Advances in Addiction & Recovery (Spring 2020)

SPRING 2020 Vol. 8, No. 2

How the Sinclair Method Changed My Mind About Naltrexone and Alcohol Recovery

By John Umhau, MD, MPH, CPE

PLUS • Counseling in the Time of COVID-19 • How the ADA Addresses Addiction and Recovery • The Convergence of Ethics and Telebehavioral Health

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SPRING 2020 Vol. 8 No. 2 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

Kristin Hamilton, JD

Advisor

Jessica Gleason, JD

Features Editor

Samson Teklemariam, MA, LPC, CPTM

Graphic Designer

Austin Stahl

■ F EAT U R ES

Editorial Advisory Committee

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

16 How the Sinclair Method Changed My Mind About Naltrexone and Alcohol Recovery

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.

By John C. Umhau, MD, MPH, CPE

22 Addressing the Stigma Around Addiction

By Jack Stein, MSW, PhD

24 How the ADA Addresses Addiction and Recovery

Roy Kammer, EdD, LADC, ADCR-MN, CPPR, LPC (CD), NCC Hazelden Betty Ford Graduate School of Addiction Studies

28 Support Recovery Through Stress Management Around COVID-19

James McKenna, MEd, LADC I McKenna Recovery Associates

By Oce Harrison, EdD

By Nancy A. Piotrowski, PhD, MAC

29 Alcohol Rehabilitation Can Reduce Hospital Readmission, Relapse, and Mortality in Patients with Alcoholic Hepatitis By the National Institute on Alcohol Abuse and Alcoholism (NIAAA)

30 Counselor Relapse: Helping Our Wounded Warriors

By Mark Sanders, LCSW, CADC

■ D EPA R T M EN TS 4 President’s Corner: Lead the Way

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

5 From The Executive Director: Counseling in the Time of COVID-19

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

6 Certification: NCC AP Update: Moving Forward to Support Our Field

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

7 Ethics: Service Opportunities and Challenges: The Convergence of Ethics and Telebehavioral Health

By Mita Johnson, EdD, LPC, MAC, SAP, CTHP II, NAADAC President-Elect, NAADAC Ethics Committee Chair

10 Membership: Meet the 2020 Candidates for NAADAC Executive Leadership Positions

By Caitlin Corbett, NAADAC Communications Specialist

14 Advocacy: Elevating the Addiction Profession in a COVID-19 Affected World

By Tim Casey, Policy Advisor, Polsinelli

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 May 2020

STAY CONNECTED

32 NAADAC CE Quiz 33 NAADAC Leadership ALL IMAGES FROM SHUTTERSTOCK UNLESS OTHERWISE NOTED

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■ PR ES ID ENT ’S CO RN E R

Lead the Way

By Diane Sevening, EdD, LAC, MAC, NAADAC President First of all, I want to thank you all for the wonderous works you do in meeting the needs of those with substance use disorders and express my sincerest gratitude for your knowledge, experience, compassion, genuine caring, and selfless efforts. These are difficult times and you are all heroes right alongside the physical healthcare providers and first responders.

Since the coronavirus pandemic entered our lives, we are all experiencing new transitions in all facets of our lives. Along with these transitions come new challenges and opportunities for self-evaluation and self-actualization. Most of us are doing our best to learn new technology skills, be resilient with policy changes, adapt to physical distancing, maintain healthy boundaries, reach out to loved ones, and offer our services where needed.

In times of crisis, there are two directions human nature can take us: fear, helplessness and victimization or self-actualization and engagement.

During these times, we look to leaders for a clear plan to move forward.

What do we want from a leader during a crisis? We can look to history for examples of great leaders during a crisis, such as Abraham Lincoln, Winston Churchill, Theodore Roosevelt, Eleanor Roosevelt, and Martin Luther King, Jr. to name a few. One commonality among these leaders is decisiveness. They saw a situation that needed a solution for the betterment of the people, proposed a plan that would be inclusive, and executed that plan. People were informed along the way of the decisions and how the solution was going to be of the greater good for all. They instilled trust, sense of duty, and availability, which is what many are seeking today from leaders.

Gallup has studied global citizens’ worries, fears and confidence during nearly every major crisis of the past eight decades and one thing is clear: global citizens look to leadership to provide direction and to provide confidence that there is a way forward to which they can contribute.

Gallup meta-analytics have found four universal needs that followers have of leaders: trust, compassion, stability, and hope.

Leaders need to be the trusted source and available to answer questions and address concerns. The communication lines need to be open and the communication plan needs to be understood. Communicating well includes not being a victim of panic or hype and laying out clear actions for what to do and when. The 10x10x10 rule applies here: say something 10 times in 10 different ways for people to retain 10%. Be clear in laying out the priorities and communicate these priorities often.

It takes repetition to make sure everyone understands the plan and can relay the message as things change and acceptance occurs.

People want reassurance that everything is operating smoothly and that programs are managing change with everyone’s interest in mind.

Being realistic with sincere, calm, and transparent communication is key, especially during these turbulent times. Times of crisis test us and define us and we do not have to have all the answers or pretend that we do.

We simply need to be willing to stay connected, to tell the truth, and to convey hope. We owe it to ourselves and to the people we care about to be this kind of leader.

I encourage each of you to lead with kindness to reduce the worry and increase employees’ confidence that your association, agency, corporation, and/or program is looking out for their best interest. As the COVID-19 4

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situation evolves, it is important to maintain a clear, honest, empathetic and straightforward approach to communication. Leaders need to be well informed by staying connected to their elected officials on the local, state, and federal levels for the most accurate and current information. There seems to be a rapid dissemination of information from multiple sources that may be questionable, and it is imperative to provide only factual information that has scientific evidence. Since COVID-19 is a new virus, medical researchers are working to collect data and looking for solutions on a daily basis. Progress may not be happening as quickly as we would like but being patient and following the guidelines of physical distancing, working from home when possible, covering our faces, and washing our hands is making a difference.

During this difficult time, self-care is vital. Leaders, along with everyone, need to practice self-care daily. Stressful times, like the present, can create anxiety and depression. We need to take time to keep a sense of humor, laugh with friends and family, read a book, dance in our kitchens, sing in the bathroom, exercise, meditate, eat healthy foods, get plenty of rest, pray, and stay connected. Somedays we can get discouraged with the news we hear but maintaining a positive attitude with positive energy keeps us moving forward.

I want to reassure you that NAADAC’s leadership and staff are here for you. On the NAADAC website there is the COVID-19 webpage located at www.naadac.org/covid-19-resources that provides you with a wealth of information. The page is updated daily with information and provides you with many valuable resources in dealing with these times.

As Eleanor Roosevelt said, “You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, ‘I lived through this horror. I can take the next thing that comes along.’” Together, we will get through this and be stronger as a result.

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.

The evolving COVID-19 pandemic is undoubtedly affecting all of us, both personally and professionally.

NAADAC wants you to know that we are here to support you as you support others.

HOW CAN NAADAC SUPPORT YOU DURING THE COVID-19 PANDEMIC?

KEEP UP WITH YOUR EDUCATION REMOTELY!

COVID-19 RESOURCES FOR ADDICTION PROFESSIONALS

With NAADAC’s remote learning resources, you can keep up with your education and training without having to leave your house!

NAADAC has addiction-specific COVID-19 resources available for you!

• Over 145 hours of free webinars! Access educational webinars taught by industry experts available online and on demand 24 hours/7 days a week. Offerings include: • Six-part Peer Supervision Series • Five-part Advocacy Webinar Series!

• Specialty online trainings, which address specific addiction treatment-related education needs. Earn a certificate upon completion!

• Independent study courses delivered directly to your door!

Learn more about NAADAC’s remote learning resources at www.naadac.org/education.

• Free COVID-19 and Telehealth webinars available on demand, including • Virtual Workplace Wellness • Telehealth During COVID-19 • Psychological First Aid During COVID-19 • Medicaid/Medicare reimbursement information • Practice management tools and resources • Latest SUD-related updates from CDC, WHO, SAMHSA, and other government agencies Find all of these resources and more on the COVID-19 resources page at www.naadac. org/covid-19-resources.

WWW.NAADAC.ORG/COVID-19-RESOURCES

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

Counseling in the Time of COVID-19

By Cynthia Moreno Tuohy, BSW, NCAC II, CDC III, SAP, NAADAC Executive Director COVID-19 is consuming the world’s attention. It is the lead topic on the news, the subject of our conversations, in our emails, and seemingly everywhere we turn. How to self-protect, self-quarantine, selfpreserve and acquire our own stockpiles of food, water and toilet paper is consuming our thoughts.

It is unlike any other time in my lifetime or that of anyone else I know. Nothing has grabbed our attention so tightly and mightily. Due to all the unknowns of COVID-19, people are scared. We all know this.

Many of us are experiencing losses during this time, whether it is the loss of a sense of security, the loss of a way of life, the loss of our health, or even the loss of a loved one. Loss and grief affect each of us in different ways, from a psychological and emotional standpoint to a physical and even behavioral standpoint. As we know, this is to divert or change the focus of our loss. Regardless of the ways we experience loss and grief, it is important at this time to recognize it, accept that it is real, and reach out for support.

So what causes the spirit to move from fear and uncertainty to peace and calm or from self-protection to neighbor or community protection? For me, it is keeping my mind on my Higher Power and that relationship that guides and nurtures me like no other human experience is able. The peace and satisfaction of helping someone else, even if they do not know it. Leaving food or toilet paper on someone’s doorstep, supporting those who have less, giving a smile as I pass a person (with physical distancing, of course) and asking, really asking, how they are and listening to their response, not just the words, but also the feeling behind it. By being tolerant with the person I live and am in quarantine with whose idiosyncrasies are about to blow my level of sanity to speak words that are not worthy of any conversation. By thinking beyond myself, my family, my colleagues and my friends to the broader neighborhood and community and world. What is my part? How do I find what I am supposed to do to “brighten the world”? What is my role and level of responsibility?

The gems that I see building out of the heat and pressure of this time are brilliant and many are things I would not expect, like finding an emerald just under the surface of the ground that I happen along when my toe stubbed on it. This time, so full of uncertainty, has given me specific certainties. I am certain that I will learn lessons from this time – lessons of humanity to others and humanity from others. Ways to connect that we were unaware of before this crisis. Ways to appreciate my family, colleagues, friends, surroundings, nature and a brisk walk, a bike ride, or a soak in the tub. Things that I have taken for granted and things that I have trusted, now reevaluated.

Some of my thoughts go to this particular season – the season of Spring – and new life and rebirth from a cold winter. Spring is a time many of us welcome as the promise of more light, warmth and freshness in the days and months to come. Some of my thoughts reflect on the spiritual aspects 6

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“Regardless of the ways we experience loss and grief, it is important at this time to recognize it, accept that it is real, and reach out for support.”

of this season. We know life is life on its terms, and that it has uncharted journeys and paths that are to be traveled and unraveled as we go. Still, that knowledge alone does not cause peace in the heart and soul, and still the feelings of uncertainly provoke our thoughts until we can find our own source of hope, light and love. Even a small light can illuminate the darkness. We are meant to be each other’s light. We know that as counselors, educators, and peers that our path is to spread hope, joy and the promise of a new day! And that is how I want to communicate to you.

It is vital that we use the skills we have to help ourselves, each other, our families and our communities to connect, to reflect, and to build tolerance and consideration of others in this time. I believe this time will teach us new ways to do this and to be grateful for all the blessings we do have. I have faith in the process and that “this too shall pass.”

It is important that you know that we, the Leadership of NAADAC, our staff and myself, are here to support you in the ways that we are able.

We are working to connect with you with more vital webinars, eblasts, and resources. We are here to listen and to respond. We have been here for 48 years and we are not going away – we are here to support you.

Together, we can, and do, make a difference.

Blessings, Cynthia 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.

■ CER T IF IC AT I O N

NCC AP Update: Moving Forward to Support Our Field

By James “Kansas” Cafferty, LMFT, MAC, NCAAC, NCC AP Chair Hello to everyone in NAADAC-land. This is the first time I am writing this column, and what a time to do it. We are all concerned about everything from our health, the health of our clients, and the health of our families, to the health of our national economy and possibly even our own personal economic security. In some ways, the world has gotten a lot smaller, as many of us have spent well over a month rarely, if ever, leaving our homes.

In other ways, the world has become much larger as most of us quickly adopted videoconferencing and telehealth. Many treatment centers have temporarily suspended all in-person services, while others are continuing to see clients as needed, and the vast majority of private practitioners have switched entirely to a telehealth platform as well.

With this backdrop, I am starting my relationship with all of you as the new Chair of the National Certification Commission of Addiction Professionals (NCC AP). While making this introduction and continuing on with our work seems, on some levels, inconsequential, the fact is that those of us who are members of NAADAC – addiction professionals – are essential to another cause that cannot be forgotten. Across the country, millions of individuals are living with and often struggling with addiction that is continuing despite, and often being exasperated by, the ongoing pandemic. We are still here for them and are unwavering. It is with this attitude that I hope to serve our beloved field, and you, if you are amongst us.

With all of this said, I need to say thank you to our outgoing NCC AP Chair, Jerry Jenkins. I have rarely met a committee I didn’t join, and I am not sure I’ve ever seen a more steadfast and hard-working leader than Jerry. While I will try, I already know that I will rarely meet his example during my tenure in this role. During his time as our Chair, NCC AP has put in vast amounts of work on behalf of the clients we serve and the counselors in our field. We have completed an exhaustive job task analysis of the substance use disorder counseling profession at the Associates, Bachelors, and Graduate levels of credentialing and we have completed the revisions and updates of all three of NCC AP’s core examinations, which are now entering into the final beta testing phase. If any of you were just thinking that it sounds like NCC AP has the most current ability in the world to test the competency of those entering our field, your thoughts were right on target, and while the commission has been working tirelessly on this update, we have Jerry’s leadership to thank for the completion of it. He is truly a class act and I hope that you will thank him for what he has done when you see him. The ripple effect that this update will have on the quality of services we provide will be impactful for an entire generation of clients and counselors.

