,2014). The culturally responsive professional helper will continually work to understand their own “-isms” (racism, sexism, ageism etc.) and strive to practice cultural humility by acknowledging the unlimited potential for diversity. Continued learning is required on countertransference reactions to diversity amongst emerging adult clients, CBT, Motivational Interviewing, EMDR, DBT, and evidence-based practices with research groups in the emerging adult age-range. It is also important for clinicians who work with emerging adults to be aware of microaggressions and their impact on the therapeutic relationship. Microaggressions can be defined as intentional or unintentional slights. For many youths of color their experience of racism intensifies during the emerging adult years as they compete for college scholarships, jobs, and housing. Counselor statements, even when intended as a compliment, such as “you speak English very well” can be perceived by emerging adults of color as a microaggression. Another example of an unintended microaggression is a counselor assuming that a female client who attends the first session wearing hospital scrubs is a nurse’s assistant. If clients have negative reactions to your statements or feel insulted, it is far more important to understand the harm done from the client’s perspective rather than to defend your position as a clinician. Updated training on cultural sensitivity is highly recommended for treatment providers working with emerging adults. In cross cultural counseling interactions, it is important to be willing to have sensitive discussions of differences if the differences appear to be barriers to connecting. It is also important to remember that engagement with emerging adults does not begin with the first session, it begins with the initial phone call and receptionist greeting. A warm voice tone on the phone and a warm greeting by the receptionist can create a welcoming feeling. Further environmental considerations for treatment programs includes diverse pictures on the walls, educational videos, written materials or brochures and ensuring the overall environment is inviting for the emerging adult seeking treatment.

Conclusion This article is not a compendium of all the guidance needed to successfully treat SUDs in emerging adult populations, but rather a thoughtful summary of the current state of treatment practices with the aim of encouraging a more in-depth inquiry into what innovations are needed to adequately assist this age group in achieving and sustaining long-term recovery from SUDs. Its authors recognize that evidence-based and individualized treatment practices are an important tool of SUD treatment that can be successfully used in many settings to promote patient recovery. This article reviews current knowledge on the characteristics of emerging adult populations, and age/developmentally appropriate services and cultural responsiveness. An understanding of these factors will help professionals better understand and effectively work with emerging adults in SUD treatment settings.

REFERENCES Andersen, S.L. & Teicher, M.H. (2009). Desperately driven and no brakes: Developmental stress exposure and subsequent risk for substance abuse. Neuroscience & Biobehavioral Reviews 33(4):516–524. Bonnie, R.J., Stroud, C., and Breiner, H. (2015). Young adults in the 21st century. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK284782/?report=classic. Dennis, M. & Scott, C.K. (2007). Managing addiction as a chronic condition. Addiction Science and Clinical Practice 4(1): 45-55. Gonzales, R., Anglin, C.D. & Glik, D.C. (2014). Exploring the feasibility of text messaging to support substance abuse recovery among youth in treatment. Health Education Research, 29(1): 13–22. Retrieved June 5, 2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3894666/. Kessler, R.C., Amminger, G.P., Aguilar-Gaxiola, S., Alonzo, J., Lee, S. & Ustun, B.T. (2007). Age of onset of mental disorders: A review of recent literature. Current Opinions in Psychiatry. 20(4): 359–364. Mameli, M. & Luscher, C. Synaptic plasticity and addiction: learning mechanisms gone awry. Neuropharmacology. 2011;61(7):1052–9. Mallow, A., (2010). Diversity management in substance abuse organizations: Improving the relationship between the organization and its workforce. Administration in Social Work, 43(3), 275-285. NIDA, (2018). Principles of drug addiction treatment: A research-based guide (3rd Ed). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition on May 5. Oberman, L., & Pascual-Leone, A. (2013). Changes in plasticity across the lifespan: cause of disease and target for intervention. Progress in brain research, 207, 91–120. doi:10.1016/ B978-0-444-63327-9.00016-3. Santos E., Noggle C.A. (2011) Synaptic Pruning. In: Goldstein S., Naglieri J.A. (eds) Encyclopedia of Child Behavior and Development. Springer, Boston, MA. doi: https://doi.org/10.1007/978-0-387-79061-9 Siddiqui, S. V., Chatterjee, U., Kumar, D., Siddiqui, A., & Goyal, N. (2008). Neuropsychology of prefrontal cortex. Indian journal of psychiatry, 50(3), 202–208. doi:10.4103/0019-5545.43634. Smith, D. C., Bahar, O. S., Cleeland, L. R., & Davis, J. P. (2014). Self-perceived emerging adult status and substance use. Psychology of addictive behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 28(3), 935–941. doi:10.1037/a0035900. Taber-Thomas, B., & Pérez-Edgar, K. (2015). Emerging Adulthood Brain Development. In Arnett, J. (Ed). Oxford Handbook of Emerging Adulthood, New York: Oxford University Press. Williams-Gray, B (2014), Ethnic sharing; Laying the foundation for culturally-informed BSW, social work practice. Journal of Baccalaureate Social Work, 19, 151-159. Yilmaz, O., Bahçekapili, H. G., & Sevi, B. (2019). Theory of Moral Development. Encyclopedia of Evolutionary Psychological Science, 1–5. doi: 10.1007/978-3-319-16999-6_171-1. Yu, C & McEllan, J (2016). Genetics of Substance Use Disorders. Child and Adolescent Clinics of North America, 25(3): 377-385. Randall Webber, MPH, CADC, is an expert in pharmacology, medication assisted treatment and counseling older adults with substance use disorders. Jessica Love Jordan-Banks, MHS, CADC, received a Master’s degree in Addictions Studies from Governors State University. She is board-certified addictions therapist, researcher & educator; & Chair to the Emerging Adults subcommittee of NAADAC’s Clinical Issues Committee.

