For the record, this is for a local issue that I had to do for a school project! The obvious solution is Medicare for all, stop locking POC in jail, and house the homeless by giving them that autonomy. This is a rough draft of this and please let me know what you think! Yes, I had to utilize government bills by D’s but it is simply the point that is what can help make things better and they absolutely refuse to do it.
INTRODUCTION
[Opiate Addiction in Sacramento County, CA: Pathways Towards Prevention]
As a country, there has always been a war on drugs. The substance that requires the most focus is opiates. In Sacramento County, there has been an uprise in opiate use. There are three categories of opiates that are the focus of this project, prescription, fentanyl, and heroin. On a national level using these substances has been an overall issue. In Sacramento, using opiates has caused loss of housing, negative impacts on mental health, and families being broken up. The significant point to keep in mind Sacramento County has been making impacts on opiate use; however, there is room for improvement on the current model the county is using to contribute to prevention. In 2016, it was 5.7% of residents who were 12 and older (apx. 74,661) have misused opiates, and only 1.0 % (13,439) of residents have been diagnosed with an opiate use disorder (www.urban.org/, 2016).
PART 1: SCOPE AND CONSEQUENCES
[Opiate Addiction in Sacramento County, CA: Pathways Towards Prevention]
According to the CDC (2021.), there are three categories of opiates, prescription (oxycodone, hydrocodone, morphine, and methadone), fentanyl (a synthetic opioid), and heroin (illegal). In Sacramento County, using opioids is common in ages 15-29,20-24, and 25-29 (http://sacopioidcoalition.org/. n.d.). It is also essential to address the impacts on a national and state level.
National Trends
According to the CDC (2021), over 841,000 people have died from a substance overdose, that’s approximately 70% have died from opioid use. Opioids were designed to assist with pain management; however, overdoses from synthetic opioids have risen (CDC, 2021). In 2019, over 50,000 people died from an overdose from the use of synthetic opioids except for methadone (CDC, 2021). According to the CDC (2021), three different waves have helped contribute to the rise of opioid use. The first wave involves the origin, which is in the 90s, prescription opioids were getting prescribed (CDC, 2021). The second wave started in 2010 with significant use of heroin, causing deaths (CDC, 2021). The third wave began in 2013 where deaths included the use of synthetic opioids (CDC,2021)
State Trends
In California, there have been 3,244 people who have died from an opioid overdose (https://skylab.cdph.ca.gov/ODdash/, 2019.). One thousand six hundred three people in California have been killed from synthetic opioid use, primarily fentanyl (https://skylab.cdph.ca.gov/ODdash/, 2019). Eleven thousand seven hundred sixty-seven people have visited the emergency room regarding an opioid overdose (https://skylab.cdph.ca.gov/ODdash/, 2019). In California, there were 17,576 679 prescriptions issued for opioids in 2019 (https://skylab.cdph.ca.gov/ODdash/, 2019). Using opioids has significantly impacted minority populations such as African-Americans and Native Americans (https://skylab.cdph.ca.gov/ODdash/, 2019).
Local Trends
In 2019, Sacramento County experienced 119 deaths (7.4/100k) related to opioids, 377 (13.1/100k) people who went to the emergency room related to opioids, 187 (8.8/100k) individuals were in the hospital regarding opioids, and 862,722 (506.4/100K) were prescribed opioids (https://skylab.cdph.ca.gov/ODdash/, n.d.). According to the Sacramento County Opioid Coalition, since 2017, there has been a significant increase in use up to 92% (http://sacopioidcoalition.org/, n.d.). There has been a decrease in mortality in prescription opioids has gone down significantly; the problem at focus is the use of heroin and synthetic opioids (http://sacopioidcoalition.org/, n.d.).
Consequences
The state of California has had a housing problem. One can argue that there is income inequality occurring. Keeping this in mind, the people who are at risk for utilizing opioids is the homeless population. Having no housing does become a challenge in terms of getting insured for treatment of opioid use. Fifteen thousand nine hundred two residents here in Sacramento County do not have health insurance and do not have access to the treatment (http://sacopioidcoalition.org/, n.d.). Six thousand eight hundred sixty-seven residents are on Buprenaphine, and 3,919 residents are on methadone (http://sacopioidcoalition.org/, n.d.).