Many of you have been following the national movement to accept peers as a part of the continuum of care. While some are still fearful of this credential becoming a “lower cost replacement” for counselors, we are consistently finding that this is not the case. NCC AP’s National Certified Peer Recovery Support Specialist credential is quickly becoming the national standard for what an appropriate scope of practice for a

recovery coach or peer ought to be, up to and including working for an agency, and under the supervision of a credentialed counselor. We are finding that areas that adopt policy around the use of credentialed peers are ending the “wild west” era of substance use disorder treatment by providing an appropriate title, set of qualifications, and scope of practice for these well-meaning entry level paraprofessionals. Most importantly, we have evidence that incorporating Peers into the continuum of cares works!

In closing, it is my honor to serve you and to serve the clients we hope to support. I am a person in long-term recovery since adolescence who has been in this field since my adolescence. It is my life’s work to be in this field, and it is my hope we can continue to inspire new counselors to take on a similar attitude and properly equip them with all of the tools they need to influence their clients and their colleagues. At last, I would also like to wish to all of you a warm, digital embrace. Remember back when we could hug a friend? A co-worker? A client? Those days and those hugs will return because the love has never left.

James “Kansas” Cafferty, LMFT, MAC, NCAAC, has been in the field of substance use disorder treatment since 1997. He has worked in private practice, IOP/ PHP, residential, hospital, and eating disorder specific treatment centers. He has provided training internationally on trauma informed care and nationally on subjects ranging from adolescent care to intervening on impaired professionals. He has been involved with NAADAC for well over a decade, joining originally to advance the National Certified Adolescent Addiction Counselor credential.

Take Your NCC AP Exam from Home!

The National Certification Commission for Addiction Professionals (NCC AP) is pleased to be able to offer distance proctoring for all of its national credential and endorsement exams and for state licensure on behalf of many state licensing/certification boards!

Distance proctoring is a method that allows the test taker to test from his or her own home or office with a computer that has a camera and audio capability. A testing date and time is scheduled with a test proctor who is on the other side of the camera and able to remotely proctor the examination.

Learn more about distance proctoring and if your state licensing/certification board accepts NCC AP exams at www.naadac.org/ ncc-ap-distance-proctoring.

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■ E T H ICS

Service Opportunities and Challenges: The Convergence of Ethics and Telebehavioral Health

By Mita Johnson, EdD, LPC, MAC, SAP, CTHP II, NAADAC President-Elect, NAADAC Ethics Committee Chair One day in 2019, everything changed, and the world progressively woke up to the domino effects of living and dying with a novel coronavirus (COVID-19). Unfortunately, that reality reminded us of the potential for emergencies and disasters to affect some populations more significantly than others. Our clients – those struggling with substance use disorders (SUDs) and co-occurring mental health disorders - are particularly vulnerable to the challenges experienced on all fronts during emergencies: physical, mental, social, environmental and SUD. Our clients are at greater risk of having serious, if not fatal, health outcomes if they are exposed to a viral outbreak like COVID-19. During times of isolation, many clients experience mental health disorders, such as depression, anxiety, paranoia, and PTSD, more intensely, which can lead to relapse, recidivism and alternative substance use as a way of coping with uncertainty and loss. It is during times such as these when our clients need more access to services, not less. What we are witnessing right now is that the e-delivery of addiction-related services is an opportunity to increase access to service providers, and with opportunities come challenges to be mindful of.

“Telebehavioral health services” refer to the use of electronic technologies (e.g., phone, emails, videoconferencing, social media, and chat and text messaging) for delivering distance behavioral health services including intake and assessment, treatment, and recovery support. Principle VI of NAADAC’s Code of Ethics speaks to e-therapy, e-supervision and social media. It states that: Addiction Professionals who choose to engage in the use of technology for e-therapy, distance counseling, and e-supervision shall pursue specialized knowledge and competency regarding the technical, ethical and legal considerations specific to technology, social media, and distance counseling.

Offering distance and e-services is a benefit to many clients who would otherwise not be able to access care and support. So, what do we, as addiction professionals, need to research and address if we are considering offering e-services to their clients to protect the clients from harm and to protect ourselves from practice violations? All current rules, laws and ethics codes for traditional modalities of service provision apply to e-delivery, but they are not enough. I would like to offer the following preliminary checklist for your consideration: ❏❏ Does the provision of e-services fall within your scope of practice, as determined by education/training and skills development through supervised experience? Do you have certifications or credentials that demonstrate that technology-based service delivery is within your scope of practice? ❏❏ Have you discussed e-service delivery with your client? What are their concerns? Does the client have access to equipment already or would they have to obtain equipment? Is your client comfortable 8

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with technology? Have you informed the client that they can refuse to engage e-therapy or e-support services? Technology is not for everyone. What extra costs are associated with e-services that the client will have to bear? ❏❏ What are the licensing and regulatory laws where you are licensed, regarding the e-delivery of services (intrastate and interstate)? ❏❏ What are the licensing and regulatory laws where the client is located at time of e-delivery, specific to intrastate and interstate e-services? ❏❏ How have you determined the actual location of the client at the time of e-service delivery? ❏❏ How have you determined or confirmed the identity of the client at the time of service? For example, for a person using emails, texts or phone – how do you know who you are conversing with? ❏❏ What are the guidelines provided by your Professional Code of Ethics regarding e-services? ❏❏ Do you have a signed Informed Consent with the appropriate mandatory disclosures? ❏❏ Do you have a separate, signed Technology Informed Consent?

This informed consent would discuss privacy, confidentiality, mandatory reporting, what to do when technology issues arise, how crises will be handled, etc. ❏❏ Have you had a conversation about the lack of privacy and confidentiality inherent in using technology? ❏❏ What HIPAA requirements are you required to adhere to when providing e-service? What about 42 CFR Part 2? ❏❏ Are you planning to record the session? What are the legalities and codes specific to recording? How will you store the recording? How will it be protected? How and when will it be disposed? ❏❏ Can the client record the session? Can the client invite a family member or other person to sit in room and listen to/attend session?

❏❏ What documentation will you be keeping related to all e-services?

Are you keeping all texts, emails, chats, etc. in the client’s folder as part of the client’s file? ❏❏ What is your back-up plan for technology failures? For example, if the internet crashes, will you both get on the phone to finish the session? ❏❏ What are your emergency management protocols? What is your emergency response plan? Do you know who to contact locally in the event that you need to report a client emergency? Do you have emergency contact information for the client? Dialing 911 is not an emergency response plan. ❏❏ Do you both have a neutral environment within which to connect? What are environmental constraints? Are there ambient sound issues? How is privacy maintained? Are headsets available? Is there a door to the room that can be closed and locked? What does lighting look like in the room? Can you see the client’s face clearly? Can they see you clearly? ❏❏ What does your room background disclose about you? Do you have access to a virtual background? Sitting on a bed is not a professional method of service delivery. Eating while in session with a client is not a professional method of service delivery. ❏❏ What modalities are suitable for using in an electronic platform?

What modalities are not suited for using electronically? ❏❏ Which mental health and substance use disorders are suitable for treating using an electronic delivery? Which SUDs and mental health disorders are not suitable for treating using an electronic delivery?

❏❏ Can you determine and how would you determine if the client was sober during the e-session? How would you handle it if they appeared impaired? ❏❏ Can you do a mental status exam using e-services? How would you go about doing it?

Please know that NAADAC and the NAADAC NCC AP Ethics Committees are here to help in any way we can during these challenging and unprecedented moments in history. We stand behind all addiction service providers along the entire continuum of care, and their desire to help clients and community members in need who are experiencing the effects and after-effects of emergencies, disasters and pandemics.

Together, we have the tools and resources to be a meaningful source of support and hope.

Mita Johnson, EdD, LPC, LMFT, LAC, NCC, ACS, MAC, SAP, CTHP II, has degrees in biology, counseling, and counselor education and supervision. She is a core faculty member at Walden University’s School of Counseling Master’s program. She became interested in the field of addictions when she discovered that the majority of her clients were dealing with co-occurring mental health and substance use disorders. She is NAADAC’s President-Elect and Ethics Chair.

She is a member of NAADAC’s Colorado state affiliate, CAAP, and serves on regulatory and professional boards and committees. In 2016, she submitted a complete revision of the existing NAADAC Ethics Code for approval. She has been working as a clinician for 30 years and currently maintains a private practice where she provides counseling, training, clinical supervision and consultation. She has been very engaged in telehealth practices over the last five years, including the development of ethical codes and practice considerations for safe distance service provision.

TELEHEALTH SUPPORT As we all navigate recommendations regarding physical distancing, NAADAC wants to ensure that you have the tools you need to provide the best possible prevention, treatment, and recovery support to the clients you serve.

To help you provide your services to your clients remotely, NAADAC is offering members:  A free telehealth preparation quiz;  Discounted access to a telehealth platform service (members can try the service for free for 90 days!);  And webinars and other educational materials regarding utilizing telehealth in your practice.

Visit www.naadac.org/telehealth for more information.

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■ M EM B ER S H I P

Meet the 2020 Candidates for NAADAC Executive Leadership Positions

By Caitlin Corbett, NAADAC Communications Specialist Help choose the future leaders of NAADAC! It’s election time again, and we are seeking new leadership to help us determine the direction of the Association. NAADAC holds elections every two years to select its Officers and four Regional Vice-Presidents (the other four Regional Representatives are selected on alternate years). This year, eight well-qualified addiction-focused professionals have been nominated as candidates for NAADAC Executive Leadership. All 2020–2022 terms will begin in October 2020, immediately following the 2020 NAADAC Annual Conference & Hill Day in Washington, DC. This spring, NAADAC received two nominations for Mid-Atlantic Regional Vice President. Please find each candidate’s statements below in order to inform your vote.

NAADAC only received one nomination each for the positions of

Candidate for President-Elect & Uncontested Winner

four year, I have served on the Membership Committee and the Awards Committee.

Angela E. Maxwell, CPS Browns Summit, NC

Philosophy statement of the nominee on the future of NAADAC: I am convinced now more than ever that NAADAC has been, is, and must continue to be the premier strategic leader for the addiction’s field. While it is understood that our field is diverse in terms of its workforce, persons served, and services provided; there must be a unified voice that consistently advocates on behalf of the field. Key issues such as 1) ensuring the full implementation of the insurance parity law; 2) establishing a nationally recognized credential; and 3) supporting the development of a diverse workforce to meet the needs of an ever-changing diverse global community, are critical factors in sustaining the addiction’s profession. NAADAC is the most qualified association to lead this unified national effort. The successful future of NAADAC is contingent upon its ability to effectively partner with state affiliates, engage its key stakeholders as well as represent the full continuum of substance use disorder services. I believe that NAADAC is equipped to meet these key areas and its future is bright!

Summarize the nominee’s NAADAC activities: My affiliation with NAADAC spans back fifteen years; beginning with my service on the board of directors for the North Carolina affiliate - Addiction Professionals of NC (APNC). On the APNC board, I served as the Prevention Committee Chair (2005– 2007); APNC Vice-President (2008–2009); APNC President (2010–2014) and Immediate Past President (2015–2019). My involvement at the national level began 2008/2009 when I served as a committee member of the Student Assistance Professional (SAP) Workgroup (National Student Assistance Association Committee) which developed recommendations for the SAP credential and was active during the initial merger discussions between NAADAC and National Student Assistance Association. I served on the NAADAC Board of Directors from 2010 to 2019. From 2015– 2019, I served as the Southeast Regional VicePresident for NAADAC as well as served on the Executive Committee of the NAADAC Board of Directors. Additionally over the past 10

President-Elect, Secretary, and Treasurer and Mid-South, Northeast, and Northwest Regional Vice-Presidents. Therefore, these six nominees will be seated in their nominated roles for the 2020–2022 term without an election. The winning candidates’ statements are listed below for your review. Congratulations to our six winners!

Voting starts on May 1, 2020 and ends May 31, 2020. All NAADAC members are eligible and encouraged to vote. Instructions for voting will be emailed to members and can be found at https://www.naadac. org/2020-leadership-elections. Members may vote online by logging into their naadac.org account or by mail. To request a paper ballot to vote by mail, please email Kristin Hamilton at khamilton@naadac.org.

Please read the following statements by and for the candidates in order to help inform your vote this spring.

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Other qualifications of the nominee for this office: Angela has served over 18 years as the Director of Prevention and Early Intervention

Services for Alcohol and Drug Services where she oversees services in ten counties. She is also the co-founder of Aspire Training and Consulting Group, LLC. Angela is currently a PhD. Candidate in Leadership Studies with an expected graduation in June 2020 (NC A&T State University). She has served as an adjunct professor for Guilford Technical Community College. Throughout her career, Angela has served extensively in leadership roles at the local and state levels. She currently serves on the NC Substance Abuse Prevention Provider’s Association - Board Chair, Guilford County Schools Student Health Advisory Council Chair, North Carolina Academy for Prevention Professionals Planning. Angela is also a national and statewide trainer in the areas of substance use prevention, workforce development, strategic planning, coalition development, workplace wellness, as well as diversity and inclusion.

Angela has received three statewide substance use professional of the year awards (2008, 2010, 2019). Her experience has enhanced her skills in leading long-range visioning, planning and evaluation, capacity building, resource management, personnel management, meeting facilitation, stakeholder engagement, as well as leadership and organizational development.

Candidate for Secretary & Uncontested Winner Susan Coyer, MA, AADC -S, MAC, CCJP, SAP Huntington, WV Summarize the nominee’s NAADAC activities: I have had the privilege of being involved in NAADAC and the West Virginia affiliate (WVAADC) for over 25 years. For the last two years, I have been honored to serve as the NAADAC Secretary and prior to that, four years as Mid-Atlantic Regional Vice President.

Prior to that, I served on the NCC AP for six years as secretary and chaired the ethics committee. I have also served on the NAADAC Membership, Conference, Bylaws, and Public Policy Committees. I am a past president of the West Virginia affiliate and a delegate to the NAADAC Board of Directors for 4 years. With WVAADC, I also held the positions of secretary and conference, membership, awards, nominations and bylaws committee chairs.

Philosophy statement of the nominee on the future of NAADAC: NAADAC’s membership and advocacy efforts are vital to support and grow our workforce. Workforce development and strong advocacy efforts are essential in ensuring the quality of prevention, treatment and recovery support services as well as improving treatment for individuals across the nation.