Fred Dyer, PhD, CADC, is an expert in counseling adolescents and emerging adults with substance use disorder and co-occurring disorders. He has authored over 100 articles and spoken internationally on behavioral health issues.

Mark Sanders, LCSW, CADC, is an international speaker in the behavioral health field whose presentations have reached thousands throughout the United States, Europe, Canada, Caribbean and British Islands. He is the author of five books. He is the recipient of numerous awards including: The Barbara Bacon Award, Health Care Alternative Systems Leadership Award and The Professional of The Year Award from the Illinois Addiction Counselor Certification Board. He is past Board President of the Illinois Association of Addictions Professionals and CoFounder of Serenity Academy Chicago, the only recovery High School in Illinois.

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The New Front Lines: Using Peer Recovery Specialists to Address and Treat Substance Use Disorder By Christopher Freer, DO, FACEP

s substance use disorders continue to devastate individuals, families and entire communities across the country, our healthcare systems are grappling with how to best serve those in need (Office of the Surgeon General, 2016). As head of emergency medicine at RWJBarnabas Health, the most comprehensive health system in New Jersey, I was struggling to treat the patients sitting right in front of me. One such patient came into the emergency department with an altered mental status and signs of a possible stroke. He also adamantly refused to provide a complete medical history. Limited by the lack of a comprehensive health background and noticing warning signs of potential substance use disorder (SUD), I turned to what has become one of our hospital’s most transformational resources in the battle against addiction: Peer Recovery Specialists. At RWJBarnabas Health, Peer Recovery Specialists, individuals who have personally experienced addiction and been in recovery for at least four

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years, have become a vital first line of defense in combatting the opioid epidemic. Working to improve both immediate treatment and long-term recovery outcomes after discharge, these specialists are revolutionizing care for people suffering from SUD. Beyond that, they’ve helped us to rewrite the narrative of how to treat SUD as a chronic disease rather than a cultural stigma or a moral failing. Peer Recovery Specialists have initiated a paradigm shift in how we, as medical professionals, treat and talk about SUD. Our healthcare system’s journey with peer recovery began in 2016. Faced with the increasing scope and heartbreaking human cost of the opioid epidemic, the statistics were especially jarring in my home state. In 2017, New Jersey had a drug-related overdose rate that outpaced the national average by 38 percent (Kaiser Family Foundation, 2018). In response to the growing public health crisis, the Peer Recovery Program at RWJBarnabas Health and the accompanying Tackling Addiction Task Force were born, heralding the start of a system-wide multidisciplinary and comprehensive approach to addressing and treating SUD.

