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Pain Management and Opioid Use with Veterans and Service Members

Mon, 06/12/2017 - 03:00

Military service brings a risk for serious injury, and with it, the possibility of severe or chronic pain. Such pain may be treated with prescription medication – sometimes opioids – which carry a risk for overuse or misuse. SAMHSA has been working with the U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA) to enhance informed prescribing practices and prevent misuse that can result in overdose or even death.

Controlling Pain

Injuries incurred during military service can be complex and the management of chronic pain requires attention. According to Friedhelm Sandbrink, M.D., VA’s Acting National Program Director for Pain Management, up to 75 percent of older veterans experience chronic pain. Prevalence of severe pain is strikingly more common in veterans than in the general population, particularly in younger veterans and in veterans who served during recent conflicts. Complicating matters even more are co-occurring disorders experienced by veterans, such as posttraumatic stress disorder and traumatic brain injury, for which additional psychotropic medications may be prescribed. Medication interaction is an important consideration.

“The challenge for those prescribing medications in the military and in the VA is to find the right balance to get the pain under control and to keep the patient safe,” said Dr. Sandbrink. “We want to ensure that patients are finding relief and taking medications as prescribed, and that we are aware of other sedating medications or alcohol use that could increase the risk of overdose.” He added, “in order to find the right balance, we nowadays rely less on medication and make much greater use of other approaches, including behavioral therapies, physical therapy and integrative health modalities, and emphasize physical and mental function.”

Providers outside the military systems and VA are accessed by more than half of those who serve, so they also need to be aware of population-specific guidance for veterans and service members. This is particularly true for members of the National Guard and Reserve, whose home communities may not include military supports.

The High Risk Of Relapse – For individuals in recovery from a substance use disorder who relapse, the risk of overdose is greatest. Tolerance of a drug during sobriety decreases, so if a person resumes at the same dosage as before recovery, that use can be lethal. For this reason, it is important to educate family members on the possibilities of misuse and how to respond.

The DoD currently has a pilot project called Building Healthy Military Communities that addresses the unique needs of geographically dispersed service members and their families that may affect readiness, resiliency, and wellbeing. SAMHSA also supports this work to address the mental health needs of service members and their families in communities throughout the U.S.

Interagency Task Force

The DoD, VA, and HHS participate in the Interagency Task Force on Military and Veterans Mental Health, created in 2013 to ensure that veterans, service members, and their families can access the services and supports that they need. SAMHSA represents the U.S. Department of Health and Human Services on this Task Force. Through this partnership, SAMHSA provides a number of resources to DoD and VA providers, including:

 SAMHSA and Veterans Affairs in Action

Dr. Karen Drexler, M.D., the National Mental Health Program Director for Substance Use Disorders in the VA, explained that, “SAMHSA resources and trainings are excellent. We are currently using many SAMHSA resources such as the PCSS-MAT and PCSS-O to educate Veterans, their families and clinicians about the best approaches to care.”

SAMHSA has been instrumental in training the prescribing workforce in the military to limit the length of opioid and other pain medication use, recognize the signs of misuse, be aware of treatment options, and understand DEA waivers to prescribe Buprenorphine (medication-assisted treatment to help people reduce or quit their use of opiates, such as pain relievers like morphine). SAMHSA uses evidence-based practices to develop these trainings that have substantially reduced dosages to stay within the recommended ranges and have encouraged providers to limit opioid use to three months.

“SAMHSA’s contribution on the Task Force has led to some specific advancements that support military service members, veterans, and their families,” said Cicely Burrows-McElwain, SAMHSA’s Military and Veteran Affairs Liaison. “In addition to reviewing the clinical practice guidelines, SAMHSA also worked with the other agencies to relay and report prescription drug information to Prescription Drug Monitoring Programs which helps to prevent over prescribing and overmedicating.”

The VA also worked to eliminate the co-pay on drugs like naloxone that are used if someone overdoses, making it much more accessible to patients and their families.