Advancing legislation at both local and national levels is imperative to continue to support and enhance our profession. Established partnerships and new ventures allow NAADAC to have a meaningful impact on legislation and lead our membership into new horizons. NAADAC remains the voice of addiction professionals and the leader in advancing addition recovery. I see our organization growing and continuing as the leader in the growth and strengthening of our profession. Expanding our partnerships with other organizations relevant to NAADAC’s mission as well with our representatives in our States on Capitol Hill will allow us to continue the exceptional work that makes NAADAC the leader in our field.

Other qualifications of the nominee for this office: I have a master’s degree in counseling with an emphasis in addiction counseling. I have held a number of clinical and management

positions in outpatient, intensive outpatient, residential, community housing and medication assisted treatment programs. My credentials include Master Addiction Counselor (MAC), Advanced Alcohol and Drug Counselor (AADC), Certified Clinical Supervisor (CCS), Certified Criminal Justice Professional (CCJP) and Substance Abuse Professional (SAP). I am currently the director of a medication assisted treatment program in Huntington, WV. I have facilitated numerous workshops and training in Motivational Interviewing, Motivational Interviewing Assessment: Supervisory Tools to Enhance Proficiency (MIA:STEP), clinical supervision, Serious and Violent Offender Reentry Initiatives (SVORI) and ethics for addiction and prevention professionals. I have participated in numerous legislative activities at the State and National level.

Candidate for Treasurer & Uncontested Winner Jerry A. Jenkins, MEd, LADAC, MAC Anchorage, AK Summarize the nominee’s NAADAC activities: • Tennessee Association of Alcoholism and Drug Abuse Counselors – Past President, Secretary, Treasurer and Legislative Committee Chair (Served 1989–1997) (Member 1985–2003) • National Association of Alcoholism and Drug Abuse Counselors (NAADAC) Member since 1985, Chair, Managed Care Committee (1999–2000) • Commissioner, NAADAC Certification Commission (NCC) 1993–1999 • Chair, National Certification Commission for Addiction Professionals (NCC AP) January 2017–January 2020 • Alaska NAADAC Affiliate - Alaska Association of Addiction Professionals (2003–Present) • Alaska Commission on Behavioral Health Certification - Treasurer- 2006–2009; 2017–Present Philosophy statement of the nominee on the future of NAADAC: I consider NAADAC the premier organization representing the substance use disorder treatment workforce and all the nuances associated with it. NAADAC is positioned to continue to lead in the areas of advocacy, workforce education and training,

and certification to recognize professionalism.

These are just a few of the ways NAADAC serves the field on a national as well as state specific levels. NAADAC provides a structure for the exchange of ideas, lessons learned and collaboration. NAADAC offers opportunities to improve skills through the broad array of trainings offered (webinars to national conference) as well as opportunities to develop leadership skills by serving in this membership organization.

Other qualifications of the nominee for this office: • COO, Alaska Behavioral Health Association - June 2018–Present • CEO, Anchorage/Fairbanks Community Mental Health Services (2003–2018) • Alaska Behavioral Health Association (ABHA) - 2003–2018 - Board of Directors - 2003–2005; 2013 – 2018; Board President 2014–2017 • healtheconnect Alaska (health information exchange) Board of Directors – November 2015–Present; Currently Board President • Commonwealth North – Health Care Action Coalition; Fiscal Policy Study Group - 2013–Present • Behavioral Health Workgroup, Alaska Criminal Justice Commission - 2016 • Alaska Division of Behavioral Health 1115 Waiver Benefits Design Team - 2016 • Alaska International Education Foundation - Board of Directors - 2006–2015

Candidate for MidSouth Regional Vice President & Uncontested Winner Representing Arkansas, Louisiana, Oklahoma, and Texas

John Cates, MA, LCDC Richmond, TX Summarize the nominee’s NAADAC activities: I have practiced professional activism since entering the field in 1976. Through involvement in the Houston Chapter of the Texas Association of Addiction Professionals (NAADAC affiliate), I have enjoyed decades of working with NAADAC. I have served all officer positions in Houston, as a state board member for TAAP, and for decades in committee activity, especially advocacy at the local, state, and national levels. I currently serve as NAADAC Regional VP (Mid South) and hope to serve a second term. In this term I have helped Arkansas S P R I N G 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 11

establish a full affiliate. It is my dream to assist Oklahoma and Louisiana to become full affiliates as well. Since entering recovery and starting the first recovery high school in 1976, I have worked in peer recovery, clinical positions, and program management, from private practice to programs with hundreds of employees. I have managed programs all over the US as well as Canada, Mexico, and as far away as Bulgaria.

Philosophy statement of the nominee on the future of NAADAC: As professionals, we are at the forefront in our society’ s battle against the ravages of substance use disorder. Historically, as well as the present, we are opposed on every front in accomplishing our dream of healing and sanity. Our adversaries command trillions of dollars and use the prejudice of generations in defending the use of neurotoxins in deadly ways. It is my belief that one of the most powerful weapons in this struggle is the unity and organization of the people who know the truth concerning how those we serve get sick and what are the best paths to healing. We must ban together and organize our efforts to be heard. NAADAC is the best venue for this organization and presentation effort. Hence, it has, and will continue to have my full support until this battle is won.

Other qualifications of the nominee for this office: In addition to my history with NAADAC and its affiliates, I have served on a variety of other professional organization boards in our field. I am presently serving as the Chairman of the Board for the Association of Alternative Peer Group Programs. I have had one book and many articles published. I have professional experience producing and directing films as well as performing in different venues as a musician and singer. I am used to hard work and am totally committed to NAADAC’s aims.

Candidate for Northeast Regional Vice President Representing Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont

Christopher J. Taylor, MAC, CASAC, OBA, LMHC Avon, NY Summarize the nominee’s NAADAC activities: I have been involved with NAADAC and

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the New York Affiliate (AAPNY) for a majority of my career. As a NAADAC member, I have attended numerous conferences and trainings, organized training opportunities for our members, and represented NAADAC on the various State initiatives. I currently serve as President of AAPNY, and represent NAADAC on the New York Certification Board of The Alcoholism and Substance Abuse Providers of New York State (ASAP). I am proud to be involved with this organization and take any opportunity to share about it and all that it has to offer.

Philosophy statement of the nominee on the future of NAADAC: As addiction prevention and treatment continues to evolve and, the role that NAADAC plays will become more and more important. The needs of those we serve are growing more complex, and individuals, their families, and their communities require more specialized and informed services than ever before. NAADAC must continue to be the National Leader in providing education, training, certification, advocacy, and ethical standards for “addiction” professionals to ensure that our workforce has the preparation necessary to do the best job for those they serve. This includes continued support of a national certification for addiction counselors. Most importantly, NAADAC must continue to advocate for access to affordable, quality, and multi-faceted services for those who suffer from addiction, including access to peer support, tale-medicine, and medication-supported treatment and recovery.

Other qualifications of the nominee for this office: I have worked in our profession since 1992, and have been credentialed as an Alcohol and Substance Abuse Counselor in New York Since 1993. I have served in a variety of roles over the past twenty-eight years. These include including Counselor, Clinical Supervisor, Clinic Director, and Executive. Along the way, I earned a Master’s Degree, a Doctorate, a New York State Mental Health Counseling License, and a MAC. Regardless of where I was working, or my role, I have remained deeply committed to serving individuals, families, and communities negatively impacted by addiction. I am excited about the potential opportunity to represent NAADAC as a Regional Vice President in order to be able to work with other affiliates within the region while continuing to have a positive impact in my home State.

Candidate for Northwest Regional Vice President

Representing Alaska, Idaho, Montana, Oregon, Washington, and Wyoming

haron “Shari” B Rigg, S LAC Missoula, MT Summarize the nominee’s NAADAC activities: I have been a member of the Montana chapter (MAADAC) of NAADAC since I was a student at the University of Great Falls (now Providence University). I have been a member of the MAADAC Board of Directors for the past 4 years. I am the current Vice President of MAADAC and will be the incoming President in two years. I have participated in the MAADAC conferences throughout my membership.

Philosophy statement of the nominee on the future of NAADAC: I believe NAADAC is vital to the ongoing promotion of Addiction medicine and the delivery of quality addiction services. I believe addiction is an epidemic in our country and it is extremely important to have well-trained and knowledgeable therapists and agencies in the field and to distinguish substance use and addiction diagnoses from other mental health diagnoses. I believe in upgrading the status of addiction professionals and would like to see national recognition of credentials.

Other qualifications of the nominee for this office: I have worked exclusively in the field of addiction for the past 20 years. I am currently the President and Executive Director of a Montana approved facility and understand service delivery from a stage agency point of view as well as a private practitioner perspective.

I have been a clinical supervisor for nearly all of my 20 years in the field and have trained and provided supervision of required clinical hours for licensure for the past 15 years.

Candidates for Mid-Atlantic Regional Vice President Ron Pritchard, CSAC, CAS, NCAC II Virginia Beach, VA Summarize the nominee’s NAADAC activities: I have personally been active in a wide spectrum of NAADAC activities that include advocacy at the White House, at Federal and State Public Comment sessions, at local General Assembly and Virginia Board of Counseling, Virginia Counseling Assoc. Current MidAtlantic RVP, and Mil/Vet Affairs Chairperson.

I am actively engaged in development of NAADAC/ACA collaborative agreement. I am actively growing NAADAC role in Dept of Defense SA Education and Certification programs. Provide yearly SA training at Uniform Services College, Bethesda. Provide state-widetraining, education and Town Hall Sessions.

Serves on Governor’s Boards of Beh Health Council for SA Services, and SA Public Policy Committees participating in funding, policy and strategic planning for state’s SA/MH service delivery. Co-founder of Virginia Summer Institute for SUD and Virginia Recovery Advocacy Coalition. Traveled and made NAADAC recruitment presentations each of 7 state affiliates in various stages of chapter development.

In-coming chairperson for NBCC/NAADAC Minority Fellowship Grant Program.

Philosophy statement of the nominee on the future of NAADAC: I believe that the future of NAADAC will be determined by the strength, vision, and visible engagement of our leadership.

NAADAC leaders must be alert and active to ensure that the policies of our federal and state governments do not relegate the roles of qualified Addiction Professionals to para-professional status. In particular, since the “opioid crisis” has brought increased concern and funding to our field, it is vital to the survival of the certified and licensed addiction treatment professional that all leaders at all levels of NAADAC be informed of state agency strategies and tactics for use of these funds. The Addiction Epidemic is the problem that must be dealt with. Incarceration will not cure it. The RVP position requires active leadership with responsiveness to the needs and concerns of all the regional membership As a member of the NAADAC Board of Directors,

Representing Delaware, Maryland, New Jersey, Pennsylvania, Virginia, Washington, DC, and West Virginia

the RVP must take an active role in ensuring NAADAC and state affiliate Boards do more than meet to plan conferences. Our future is our leadership’s responsiveness to our membership’s needs and to recognize and carry out effective advocacy strategies. We must nurture our role as the nation’s SUD treatment leaders.

Other qualifications of the nominee for this office: I have experience in prevention, intervention, treatment and post-treatment care as a consultant to SUD treatment programs and as a clinician with SUD patients in both military and non-military communities. As an Interventionist, Clinician, and Program Manager, I have provided SUD services for Active Duty military, Behavioral Health Professionals, Homeless citizens, and the incarcerated community for over 30 years.

I have participated as founder, or co-founder of several successful non-profit organizations with focus on education, prevention, treatment, and recovery in the MH/SUD population. Retired from the US Navy and past Head of Addiction Medicine Services at Portsmouth Naval Hospital, I continue to be active in lecturing and training in Department of Defense and other audiences of Behavioral Care providers.

Self-employed, I am the owner/manager of Addictions Program Consulting and provide guidance and strategic planning for SUD program development. I serve on a variety of boards and councils and constantly advocate for the recognition and inclusion of us in the addiction counseling arena. I continue to participate in, or coach SUD interventions with SUD clients and their families.

Secretary of the Association. I have served in several positions, which evidentially led to becoming the WVAADC’s President with my term ending in 2015. Throughout my time as a member of NAADAC, I have assisted the state association in various capacities: serving as a volunteer, on the board, attending the National Conferences and Advocacy Day, and as a mentor. I continue to support NAADAC and colleagues when called upon.

Philosophy statement of the nominee on the future of NAADAC: I believe that NAADAC has become a national voice for our profession in assisting in the growth in the areas of education and creditability. I hope to continue to support these efforts and help strengthen the connections between professionals, not just on the state level. I believe that everyone needs a voice and needs to feel “we” matter. NAADAC is in a great spot to make ad influence change not only on the national level, but on the state level, especially in “rural” America.

Wanda S. Wyatt, MS, LSW, MAC, ADC-S, SAP Dunmore, WV

Other qualifications of the nominee for this office: During my career in the the human resource field (mental health and addictions).

I have worked with children, adolescents, and adults in various settings, including group homes, schools, corrections, and outpatient settings. I have presented at local and state levels on various topics, including Ethics, Clinical Supervision, Self Care, and Crisis Intervention. I received a Ambassador for Youth Award in 1994, and an Appreciation Award for services with adolescents in 2004. For work in the addiction field, I was awarded the Lisa Grossi Award in 2010 from the WV Certification Board. In 2008, I received the President’s Award for services to WVAADC, and the Russ Taylor Advocacy Awareness Award in 2015 and from WVAADC.

Summarize the nominee’s NAADAC activities: I have been attending NAADAC/ WVAADC events since 1997. I became more involved at the level in 2000/2001 when I started volunteering at West Virginia’s annual conferences. This led to becoming apart of the Board of Directors in 2002/2003 year. At that time I became Co-Chairperson of the Annual Conference, which then led to becoming the

Caitlin Corbett is the NAADAC Communications Specialist and works on NAADAC communications, marketing, graphic design, and digital media, including the website and social media. She also contributes to the planning and logistical coordination of NAADAC events and conferences. Before coming to NAADAC, Corbett worked in government contracting with the Department of Justice on the Office of Juvenile Justice and Delinquency Preventions Youth Violence Prevention Training and Technical Assistance Initiative. Corbett holds a Bachelor of Arts degree in Criminology from West Virginia University in Morgantown, WV.