Peer Recovery Specialists provide consults, albeit admittedly unique a choice or decision. When a Peer Recovery Specialist walks in, dressed in ones. When patients arrive with sepsis or diabetic ketoacidosis, the next professional attire and willing to relive the most vulnerable moments of steps are clear – stabilize the patient and call the endocrinologist or other their past to serve others, the stigmatizing label “addict” fades away and specialist for further support. Prior to 2016, that wasn’t the case for our the stark realization that this is a disease like any other truly hits home. patients with SUD. An individual would be admitted near death, havIncorporated into the daily operations and inner workings of the ing just overdosed and been reversed with naloxone. But after providing ED, Peer Recovery Specialists have become a key part of our overall care immediate care, our options were incredibly limited. Besides handing team, sharing best practices with the rest of the clinical staff. We’ll hold a out pre-scanned pamphlets with phone numbers for treatment centers, meeting to discuss how to treat sepsis and aggressive fluid retention and there was a distinct lack of resources for patients and a prevailing attitude in the midst of that meeting, Peer Recovery Specialists are sharing what amongst the department staff – myself init feels like to be in withdrawal – “the flu cluded — that reflected a lingering stigma times 1,000”— so that the rest of the team When a Peer Recovery Specialist and sense of hopelessness. is better informed about how to treat and Enter the Peer Recovery Program. walks in, dressed in professional attire care for their patients. Our team of over 100 Peer Recovery With nationwide drug-related deaths and willing to relive the most Specialists and 11 Patient Navigators sucnearing 69,000 in 2018 and emergency vulnerable moments of their past to departments situated on the front lines cessfully break down barriers that medical professionals often can’t. They each bring of the opioid epidemic, Peer Recovery serve others, the stigmatizing label their own unique and personal journey Programs are propelling a new care model “addict” fades away and the stark with them and use their past experiences (National Center for Health Statistics, to forge honest, genuine connections with realization that this is a disease like 2018). This holds true both here at our patients with SUD. These connecRWJBarnabas Health and throughout any other truly hits home. tions make a lasting impact. Not unlike our country’s healthcare systems (Bassuk, other disease-specific medical consultaHanson, Greene, Richard, & Laudet, 2016; tions, our program enables physicians and McGuire et al., 2020). People are coming staff to call on Peer Recovery Specialists to provide bedside consultations to hospitals suffering from this disease and we are called to serve them with patients. Now, I can execute an order form in our EMR and within to the best of our ability – and that includes compassionate care just as ten minutes or so, a Peer Recovery Specialist has responded and is ready much as comprehensive care. to engage with the patient. They gather medical histories that allow The Peer Recovery Specialist who connected with my patient in the for more accurate diagnoses and guide patients towards recovery with ER that day discovered critical health background information that an intimate knowledge of what that process looks and feels like. They changed my medical diagnosis and enabled me to develop an action plan know how to speak with a patient coming out of withdrawal, who may incorporating pharmaceutical treatment and peer support. This type of be equal parts combative or terrified, simply because they’ve been there combined care is invaluable and is saving countless lives. I am privileged themselves. Our Peer Recovery Specialists are now critical members of to be a part of this transformational team. our clinical care teams. Peer Recovery Specialists are living, breathing examples of hope for REFERENCES Bassuk E. L., Hanson J., Greene R. N., Richard M., Laudet A. (2016). Peer-delivered recovery patients suffering from SUD and are there to speak with them and befriend support services for addictions in the United States: a systematic review. J Subst Abuse them. And because not all patients are ready to commit to treatment, Treat. 63, 1–9. doi:10.1016/j.jsat.2016.01.003 the team stays in communication with patients for weeks — sometimes Kaiser Family Foundation. (2017). Opioid Overdose Death Rates and All Drug Overdose Death Rates per 100,000 Population (Age-Adjusted). Retrieved from https://www.kff.org/ months — after they’ve left our facilities, working with them for when other/state-indicator/opioid-overdose-death-rates/?currentTimeframe=0&sortModel=%7 the time is right to make the commitment. There’s also a preventative B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D element of the process – we have instituted automatic triggers through- McGuire, A. B., Powell, K. G., Treitler, P. C., Wagner, K. D., Smith, K. P., Cooperman, N., . . . Watson, D. P. (2020). Emergency department-based peer support for opioid use disorder: out our systems that recognize and flag warning signs of patients who Emergent functions and forms. J Subst Abuse Treat. 108, 82-87. doi:10.1016/j. may be at risk of SUD. jsat.2019.06.013 As of December 2019, the Peer Recovery Specialists dispersed National Center for Health Statistics. (2018). Provisional Drug Overdose Death Counts (Estimates for 2018 and 2019 are based on provisional data). Retrieved from https://www. throughout 19 emergency departments and 11 RWJBarnabas Health cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm hospitals have connected with over 30,000 patients identified with SUD. Office of the Surgeon General. (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: U.S. Department of Health and They are rarely turned away – over 80% of qualifying patients accepted Human Services. peer support services. Peer support, clinical navigation and care management then continues in community-based settings for a minimum of Christopher Freer, DO, FACEP, is the system director of emergency services for RWJBarnabas Health, chairman of the Saint Barnabas Medical Center eight weeks, where forty percent of patients accept the next level of care. Emergency Department, and co-chair of the RWJBarnabas Health Tackling Equally important, our Peer Recovery Team has sparked a comAddiction Task Force. As co-chair, Freer has been instrumental in implementplete transformation in emergency department culture and has radically ing a paradigm shift towards a more effective way of assessing and treating individuals with Substance Use Disorder (SUD). Freer received his Bachelor’s changed how we engage with SUD patients. They have highlighted the degree from the University of Delaware and his Doctorate degree from the biases we were harboring towards SUD patients and advocated for an emUniversity of Medicine and Dentistry of New Jersey. pathic approach that addresses SUD as the chronic illness it is rather than W I N T E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 2 5

Trauma Treatment and Addictions: Results of the NAADAC Member Survey By Tom Alexander, PhD, LPC, Mary Hoke, PhD, MAC, BC-TMH, Karlene Barrett, PhD, CASAC2 and Edward Cumella, PhD, CEDS

If you completed the NAADAC Member Survey on trauma treatment this past spring, thank you! The results are here. If you didn’t have a chance to take the survey, you can see here what 451 of your colleagues had to say about trauma treatment in SUDs.