Dr. Drexler’s experience with SAMHSA’s trainings and work on the Task Force has changed the way she thinks about treatment. She explained that she had a patient with multiple medical problems that increase the risk for overdose such as sleep apnea and emphysema who was stable on medication-assisted treatment for opioid use disorder, but life stressors led him to relapse to benzodiazepine use. “Every time he came in, he was intoxicated, so we couldn’t have a meaningful discussion about treatment and I was especially concerned about overdose because he lived alone.”

The SAMHSA training encourages providers to think creatively about care and who to involve in overdose prevention and education. As a result, Dr. Drexler reached out to her patient’s sister and shared information learned in the SAMHSA training and prescribed a naloxone rescue kit. Educating his sister helped her to assist in limiting his access to illicit pills.  “My very next visit with him, he was alert, and I was able to have a meaningful talk with him about recovery and safety.”

“The federal coordination made it possible to look at risks and safety concerns across an entire spectrum of federal efforts,” said A. Kathryn Power, M.A., Executive Lead for SAMHSA on the Interagency Task Force. “The coordination, weekly communication, and measured positive outcomes all point to better care for military service members and veterans. That has been, and continues to be, our driving force.”

Although advancements have been made to better equip treatment providers with information and training to prevent circumstances that could lead to addiction, opioid misuse continues to be a serious public health concern. Providers in the DoD and VA continue their efforts to address pain and limit opioid use, while discussing potential associated risks with military service members, veterans, and their families. SAMHSA’s work with the Task Force, and work done to support states across the country through the SMVF TA Center,  will ensure that the support, resources, and training to improve care and prevent substance use disorders is accessible no matter where military service members and veterans go for care.

Daniel and Stephanie Keegan’s Story

Daniel Keegan, a soldier in the 82nd Airborne and son of Stephanie Keegan (in above image) who works with a number of advocacy groups to raise awareness. Daniel struggled with opioid addiction and overdosed two weeks before the start of his treatment in the VA. Stephanie calls this her “joy” picture because of his smile and the cup he is holding – it was the last image taken before he passed away.

“My son Daniel was a soldier for nearly eight years, deploying to Afghanistan twice. He came home from his second deployment with a serious case of PTSD and quickly became addicted, as a means of self-medicating. Daniel wanted to get well so that he could help the struggling veterans following in his footsteps. I promised him that if we lost him, I would take up the fight in his place. I will continue on this mission until my last breath.” – Stephanie Keegan


The Voice Awards 2017 – A Focus on Veterans

The Voice Awards will take place on August 16, 2017 at UCLA’s Royce Hall. The annual event recognizes individuals in recovery who have promoted family involvement in recovery, have led efforts to reduce the negative attitudes and misperceptions of behavioral health conditions, and have had a positive influence where they live and work. This year, special consideration will be given to leaders who are working to ensure that America’s military and veteran communities have access to the mental health and substance use treatment and services they deserve.



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“Making Each Day Count” for Prevention Week

Mon, 05/22/2017 - 10:00

Pictured at the Prevention Week 2017 Kickoff Event from SAMHSA are Frances M. Harding, Director of the Center for Substance Abuse Prevention and Kana Enomoto, Acting Deputy Assistant Secretary for Mental Health and Substance Use; Angie Goff, News Anchor for NBC4 in Washington, DC; Peter Konwerski, Vice Provost and Dean of Student Affairs, The George Washington University.

The 2017 observance of Prevention Week focused on the theme, “Making Each Day Count.” The annual observance raises awareness and promotes action on substance use and mental health. In addition to a kick-off event in Washington, DC, communities around the country participated in events and educational outreach and celebrated achievements made to prevent behavioral health issues. Participants also shared their prevention efforts on social media using #PreventionPower and #NPW2017 in their posts. Each day of Prevention Week had a prevention focus, including youth tobacco use, underage drinking and alcohol misuse, prescription and opioid drug misuse, illicit drug use and youth marijuana use, suicide, and mental health and wellness.