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Elevating the Addiction Profession in a COVID-19 Affected World

By Tim Casey, Policy Advisor, Polsinelli The COVID-19 pandemic has greatly impacted our nation’s health care and social service systems, including your abilities to deliver vital services to clients in need. While the size and scale of the federal response has been substantial, we continue to advocate every day for the addiction profession and for those battling substance use disorders (SUD) across the country.

NAADAC has been communicating with lawmakers, the Administration, and federal agencies about the impact of the pandemic on treatment and recovery services, as well as on the addiction workforce, throughout the crisis. We have elevated our voice to help enact relief measures and support calls for increased funding. As we continue to urge additional action, feedback from NAADAC members about their experience during the pandemic remains key to shaping our outreach to Capitol Hill and the Administration.

Telehealth Throughout the crisis, NAADAC has collaborated closely with key partners to advocate for measures that preserve continuity of care for individuals with SUD. In an environment of physical distancing and stay-at-home orders, telehealth has been a valuable tool for many. NAADAC has and continues to lend its voice to efforts that remove barriers for treatment and recovery services.

The passage of the CARES Act (P.L. 116-136) marked a critical infusion of funding and an important first step in providing regulatory relief for health and social service providers. The new law gave the Centers for Medicare and Medicaid Services (CMS) broad authority to waive telehealth restrictions. CMS moved quickly to grant flexibility to providers and suppliers and continues to remove barriers for those who furnish services to Medicare and Medicaid beneficiaries. Governors across the country have also sought to provide similar flexibilities in response to the pandemic, acknowledging the importance of telehealth in maintaining continuity of care.

We encourage you visit the robust NAADAC website for information concerning COVID-19, telehealth educational and practice resources, and information and links to the telehealth platform that NAADAC is endorsing that offers our members a free 90-day trial period and a 15% discount after that.

NAADAC encourages you to share your experience. Your ability to deliver services through this trying time is vital, and we want to know what barriers you might be facing.

Economic Relief Despite the proliferation of virtual solutions, facilities and practitioners are facing difficult challenges. Throughout the COVID-19 crisis, NAADAC has called on lawmakers and the Administration to reinforce the nation’s public health infrastructure through loans, grants, and other support programs.

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CARES Act established and funded the Public Health and Social Services Emergency Fund. The $100 billion federal program provided grants to eligible health care providers, including public entities, Medicare or Medicaid-enrolled suppliers and providers, and other for-profit entities and not-for-profit entities impacted by the pandemic.

The CARES Act includes a number of additional actions of relevance to address the crisis: • SAMHSA Emergency Response Grants: $100 million in flexible funding has been allocated to address mental health, substance use disorders, and provide resources and support to youth and the homeless during the pandemic.

• Confidentiality and disclosure of records relating to substance use disorder: 42 CFR Part 2 regulations, which govern the confidentiality and sharing of substance use disorder treatment records, have been aligned with Health Insurance Portability and Accountability Act (HIPAA), with initial patient consent with the aim to allow for additional care coordination. NAADAC is watching this closely to learn the effects on clients seeking care. We have asked other Federal partners to do the same.

• Guidance on protected health information: The Department of Health and Human Services (HHS) is required to issue guidance on what is allowed to be shared of patient records during the public health emergency related to COVID-19.

• Expanding Medicare Telehealth Flexibilities: Beneficiaries will be able to access home-based telehealth from a broader range of providers in hopes of reducing COVID-19 exposure.

• Extension and Expansion of Community Mental Health Services Demonstration: The Medicaid Community Mental Health Services demonstration that provides coordinated care to patients with mental health and substance use disorders is extended through November 30, 2020 and to two additional states.

• Extension of Demonstration Projects to Address Health Professions Workforce Needs: The Health Professions Opportunity Grants (HPOG) program is extended through November 30, 2020 at current funding levels. This program provides funding to help lowincome individuals obtain education and training in high-demand, well-paid, health care jobs.

• Coronavirus Relief Fund: $150 billion is being provided to states, territories, and tribal governments to use for expenditures incurred due to the public health emergency with respect to COVID-19 in the face of revenue declines, allocated by population proportions, with a minimum of $1.25 billion for states with relatively small populations.

While these and subsequent measures have helped soften the blow for some, NAADAC is urging Washington to do more and we are working to improve other newly enacted programs to ensure relief to the addiction workforce.

Congressional Roundtable Works toward Comprehensive Solution Just prior to COVID-19 closures, NAADAC participated in a small roundtable on Capitol Hill, hosted by Representatives Kennedy (D-MA), Tonko (D-NY), Matsui (D-CA), Cardanes (D-CA), Trone (D-MD), and Chairwoman Eshoo (D-CA). During the roundtable we discussed barriers, challenges, and solutions for improving our mental health and addiction care systems. The meeting brought together Representatives and stakeholders from both public and private sectors around a comprehensive effort to improve mental and behavioral health treatment and access to care.

The dialogue focused on ways to better coordinate care, enforce parity laws, incentivize workforce development, and understand the comorbidity associated with other illnesses, including substance use disorder.

NAADAC Executive Director Cynthia Moreno Tuohy underscored the importance of focusing on workforce, the impact of low reimbursement rates and wages on retention and recruitment, and the need to create and bolster incentives, like tuition support and student loan repayment.

The convening Members of Congress and their staff have since collected stakeholder feedback in hopes of unveiling comprehensive legislation. NAADAC submitted feedback urging explicit inclusion of the addiction discipline, greater funding for public-funded SUD facilities through SAPT block grants, and support for workforce development measures and incentives. NAADAC also emphasized the importance of preserving privacy protections for individuals with SUD, the need for universally recognizable and portable credentials, and collaboration between community-based addiction and mental health professionals in school-based programs.

NAADAC was pleased to participate in the roundtable and continues to communicate with lawmakers leading the charge.

Elevating the Addiction Profession NAADAC continues to focus on elevating the voice of the addiction profession with lawmakers and regulators. In addition to our advocacy in Washington, we are working to strengthen our voice in states and districts across the country by giving you the tools to amplify the message.

On May 1st, NAADAC launched its 2020 Advocacy Webinar Series with the webinar entitled Shaping Policy and Practice through Advocacy.

In the series, we will examine the central policy discussions surrounding the addiction profession and the critical role advocacy plays in shaping the delivery of treatment and recovery services.

We urge you to join us as we explore topics surrounding workforce, reimbursement, parity, support for federally funded addiction and treatment programs, protecting privacy, and other pressing issues. Please visit the Advocacy pages on the NAADAC website for updates on these issues and provide your feedback.

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.

2020 Advocacy Webinar Series

Become an active advocate for the addiction profession!

Watch the free 2020 Advocacy Webinar Series to learn about important advocacy issues! Earn up to 7.5 CEs! Shaping Policy and Practice Through Advocacy

Recorded on Friday, May 1, 2020 - available on demand!

Updates on Federal SUD Funding

Friday, July 10, 2020 @ 12:00-1:30pm ET

Bolstering the Addiction Workforce – A Call to Action Friday, August 7, 2020 @ 12:00-1:30pm ET

Confidentiality Rule Changes and 42 CFR

Wednesday, September 2, 2020 @ 3:00-4:30pm ET

Bringing it Home – Grassroots Advocacy Friday, October 30, 2020 @ 12:00-1:30pm ET

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How the Sinclair Method Changed My Mind About Naltrexone and Alcohol Recovery

By John C. Umhau, MD, MPH, CPE

The Science of Naltrexone When naltrexone first came on the market as a treatment for alcohol use disorder (AUD), I was conducting clinical research on the treatment ward of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health in Bethesda, Maryland. We soon began to prescribe naltrexone daily whenever we discharged someone from detox.

Naltrexone did help patients stay abstinent, but most did not take it for long, and they typically resumed excessive drinking when they stopped (Jonas et al., 2014). Naltrexone did not seem to be the alcoholism cure my research colleagues were working for.

My thinking about naltrexone began to change when my friend Mark* asked me for a naltrexone prescription. I was surprised to learn he had a problem with alcohol; he was a successful executive—I had never seen him drink. However, when Mark held a business reception, he would lose control of his drinking and embarrass himself. He said he couldn’t stop after just one drink unless he took naltrexone first. He thought it would help if he always took it before drinking. Now he wanted a refill.

Here was a conundrum: My friend was clearly in danger of developing a serious problem with alcohol. I had seen suffering when people tried but failed to drink moderately. I also had seen the benefits of abstinence, and I admired the personality development of those who worked twelve-step programs. However, if I was adamant that Mark embrace abstinence, I risked ending further discussions with him about treatment. On the other hand, if I wrote Mark a prescription for naltrexone, that would give my tacit approval to keep drinking, and it would be on my conscience if Mark drank and had a bad outcome. *Names have been changed.

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The use of naltrexone targeted for use before drinking is popularly credited to John David Sinclair, PhD (1943–2015), whose animal research showed that alcohol’s reinforcing effect could be blocked by naltrexone.

Sinclair found that, over time, animals trained to drink alcohol would “extinguish” or unlearn their drinking behavior if alcohol was always preceded by naltrexone (John David Sinclair, 2001). Sinclair also found that the longer alcohol-drinking animals were deprived of alcohol, the more they would press a lever to get it, an effect he attributed to upregulation of opiate receptors. He called this the “alcohol deprivation effect,” a parallel to the increase in alcohol craving experienced by some people with AUD the longer they abstained from drinking. Sinclair reasoned that if a person who craved took naltrexone before they drank alcohol, alcohol drinking would not be reinforced. If this occurred repeatedly, the craving would gradually be “extinguished” by the effect of naltrexone.

Sinclair confirmed his hypothesis with clinical studies in Finland, and found that targeted naltrexone could not only help people drink less, but over time, it could help them lose the desire for alcohol. He called this process pharmacological extinction (Heinälä et al., 2001).

Sinclair recognized that for behavioral adaptation to occur, healthy pleasurable activities must be reinforced, so he encouraged no use of naltrexone on non-drinking days. This allowed endorphins produced by non-drinking behaviors (e.g., taking a walk in the park, enjoying a game) to reinforce those healthy behaviors. Sinclair postulated that this would help “rewire” the brain by replacing the drive to drink alcohol with a drive for healthy activities (John David Sinclair, 2001). Sinclair observed that the process of extinction typically takes four to six months or more, and that 78% of those who completed treatment could reach extinction (John David Sinclair, 2001).

Sinclair patented his proposal for therapy in 1989, and after publishing papers on its success in Finland, worked to commercialize his therapeutic technique (John D Sinclair, 1989). When naltrexone was approved by the U.S. Food and Drug Administration in 1995, the label omitted any reference to targeted use in actively drinking people and therefore did not impinge on Sinclair’s patented method. Also, the method’s unconventional requirement for drinking to continue during treatment conflicts with the tenants of traditional abstinence-based treatment, and is a significant barrier to wider acceptance by the treatment community (Barrio & Gual, 2016). Perhaps for these reasons, Sinclair’s method has remained relatively obscure.

As I reviewed naltrexone research, I found considerable support for Sinclair’s method (Niciu & Arias, 2013). Data shows that patients with AUD can be compliant with as-needed dosing and that taking naltrexone before drinking can reduce craving, consumption, and therefore the harm from alcohol (Volpicelli et al., 1997). Studies suggested that naltrexone was most effective for those who drank alcohol while taking it; this unusual finding was consistent with naltrexone trials showing that therapy promoting abstinence was ineffective compared to therapy which helped people cope with drinking (O’malley et al., 1992; John David Sinclair, 2001). This more successful counseling approach encouraged people who had a “slip” to keep taking naltrexone. Targeted naltrexone can also reduce consumption gradually, thereby eliminating the need for inpatient detoxification (John David Sinclair, 2001).

Long-term daily use of naltrexone can be hard to maintain; it can reduce healthy pleasures and cause a blah, dull feeling about life.

Targeted use provides a realistic way to treat a lifelong condition while

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minimizing cost and the potential for adverse effects (Heinälä et al., 2001).

Nalmefene, an opioid antagonist similar to naltrexone, is approved for targeted use in Europe to reduce alcohol consumption (Marazziti et al., 2015; Soyka, 2014).

Talking to Patients About Naltrexone I first tried the Sinclair Method with Zoe, a very accomplished nurse who had come to realize that consuming a bottle of wine every night was not normal. She had no interest in abstinence or Alcoholics Anonymous, but she was interested in drinking less.

We discussed naltrexone and how it could provide a protective effect, or “wall” against the euphoria that can drive excessive drinking.

After watching a TEDx talk given by actress Claudia Christian about the method (available at www.alcoholrecoverymedicine.com/sinclairmethod), Zoe was keen to try it. She was hopeful that if she used naltrexone faithfully an hour before drinking, she could be free of obsessive thoughts about alcohol.

——— Insisting on abstinence as the end goal of all alcohol treatment can create an unnecessary barrier that keeps people from seeking help (Mann, Aubin, & Witkiewitz, 2017). When I first saw Zoe, she was nowhere near hitting “rock bottom.” If I had insisted on abstinence, I doubt I would have ever seen her again. The patient-centered approach of Sinclair’s method not only kept her engaged in treatment, but the data suggests that insisting on abstinence renders naltrexone therapy less effective (Barrio & Gual, 2016; O’malley et al., 1992). In Zoe’s case, I empathized with her about craving and discussed coping skills (J. Sinclair et al., 2014). Zoe knew that I considered abstinence to be the best option, and she admitted that if the Sinclair Method actually worked, she might be willing to give up drinking altogether.

——— Next time I saw her, Zoe related a remarkable story. After she took her first naltrexone pill, she waited the required hour, and then had a drink. The usual “buzz” was gone. One glass of wine was all she wanted. Naltrexone had blocked her desire to drink. Her story matches what I often hear from other patients; one wrote: … I am nothing short of amazed at the difference in my attitude towards alcohol. The very first drink I took after my first dosage was vastly different than any other drink I can remember. The intense satisfaction and almost euphoric feeling was simply not there. I really struggled to finish that glass of wine the first time—I just wasn’t terribly interested in drinking it.

After a few months of faithful use, Zoe was drinking only on weekends, and made a point of enjoying the outdoors on alcohol-free days. After 6 months she had reached “extinction” and no longer thought about alcohol. She would go for 6 weeks without drinking anything, but if she did drink, she was careful to take naltrexone and she did not exceed two drinks.