According to the National Institute on Drug Abuse (2021), using opioids binds to the brain's pain receptors and release, which makes one use this substance more. The short-term effects of opioid use include drowsiness, confusion, nausea, constipation, euphoria, and slow breathing (NIDA, 2021). However, slow breathing can cause hypoxia, involving little oxygen reaching the brain (NIDA, 2021). Using opioids can also play a role in mental health in a negative way. The NIDA (2020) suggests that individuals who already have a mental illness will aggravate it by creating adverse moods (e.g. paranoia, depression, anxiety, etc.). The NIDA (2020) also states that sometimes when people have not had a mental health issue before, users could create those issues because of the effects of opioid use. 43.4 million adults experience a mental health illness, and 8.1 million individuals have a substance use disorder (NIDA, 2020).
In Sacramento County alone, the total number of individuals and families currently occupying this county is about 1,530,000, and about 29,833 were insured by Medi-Cal (https://dhs.saccounty.net/, 2019). Residents in Sacramento have experienced a lack of health care, been evicted from their housing, not caring for themselves, and families keeping their distance.
Goal Sentence
Providing access to healthcare, utilizing psychoeducation, and building treatment centers will significantly impact opioid use and will be a pathway for prevention.
PART 2: SOCIAL-ECOLOGICAL MODEL
[Opiate Addiction in Sacramento County, CA: Pathways Towards Prevention]
To understand this epidemic in its entirety, it is essential to understand the risk and protective factors. NIDA (2020) describes that a risk factor that will promote drug use and protective factors protects people from using. Another way to think of protective factors they are prevention. It is also essential that we look at this from four contributing points to use, individual, relationships, community, and societal.
Individual Factors
SAMHSA (2019) explains individual factors can include a possible predisposition to substance use or exposure to use in the womb. However, in terms of risk and protective factors, the NIDA (2020) states that a risk factor on an individual level would include early aggressive behavior in childhood. A protective factor would be self-control (NIDA, 2020). There have been numerous theories on substance use and why people make those choices to use. NIDA (2020) suggests that depending on the environment a person either grew up with or the environment people see beyond the family dynamic. To note though, risk factors do not occur specifically in childhood but can occur at any point in an individual's life. However, there has not been any data in Sacramento County that addresses this factor.
Relationship Factors
When an individual is struggling with addiction, in most cases, families will separate themselves from the person that is struggling. Tucker et al. (2020) discuss critical elements in adolescence, such as utilizing other substances like marijuana and alcohol. Tucker et al. (2020) also suggest that the Theory of risk lies in parental monitoring and disapproval on a family level. The risk is approval from peers and delinquency (Tucker et al., 2020). NIDA (2020) summarizes that the risk of use on this level lacks parental support, and a protective factor is monitoring. Parental monitoring needs to be done with caution because if it is approached aggressively, it may cause the opposite effect that a parent truly wants (NIDA, 2020). Another factor to keep in mind is peer influence. The risk is substance use on a peer level, and a protective factor is an academic competence (NIDA, 2020).
Community Factors
NIDA (2020) describes on a school level the risk factor is substance availability, and the protective factor is Anti-Drug use policies. Tucker et al. (2020) discuss the signs one would be able to identify if suspected use. For example, if we are working with an adolescent, then as professionals, we would see the performance in school would be low, academic achievements would be inadequate, and little school bonding (Tucker et al., 2020). Another factor to consider, which most people do not believe, is the neighborhoods. NIDA (2020) describes the risk factor with the community as poverty, and the protective factor is strong neighborhood attachments.
In the state of California, there is a significant problem with homelessness. Miller (n.d.) stated there are 5,570 individuals in Sacramento; about 70% of people do not have a home. 30% of people are in stable housing (Miller, n.d.). Out of that 5,570, 80% are adults (25+), 8% youth (18-24), and 12% are children (under 18) (Miller, N.d.). Compared to 2019, the homeless population continues to grow and has increased up to 19% (Miller, N.d.). On a national level, 2.5-3.5 million are experiencing homelessness a year; about 550,000 people are homeless at any point in time (Yamamota et al., 2019).
To keep in mind with those that experience homelessness for a significant period, individuals are also sharing high and low disease burdens, mortality is higher, and using substances is at a high rate (Yamamota et al., 2019). In addition, the risk of overdose is higher among the homeless compared to those with low-income individuals (Yamamota et al., 2019). Finally, the risk is higher with the homeless population because there is a lack of healthcare; more than likely, an individual who is homeless will utilize the emergency and inpatient services compared to low income (Yamamota et al., 2019).