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ased on the rapid growth of co-occurring traumarelated and substance use disorders (SUDs), urgency for treatment by qualified and prepared clinicians cannot be overemphasized. Effectively treating trauma in individuals with SUDs has the potential for significantly reducing substance use behavior (Hien et al., 2010). Although Capezza and Najavits (2012) addressed the prevalence of trauma-informed care in substance use treatment facilities, Giordano et al. (2016) noted that research into specific types of trauma treatment provided by addiction professionals is lacking. The 2019 NAADAC Member Survey examines the types of trauma treatment being provided, including: clinician demographics; licensure; specialty certifications; graduate preparedness; and the comfort level of clinicians in treating trauma. The survey results provide a look at current NAADAC members, the types of trauma treatment they provide, and their level of preparedness, expertise, and comfort in providing trauma treatment. Obtaining accurate and current data on the skills and availability of professionals in the field can help establish pathways for the intentional and effective integration of treatment approaches. This information can also inform future decisionmaking related to training and educational needs. A large group of NAADAC’s professional members, N = 451, completed a survey of trauma training and experience during April 22 - June 1, 2019. Of the respondents, 33% were licensed to treat substance use disorder, 22% held certification, and 39% were both licensed and certified; 5% had neither credential, and 1% were interns. It is important to note that licensure and certification requirements can vary from state to state. Typically, licensure indicates a higher level of training and preparation than certification. However, some states provide certification levels that are essentially equivalent to licensure in other states. For the purpose of this survey, both licensed and certified practitioners are considered equally qualified to treat SUD. Among respondents, 70% possessed Master’s degrees, 9% Doctoral degrees, 15% Bachelor’s degrees, 3% Associate’s degrees, and 3% reported no higher education in the addiction profession. Reported demographics from the survey indicated that respondents were 76%, White, 10% African American, 7% Hispanic, 5% Native American, 1% Asian, and 1% Biracial. Of note, only 16% of the survey respondents reported that their graduate program prepared them well to treat trauma, with 47% reporting that they were not prepared at completion of graduate school to treat cooccurring trauma-related and SUDs. Similarly, only 15% reported being certified to treat trauma. Moreover, 23% indicated being trained to treat trauma following graduate school, but not certified. 63% reported being neither certified nor trained to treat co-occurring trauma and SUDs. In contrast, 61% were comfortable treating trauma, 24% were somewhat comfortable, and only 15% were not comfortable doing so. The most common trauma treatment modalities used by NAADAC’s professional members include cognitive-behavioral therapy (CBT), 65%; group therapy, 52%; and manualized evidence-based approaches, 49%. Some respondents, 24%, used family therapy to treat trauma, with 22% using EMDR, 21% psychodynamic therapy, and 16% creative arts therapy. Less than 10% used exposure therapy, the Emotional Freedom Technique, or brief eclectic approaches.

Discussion and Implications Comfort Level of SUD Clinicians Who Provide Trauma Treatment The survey of professional NAADAC members included the following question: What is your comfort level in providing in-depth trauma treatment for clientele? The aim of this question was to gather data on the relationship between the clinician’s “comfort treating trauma” and the following three categorical variables: “holds specialty certification in trauma treatment”; “has training in trauma treatment but is not certified”; “has neither training nor certification in trauma treatment”. The results of the survey showed that 15% of survey respondents hold a specialty certification in trauma treatment; 23% have some level of training but no certification; and 63% have neither training nor certification. Further analysis showed that for SUD clinicians holding a specialty certification in trauma treatment: 61% are mostly or very comfortable in providing trauma treatment; 24% are somewhat comfortable; and 15% are not comfortable. It is evident from the data that 85% of SUD clinicians who hold a specialty certification are more comfortable in providing trauma treatment. An implication of this result is relevant to an important part of NAADAC’s vision, which is to empower professionals who treat individuals and their families with the knowledge, skills, and support to be effective in their work. The data showing that only 15% of respondents hold a specialty certification in trauma treatment supports the need for expanded availability of certification. A foundational purpose for administering the NAADAC Member Survey was to ascertain which types of trauma treatments SUD treatment providers are using. The current body of literature does not identify which treatment type is most effective or the degree to which integrated trauma treatment in a SUD setting is used (Killeen, Back, & Brady, 2015). However, the Veteran’s Administration (VA) and the American Psychological Association (APA) strongly recommend certain treatment approaches for addressing trauma. The strongly recommended treatment approaches include Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Cognitive Behavioral Therapy (CBT) specifically focused on trauma, such as Trauma-Focused CBT (Watkins, Sprang, & Rothbaum, 2018). The results of the NAADAC survey were generally in line with the VA and APA strongly recommended treatment interventions, with 65% of respondents providing some form of cognitive therapy to address trauma (CBT, TF-CBT, and CPT). However, the survey found that the subsequent highest modalities used were group therapy, manualized evidence-based approaches, and family therapy, respectively. Each of these approaches can be effective in treating trauma, but at this time are not strongly recommended by the APA or the VA as frontline treatment interventions. Additionally, survey results indicated a 22% use of EMDR and 21% use of psychodynamic therapy. EMDR is a treatment strongly recommended by the VA but is not strongly recommended by the APA at this time (Watkins, Sprang, & Rothbaum, 2018). Psychodynamic therapy is neither strongly nor partially recommended by the APA or VA for the treatment of trauma. Finally, PE therapy is strongly recommended by both the VA and APA and is substantiated by a strong evidence based in the literature. However, the NAADAC survey found that PE is being W I N T E R 2 02 0 | A d va n ce s i n A d d i c t i o n & R e c o v e r y 27

used at a rate of less than 10% among SUD clinicians. Although the survey takes a first step in painting the picture of modalities being used to treat trauma in SUD settings, it does not provide reasons for choice of modality. Further research could benefit from analyzing, perhaps qualitatively, the reasons behind clinicians’ choices of modality for treating trauma in SUD settings.