——— Success with the Sinclair Method is predicated on total compliance.

If drinking ever occurs without first taking naltrexone, the resulting

The Sinclair Method Possible Benefits

Possible Harms

• • • • •

• Patients may feel that drinking has been sanctioned by their physician.

• Patients who can remain abstinent may be encouraged to continue drinking.

• The use of medication to reduce drinking may delay someone from seeking psychosocial support for abstinence.

• If driving occurs while intoxicated, naltrexone may further impair coordination.

• Patients may develop a false confidence on their ability to safety drink while taking naltrexone.

• Medication-only treatment may reduce the potential for personal growth derived from following 12-step principles.

• • • • •

Patients unwilling to be abstinent can be engaged in treatment.

Long-term compliance is enhanced compared with daily use.

Patients are actively involved in treatment.

Less risk of adverse effects exists than with daily use of naltrexone.

Pleasurable endorphins from healthy activities are only blocked when naltrexone is used.

Gradual reduction of drinking reduces the risk of delirium-tremens.

Costly and inconvenient inpatient treatment may be avoided.

Alcohol craving may be permanently eliminated.

Targeted use costs less than daily use of naltrexone.

It is low cost and applicable for use in developing countries.

endorphin stimulus can reverse the process of extinction. Persevering through months of treatment ups and downs can be daunting, and without frequent encouragement, many will give up without reaching extinction. Keeping a daily record of drinking can help promote compliance, especially for the segment of patients who do not have dramatic response to naltrexone.

——— Once, I pulled one of our alcohol counselors into the exam room to hear Zoe’s story firsthand.

I could feel Zoe’s excitement as she shared her story, but my colleague did not seem to understand extinction or the progress Zoe experienced.

The elephant in the room was our programmatic requirement for abstinence. My colleague invited Zoe to join a support group, but was careful to explain that the group would not condone any drinking.

Once the counselor left, and we were alone, Zoe confided that she would never attend such a group – the Sinclair Method had given her hope, and she had no desire to be shamed by her choice of therapy. I remember wishing I had somewhere to send her for support.

——— Sinclair’s method requires a lifelong commitment to take naltrexone before every drink (John David Sinclair, 2001), but finding appropriate long-term support can be difficult. Naltrexone can take away alcohol craving, but it doesn’t remove all reasons to drink (Umhau, 2019a). Alcohol has anesthetic and anti-inflammatory properties, and can rapidly relieve physical and emotional pain, as well as boredom. Habits and peer pressure to drink can be hard to resist, especially without an understanding support system. Lifestyle counseling that promotes recovery through socialization, exercise and healthy foods (especially those that contain the omega-3 fatty acids found in seafood) may prove to be critical for long term success with the Sinclair Method.

——— I didn’t hear from Zoe for more than a year, but when I did, it was because she had relapsed after drinking at a wedding. Although Zoe was faithful

to take naltrexone before the wedding, and although naltrexone blocked the “buzz” from her first drink, as the wedding day progressed and she kept drinking, by evening she began to feel the familiar euphoric effect of alcohol. Once she broke through the naltrexone “wall,” drinking alcohol felt too wonderful to stop. The next day she did not bother to take naltrexone at all. Now, she was eager for help from a counselor and peer support. When she reached extinction again, she would choose abstinence.

Understanding the Naltrexone Wall Sixty minutes after swallowing a tablet, naltrexone blood concentrations are at their maximum, endorphin receptors are blocked, and this “wall” prevents alcohol induced euphoria. Since a “first drink” induces maximum alcohol craving, this is the critical time for naltrexone to have effect (Hendershot, Wardell, Samokhvalov, & Rehm, 2017). The endorphin release induced by subsequent drinks is less than the first, and therefore waning naltrexone concentrations may continue to provide an effective wall. However, four to six hours after taking the pill, naltrexone concentrations have dropped, a stiff drink can break the naltrexone wall, and relapse is possible.

The naltrexone labeling implies that 50 mg of naltrexone can block euphoria from heroin for 24 hours, however the effect on alcohol may not last this long (Umhau, 2019b). For a given dose of naltrexone, different people can have very different blood levels, and only those with the highest levels benefit (Brünen et al., 2018). Because of this variability, some people may require a repeated or higher naltrexone dose. Slowly drinking less concentrated alcoholic drinks may minimize the need for higher doses of naltrexone. Therapy can be informed by the subjective effect of alcohol in relation to the time elapsed since taking naltrexone.

Side Effects Naltrexone is well tolerated; common symptoms such as nausea or headache typically resolve over time and can be minimized by taking the pill with food and fluids (Croop, Faulkner, & Labriola, 1997). Suicidal thoughts are a rare side-effect requiring special caution. Naltrexone may also require monitoring of liver function. Naltrexone will also block the effect of opioid pain medications, so people on naltrexone should carry S P R I N G 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 19

Patient-Centered Treatment of Alcohol Use Disorder (AUD) This flow chart represents one potential approach to providing evidence-based care and illustrates options available to those struggling with alcohol use disorder of variable severity.

a wallet card indicating this fact. Naltrexone can precipitate opiate withdrawal in the chronic opioid user; it is possible that daily drinkers develop a milder but analogous situation when they begin naltrexone and the endorphins produced by heavy drinking are blocked. Naltrexone does not block alcohol intoxication, and may enhance the impairment of peripheral vision and divided attention associated with intoxication.

With daily naltrexone use, opioid receptors up-regulate, and can retain this increased sensitivity if naltrexone is suddenly stopped. Therefore, someone taking naltrexone every workday, but who stops on the weekend, may find that their super-sensitized opiate receptors make drinking especially pleasurable. This increased euphoria with drinking can reverse the previous progress towards extinction and also explain why compliance is critical for those prescribed daily naltrexone (Tempel, Gardner, & Zukin, 1985; Volpicelli et al., 1997).

The Future of Alcohol Treatment Robust scientific evidence supports the use of medication to reduce alcohol consumption. However, less than 9% of patients who could benefit receive these potentially lifesaving drugs (Kranzler & Soyka, 2018).

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Recently I was talking to a patient who was very happy with the way medication had helped him overcome alcohol craving and allowed him to be abstinent. However, he confided that if he had known such medication existed 14 months earlier, he would not now be facing divorce and the loss of his family.

There is much we need to know about the best use of medication to treat AUD. In addition to naltrexone, FDA approved medications for AUD include acamprosate and disulfiram; other medications are used “off label,” including topiramate, baclofen, prazosin, and ondansetron (Kranzler & Soyka, 2018), but we don’t know if any of these medications can produce extinction. We also don’t know if using a monthly injection of depo naloxone can augment the use of targeted naltrexone when compliance is an issue (Brünen et al., 2018). Critically, there is no published data on therapy for those who reach extinction with naltrexone and later relapse.

Although most physicians are familiar with naltrexone, few are aware of the research literature supporting targeted naltrexone for AUD and even fewer have experience with the Sinclair Method. Sinclair’s method may be particularly effective early in the disease when people first

Hendershot, C. S., Wardell, J. D., Samokhvalov, A. V., & Rehm, J. recognize that they have a problem with alcohol yet When people first (2017). Effects of naltrexone on alcohol self‐administration and retain the resources necessary to maintain complimeta‐analysis of human laboratory studies. Addiction recognize that they have craving: Biology, 22(6), 1515-1527. ance with naltrexone.

Jonas, D. E., Amick, H. R., Feltner, C., Bobashev, G., Thomas, K., Part of the reason that medications that reduce an alcohol problem, Wines, R., . . . Rowe, C. J. (2014). Pharmacotherapy for adults drinking are underused may be due to poor comwith alcohol use disorders in outpatient settings: a systematic Sinclair’s method not review and meta-analysis. Jama, 311(18), 1889-1900. munication between members of the health care H. R., & Soyka, M. (2018). Diagnosis and pharmacoteam. Medication requires considerable psychosocial only provides hope, but it Kranzler, therapy of alcohol use disorder: a review. Jama, 320(8), support for success. For counselors who have a good also engages them with 815-824.

Kranzler, H. R., Tennen, H., Armeli, S., Chan, G., Covault, J., Arias, relationship with a prescriber, discussing patients and & Oncken, C. (2009). Targeted naltrexone for problem sharing information can lead to the best outcome addiction professionals. A., drinkers. Journal of Clinical Psychopharmacology, 29(4), 350.

(Oslin et al., 2014). For counselors who lack a close Lee, C. M., Scheuter, C., Rochlin, D., Platchek, T., & Kaplan, R. M. (2019). A Budget Impact Analysis of the Collaborative Care relationship with a prescriber, incorporating medical Model for Treating Opioid Use Disorder in Primary Care. Journal treatment can be facilitated by the use of telemediof general internal medicine, 1-2. cine. Video links allow convenient collaboration between a counselor and Mann, K., Aubin, H.-J., & Witkiewitz, K. (2017). Reduced Drinking in Alcohol Dependence Treatment, What Is the Evidence? European addiction research, 23(5), 219-230. a prescriber, and can expand the availability of physicians who specialize in Marazziti, D., Presta, S., Baroni, S., Mungai, F., Piccinni, A., Mucci, F., & Osso, L. (2015). treating AUD. When the telemedicine visit occurs at a counselor’s office, Nalmefene: a novel drug for an old disorder. Current medicinal chemistry, 22(27), medical treatment can begin with the client’s initial visit.

3162-3168.

Regardless of how patients get their medications, they will benefit Niciu, M. J., & Arias, A. J. (2013). Targeted opioid receptor antagonists in the treatment of alcohol use disorders. CNS Drugs, 27(10), 777-787. from skilled counseling support. This can be reimbursed through the O’malley, S. S., Jaffe, A. J., Chang, G., Schottenfeld, R. S., Meyer, R. E., & Rounsaville, B. (1992). collaborative care model, a team-based approach to enhance primary care Naltrexone and coping skills therapy for alcohol dependence: a controlled study. Archives of General Psychiatry, 49(11), 881-887. with behavioral health integration. In this model, an addiction medicine specialist provides consultation to both the primary care team and a be- Oslin, D. W., Lynch, K. G., Maisto, S. A., Lantinga, L. J., McKay, J. R., Possemato, K., . . .

Wierzbicki, M. (2014). A randomized clinical trial of alcohol care management delivered in havioral health care manager, (e.g., a Certified Addiction Counselor), Department of Veterans Affairs primary care clinics versus specialty addiction treatment.

Journal of general internal medicine, 29(1), 162-168. who has a collaborative relationship with the health care team (Oslin et Sinclair, J., Chick, J., Sørensen, P., Kiefer, F., Batel, P., & Gual, A. (2014). Can alcohol dependent al., 2014). Medicaid and private payer reimbursement codes provided for patients adhere to an ‘as-needed’medication regimen? European addiction research, 20(5), this model can result in a net positive revenue potential (Lee, Scheuter, 209-217.

Sinclair, J. D. (1989). Method for treating alcohol-drinking response: Google Patents.

Rochlin, Platchek, & Kaplan, 2019).

The most effective treatment systems and programs have yet to be Sinclair, J. D. (2001). Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism. Alcohol and Alcoholism, 36(1), 2-10. developed, and when they are, they may look very different than programs Soyka, M. (2014). Nalmefene for the treatment of alcohol dependence: a current update.

International Journal of Neuropsychopharmacology, 17(4), 675-684. of today. For example, some patients may require a controlled environTempel, A., Gardner, E., & Zukin, R. S. (1985). Neurochemical and functional correlates of ment that enforces compliance and provides psychosocial and nutritional naltrexone-induced opiate receptor up-regulation. Journal of pharmacology and experisupport, while others with less severe disease and a healthy lifestyle may mental therapeutics, 232(2), 439-444.

Umhau, J. C. (2019a). Conquering the Craving: Treatment to Curb Alcohol Use Disorder. simply require education and medication follow up.

Journal of Christian Nursing, 36(3), 148-156.

Many important scientific advances disrupt the status quo, and the Umhau, J. C. (2019b). Therapeutic Drug Monitoring and the Clinical Significance of use of targeted naltrexone is unlikely to be an exception. Early intervenNaltrexone Blood Levels at the Time of a First Drink: Relevance to the Sinclair Method.

Alcohol and Alcoholism, 54(2), 192-192. tion with targeted naltrexone has enormous public health implications Volpicelli, J. R., Rhines, K. C., Rhines, J. S., Volpicelli, L. A., Alterman, A. I., & O’Brien, C. P. as a treatment option for AUD (Niciu & Arias, 2013). When people first (1997). Naltrexone and alcohol dependence: role of subject compliance. Archives of recognize that they have an alcohol problem, Sinclair’s method not only General Psychiatry, 54(8), 737-742. provides hope, but it also engages them with addiction professionals. I am John C. Umhau, MD, MPH, served for more than 20 years as a Senior Clinical encouraged that this and other new interventions may one day remove Investigator at the National Institute on Alcohol Abuse and Alcoholism. He both the stigma and the scourge of AUD. In the case of my friend Mark, has authored numerous papers on nutritional neuroscience and alcoholism.

He earned a Bachelor of Science degree at Davidson College, a Doctor of Sinclair’s method provided a path to abstinence, and freedom from adMedicine degree at Wake Forest University and a Master of Public Health diction to alcohol.

REFERENCES Barrio, P., & Gual, A. (2016). Patient-centered care interventions for the management of alcohol use disorders: a systematic review of randomized controlled trials. Patient preference and adherence, 10, 1823.

Brünen, S., Bekier, N. K., Hiemke, C., Korf, F., Wiedemann, K., Jahn, H., & Kiefer, F. (2018).

Therapeutic drug monitoring of naltrexone and 6β-naltrexol during anti-craving treatment in alcohol dependence: reference ranges. Alcohol and Alcoholism, 54(1), 51-55.

Croop, R. S., Faulkner, E. B., & Labriola, D. F. (1997). The safety profile of naltrexone in the treatment of alcoholism: results from a multicenter usage study. Archives of General Psychiatry, 54(12), 1130-1135.

Heinälä, P., Alho, H., Kiianmaa, K., Lönnqvist, J., Kuoppasalmi, K., & Sinclair, J. D. (2001).