Societal Factors
Many can make the argument that anything we do as individuals is influenced by what society teaches us. The U.S. Department of Health and Human Services (2018) states that as a society that we can all agree that a symptom of OUD (Opiate Use Disorder) more a less a pre-symptom is the economic and social challenge that is occurring in this country. Due to the economic and social difficulties, not only are suicide rates high but substance use as well (U.S. Department of Health and Human Services, 2018). This problem does not apply to upper-class individuals but working-class individuals (U.S. Department of Health and Human Services, 2018). Even with promotion from mainstream media that youth should not use, it is not enough. Today, if one does not have a college degree, it is a challenge to have a good quality of life (U.S. Department of Health and Human Services, 2018).
PART 3: THEORIES OF PREVENTION
[Opiate Addiction in Sacramento County, CA: Pathways Towards Prevention]
As counselors, we always would like to know what we can do to help a client. Just like the role of a scientist would like to know what causes a problem so we can fix it. There are many theories when it comes to substance use and why people use them. According to The National Cancer Institute (2005), there are two different theories regarding explaining the issue, explanatory, and change Theory. However, the ones that will be the primary focus are the Theory of planned behavior and reasoned action.
Theory of Reasoned Action
According to The National Cancer Institute (2005), the Theory of reasoned action involves exploring relationships between behavior with beliefs, attitudes, and intentions. TRA (Theory of Reasoned Action) aligns with explanatory Theory. Explanatory Theory explains reasons why a problem exists (The National Cancer Institute, 2005). Fleming et al. (2017) address that to understand why there is a problem, one must understand the behavioral intention. Then once the behavior intention is identified, that turns into a subjective norm and influences the individual attitude (Fleming et al., 2017). The behavior intention can be measured by asking the question, "Are you likely or unlikely to use (in this case opioids)"? The National Cancer Institute (2005) defines this as a perceived likelihood someone will perform a behavior.
Attitude is defined as positive or negative feelings about performing a behavior (Fleming et al., 2017). The way that attitude is measured is by simply asking, "Do you see the behavior as good, neutral, or bad?" Another concept in this model is the subjective norm. Fleming et al. (2017) define this as whether key individuals approve or disapprove of the behavior. According to The National Cancer Institute (2005), this is measured by asking, "Do you agree or disagree that most people approve….?" In the case of opioid use, what has been found is that the reason people utilize opioids is to help treat pain (Fleming et al., 2017). However, when exploring research for Sacramento County, no research could be conducted to confirm this was the primary reason people are utilizing opioids.
Theory of Planned Behavior
The Theory of Planned behavior is like TRA, but the only different thing is that with TPA, there is an additional component. Fleming et al. (2019) argue three different belief systems, behavioral, normative, and control. If one is trying to investigate the behavioral belief, an example would be, "What are the advantages/disadvantages of using opioids?" The normative question would be, "What individual/groups would approve or disapprove of using opioids?" The control question would then be presented as, "What circumstances enable or make it difficult?" TPB has been a practice that pharmacists use in their practice books (Fleming et al., 2019). However, upon researching in Sacramento County, no research was done to explain opioid use.
Evidence-Based Practice
The opioid crisis has made a significant impact nationwide. To align with the TRA and TPB, a suggested intervention is identifying the risk. Another factor that needs to be kept in mind is that opioids are due to manage pain. Therefore, there must be a solution for prevention and to assist people who are currently experiencing this problem. St. Marie B (2019) utilized the opioid risk tool for opioid use disorder. The opioid risk assessment serves three purposes: to assure those anxious about the risk and there would be alternatives to manage pain, provide the information for clients and plan for safe pain management, and those who have a history of substance use would be a safeguard.
The problems occurring in Sacramento County are individuals misusing opioids, but environmental factors are contributing to this problem. As a counselor, we must find a common theme on why people use opioids. The problem is that there is a stigma with substance use in general and the overall assumption is because people want to use it. There has been an improvement in the prevention of opioid use in Sacramento, but it can be better. The prevention programs being utilized in Sacramento are community-based. The proper solution to this epidemic is finding out the reason why once the reason why is identified, then an effective community prevention program. According to The National Cancer Institute (2005), change theory guides interventions, including community organizations with the diffusion of innovations.
PART 4: DIVERSITY AND ETHICAL CONSIDERATIONS
[Opiate Addiction in Sacramento County, CA: Pathways Towards Prevention]
Part of the role in being in counseling is honoring and abiding by the ACA code of ethics. The first part of the ACA Code of Ethics (2014), section A.1.a primary responsibility, states that we must respect the dignity of the clients we see and promote welfare. When we are looking at our culture, it is constantly changing, and we must acknowledge that because diversity has been growing and we must respect others' beliefs. California is one of the most diverse states in the country.