Prevention resources on all of these topics and more can be found at

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Spotlights on Six Trauma-Informed Resilient Communities

Tue, 05/16/2017 - 10:00

Establishing and integrating a trauma-informed approach to addressing mental and substance use disorders is important not only for individuals, but for communities as well. To further this goal, SAMHSA recently published Spotlight: Building Resilient and Trauma-Informed Communities, a series that highlights efforts underway in six different cities across the United States to build trauma-informed, resilient communities.

SAMHSA defines a trauma-informed approach as one where people realize the prevalence of trauma, recognize the impact and responses to trauma, and resist practices that could cause more harm.

The Spotlight Series

Following are some examples of trauma-informed community programs from the Spotlights.

Kansas City

Molly Ticknor, Director of Mental Health Services with Kansas City Public Schools, holding a “Power Plan” that teachers and student create in trauma-informed schools to keep them in tune with their own self-care.

In Kansas City, MO, advocates for trauma-informed care organized Trauma Matters KC (TMKC), bringing together 40 organizations to address social and economic challenges. The Spotlight describes their collective action to build resilience and to address special needs. For example, in the Kansas City Trauma Sensitive Schools, children and teachers create their own self-care plans as a tool for managing stress or distress during the day.

Spotlight: Kansas City: One of the most striking aspects of TMKC is the breadth of community involvement. At any monthly meeting you might find a landscape architect whose designs promote resilience, a judge who runs a trauma-informed court, an author or journalist who wants to learn more, a sports coach concerned about the young people on his team, or a community planner considering implications for urban development.

Tarpon Springs

Another Spotlight looks at the strides made in Tarpon Springs, FL. After learning about Adverse Childhood Experiences (ACE), Tarpon Springs former commissioner and vicemayor Robin Saenger initiated a community effort called Peace4Tarpon (P4T). This effort gathered city officials, professionals, and city residents into a group that coordinated multiple trauma-informed activities including a library-sponsored community education day, and a public “peace flags” event in which businesses and residents donated a wide variety of efforts and materials.

Building on the P4T effort, the Pinellas Ex-Offender Reentry Program (PERC) Clinical Director, Denise Hughes Conlon, added ACE assessment into PERC evaluations and found surprisingly high scores for childhood trauma among this population. In response, she incorporated the Seeking Safety curriculum into PERC’s substance abuse treatment program.

Spotlight: Tarpon Springs: “If one person or agency expresses a need, chances are good that someone else will meet it.”


The Porch Light Program in Philadelphia uses art as a public health strategy, strengthening community engagement, promoting behavioral health recovery, and addressing social and economic factors such as poverty, racism, violence, and resource disparities. People with behavioral health concerns and intellectual disabilities work side-by-side with service providers, local funders, academics, and local artists to create public art in neighborhoods across the city. The process improves morale, builds connections, and heals communities by exploring health related issues.

Spotlight: Philadelphia: “Relationships forged during the process often lead to ongoing activities. In one neighborhood, the collaboration led to a yearly conference to address community concerns.”

“The effects of traumatic events place a heavy burden on individuals, families and communities and create challenges for public institutions and service systems,” said Larke Huang, Ph.D., SAMHSA’s Trauma and Justice Strategic Initiative Lead and Director of the Office of Behavioral Health Equity. “We hope these spotlights will motivate other cities and regions to consider how they can take similar steps in their communities.”

SAMHSA offers many resources for addressing trauma, including SAMHSA’s National Center for Trauma-Informed Care, a technical assistance center, which provides training and support to organizations throughout the United States. Additional resources are provided below.

Learn more about SAMHSA’s 6 Principles of a Trauma-Informed Approach in the Spotlight Introduction.


Resources On SAMHSA’s YouTube Channel Related SAMHSA Blogs

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Olympians Phelps and Schmitt Join with SAMHSA to Promote Children’s Mental Health

Tue, 05/16/2017 - 07:30

Olympic medalists Michael Phelps and Allison Schmitt served as honorary chairs for SAMHSA’s National Children’s Mental Health Awareness Day event on May 4. Both have experienced depression and eventually found help. Health and Human Services Secretary Thomas E. Price, M.D., presented both Michael and Allison with SAMHSA Special Recognition Awards for their support of children, youth, and young adults with mental and substance use disorders.