Targeted use of naltrexone without prior detoxification in the treatment of alcohol dependence: a factorial double-blind, placebo-controlled trial. Journal of Clinical Psychopharmacology, 21(3), 287-292.

degree at Johns Hopkins University, and completed a residency in Clinical Preventive Medicine at Johns Hopkins University. He is board certified in both Addiction Medicine and Preventive Medicine. He treats AUD though telemedicine at AlcoholRecoveryMedicine.com

For more information on the use of medications for the treatment of AUD or to contact the author, go to AlcoholRecoveryMedicine.com.

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Addressing the Stigma Around Addiction

By Jack B. Stein, MSW, PhD, Chief of Staff, National Institute on Drug Abuse

A

s we confront the health disparities that are exacerbating the opioid crisis and health consequences associated with it, ranging from fatal overdose to spread of infectious diseases like HIV and hepatitis C, it is increasingly important that we confront the issue of stigma. Stigma is one of the main factors standing in the way of delivering needed care to the nearly 20 million people in the U.S. with substance use disorders. It prevents them from receiving needed treatment in medical settings—especially a concern in the current COVID-19 pandemic, when healthcare resources are strained (Volkow, Ann Intern Med. 2020). It also causes those individuals to avoid seeking treatment in the first place, because they expect to be mistreated or ignored.

Stigma attaches to sufferers of many health conditions, but it is particularly intense and powerful around people with drug and alcohol problems. Because drug-taking is viewed as a free choice, people with substance use disorders are widely seen as having brought their troubles on themselves through lack of self-control and moral weakness. Even when caregivers understand that addiction is a disease, it can be hard to show compassion when an individual’s drug problem leads them to lie or steal to support their addiction.

In a recent Perspective in The New England Journal of Medicine, NIDA Director Dr. Nora Volkow argues that stigma plays a more central role in sustaining a substance use disorder than it might in other conditions (Volkow, N Engl J Med 2020). She cites recent research in the lab of NIDA scientist Marco Venniro showing not only that animals will choose social interaction over drugs even if they are drug-dependent—something that had long been known from research in the power of isolation in promoting drug use—but that when animals are punished somehow for their social choice, they will revert to self-administering the drug (Venniro, 2018).

This suggests to Dr. Volkow that enduring stigma—such as being turned away from emergency care on the assumption that the individual 22

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is drug-seeking, or enduring other forms of humiliation as an “addict”— may act as a punishment spurring further drug use. People use drugs to alleviate social pain such as the pain of isolation and rejection. Thus, the discrimination and rejection of society toward the individual with a drug problem may become part of the vicious cycle of their disorder.

Promoting the awareness of addiction as a disorder with a neurobiological basis encourages addressing it as a medical condition and thus is crucial for expanding the reach of effective medical treatments and increasing the support for such treatments. By itself, however, increased scientific education may not reduce stigma by the wider public. The most effective approaches in reducing stigma around mental disorders are those that promote interaction between the affected group and others, for instance by working toward a common goal (Corrigan, 2018). Such interventions break down the barriers to identifying with, and thus feeling compassion toward, people who have mental illness and substance use disorders.

But short of active interventions, considerate use of language can be one important way of breaking down barriers and promoting identification. Research by Dr. John F. Kelly at Harvard has shown that word choice powerfully influences people’s perception of individuals with substance use disorders. In a series of studies, Kelly found that mental health and addiction professionals more likely to favor punishment (a jail sentence) over treatment when subjects in case vignettes were described as “substance abusers” than when they were described as having a “substance use disorder” (all of the other language being the same) (Kelly, Dow, 2010; Kelly, Westerhoff, 2010).

Person-centered language (“person with a substance use disorder” or “person in recovery”) avoids reducing the individual to their disorder.

Unfortunately, not only health professionals and people in law enforcement but even people in treatment and recovery continue to use stigmatizing language such as “addict,” “abuser,” and “alcoholic,” and to describe being drug-free as being “clean.” It is important that we move beyond these terms and the essentializing and blaming mode of thinking

they activate. As part of its NIDAMED resources for healthcare professionals, NIDA has compiled a set of guidelines for communicating about substance use and addiction in a non-stigmatizing way.

Uncareful use of language can reinforce a moralizing mindset, even when terms are not directly stigmatizing. Describing people who use drugs as “getting high,” is one example. Initial or infrequent substance use produces euphoria, but the brain changes in addiction cause reduced ability to feel pleasure from the substance or anything else; the primary motivation of the individual with addiction is often to temporarily escape the lows of withdrawal, not to feel euphoric. Given that the judgment and moralizing directed at people with substance use disorders arises from the belief that they have willfully forsaken their responsibilities for the pursuit of pleasure, we must be careful not to automatically characterize addiction as a pursuit of the drug high.

Especially during the COVID-19 pandemic, when social distancing is enhancing everyone’s isolation and creating special difficulties for those in addiction treatment or in recovery (Volkow, 2020), it is incumbent upon providers and counselors who work with people who have substance use disorders that they continue to treat these individuals with dignity and worth, and take care not to reinforce what may already be a diminished self-concept due to their condition. It is especially important to set an example for others, for instance through the language they use when referring to people with drug or alcohol problems. As counselors and as members of a society where ten percent of people will have a substance

use disorder at some point in our lives, we must recognize ourselves in the suffering individual, and vice versa.

REFERENCES Corrigan PW, Nieweglowski K. Stigma and the public health agenda for the opioid crisis in America. Int J Drug Policy 2018;59:44-49.

Kelly JF, Dow SJ, Westerhoff C. Does Our Choice of Substance-Related Terms Influence Perceptions of Treatment Need? An Empirical Investigation with Two Commonly Used Terms. J Drug Issues 2010;40(4):805–818. https://doi.org/10.1177/002204261004000403 Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy 2010;21(3):202–207. https://doi.org/10.1016/j.drugpo.2009.10.010 Venniro M, Zhang M, Caprioli D, et al. Volitional social interaction prevents drug addiction in rat models. Nat Neurosci 2018;21:1520-1529.

Volkow ND. Collision of the COVID-19 and Addiction Epidemics. Ann Intern Med. 2020; [Epub ahead of print 2 April 2020]. https://doi.org/10.7326/M20-1212 Volkow ND. Stigma and the toll of addiction. N Engl J Med 2020; 382:1289-1290. https://doi.org/10.1056/NEJMp1917360

Jack Stein, PhD, MSW, joined the National Institute on Drug Abuse (NIDA) in August 2012 as the Director of the Office of Science Policy and Communications (OSPC). In addition to this position, Stein was appointed the NIDA Chief of Staff in March 2019. He has over two decades of professional experience in leading national drug and HIV-related re-search, practice, and policy initiatives for NIDA, The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of National Drug Control Policy (ONDCP) where, before coming back to NIDA, he served as the Chief of the Prevention Branch.

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 the opportunity to connect with Congressional leaders and advocate for the addiction profession.

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

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How the ADA Addresses Addiction and Recovery

By Oce Harrison, EdD, Project Director, New England ADA Center

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ince the passage of the Americans with Disabilities Act (ADA) civil rights law in 1990, everything about disability in America has changed. At the time of that milestone, young people with mostly visible conditions (significant mobility limitations, blindness and deaf) led the movement. They modeled it on the Civil Rights and Women’s movements and embraced an identity as people with disabilities. Today, US Census reports that 27% of the US adult population have disabilities (US Census, 2018). Millions of individuals are in recovery from addiction, and many unaware of their civil rights under the ADA. The goal of this article is to explain how the ADA addresses alcohol use disorder (AUD) and substance use disorder (SUD). The ADA applies to AUD and SUD differently. This difference will be illustrated with stories about alcohol, opioids, cocaine, and marijuana.

The ADA ensures that people with disabilities have the same civil rights and opportunities as everyone else; this includes people with alcohol and substance use disorders. The ADA is clear – people with addiction are people with disabilities and have civil rights under the law if 24

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they meet the ADA’s definition of disability (Americans with Disabilities Act as Amended, 2008). The section of the ADA that addresses rights of people with Alcohol Use Disorder (AUD) and Substance Use Disorder (SUD) is the most underutilized part of the law. This article will hopefully change that.

What rights do people with addiction have? Rights are protected and obligations are defined in three of five main areas: 1. Access to employment (Title I) with a focus on reasonable accommodation, which is a change in the way work is performed (Americans with Disabilities Act, 2008).

2. Access to state and local government services, programs, and activities (Title II), such as public education, corrections and the courts (ADA, 2008).

3. Access to places of public accommodation (Title III), such as recovery homes, health care facilities and other private businesses that serve the public (ADA, 2008).

To be considered a person with a disability under the ADA, a person must meet one of the three definitions below. A person: 1. Has a physical or mental impairment that substantially limits one or more major life activities, e.g. someone with bi-polar disorder, diabetes or alcohol use disorder; or 2. Has a history of an impairment that substantially limits one or more major life activities, e.g. someone who has a history of cancer or someone in recovery from substance use; or 3. Is regarded as having such an impairment, e.g. an employer assumes an employee has a substance use disorder (whether or not the person actually has a SUD), and takes a negative employment action based on that belief, such as refusal to promote, giving a bad performance rating, or termination (ADA, 2008).

Major life activities include, but are not limited to walking, seeing, caring for oneself, learning, working, thinking, communicating and the operation of bodily functions, such as neurological and brain functions. Addiction is an impairment that affects brain and neurological functioning. which often impacts working, learning, and thinking, therefore addiction is an impairment that substantially limits one or more major life activities.

The ADA applies to alcohol use disorder and substance use disorder differently.

Alcohol Use Disorder & the ADA Alcohol use disorder is generally considered a disability whether it is in the present or in the past. However, a person must meet the definition of disability. Notably, ADA applies to private employers with 15 or more employees and all state and local government employers to all aspects of employment; from the job application to benefits (ADA, 2008). The below workplace-related scenarios are fictional, and the purpose is to illustrate how the ADA applies to employment.

MICHAEL’S STORY Michael is often late for work. His supervisor warns him about tardiness. The third time Michael is late, his supervisor gives him a written warning, stating that one more late arrival will result in termination. Michael tells his supervisor that he is addicted to alcohol. He says his late arrivals are due to his drinking and that he needs immediate time off for treatment.

Is Michael protected under the ADA? Yes, he is a person with a disability (alcohol use disorder), but it’s complicated. The employer does not have to withdraw the written warning or grant an accommodation that supports Michael’s drinking, like allowing him to arrive late in the morning. The employer can require an employee with addiction to alcohol to meet the same standards of performance and behavior as other employees. What the employer must grant is Michael’s request to take leave to enter a rehabilitation program, unless the employer can prove that Michael’s absence would cause a great difficulty or expense (undue hardship).

ISABELLA’S STORY Isabella’s manager hears a rumor that she is addicted to alcohol, and reassigns her to a less stressful job with lower pay because of concerns that work stress contributes to her drinking, despite the fact that she has not had any work-related problems.

Is Isabella protected under the ADA? Yes, she is being regarded as having a disability (whether she actually has AUD or not) and has been negatively affected. Isabella’s manager violated the ADA when he reassigned Isabella to a lower paying job.

Substance Use Disorder & the ADA Unlike AUD, the ADA has specific rules regarding SUD, and the ADA protects only people in recovery who are no longer engaging in the illegal use of drugs.

The illegal use of drugs pertains to both: 1. Use of illegal drugs such as heroin or cocaine.

2. Use of prescription medications such as OxyContin or Morphine IF the person has no prescription, OR is using more than is prescribed, OR has a fraudulent prescription.

The ADA defines current illegal use as, “use occurring recently enough to justify a reasonable belief that a person’s drug use is a real and ongoing problem” (US Commission on Civil Rights, 2000).

Does this mean days, weeks, or months? Clearly, if an individual’s drug test is positive, current use is indicated. Courts have considered how close in proximity an individual’s illegal drug use is to an adverse action to be considered “currently engaging” in the illegal use of drugs. Under the ADA, whether someone is currently using drugs illegally is decided on a case-by-case basis.

The below scenarios are fictional, and the purpose is to illustrate how the ADA protects people in recovery who are no longer engaging in the illegal use of drugs.

MARIANNA’S STORY Marianna has been heroin-free for three years. She applies for a job that she is qualified to do. The employer refuses to hire her because he knows about her past addiction.

Is Marianna protected under the ADA? Yes, she is protected under the ADA because she has a history of an impairment (addiction to heroin), and has refrained from the use of illegal drugs for three years, which is a good indication that there is not an ongoing problem and she is not engaging in current illegal use. The potential employer violated the ADA when he refused to hire Marianna because of her recovery status.

BINH’S STORY Binh’s supervisor notices changes in his behavior. She sees Binh sleeping at his desk, hears him slurring his speech on the phone, and notices that he has lost weight. In addition, his work productivity is lower. She speaks with Binh about his behavior and job performance. Binh tells her that he is using heroin and needs to go to treatment.

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Does Binh have any protections under the ADA? No, Binh is not protected by the ADA. Binh’s performance and conduct is due to his current illegal use of drugs, therefore, the employer has no legal obligation to provide a leave of absence and may take whatever disciplinary actions deemed appropriate. Under the company’s drug use policy, Binh can be fired for using illegal drugs at work. However, nothing in the ADA would limit the company’s ability (if the company chooses) to offer leave or other assistance that may enable Binh to receive treatment.

Last Chance Agreements A provision in the ADA that can be used only for people with AUD and SUD who are about to be terminated from their job is called, “last chance agreement” (The U.S. Equal Employment Opportunity Commission, 2017).

“Last chance agreements” are typically structured with a time frame, and are crafted and signed by the employee and employer. An employer agrees not to terminate the employee in exchange for an employee’s agreement to, for example, receive substance use treatment, take periodic drug tests, and avoid further workplace conduct or performance problems. A violation of the agreement such as frequent disappearances from the worksite, absences without notification, or unreliability in keeping appointments might warrant termination because the employee failed to meet the conditions agreed for continued employment.

Knowing that relapse is a part of the recovery process, there are ways to reduce relapse with an accommodation. For example, a nurse with SUD was restricted from dispensing medication after being caught using illegal drugs. Her employer had a policy of allowing employees to participate in rehabilitation and return to work with a last chance agreement. When the nurse returned to work from rehabilitation, she was offered a position that did not require her to dispense medication and given periodic drug tests (Job Accommodation Network, 2020).