Level of Trauma Treatment Preparedness in Graduate Programs The value of qualified clinicians in mental health cannot be overstated and consistent attention has been given to standardization of training and credentialing by state and national organizations, including NAADAC. With increased understanding of the role of trauma in the experience of individuals who use substances, the preparation of clinicians to provide quality trauma treatment is of equal importance. The current survey queried members perceptions of how well their graduate programs had prepared them for treating individuals with co-occurring trauma and SUDs. Among participants, 70% had a Master’s degree, 15% had a Bachelors, and 9% had a Doctorate degree. More than half indicated they felt prepared by their graduate programs at some level to treat both SUDs and trauma: 5% felt very prepared, 11% felt mostly prepared, and 36% felt somewhat prepared. Of those remaining, 36% felt unprepared and 11% were neutral. Among those with a Doctorate degree, 29% believed they were very or mostly prepared, but among those with a Master’s degree, only 15% felt similarly. Highest scores among all graduates were in the area of being somewhat prepared (37%) or not prepared (36%). An important observation from this survey is that many NAADAC members are clearly aware of the need for trauma treatment among individuals with SUDs and are offering treatment at some level. However, the survey did not specifically inquire about what was involved in being prepared at each level (asking only “well”, “mostly”, or “somewhat” prepared) and responses were, therefore, somewhat subjective. There is room for additional exploration of what was involved in the actual preparation, especially in the mostly and somewhat prepared categories. Likewise, since 36% of participants indicated they did not feel prepared by their graduate programs, there is further opportunity for research. Both observations indicate a significant opportunity for continued growth and development among academic and credentialing institutions in graduate preparation and certification for the treatment of co-occurring traumarelated and substance use disorders (SUDs). Overall, the NAADAC Member Survey identified key areas of opportunity in the continued integration of trauma and substance use treatment. Notably, graduate preparedness, access to trauma-specialty certification, and delineating reasons for clinician choice of trauma treatment modality

Are you a current NAADAC member who is looking to disseminate a survey to NAADAC’s membership and/or constituents for academic research? Learn more about the NAADAC PhD Candidate Survey Service and how it can help you by visiting www.naadac.org/phd-survey-service.

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were primary dimensions identified for future, more in-depth, inquiry. Moreover, understanding key constructs, which underpin clinicians’ comfort levels in providing trauma treatment for individuals with SUDs, emerged as an overarching area of continued research need. Ultimately, the NAADAC Member Survey reiterates the need to continue taking critical steps toward the implementation of a fully integrated and effective model of trauma treatment for persons with SUD. REFERENCES Capezza, N. M., & Najavits, L. M. (2012). Rates of trauma-informed counseling at substance abuse treatment facilities: Reports from over 10,000 programs. Psychiatric Services, 63(4), 390-4. Giordano, A. L., Prosek, E. A., Stamman, J., Callahan, M. M., Loseu, S., Bevly, C. M., . . . (2016). Addressing trauma in substance abuse treatment. Journal of Alcohol and Drug Education, 60(2), 55-71. Hien, D. A., Jiang, H., Campbell, A. N. C., Hu, M., Miele, G. M., Cohen, L. R., . . . Nunes, E. V.(2010). Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s clinical trials network. The American Journal of Psychiatry, 167(1), 95-101. Killeen, T. K., Back, S. E., & Brady, K. T. (2015). Implementation of integrated therapies for comorbid post-traumatic stress disorder and substance use disorders in community substance abuse treatment programs. Drug and Alcohol Review, 34(3), 234–241. doi:10.1111/dar.12229 Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidencebased psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258. doi:10.3389/fnbeh.2018.00258

Tom Alexander PhD, LPC, serves as an adjunct faculty member in the Graduate Psychology Department at Purdue University Global. He is passionate about teaching and leading others to better understand and engage in effective treatment practices in the field of addiction counseling. His clinical work and research interests are centered around the intersection of trauma and addiction.

Mary Hoke, PhD, MAC, BC-TMH, holds a doctorate in psychology and is licensed in both Arizona and Missouri. Hoke is actively involved in teaching and developing curricula at the graduate level. She is published in the areas of group therapy with children, program evaluation and nonprofit compensation strategy. Hoke’s current research interest is in the area of the intersection between trauma and addiction.