Allison Schmitt, SAMHSA Acting Deputy Assistant Secretary Kana Enomoto, Health Resources and Services Administration Administrator George Sigounas, Health and Human Services Secretary Tom Price, and Michael Phelps at Awareness Day event.

During the event, Michael explained why partnering with SAMHSA, was so important. “I want to be able to get out in front and talk and say – look, I’ve done these great things in the pool, but I’m also a human, just like other people in the world that are going through the exact same struggle.”

His remarks were echoed by Allison who described the special recognition award from SAMHSA as the most meaningful award of her life. Allison spoke of the importance of reaching out for help – something that was not easy for her. “I was battling depression – and my 17-year-old cousin was also battling depression, and we didn’t know it. She lost her life one week after her 17th birthday to suicide. She was in such a dark place, and so isolated, and felt so alone inside,” said Allison.

The two talked about the “red flag” of isolation and said that isolation can be a warning sign to others that something is not right.

Allison described a time when she returned to her home and chose to park in an unusual spot, so her college roommates would not realize she was there. She went to her room and cried in her closet – isolating herself from her friends or anyone else who could help. Michael had a similar experience when, in the depths of his depression, he stayed in his room for days, wondering if life was worth continuing. They both sought treatment and now support each other.

“Allison and Michael demonstrate that reaching out for help is a sign of strength and self-awareness,” said Paolo Delvecchio, M.S.W., Director of SAMHSA’s Center for Mental Health Services. “They provide a living example of resilience and recovery by sharing their stories publicly and supporting each other.”

This year marks the 12th year of SAMHSA’s National Children’s Mental Health Awareness Day. Each year more than 1,100 communities across the country and 160 national organization and federal programs conduct Awareness Day activities. New collaborating organizations this year included American Academy of Family Physicians, American Diabetes Association, Association of State and Territorial Health Officials, the President’s Council on Physical Fitness and the Medical Reserve Corps.

Awareness Day 2017: “Partnering for Help and Hope” focused on the importance of addressing physical, mental, emotional, and behavioral health needs when providing services and supports for children, youth, and young adults.

During the event, SAMHSA released reports combining 2005 to 2014 data showing that major depressive episodes were more common among adolescents ages 12 to 17 with asthma (11.4 percent) or diabetes (14.3 percent), than among adolescents without asthma (8.8 percent) or diabetes (9.0 percent). In addition, adolescent girls who were overweight or obese were more likely to have experienced a major depressive episode in the past year than those who were a healthy weight (20.5 percent vs. 17.4 percent).

To view the webcast of the national event, go to

“We commend Michael Phelps and Allison Schmitt for having the courage to speak out about their mental health challenges. Their honesty and candor have shown countless Americans quietly struggling with mental illness that seeking help is a sign not of weakness, but of strength,” said Health and Human Services Secretary Tom Price, M.D.


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Self-Care for Providers During Change and Stress

Wed, 05/03/2017 - 09:00

People working in health care recognize stress as something that can compromise the wellness of the people they serve. However, health care workers may neglect their own wellness and not realize that an even a greater challenge is to manage their own stress. Long hours, large workloads, and exposure to the physical and psychological trauma of others can contribute to provider stress, burnout, and diminished well-being. Maintaining good self-care is especially important to avoid the toll that stressful challenges take on mood, behavior, physical health, and patient care.

Significant events such as a job change, the loss of a family member, an empty nest, divorce, or even age-related biological changes can decrease the ability to cope with daily stressors. This is amplified during times when a community is affected by disaster or disease, which often presents service providers with additional challenges to maintaining their own health and well-being while helping others. Therefore, it is essential that healthcare workers adopt and maintain healthy lifestyles and employ self-care strategies during times of stress.

