Transcript Referral to Treatment

Referral to Treatment:
The Next Steps
Jennifer G. Smith, MD
Division of General Medicine & Primary Care
John H. Stroger, Jr. Hospital
Cook County Bureau of Health Services
[email protected]
Overview
• Addiction is a common, treatable disease but most
people who have it go untreated
• Treatment for addiction can begin with screening,
assessment, & referral in general healthcare settings
• Building a successful “continuum of care” for addiction
diseases means change for general healthcare and
addiction treatment providers
• Taking steps to implement successful referral between
general healthcare and addiction treatment organizations
Overview
• Addiction is a common, treatable disease but most
people who have it go untreated
• Treatment for addiction can begin with screening,
assessment, & referral in general healthcare settings
• Building a successful “continuum of care” for addiction
diseases means change for general healthcare and
addiction treatment providers
• Taking steps to implement successful referral between
general healthcare and addiction treatment organizations
DSM IV Substance Abuse Disorder
(Use with Consequences)
Continued substance use, in spite of 1 or more
recurring negative consequences over one year:
•
•
•
•
Interference with role obligations
Risk of physical injury
Legal problems
Interpersonal problems
DSM IV Substance Dependence Disorder
(Alcoholism, Addiction)
Continued substance use in spite of 3 or more
recurring negative consequences over one year:
• Tolerance - Increased amounts needed to achieve effect
• Withdrawal - Signs of, use to avoid or relieve
Loss of control over use, compulsive use, craving • More or longer use than intended
• Unsuccessful attempts to cut down or control use
• Much time spent getting, using, recovering
• Activities given up or reduced to facilitate use
• Use despite knowledge of related problems
Addiction is a Brain Disease
• Using drugs repeatedly
over time changes brain
structure and function in
fundamental and longlasting ways
• Long-lasting brain
changes in the brain's
natural motivational
control circuits are
responsible for the
compulsion to use drugs
that is the essence of
addiction
Leshner AI, JAMA, 282 (1999): 13141316
Addiction Treatment is Effective
• Goal of addiction treatment is to return to
productive functioning
– Treatment reduces substance use by 40-60%
– Treatment reduces crime by 40-60%
– Treatment increases employment by 40%
• Rates of adherence similar to treatment for other
chronic diseases such as diabetes, asthma,
hypertension
• Every $1 spent for treatment saves up to $12 in
reduced health care and crime-related costs
McLellan AT, Lewis DC, O'Brien CP, Kleber HD, JAMA, 284 (2000): 16891695
NIDA, Principles of Drug Addiction Treatment: A Research-Based Guide, NIH
Bethesda, MD, July 2000
90% of People with Active Substance Use
Disorders are Untreated
10%
23.2 million (9.5%) of US pop. > 12 years
old have a current substance use disorder
5%
Did not feel need for
treatment
Felt need for treatment
but did not receive
Received specialized
treatment
85%
69% paid with own or family savings
28% public assistance
45% medicare/medicaid
32% private insurance
National Survey on Drug Use and Health, SAMHSA, 2005
Overview
• Addiction is a common, treatable disease but most
people who have it go untreated
• Treatment for addiction can begin with screening,
assessment, & referral in general healthcare settings
• Building a successful “continuum of care” for addiction
diseases means change for general healthcare and
addiction treatment providers
• Taking steps to implement successful referral between
general healthcare and addiction treatment organizations
People with Substance Use Disorders Seek Care
in General Healthcare Settings
Distribution of Persons w/ SUD Treated in Ambulatory Settings
General medical (ED, MD office)
43.3%
Specialty mental health
42.6%
Professional human services
19.0%
Self-help groups
7.9%
Specialty addiction
6.3%
Narrow et al. Arch Gen Psychiatry. 1993;50:95-107
Prevalence of Substance Dependence Disorder
among Primary Care Patients
#
Patients
Alcohol
Dependence
Illicit Drug
Use
Study
Patients
Fleming
(1998)
Men & women
18-65 y
21,282
5%
5%
Piccinelli
(1997)
Men & women
18-65 y
482
2%
-
Volk
(1997)
Men & women
mean age 39-47 y
1,333
5-7% women
11-14% men
-
Prevalence of Substance Dependence Disorder
among General Hospital Admissions
Study
Facility
Patient type
Smothers
(2003)
90 Hospitals
2,040
18+ y, All Services
6.3%
10.9%
(Drug Use)
Brown
(1998)
Univ Hospital
18-49 y, Med/Surg
374
10.5%
2.5%
Soderstrom Level 1 Trauma
(1997)
18+ y, Trauma
1,118
24.1%
17.7%
Canning
(1999)
2,988
-
4%
(Drug Use)
Teaching Hospital
18-85 y, Medicine
#
Alcohol
Illicit Drug
Patients Dependence Dependence
At-Risk & Dependent Use by Inpatient Service
Stroger Hospital, 2004-2005
Cocaine
Heroin
30
30
20
20
10
10
0
0
Trauma
HIV
Med-Surg
Trauma
OB
Marijuana
HIV
Med-Surg
OB
Alcohol
30
30
20
20
10
10
0
0
Trauma
HIV
Dependent
Med-surg
At-Risk
OB
Trauma
HIV
Med-surg
OB
Prevalence of Alcohol Dependence by Age:
Hospitalized Patients vs. Community
Prevalence %
25
20
15
10
5
0
18-24
25-34
35-44 45-54 55-64
> 65
Years
Alcohol Dependence in Hospitalized Patients, CCBHS
Alcohol Dependence in Community Members, Illinois
Drug Dependence by Age:
Hospitalized Patients vs. Community
Prevalence %
25
20
15
10
5
0
18-24
25-34
35-44
Years
45-54
55-64
> 65
Cocaine Dependence in Hospitalized Patients, CCBHS
Heroin Dependence in Hospitalized Patients, CCBHS
Any Drug Dependence in Illinois Community
Not ready
Unsure
Heroin
Marijuana
Alcohol, Cocaine
Readiness Ruler: How ready are you to
make a change in your use?”