The Statistics
In Sacramento County, it has been found that people who are abusing opioids are white males (815,150) aged 24-34 (206,640) (https://urbanobservatory.maps.arcgis.com/, n.d.). Approximately 306,196 Hispanic males, 203,210 Asian, 147,058 African Americans, other races 131,691, and 93,511 multiracial males abuse opioids (https://urbanobservatory.maps.arcgis.com/, n.d.). There was no data in Sacramento County that identifies which race has been significantly impacted by opioid use. Considering that there has been no information published about race and age combined, we must consider them separately. The focus age population will be individuals aged 24-34.
The Research
According to the ACA Code of Ethics (2014), C.2.f summarizes that counseling professionals need to stay aware of new science and professional information. This does include culture but also technology. I grew up in the 90s where technology was beginning to rise and be recognized. Today, society has become dependent on technology which impacts the younger generation. Marshall et al. (2018) found that for white males aged 24 (internet recruitment), 60% would recruit others to use opioids in a nonmedical way, and 66.6% of white males aged 26 (field recruitment) would recruit others. 15.4% of African Americans aged 24 would recruit others (internet), and 16% aged 26 would recruit others(field) (Marshall et al., 2018). 16.8% of Hispanics aged 24 would recruit (internet), and 10% of Hispanics aged 26 would recruit(field) (Marshall et al., 2018).
There is a significant homeless problem in Sacramento, and there is no data provided on the homeless population in terms of race. However, Marshall et al. (2018) found that 17.7% of individuals who used internet recruitment aged 24 and 36.7% would recruit people in the field aged 26. Keeping in mind the target age 24-34, a study must be conducted on this age group to narrow down the basic demographic information. Marshall et al. (2018) suggest that conducting an internet-based study would be beneficial to appeal to the younger population. Marshall et al. (2018) also mention that conducting an internet-based study is cost-effective. By conducting this study, as counselors, we would be able to engage this population. Therefore, we would have a more straightforward path to prevention (Marshall et al., 2018).
Cultural Relevance
As described by Reese & Vera (2007), culture relevance is interventions that are designed to be consistent with values and beliefs. According to the ACA Code of ethics (2014) section, F.7.c states that it is our responsibility to ensure we infuse material related to multiculturism and diversity. F.7.c also states that workshops include multiculturism (ACA Code of Ethics, 2014). The issue that is occurring in terms of diversity is the fact there is no conceptualization of culture. Reese & Vera (2007) mention that the concept of cultural relevance has not been made clear. Two other contributing factors that have not effectively help see the full potential of cultural relevance described by Reese & Vera (2007) are no models that effectively show how culture can affect behavior and change. The second is the description of prevention programs tailored to cultural relevance (Reese &Vera, 2007).
Reese & Vera (2007) mention an essential factor that would be a ground-based approach to making prevention more substantial: cultural competency. As counselors, it is in our code of ethics that we must always be sensitive, specifically section A.2.c and C.2.a. The ACA code of ethics (2014) states in A.2.c, communicate any information that is both developmentally and culturally appropriate, and section C.2.a states counselors should practice within their own competence based on education and training. To build on the current model of prevention in Sacramento County, we must ensure cultural competency and detect if there is any bias so we can address the issue. Utilizing this model ensures that if there is an issue the counselor and the supervisor can problem solve it. In addition, we need to conduct a study in Sacramento County to get a temperature of the diversity that is abusing opiates.
PART 5: ADVOCACY
[Opiate Addiction in Sacramento County, CA: Pathways Towards Prevention]
As counselors, we must advocate not just for our clients but also for the populations we work with when in the field. Although Sacramento County has made progress in the prevention, there is room to improve this program. For example, even though different ages and races are currently using opioids, we must focus on the third wave, synthetic opioids (CDC, 2021). The issue at hand is the statistics are inconsistent on the local level. There were also no cultural statistics done, such as those who identify themselves with the LGBTQ.
Institutional
The barrier itself is that even though, as a nation, we recognize there is a severe epidemic; however, there are bills in congress that have been introduced but not heard. There is a bill in congress that is awaiting to go through regarding this issue. H.R. 2448 (Opioid Settlement Act), introduced by Rep. David McKinley, addresses in this bill that funding would no longer go to opioid providers on a state level. Still; instead, the funds would be directed to the prevention of opioid use and treatment (McKinley, 2021). It also prohibits Medicaid from taking any of those funds and considers that funds collected cannot be used as an overpayment (McKinley, 2021). Having this bill implemented would provide local counties to address the epidemic in depth. The counties would be able to get more in-depth data and more funds to fight the stigma.