Stress can cause headaches, fatigue, sexual disinterest, stomach problems, and sleep disturbance. It can decrease energy, make a person more irritable, and lead to feelings of depression or anger. Stress can also decrease an individual’s efficiency, quality of interpersonal interactions, and lead to serious changes in behavior such as isolation, substance use, and changes in eating and exercise habits.

Self-Care Strategies

Providers can learn to recognize their own need for self-care by learning the common causes of stress and how stress impacts them as individuals. SAMHSA offers many resources on resilience, protective factors, and self-care strategies to lessen the effects of stress. Some of the recommended strategies include:

  • Follow a healthy lifestyle. Eat healthy foods and limit alcohol intake. Don’t smoke or use addictive substances. Exercise regularly. Consistently practice good sleep habits. And make time for rest and relaxation.
  • Make wellness part of everyday life. Address emotional and general health to improve personal resilience and manage stress. This may include exercise, time by yourself, or mindfulness exercises.
  • Connect with friends and family. Relationships and social networks that provide support, friendship, love, and hope are essential to one’s well-being. At work, if case load or other work issues are creating stress, connect with a supportive colleague or workplace mentor to think through helpful strategies.
  • Schedule annual checkups and health screenings. Take care of the basics to ensure your best health in the event of any adversity and to help manage stress.
  • Seek support from a support group or mental health professional. If stress is starting to affect your mood, behavior, or physical health, it may be helpful to talk with a physician or counselor to talk through strategies to help balance.

Carlton Speight, public health advisor with SAMHSA’s Center for Mental Health Services, provides additional perspective. “If providers take the steps to build resilience through wellness practices and healthy supportive relationships, they will be better equipped to manage adversity. A little thought, intention, and time are key before a crisis arises.”

Resources On SAMHSA’s YouTube Channel

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Systems of Care Grantees Tap Faith Communities to Help Young People

Mon, 04/17/2017 - 09:00

Young people face challenges as they approach adulthood and independence, but those who have mental health issues and economic hardship encounter additional obstacles. To support these youth and their families, SAMHSA developed Systems of Care grants, under the Children’s Mental Health Initiative, which use a wraparound approach to develop community-based interventions to work in tandem with treatment services. This approach includes other supportive people – such as family members, caregivers, teachers, mentors, and coaches – as part of the care team. The services they provide may include case management, vocational training, evidence-based therapeutic services, respite services, crisis intervention, family and peer support, and life skill development (including tutoring, or financial planning). Coordination of a wide array of services has been shown to enhance recovery outcomes.

Building on the wraparound approach, System of Care grantees are incorporating a model called The Open Table. This model taps into the resources of faith communities to address the barriers that keep people from achieving employment, a livable wage, and life stability – issues that many young adults and families, including those supported by the Systems of Care grant program, often face.

SAMHSA embraced The Open Table model in an effort to expand public-private partnerships and engage faith organizations in delivering services to the larger community. This team approach provides mentorship, support, and friendship, while providing coordinated care – similar to the wraparound approach in Systems of Care.

To date, the System of Care grantees that have integrated this model include the Chatauqua Tapestry Expansion Initiative, Saginaw Max System of Care, Wraparound Orange, Bringing Systems of Care to Scale, and HELPing BC-SCORES. Project directors for these programs have reported life-changing experiences for all participants because of the relationships and natural supports that develop over time.

“Having service come through a faith community, as a coordinated network, is incredibly helpful. The volunteers care deeply about helping,” says Gary Blau, Chief, Child, Adolescent and Family Branch at SAMHSA’s Center for Mental Health Services. “Systems of Care grantees immediately saw this model as a natural extension of their work and as a powerful tool to provide continued support.”

Systems of Care Values and Principles
  • Family Driven
  • Youth Guided
  • Culturally and Linguistically Competent
  • Evidence Based Practices and Clinical Excellence
  • Continuous Quality Improvement

The Open Table model began in 2006 when founder Jon Katov realized that people living in poverty needed more than clothing or food to change their situation – they needed relationships.  Over the course of a year, volunteers meet on a weekly basis to work with a person (called a “brother” or “sister”) seeking support to change. The program educates and trains the volunteers, who can be anyone in a faith- or community-based organization. The group of volunteers then forms a “Table,” guided by a “life plan” that outlines goals specific to a brother or sister.