Karlene Barrett, PhD, is a Clinical Psychologist and Credentialed Alcohol and Substance Abuse Counselor (CASAC2) practicing in New York. She is an experienced clinician (for over 20 years), an internship supervisor, and has served as director of both an outpatient treatment program and department of counseling at a local church. She teaches graduate psychology courses at Purdue University Global where she is also a thesis reader. Barrett currently maintains a private practice and her research and clinical interests include trauma, faith and spirituality, and women’s issues. Edward Cumella, PhD, CEDS, received his Bachelor of Arts degree at Harvard, and Master of Arts and Doctor of Philosophy degree in Psychology from the University of North Carolina Chapel Hill. He has worked in mental health and addictions for 34 years and has been Professor of Graduate Psychology at Purdue University Global for the past 10 years. Prior to Purdue, Cumella was Executive Director at America’s largest eating disorder treatment facility; in private practice; and mental health director for the Indian Health Service in Nevada. Cumella has presented at 100s of professional conferences, published 90 peer-reviewed articles, and been interviewed on TV, radio, and in newspapers, e.g., ABC, FOX, New York Times, as a mental health expert. He is editor of a book on eating disorders.

Save the Date! NAADAC, the Association for Addiction Professionals, and it’s Northwest affiliates invite you to the 2020 Northwest Regional Conference: Embracing the Future! This three-day conference will take place from June 11 through June 13, 2020 at the DoubleTree by Hilton Seattle Airport in Seattle, WA. Earn up to 18 CEs!

Registration opening soon!

SAVE THE DATE!

NAADAC 2020 Annual Conference & Hill Day Learn Connect Advocate Succeed September 25 - 30 Washington, DC

NAADAC, the Association for Addiction Professionals, invites you to its 2020 Annual Conference & Hill Day: Learn  Connect  Advocate  Succeed, in Washington, D.C. from September 25 - 30 at the Gaylord National Resort & Convention Center. Earn up to 43 CEs! Don’t miss six days of unique educational experiences for addiction professionals, plus a visit to Capitol Hill to meet with Congressional leaders and advocate for the addiction profession on September 29. Registration opens in March!

For more information, please visit www.naadac.org/annualconference.

Earn 1 CE by Taking an Online Multiple Choice Quiz Earn one Continuing Education hour by taking a multiple choice quiz on this article now at www.naadac.org/magazine-ce-articles. $15 for NAADAC members and non-members. 1. What are some of the primary areas of conflict presented in Dr. Sara Gilman’s article on Substance Use Disorders in First Responders? a. Over prescription of opioid medication, trauma-related symptoms, and acceptance. b. Stigma, over prescription of opioid medication, and traumarelated symptoms. c. Stigma, misdiagnosed or under-diagnosed co-occurring disorders, and trauma-related symptoms. d. Misdiagnosed or under-diagnosed co-occurring disorders, incredible resilience, and acceptance. 2. What percentage of female firefighters reported binge drinking problematic behaviors, in the Ruderman White Paper on Mental Health and Suicide of First Responders (2018)? a. 40% b. 50% c. 75% d. 28% 3. Which is an example of commonly accepted cultural norms in the first responder workforce that contributes to ineffective stigma? a. Regular therapy check-in sessions, physical fitness, and balanced sleep health is a job requirement. b. Toughness, balanced sleep health, and physical fitness is a job requirement. c. Trauma, overworking, and domestic violence is a part of the job. d. Trauma, overworking, and alcohol use is a part of the job. 4. What are the most common treatment modalities used by NAADAC’s professional members, revealed by the NAADAC Member Survey? a. Cognitive-Behavioral Therapy (CBT), Group Therapy, and Manualized Evidence-Based Approaches b. ACT, DBT, and CBT c. Group Therapy, 12-Step, and Cognitive Behavioral Therapy (CBT) d. EMDR, Exposure Therapy, and Emotional Freedom Technique 5. What percentage of respondents from the NAADAC Member Survey reported that they did not feel prepared by their graduate programs to treat trauma co-occurring with SUDs? a. 49% b. 12% c. 82% d. 36% 6. When considering an individualized treatment plan, counselors must consider the age range of the client because…? a. Millennials and Generation-X’ers are different. b. Incidence of many serious psychiatric problems occurs in the late teens to mid-twenties. c. Each age range may represent preferred languages and socioeconomic levels. d. Manualized treatment models are prescribed differently for each age range. 30

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7. Emerging adulthood is a developmental stage that commonly occurs in what age range? a. Ages 16 – 21 b. Ages 18 – 32 c. Ages 18 – 25 d. Ages 25 – 35 8. How do Peer Recovery Support Specialists improve quality of care for patients presenting with SUD-related symptoms? a. Helping to rewrite the narrative of how to treat SUD as a chronic disease rather than a cultural stigma or moral failing. b. By helping to gather medical histories that allow for more accurate diagnoses and guide patients towards recovery with an intimate knowledge of what that process looks and feels like. c. Creating a connection point for transition of care or aftercare planning (beyond a pamphlet with phone numbers). d. All of the above. 9. According to recent studies from Yale University, in collaboration with the U.S. Department of Veterans Affairs, integrated stepped alcohol treatment (ISAT) showed… a. That stepped AUD treatment improves treatment outcomes at 6 months. b. That participants randomized to stepped AUD treatments were more likely to achieve an undetectable HIV viral load. c. That stepped AUD treatment does not affect treatment success at 3, 6, or 12 months. d. That those patients receiving stepped AUD treatments were less likely to comply with HIV medication prescription. 10. Regarding trauma treatment for persons with SUD, the NAADAC Member Survey confirms that… a. Counselors in the addiction treatment profession are confident in their range of skills and efficacy in treating trauma-related and substance use disorders. b. Further research is needed to better understand the addiction professional’s level of confidence in treatment trauma-related and substance use disorders. c. The addiction treatment industry is still in need of a fully integrated and effective model specific to trauma-related and SUD treatment. d. The average addiction treatment professional receives adequate graduate-level training on trauma-related and substance use disorders.