Substance Use Disorder and the Legal Use of Drugs The ADA applies to persons who become addicted while taking a prescription drug in the prescribed manner and in prescribed amounts.

JENNIFER’S STORY Jennifer became addicted to Percocet while taking the medication in a prescribed manner and in prescribed amounts.

Is Jennifer protected under the ADA? Yes, she is protected under the ADA because she is legally using a drug as prescribed for an underlying condition. However, if she takes more than prescribed, she may not be covered under the ADA. If Jennifer wants to take a leave of absence from work to taper off Percocet, she is a person with a disability and may have rights to an accommodation. She needs to discuss the possibility of an accommodation with her employer.

The ADA, Medical Marijuana, and State Law Both recreational and medical marijuana are illegal under Federal law.

Therefore, the ADA, which must follow Federal law, offers no protection if an employer makes decisions against an individual based on his or her

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use of marijuana. However, under some state laws, medical marijuana use is legal. If medical marijuana is legal under state law, employers may need to consider reasonable accommodations under a state disability discrimination law for off worksite use (Barbuto v. Advantage Sales and Marketing, 2017). There is a wide variance in what these laws say and what type of protection they may extend to job applicants and employees.

Medication Assisted Treatment Medication-assisted treatment (MAT) includes granting an individual a legal prescription of a medication such as Suboxone, Methadone, or Vivitrol to treat his or her addiction. These drugs are legally prescribed medications used to treat addiction, just like insulin is legally prescribed to treat diabetes.

JULIE’S STORY Julie has been in recovery from addiction to Oxycontin for 5 years and is receiving MAT. She works in the office at a day care center.

Her boss learns about her former addiction and tells her to “get off methadone” or “you’ll be fired.”

Does Julie have protections under the ADA? Yes, Julie has a history of addiction and is being regarded as a current user of illegal drugs because of her medical treatment. Her boss is incorrectly regarding the use of methadone as an illegal drug.

The ADA requires that people with disabilities must be able to participate in and benefit from state and local government services, programs, and activities in public education, corrections, and the courts (Title II of the ADA, 2008).

TOM’S STORY Tom is in medication-assisted treatment (MAT). In MAT, a person is legally prescribed medication such as Suboxone, Methadone, or Vivitrol to treat their addiction. He appeared in family court and requested that he begin to see his children on the weekend. The judge responded to his request saying, “You’ll see your children when you get off Suboxone.”

Is Tom protected under the ADA? Yes, he has a history of addiction which is usually true for MAT participants. Suboxone is a legally prescribed medication to help Tom function just like insulin is prescribed for the health and function of a person with diabetes. Family court is regarding the use of Suboxone as though it is an illegal drug. Tom’s use of Suboxone cannot, by itself, justify the court refusing to let Tom see his children on the weekend.

People who enter the correctional system in MAT are often discontinued on their medication. Are inmates protected under the ADA? Yes, generally correctional systems have an obligation to provide legally prescribed medications to people when the correctional facility has a medication dispensary program. If such programs exist, then MAT should be dispensed just like it is in the case of medication for cancer, bi-polar disorder or epilepsy. When the correctional system does not have a medical dispensary, a reasonable modification of policy can be written to provide a person access to their medication (Pesce v. Coppinger, 2018).

In the third main area of protected rights, the ADA requires places of public accommodations to provide goods and services to people with

disabilities in such places as sober homes, health care facilities and other private businesses that serve the public (Title III of the ADA, 2008).

ALEX’S STORY Alex had a double hip replacement and needs to go into a private rehabilitation facility for physical therapy for a month. When the rehabilitation facility finds out he is being prescribed methadone, they refuse to accept him as a patient.

Is Alex protected under the ADA? Yes, methadone is a legally prescribed drug used to treat addiction. The rehabilitation facility violated the ADA when it denied Alex admission because of his medication assisted treatment.

Whether a state or local government or a privately owned facility, many recovery homes and sober houses deny residents use of legally prescribed medicine to treat opioid use disorder. It can be a violation of the ADA, the Fair Housing Act (FHA) or both laws, to turn people away from sober and halfway houses for MAT. Both the ADA and FHA require public entities to grant “reasonable accommodations to policies, practices and procedures” so that individuals with disabilities can access equal housing opportunities (Miller, 2018).

Conclusion Thirty years after the passage of the ADA, thousands of people in recovery are unaware of their civil rights under the law. It is critical for addiction professionals to be aware that the ADA has protections for the people they serve. It helps professionals to stay informed and provides those they serve with the information, support and advocacy to trigger those rights.

When the ADA was passed, US Congress asked, “How will people understand this very complex law?” Their response was to create ten regional ADA Centers to provide information, guidance and training on the ADA, called the ADA National Network (ADANN) (www.ADAta.org).

The ADANN provides a safe, confidential way for individuals, businesses and governments to ask an ADA question.

It took 30 years of people with disabilities telling their stories and triggering their civil rights under the ADA to bring about systemic changes in education, employment, and civic life. Today, people with addiction and addiction professionals must become aware of their civil rights, so lives can change for the better and end discrimination under the ADA. The ADA provides a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities. It’s up to all of us to make this part of the law a more utilized one.

REFERENCES Americans with Disabilities Act of 1990 as Amended (P.L. 110-325) Sec. 12114. Illegal use of drugs and alcohol p. 45–47 (2008). Retrieved from https://www.ada.gov/pubs/adastatute08.pdf Americans with Disabilities Act of 1990 as Amended (P.L. 110-325) Sec. 12102. Definition of disability p. 7 (2008). Retrieved from https://www.ada.gov/pubs/adastatute08.pdf Americans with Disabilities Act 1990, as Amended Subchapter I – Employment [Title I] Sec. 12111. P. 8 (2008). Retrieved from https://www.ada.gov/pubs/adastatute08.pdf Americans with Disabilities Act 1990, as Amended (P.L. 110-325) Subchapter II – Public Services [Title II] Sec. 12131. P. 16 (2008). Retrieved from https://www.ada.gov/pubs/ adastatute08.pdf Americans with Disabilities Act 1990, as Amended (P.L. 110-325) Subchapter III – Public Accommodations and Services Operated by Private Entities [Title III] Sec. 12181. P. 30 (2008).

Retrieved from https://www.ada.gov/pubs/adastatute08.pdf

Learn About Your Rights The ADA National Network Find your ADA Center: www.ADATA.org The ADA, Addiction and Recovery Fact Sheet https://adata.org/factsheet/ada-addiction-and-recovery The ADA, Addiction, Recovery and Employment Fact Sheet https://adata.org/factsheet/ ada-addiction-recovery-and-employment ADA, Addiction and Recovery PDF https://www.newenglandada.org/addiction-and-recovery

How to File a Complaint US Equal Employment Opportunity Commission (EEOC) https://www.eeoc.gov/employees/howtofile.cfm 1-800-669-4000 or info@eeoc.gov United States Attorney’s Office Civil Rights Unit Opioid Initiative in each state Department of Justice office State and Local Governments and Public Accommodations Department of Justice https://www.ada.gov/filing_complaint.htm 1-800-514-0301 Barbuto v. Advantage Sales and Marketing, Supreme Judicial Court of Massachusetts.

SJC-12226. Reporter 477 Mass. 456 (2017). Retrieved from https://www.ebglaw.com/ content/uploads/2017/10/Barbuto-v-Advantage-Sales-and-Marketing-LLC-477-Mass.pdf Batiste, L. Job Accommodation Network Last Chance Agreements for Employees with Drug and Alcohol Addictions. Retrieved from https://askjan.org/publications/consultantscorner/Last-Chance-Agreements-for-Employees-with-Drug-and-Alcohol-Addictions.cfm Miller, J. (2018, May 17). Settlement clarifies discrimination for buprenorphine use.

Retrieved from https://www.psychcongress.com/article/ethics/ settlement-clarifies-discrimination-buprenorphine-use Pesce v. Coppinger, United States District Court of Massachusetts. Nov 26, 2018 355F. Supp.3d (D.Mass. 2018). Retrieved from https://www.aclum.org/en/cases/ pesce-v-coppinger US Census. (2018). Americans with disabilities: 2014 Household economic studies current population reports: Danielle M. Taylor Author. Retrieved from https://www.census.gov/ content/dam/Census/library/publications/2018/demo/p70-152.pdf U.S. Commission on Civil Rights. (2000). Sharing the dream: Is the ADA accommodating all?

Chapter 4 Substance Abuse under the ADA. US Commission of Civil Rights: Author.

Retrieved from https://www.usccr.gov/pubs/ada/main.htm U.S. Equal Employment Opportunity Commission. (1997). The Americans With Disabilities Act: Applying performance and conduct standards to employees with disabilities. Section G. U.S. Equal Employment Opportunity Commission: Author. Retrieved from https://www.eeoc.gov/facts/performance-conduct.html#fn3 The New England ADA Center is one of ten ADA Centers comprising the ADA National Network.

The New England ADA Center is funded under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0087). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS).

Oce Harrison, EdD, has directed the Institute for Human Centered Design’s New England Americans with Disabilities Act (ADA) Center since 2001. She provides ADA Employment trainings and Addiction, Recovery and the ADA trainings throughout New England. Recently, Harrison has been working with organizations such as Learn to Cope and Massachusetts Organization for Addiction Recovery. She is also conducting research on identifying characteristics of people with disabilities and challenges to implementing the ADA for municipalities in New England.

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Support Recovery Through Stress Management Around COVID-19

By Nancy A. Piotrowski, PhD, MAC

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tress is ubiquitous in everyday life. It can be good (eustress) and bad (distress) (Selye, 1976). It can vary on a temporal continue, from acute to episodic to chronic. It also varies by the degree to which an individual can exert control over it. And then, even though two individuals may live through the same kind of stress, how they perceive it can make the experience and impact differ. These variations show some of the many dimensions of stress (Cooper & Campbell Quick, 2017; Selye, 1976).

For patients who have substance use disorders and other addictive behaviors, stress is often a trigger to use (Wemm & Sinha, 2019). And if there are accompanying comorbid conditions, stress is also capable of triggering symptoms for those conditions as well. Worse yet, if there are also physical health conditions on board, stress can worsen those, or vice versa, and that combination of factors can serve as a trigger for substance use and other mental health disorder symptoms (Vig, El-Gabalawy, & Asmundson, 2019).

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Unfortunately for just about everyone, the coronavirus (COVID-19) pandemic (World Health Organization, 2020) has created a situation where the stress is present, bad, and prolonged. Additionally, because viruses are invisible and the initial symptoms of COVID-19 infection are relatively common and slow to materialize (e.g., taking up to 14 days to show), this also serves to heighten anxiety around symptoms, while also minimizing feelings of control related to avoiding infection. Add in a lot of threat messaging through media exposure, and this heightens anxiety further (Gao et al., 2020). Together these factors combine to create significant triggers for lapse and relapse for just about all substances for many of our patients.

Add in the impact of shelter in place orders – such as the need for social isolation, financial pressures from job loss or furloughs, potential boredom, or potential inescapable conflict with family members also sheltering in place – and we have treacherous conditions for stress with many familiar triggers for relapse.

As such, other outcomes that should be recognized from the overall event of COVID-19 are lapses and relapses for substance use and other mental health conditions. The need for swift mental health and addiction care are critical to prevent worsening. Remember that stress management may benefit overall treatment progress through reducing triggers to use and making it easier for patients to adhere to other aspects of treatment. Whatever can be done to minimize amplification of symptoms via cognitive distortions, increase mindfulness to support calmness and resilience, minimize interpersonal conflict, stimulate engaged productive behavior and realistic goal setting, and preserve self-care behaviors to avoid known triggers will be critical. It is also important to remember that even for those who do not lapse, continued support will be important to sustain strength in the face of a chronic stress. Finally, keep in mind that the stressors present are not just risks for relapse, but also for domestic violence and suicide. This is a time to listen carefully for warning signs of both of these conditions and brush up on treatment improvement protocols (TIPS) (Substance Abuse and Mental Health Administration, 2015a; 2015b) on these topics. There is also a suicide prevention resource center website available with additional resources on COVID-19 (SPRC, 2020).

Ironically, surveys of Americans find that dealing with healthcare is stressful, among a myriad of stressors in everyday life including money, work, and the future of the nation, where there is no pandemic (American Psychological Association, 2017; 2019). On the plus side, we have many evidence-based approaches and tools to support the work of combatting stress (Coulin, Monroe, & West, 2016; Vavogli & Darviri, 2011). Given the strong potential stress has to influence substance use and other addictive behaviors, it is imperative to not leave stress off the table as a complicating factor needing attention during treatment. A side benefit: when we practice what we preach, we become models for our patients and supervisees – and the benefits of vicarious learning (Bandura, 1995; Scovholt & TrotterMathison, 2011) become possible. So do not forget yourself as you think about this topic!

REFERENCES Bandura, A. (Ed.) (1995). Self-efficacy in changing societies.

New York, NY: Cambridge University Press.

Cooper, C.L., & Campbell Quick, J. (Eds.) (2017). The handbook of stress and health: A guide to research and practice.

Malden, MA: Wiley.

Coulin, S.M., Monroe, C.M., & West, D.S. (2016). A systematic, multi-domain review of mobile smartphone apps for evidence-based stress management.

American Journal of Preventative Medicine, 51(1), 95-105.

Gao, J., Zheng, P., Jia, Y., Chen, H., Mao, Y., Chen, S., …

Dai, J. (2020). Mental health problems and social media exposure during COVID-19 Outbreak. SSRN. https://ssrn.com/abstract=3541120.

Selye, H. (1976). Stress in health and disease. Boston, MA: Butterworth.

Skovholt, T.M., & Trotter-Mathison, M. (2011). The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and health professionals, 2nd Ed. New York, NY: Routledge.

Vavogli, L., & Darviri, C. (2011). Stress management techniques: Evidence-based procedures that reduce stress and promote health. Health Science Journal, 5(2), 74-89.

Vig, K.D., El-Gabalawy, R., & Asmundson, G.J.G. (2019).

Stress and comorbidity of physical and mental health.

In K.L. Harkness & E.P. Hayden (Eds.). The Oxford handbook of stress and mental health (pp. 311-330).

New York, NY: Oxford University Press.