Volunteers contribute $10 per month to support the program and they have “homework” that helps the brother or sister with socialization, life skills, or other needs. Assignments might include providing a cooking lesson, teaching bookkeeping basics, finding affordable health insurance, or fixing a bike found at a yard sale so that it can be used for transportation to work. Together, the Table tackles each obstacle to improve functioning and economic stability.

Through the trust forged between Table members, doors open to allow exploration of paths to employment, housing, health care, and education and training.

“Because of the Table, brothers and sisters have their own individual support networks, and subsequently access to many other connections to address housing or other needs,” says Rachel Ludwig, LCSW, Project Director for the Chautauqua Tapestry Expansion Initiative. Ms. Ludwig currently sits on a Table herself. “I have felt friendships mature as our group of relative strangers – our Table – develops into a family that is resilient and loyal,” she says.

Systems of Care grantees support the faith community and their Tables by providing facilitation, coordination, funding, and referrals to behavioral health professionals that might be helpful to the person receiving services.

SAMHSA also works with faith and community-based initiatives to support several programs in mental health services, substance abuse prevention, and addiction treatment at the national, state, and local levels. The Community Substance Abuse Prevention Partnership Program includes more than 800 faith-based community partners among its grantees, and grant program funds are available through the states to faith-based organizations that engage people with or at risk for mental health and substance use disorders. Because of the success with The Open Table model, SAMHSA is also exploring its use with Center for Substance Abuse Treatment grantees.

Video clips courtesy of The Open Table and Cinematographer Brian Simmermacher.

Resources SAMHSA Blog

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Transitioning from Prison to Community

Thu, 04/06/2017 - 08:00

Jails and prisons house significantly greater proportions of individuals with mental, substance use, and co-occurring disorders than are found in the general public. Upon release from jail or prison, many people with mental or substance use disorders lack access to services and, too often, fall into a recurring, costly cycle of involvement with the justice system.

Experts in the justice, behavioral health, and public policy fields agree that by providing behavioral health support services to these people in transition they can increase their chances of returning to healthy and productive lives in the community.

To support this goal, SAMHSA recently released Guidelines for Successful Transition of People with Mental or Substance Use Disorders from Jail and Prison: Implementation Guide. The guide provides behavioral health, correctional, and community stakeholders with approaches for effectively transitioning people with mental or substance use disorders from institutional correctional settings into the community. The guide also promotes the Assess, Plan, Identify, and Coordinate (APIC) approach to identifying various successful evidence-based strategies that work across jurisdictional systems, and describes 10 guidelines. These include –

  1. Conduct universal screening.
  2. Follow up positive screens with comprehensive assessments.
  3. Design individual treatment plans.
  4. Develop collaborative responses that match need and risk.
  5. Identify interventions in transition planning practices.
  6. Establish policies to facilitate continuity of care.
  7. Coordinate justice system and community services.
  8. Share information to advance cross-system goals.
  9. Encourage cross training.
  10. Collect and analyze data.

These APIC approaches have been successfully implemented in communities throughout the nation such as Allegheny County, PA.; Franklin County, MA; Gwinnett County, GA.; Hampden County, MA; Hancock Count, OH; Montgomery County, MD.; and Pima County, AZ. It has also been adopted on a statewide basis in Hawaii, North Carolina, and New York.

“Reentry assistance provides justice and behavioral health agencies the opportunity to identify and address barriers that prevent people with mental and substance use disorders from integrating and thriving in communities,” said Captain David Morrissettee, Ph.D., LCSW, with the U.S. Public Health Service in SAMHSA’s Center for Mental Health Services. “The guidelines help providers give people the best opportunity to overcome these barriers and stay connected to community supports.”

Related Articles  Resources

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