■ NA A DAC L E ADE RS H I P NAADAC EXECUTIVE COMMITTEE

NAADAC COMMITTEES

Updated 2/15/2020

North Central

STANDING COMMITTEE CHAIRS

President Diane Sevening, EdD, LAC, MAC

(Represents Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota and South Dakota)

Awards Committee Chair Mary Woods, RN-BC, LADC, MSHS

President-Elect Mita Johnson, EdD, LPC, LAC, MAC, SAP Secretary Susan Coyer, MA, AADC-S, MAC, CCJP Treasurer Gregory J. Bennett, LAT, MAC Immediate Past President Gerard J. “Gerry” Schmidt, MA, MAC, LPC, CAC National Certification Commission for Addiction Professionals (NCC AP) Chair James “Kansas” Cafferty, LMFT, NCAAC Executive Director Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP REGIONAL VICE-PRESIDENTS Mid-Atlantic (Represents Delaware, the District of Columbia, Maryland, New Jersey, Pennsylvania, Virginia and West Virginia)

Ron Pritchard, CSAC, CAS, NCAC II

James “JJ” Johnson Jr., BS, LADC, ICS Northeast (Represents Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont)

William Keithcart, MA, LADC, SAP Northwest (Represents Alaska, Idaho, Montana, Oregon, Washington and Wyoming)

Malcolm Horn, PhD, LCSW, MAC, SAP Southeast (Represents Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina and Tennessee)

Marvin M. Sandifer, LCSW, LCAS Southwest

(Represents Arizona, California, Colorado, Hawaii, Nevada, New Mexico and Utah)

Thomas P. Gorham, LMFT, CADC II

Organizational Member Delegate Jim Gamache, MSW, MLADC, IAADC

Mid-Central (Represents Kentucky, Illinois, Indiana, Michigan, Ohio and Wisconsin)

Bylaws Committee Chair Ronald A. Chupp, LCSW, LCAC, NCAC II, ICAC II Clinical Issues Committee Chair Mark Sanders, LCSW, CADC Ethics Committee Chairs Mita Johnson, EdD, LPC, LAC, MAC, SAP Rose Marie, MAC, LCADC, CCS Finance & Audit Committee Chairs Mita Johnson, EdD, LPC, LAC, MAC, SAP Gregory J. Bennett, LAT, MAC Membership Committee Chair John Korkow, PhD, LAC, SAP Military & Veterans Advisory Committee Chair Ron Pritchard, CSAC, CAS, NCAC II Nominations and Elections Chair Gerard J. “Gerry” Schmidt, MA, MAC, LPC, CAC Personnel Committee Chair Diane Sevening, EdD, LAC, MAC Professional Practices and Standards Committee Chair Kirk Bowden, PhD, MAC, NCC, LPC Public Policy Committee Co-Chairs Michael Kemp, ICS, CSAC, CSW Sherri Layton, MBA, LCDC, CCS

Gisela Berger, PhD, MAC, LPC, NCC Mid-South

Student Committee Chair Jeff Schnoor, MA, LICDC (pending), CCSTA, QMHP-CS, Certified Interventionist

(Represents Arkansas, Louisiana, Oklahoma and Texas)

James C. Cates, MA, LCDC

NATIONAL CERTIFICATION COMMISSION FOR ADDICTION PROFESSIONALS (NCC AP)

International Committee Chair Elda Chan, PhD, MAC, Grad. Dip. Family Therapy

AD HOC COMMITTEE CHAIRS Adolescent Specialty Committee Co-Chairs Chris Bowers, CSAC, NCAAC Steven Durkee, NCAAC

James “Kansas” Cafferty, LMFT, NCAAC NCC AP Chair California

PAST PRESIDENTS 1974-1977 Robert Dorris 1977-1979 Col. Mel Schulstad, CCDC, NCAC II (ret’d) 1979-1981 Jack Hamlin 1981-1982 John Brumbaugh, MA, LSW, CADAC IV, NCAC II 1982-1986 Tom Claunch, CAC 1986-1988 Franklin D. Lisnow, MEd, CAC, MAC 1988-1990 Paul Lubben, NCAC II 1990-1992 Kay Mattingly-Langlois, MA, NCAC II, MAC 1992-1994 Larry Osmonson, CAP, CTRT, NCAC II 1994-1996 Cynthia Moreno NCAC I, CCDC II 1996-1998 Roxanne Kibben, MA, NCAC II 1998-2000 T. Mark Gallagher, NCAC II 2000-2002 Bill B. Burnett, LPC, MAC 2002-2004 Roger A. Curtiss, LAC, NCAC II 2004-2006 Mary Ryan Woods, RNC, LADC, MSHS 2006-2007 Sharon Morgillo Freeman, PhD, APRN-CS, MAC 2007-2010 Patricia M. Greer, BA, LCDC, AAC 2010-2012 Donald P. Osborn, PhD (c), LCAC 2012-2014 Robert C. Richards, MA, NCAC II, CADC III 2014-2016 Kirk Bowden, PhD, MAC, NCC, LPC 2016-2018 Gerard J. Schmidt, MA, LPC, MAC