Another bill that would be effective for the prevention of illicit opioid use addresses the urgency for it. Representative Ann Kuster wrote this bill called the STOP Fentanyl act (H.R. 2366), and it entails that there should be specific programs to address the urgency of the use of illicit opioids and other types (2021). H.R. 2366 advocates the need for programs or prevention from fentanyl overdose (Kuster, 2021). The issue at hand is we as a nation have the ideas to help solve issues in our country.
However, humanity is damaged, and it is up to us as advocates to help remind them that there is human life, and it should not be treated like we are a second thought. As advocates, we can remind them that there is an epidemic of people dying from overdose opioids. We have the facts to assist with finding a solution—remembering that the people we see as counselors are a priority, making things easy and accessible to them.
Community
Currently, Sacramento County has an advocacy coalition called the Sacramento County Opioid Coalition. This coalition is made up of healthcare professionals, community-based organizations, law enforcement, county agencies, as well as local citizens (About Us – Sacramento County Opioid Coalition, n.d.). The primary focus for this coalition is to bring awareness; however, the barrier of this coalition is that there is not much focus on advocacy to access the treatment. As mentioned above, there are currently over 15,000 individuals who are not insured, and Sacramento County has a homeless concern.
As advocates, we cannot ignore this problem because the homeless population is increasing. Another factor to consider is there are not enough statistics. The statistics that have come up have been inconsistent, meaning there is no information on a cultural level or anything that matches (i.e., which race and genders used synthetic opioids). For The Sacramento County Opioid Coalition to be a success, there needs to be updated statistics and more in-depth information on how we as mental health providers can help. The more knowledge we have on this epidemic, the better we can serve.
Currently, the focus that has been at the center is addressing the first wave mentioned by the CDC. The focus is addressing how much providers are prescribing and monitoring that progress. Although the CDC does provide information regarding the opioid crisis, the focus should be on finding out why people are utilizing opioids. The focus is that people automatically assumed that people who utilize opioids are because they are in pain. The first barrier is making a dent in the stigma. Sacramento County ran an anti-stigma campaign on opioid use and had individuals share their stories (https://sacopioidcoalition.org/anti-stigma-campaign/, n.d.). The focus should be on the stigma itself. If individuals hear more success stories, it will encourage others to stay clean from opioids or look for alternative options through a provider.
Public Policy
Currently, there are two prominent city-run organizations: Sacramento County Adult systems of care with 4 locations and two youth locations (Sacramento County Opioid Coalition). Sacramento County has contracted with only 16 providers that offer various services such as residential rehab, detox, transitional housing that assists in helping maintaining sobriety, outpatient, Intensive outpatient, and medication-assisted providers (Sacramento County Opioid Coalition). The highlighted issue is that Sacramento County only has four contracted prevention programs utilized, and we need to expand this further. Another barrier is that those insured are limited to specific providers, which takes away autonomy from the individual seeking the help.
According to the WELFARE and INSTITUTIONS CODE, Section 14197 (n.d.), those who reside in Sacramento are only limited to see someone 15 miles away from where they reside. This also applies to opioid treatment centers. Also, as we remind ourselves, there is a homeless problem in Sacramento. McLaughlin et al. (2021) argue that the homeless population is vulnerable to opiate use, contributing to HIV and Hepatitis C. In addition, McLaughlin et al. (2021) state they require that quality of care because the homeless population lacks access to the needs to get it.
Proposed Solution
As counselors, we accept regardless, and no judgment is attached. There is one thing to keep in mind in terms of the mental health field we are dealing with various stigmas. What if someone was offered a provider that they could not work with due to past trauma, even by association? However, there is another provider with better quality care. The client would like to utilize them. The catch is this client had no way there, no access to a phone, and you are the only source. One must ask why this quality of care is not universal? McLaughlin et al. (2021) suggest the homeless population has challenges trusting others with various multi-barriers.
In Sacramento County, we need to gain data on the homeless population between the ages of 24-34. In addition to what The Sacramento County Opioid Coalition is providing by bringing awareness and direction for medications, there needs to be data that addresses the cultural needs, and more importantly, identifying what someone is looking for in quality of care. A factor to keep in mind is that the homeless population is not only vulnerable to opiate addiction but can develop a mental illness (McLaughlin et. al., 2021).
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