Wemm, S.E., & Sinha, R. (2019). Drug-induced stress responses and addiction risk and relapse.

Neurobiology of Stress, 10, 100148. doi: 10.1016/j. ynstr.2019.100148.

World Health Organization. (2020, March, 26).

Coronavirus. https://ssrn.com/abstract=3541120 RESOURCES American Psychological Association (2017). The state of our nation. https://www.apa.org/news/ press/releases/stress/2017/state-nation.pdf American Psychological Association (2019). Stress in America. https://www.apa.org/news/press/ releases/stress/2019/stress-america-2019.pdf American Psychological Association (2020). Stress relief is within reach. https://www.apa.org/topics/ stress/index Substance Abuse and Mental Health Authority (2015a). Addressing suicidal thoughts and behaviors in substance abuse treatment: Quick guide for clinicians based on TIP 50. https://store.samhsa.gov/product/ addressing-suicidal-thoughts-and-behaviors-substance-abuse-treatment-quick-guide-clinicians Substance Abuse and Mental Health Authority (2015b). Substance abuse treatment and domestic violence: Quick guide for clinicians based on TIP 25. https://store.samhsa.gov/product/ substance-abuse-treatment-and-domesticviolence Suicide Prevention Resource Center https://www.sprc.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 and serves as its Federal Advocacy Coordinator in their 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.

Alcohol Rehabilitation Can Reduce Hospital Readmission, Relapse, and Mortality in Patients With Alcoholic Hepatitis

By National Institute on Alcohol Abuse and Alcoholism (NIAAA)

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arly alcohol rehabilitation can reduce the risk of hospital readmission, alcohol relapse, and mortality among patients hospitalized for alcoholic hepatitis (AH), according to a recent NIAAA-supported study. AH is a potentially life-threatening alcohol-associated liver disease; many patients who are hospitalized with severe cases of AH die within weeks of diagnosis. For hospitalized patients who survive an episode of AH, abstinence and the prevention of alcohol relapse are crucial to their long-term survival. A large body of research has demonstrated the effectiveness of alcohol treatment in promoting abstinence. Alcohol treatment integrated with AH treatment has the potential to improve health outcomes and contribute to long-term survival.

In the current study, researchers examined data from two groups of patients (one for testing the hypothesis; the other for validation) hospitalized for AH. The first cohort consisted of 135 AH patients hospitalized at the Mayo Clinic from 1999 to 2016 (“test cohort”).

The second cohort consisted of 159 hospitalized AH patients who participated in NIAAA’s Translational Research and Evolving Alcoholic Hepatitis Treatment (TREAT) multi-site research consortium from 2013 to 2017 (“validation cohort”). A major goal of the study was to determine the rates of 30-day hospital readmission, 30-day alcohol relapse, and mortality after hospital discharge for AH and whether early alcohol rehabilitation programs after discharge could improve these outcomes.

Alcohol rehabilitation consisted of residential or outpatient treatment and/or mutual support groups. After hospital discharge, only 16–20 percent of patients from the cohorts participated in early alcohol rehabilitation.

The researchers found that the rate of 30day hospital readmission among AH patients who received alcohol rehabilitation shortly after

hospital discharge was significantly lower than those who did not receive rehabilitation (11.0 percent vs. 35.2 percent, respectively, in the test cohort and 21.1 percent vs. 45.0 percent, respectively, in the validation cohort). Even more striking were the differences in the rates of alcohol relapse in the 30 days after hospital discharge among AH patients who received alcohol rehabilitation compared to those who did not (7.4 percent vs. 44.4 percent, respectively, in the test cohort and 5.3 percent vs. 45.9 percent, respectively, in the validation cohort).

Participating in alcohol rehabilitation was also associated with an 80 percent lower risk of longterm mortality.

The authors conclude that these findings strongly suggest that all patients hospitalized for AH should be evaluated by addiction specialists and referred to treatment, thus providing further support for the integration of addiction medicine in hepatology practice.

REFERENCE Peeraphatdit, T.B.; Kamath, P.S.; Karpyak, V.M.; Davis, B.; Desai, V.; Liangpunsakul, S.; Sanyal, A.; Chalasani, N.; Shah, V.H.; and Simonetto, D.A. Alcohol rehabilitation within 30 days of hospital discharge is associated with reduced readmission, relapse, and death in patients with alcoholic hepatitis. Clinical Gastroenterology and Hepatology. In press. PMID: 31042580

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Counselor Relapse: Helping Our Wounded Warriors

By Mark Sanders, LCSW, CADC

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eople in recovery have offered their support to those who seek recovery since the Washingtonians of the 19th century (White, 2014). The progress made by counselors in recovery provides evidence that recovery is possible. These counselors are often dubbed wounded warriors due to their selfless efforts in laying the foundation for recovery in the SUD treatment industry.

When individuals from professions widely accepted as society’s great protectors, such as police officers, veterans, doctors, firefighters, and pilots, seek SUD treatment, treatment providers serve this group with dignity during their recovery journey as they prepare their return to the field.

However, this is often not the case when SUD counselors seek that same treatment. Often, counselors in recovery lose their job whenever they relapse. As a result of this disparate treatment, addiction professionals in recovery work with a fear of relapsing when they offer recovery services to others. However, a counselor in recovery who relapses is a wounded warrior who deserves the same quality services as the other great protectors in society. It is time we honestly examine if counselors in recovery are granted the same level of understanding and compassion.

Those receiving treatment as a current helping professional are sometimes referred by an Employee Assistance Program (EAP). One of the first goals in SUD treatment is to ease the guilt and shame commonly associated with this disease. Here, psychoeducation groups introduce the concept of addiction as a disease. Curriculum also clarifies that addiction 30

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is not a moral dilemma and teaches the diagnostic criteria for a SUD. However, it is clear that “addiction as a disease” is not universally accepted as true. If an employee’s tumor returns, and they need cancer treatment, their job is protected. For most addiction professionals in recovery, they often lose their job if their addiction reoccurs.

James Kemper, Jr., founder of Kemper Insurance Company and one of the leaders in the new Employee Assistance Program (EAP) movement, was a recovering alcoholic. He stated that, “The most expensive way to handle alcoholics is to fire or ignore them. The most profitable and effective way is to help them recover” (Janega, 2002). The same holds true for SUD counselors with SUD. Are there existing aspects of the SUD treatment profession that influence a counselor in recovery to relapse? Are there known cautions that these counselors may use to provide quality care and maintain the support to others concurrently? Such questions ought to be considered in the profession. According to (White & Cloud, 2008), several toxic factors within a work environment may increase the risk of relapse, burnout, stress, and fatigue.

Studies show that an organization plays an essential role in employee safety and general motivation. An organization’s safeguards may include celebrating an individual’s achievements, teambuilding retreats to improve morale while helping others, creating a healthy working environment and establishing protocols to reduce organizational stress (Griffin, &

“The most expensive way to handle alcoholics is to fire or ignore them. The most profitable and effective way is to help them recover.”

– James Kempler, Jr.

Neal, 2000). Support can also be provided by consistent and structured clinical supervision. Clinical supervisors can take the task of evaluating individuals they supervise and assess their level of happiness while at work, their workload, and their self-care practices, which will ease burnout and fatigue while providing support. Assessing these factors regularly builds a supervisory alliance that protects the overall therapeutic environment and allows the supervisor to monitor risks of reoccurrence.

Policies must be carefully reviewed by administrators, employee assistance professionals, and human resource directors to ensure they align with the Drug-Free Workplace Act and the Americans with Disabilities Act (SAMHSA, 2019). Both laws are clear that you cannot terminate an employee on the grounds of having a substance use disorder (Richard, M., Emener, W., Hutchinson, W. 2009). Work-related discipline is permitted on the grounds of poor work performance and having an illicit drug or alcoholic substance in their system while at work (SAMHSA, 2019).

The Americans with Disabilities Act protects employees from being terminated on the grounds of seeking or receiving SUD treatment (ADA, 2008). These policies are written, but not always adhered to. Continued review, compliance assessment, implementation, training, and regulation is needed to ensure termination procedures are not influenced by the sigma of addiction.

For every counselor in recovery, there are best practices to maintain personal recovery while providing similar treatment services to others. The experience for counselors in recovery can either be described as wearing two conflicting hats or two complimentary hats, depending on personal perspective. One should put personal recovery first and separate this from paid work, managing personal care strategies to prevent work burnout and fatigue (Repper & Perkins, 2009). Many entered recovery rehearsing the first step: “we admitted we were powerless over (fill in the drug here),” and this step transfers into the profession when providing treatment to those in reoccurrence. A counselor in recovery has very little power over his or her client’s recovery or reoccurrence. Continued self-assessment in critical recovery areas is essential, such as building a support network, maintaining pro-recovery rituals, working towards greater balance, and seeking regular counseling for supportive accountability. Being a counselor while in recovery is possible, but there are successful and unsuccessful approaches to achieve this.

In conclusion, when relapse occurs, the addiction profession generally receives the client with a non-judgmental attitude and with a lot of compassion. Professionals understand and acknowledge that relapse is part of the recovery process; it is a learning process and a normal part of recovery from any disease. Some who relapse feel uncomfortable and unwilling to return to the field for fear of being judged. Quality care cannot discriminate, and thus anyone returning to work after receiving treatment for a SUD-related reoccurrence must receive the same compassion and a

non-judgmental attitude from their colleagues as those welcomed back after receiving cancer treatment.

REFERENCES ADA, 2008. https://www.ada.gov/pubs/adastatute08.pdf Griffin, M. A., & Neal, A. (2000). Perceptions of safety at work: a framework for linking safety climate to safety performance, knowledge, and motivation. Journal of occupational health psychology, 5(3), 347.

Janega, J. James S. Kemper Jr., 88, Chicago Tribune Obituary page, July 5, 2002 Repper, J., & Perkins, R. (2009). Recovery and social inclusion. Mental Health Nursing Skills, 85-95.

Richard, M, Emener, W., Hutchinson, W. (2009). Employee Assistance Programs. Charles Thomas Publisher, LTD. Springfield, IL. SAMHSA, (2019). Drug Free Workplace Toolkit. https://www.samhsa.gov/workplace/ toolkit#policy White, W. Slaying the Dragon: The History of Addictions Treatment and Recovery in America, (2014). Chestnut Health Systems, Bloomington, IL. White, W., & Cloud, W. (2008). Recovery capital: A primer for addictions professionals.

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 5 books. He has also had two stories published in the New York Times Best Selling Book Series, Chicken Soup for The Soul. Sanders is the recipient of numerous awards including: The Barbara Bacon Award for outstanding contributions to the Social Work Profession as a Loyola University of Chicago alumni, 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 Co-Founder of Serenity Academy Chicago, the only recovery High School in Illinois.

NOMINATE AN ADDICTION PROFESSIONAL OR ORGANIZATION

2020 NAADAC AWARDS Addiction Educator of the Year Award Lifetime Honorary Membership Award Lora Roe Memorial Addiction Counselor of the Year Davida Coady Gorham Medical Professional of the Year Mel Schulstad Professional of the Year Organizational Achievement Award William F. "Bill" Callahan Award NOMINATIONS DUE: MAY 31

Learn more at www.naadac.org/awards.

S P R I N G 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 31

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. According to the patient-centered approach of Sinclair’s method, data suggests that insisting on abstinence renders naltrexone therapy __________ effective. a. more b. equally c. less d. as 2. Data shows that patients with Alcohol Use Disorder (AUD) can be compliant with as-needed dosing and that taking naltrexone during drinking can … a. reduce craving, consumption, and therefore the harm from alcohol. b. cure alcohol use disorder (AUD). c. replace less effective therapeutic methods. d. force a person to not take that 2nd drink during a reoccurrence.

3. Which section of the Americans with Disabilities Act (ADA) is considered the most underutilized part of the law? a. The section that addresses. b. The section that addresses co-occurring disorders. c. The section that addresses trauma-related disorders. d. The section that addresses rights of people with Alcohol Use Disorder (AUD) and Substance Use Disorder (SUD).

4. A provision in the ADA that can be used only for people with AUD and SUD who are about to be terminated from their job is called a ____________. a. employer violation agreement b. provision of protected employer c. MAT Provision d. last chance agreement 5. Regarding the use of recreational and medical marijuana, which level of law must the ADA follow? a. state b. program-specific c. federal d. international 6. In Mark Sanders article, who did he refer to as one of the leaders in the Employee Assistance Program (EAP) movement who made great strides for SUD treatment and was also a recovering alcoholic? a. James Kemper, Jr. b. Henry Cloud c. John Townsend d. Sean McDowell

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7. A series of studies found that counselors were more likely to favor _______________ over treatment when subjects in case vignettes were described as “substance abusers” than when they were descried as having a “substance use disorder.” a. outpatient therapy b. punishment (a jail sentence) c. acceptance (reentry programs) d. understanding (cases dismissed) 8. As part of its ________________ for healthcare professionals, NIDA has compiled a set of guidelines for communicating about substance use and addiction in a non-stigmatizing way. a. NIDAMED resources b. NIDAHEALTH resources c. hope for future research d. protest 9. The CARES Act includes a number of additional actions of relevance to address the COVID-19 crisis. Which list is most accurate? a. SAMHSA Emergency Response Grants, Restricting Medicare Telehealth Flexibilities, and Coronavirus Relief Fund b. SAMHSA Emergency Response Grants, Restricting Medicare Telehealth Flexibilities, and Coronavirus Relief Fund c. SAMHSA Emergency Response Grants, Shutting Down Mental Health Services Demonstrations, and Coronavirus Relief Fund d. SAMHSA Emergency Response Grants, Expanding Medicare Telehealth Flexibilities, and Coronavirus Relief Fund 10. Telebehavioral health services refer to: a. Only the use of phones for delivering distance behavioral health services b. The use of electronic technologies like video games, electronic cars, and drones to deliver behavioral health services c. The use of electronic technologies (e.g., phone, emails, videoconferencing, social media, and chat and text messaging) for delivering distance behavioral health services including intake and assessment, treatment, and recovery support d. The use of tele-commuting to provide behavioral health services such as MST, FFT, EFT, and DBT

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

NAADAC COMMITTEES

Updated 5/1/2020

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

Gloria Nepote, Kansas 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

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.