Jerry A. Jenkins, MEd, LADAC, MAC NCC AP Immediate Past Chair California Rose Maire, MAC, LCADC, CCS Secretary New Jersey Kirk Bowden, PhD, MAC, LPC Arizona Elda Chan, PhD, MAC, Grad. Dip. Family Therapy Hong Kong, China Gary Ferguson, BS, ND Alaska Nancy A. Piotrowski, PhD, MAC California Michael Kemp, NCAC I Oregon Diane Sevening, EdD, LAC, MAC (ex-officio) South Dakota

NAADAC EDUCATION & RESEARCH FOUNDATION (NERF) NERF President Diane Sevening, EdD, LAC, MAC NERF Events Fundraising Chair Nancy Deming, LCSW, MAC, AADC-S

NAADAC REGIONAL BOARD REPRESENTATIVES NORTHEAST NORTH CENTRAL

MID-CENTRAL

Amanda Richards, MA, LPCC, LADC, MAC, Minnesota Tom Barr, LIMHP, LADC, Nebraska Megan Busch, LAC, LPCC, North Dakota Mark Young, South Dakota

Renee Lee, MSW, CADC, Illinois Stewart Ball, MAC, LCAC, LMFT, LCSW, Indiana Geoff Wilson, LCSW, LCADC, Kentucky Deborah Garrett, BS, CPRM, CPS, Michigan Raynard Packard, Ohio Daniel Bizjak, MSW, ICS, CSAC, Wisconsin

Susan Campion, LADC, LMFT, Connecticut Ruth A. Johnson, LADC, SAP, CCS, Maine Joe Kelleher, LADC-1, Massachusetts Alexandra Hamel, MLADC, MAC, New Hampshire Christopher Taylor, CASAC, LMHC, MAC, SAP, New York John Mann, LADC, Vermont

NORTHWEST Courtney Donovan, PhD, Alaska Lindsey Hofhine MEd, LPC, MAC, ACADC, Idaho Tim Warburton, BS, LAC, Montana Ray Brown, CADC II, Oregon Terri Roper, MS, NCAC II, Washington Frank Craig, Wyoming

SOUTHWEST

MID-ATLANTIC

Yvonne Fortier, MA, LPC, LISAC, Arizona Debbie Freeman, California Jonathan DeCarlo, CAC III, Colorado David Marlon, MBA, MS, LADC, CAd, Nevada Brian Serna, New Mexico Shawn McMillen, Utah

Jevon Hicks Sr., BS, ICADC, Delaware Johnny Allem, MA, District of Columbia David Semanco, MAC, CAADC, CSAC, CACAD, Virginia Heather Sharp-Spinks, West Virginia

SOUTHEAST MID-SOUTH Sherri Layton, LCDC, CCS, Texas Abby Willroth, BA, RDS, ADC, IADC, PR, SAP, MATC, Arkansas

Sam Long IV, NCAC I, Alabama Bobbie Hayes, LMHC, CAP, Florida Donna Ritter, BT, CAC II, CCS, Georgia Jessica Holton, MSW, LCSW, LCAS, North Carolina James E. Campbell, LPC, CAC II, MAC, South Carolina Terry Kinnaman, LADAC II, MAC, QCS, Tennessee

YOUR INVITATION TO SPONSOR, EXHIBIT, AND ADVERTISE!

NAADAC 2020 Annual Conference & Hill Day Learn Connect Advocate Succeed September 25 - 30 Washington, DC

NAADAC, the Association for Addiction Professionals, invites you to join the family of sponsors, exhibitors, and advertisers at its 2020 Annual Conference & Hill Day: Learn  Connect  Advocate  Succeed, September 25 - 30 2020 at the Gaylord National Resort & Convention Center in Washington, DC. Exhibit dates are September 25 - 27. Showcase your institution, product, or organization at this prestigious event and in front of NAADAC leadership and constituents from around the country. For more information, visit www.naadac.org/ac20-exhibit-sponsor-advertise. We offer various levels of sponsorship to fit your budget, including some of these exclusive sponsor opportunities:  Conference App  Wireless for Attendees  Refreshment Breaks  Photographer for Free Onsite Professional Photographs for Attendees  Hotel Key Cards  Commemorative T-shirt. Limited booth space available. Space available on a first-come, first-serve basis. Exhibit hall will sell out; reserve your space now!

Don’t be left out in 2020! Reserve your space now! Please contact Irina Vayner at ivayner@naadac.org today.