Ready
Average response of patients dependent on that substance
Identification & Intervention for Substance Use
Disorders among General Healthcare Patients
Patients
Identified
by MD Team
Patients with
Intervention
by MD Team
7-66%
35%
Study
Setting, Patients
Moore
(1989)
University Hospital
+ Alcohol screen
Hearne
(2002)
General Hospital
+ Alcohol Use Disorder
20%
8%
Smothers
(2004)
90 General Hospitals
+ Alcohol Use Disorder
57%
21%
Overview
• Addiction is a common, treatable disease but most
people who have it go untreated
• Treatment for addiction can begin with screening,
assessment, & referral in general healthcare settings
• Building a successful “continuum of care” for addiction
diseases means change for general healthcare and
addiction treatment providers
• Taking steps to implement successful referral between
general healthcare and addiction treatment organizations
Illinois SBIRT Interventions
Low Risk Use
Screening
General Health
Information
At-Risk Use
Brief
Assessment
Brief
Intervention
Use with
Consequences
Dependent Use
CCBHS Hospitals
& Health Centers
Assess &
Referral
Chemical
Dependency
Treatment
State Licensed
Treatment Providers
Illinois SBIRT Interventions
Low Risk Use
Screening
General Health
Information
At-Risk Use
Brief
Assessment
Brief
Intervention
Use with
Consequences
Dependent Use
CCBHS Hospitals
& Health Centers
Assess &
Referral
Chemical
Dependency
Treatment
State Licensed
Treatment Providers
Outcome of Screening
28 months, 3/30/04 – 7/27/06
Low Risk
At-Risk Use
Received Brief Intervention
Use w/ Consequences
Received Brief Intervention
Dependent Use
Received BI, offered Referral
Accepted Referral to
Treatment
Hospitalized
Patients
Ambulatory
Patients
N (% of screened)
N (% of screened)
34,507 (75.3)
5,493 (86.6)
4,820 (10.5)
548 (8.6)
1383 (3.0)
106 (1.7)
5,121 (11.2)
195 (3.1)
2,752 (8)
39 (1)
(54% of dependent pts)
(20% of dependent pts)
Patient Placement Criteria for Addiction Treatment
(American Society of Addiction Medicine)
1.
2.
3.
4.
5.
6.
Multidimensional Assessment:
Acute intoxication, Withdrawal potential
Biomedical conditions and complications
Emotional/Behavioral/Cognitive conditions and
complications
Readiness to change
Relapse/Continued use/Continued problem
potential
Recovery environment
ASAM PPC
Treatment Levels of Service:
I.
II.
Outpatient Treatment
Intensive Outpatient and Partial
Hospitalization
III. Residential/Inpatient Treatment
IV. Medically-Managed Intensive
V. Inpatient Treatment
Illinois SBIRT Interventions
Low Risk Use
Screening
General Health
Information
At-Risk Use
Brief
Assessment
Brief
Intervention
Use with
Consequences
Dependent Use
CCBHS Hospitals
& Health Centers
REFERRAL
COORDINATOR
Assess &
Referral
Chemical
Dependency
Treatment
State Licensed
Treatment Providers
Patients Referred to Treatment
28 months, 3/30/04 - 7/27/06
# Patients
Referred
Total
2,773
Brief Treatment (Individual Counseling)
793
Residential
921
Methadone Maintenance
576
Intensive Outpatient
232
Outpatient
251
Entry into State Funded Treatment
within 60 Days from Hospital Discharge
Substance
Dependent
Patients
Entered
Treatment
Accepted Referral to
Treatment while
Hospitalized
983
161 (16%)
Did Not Want Referral
to Treatment while
Hospitalized
292
5 (2%)
Sample of dependent patients discharged from Stroger Hospital matched
with State-funded treatment data base (2004-2005)
Illinois SBIRT Interventions
Low Risk Use
Screening
General Health
Information
At-Risk Use
Brief
Assessment
Brief
Intervention
Use with
Consequences
Dependent Use
CCBHS Hospitals
& Health Centers
REFERRAL
COORDINATOR
Assess &
Referral
Brief
Treatment
Chemical
Dependency
Treatment
State Licensed
Treatment Providers
Time to Treatment “Intake” Appointment
Modality
Mean
95% CI
Brief treatment
Intensive outpt
Tx
Residential
Outpatient
Methadone
Tx
0
4
8
12
16
20
28
Tx Estimated time to beginning of treatment
Intake representative of beginning of treatment
42 Days
Entry into State Funded Treatment
within 60 Days from Hospital Discharge
Referred to Brief
Treatment (with or w/out
other traditional modality also
intended)
Referred to Traditional
Treatment Modality
Substance
Dependent
Patients
Entered
Treatment
274
72 (26%)
709
89 (13%)
(without Brief Treatment first)
Sample of dependent patients discharged from Stroger Hospital matched
with State-funded treatment data base
Illinois SBIRT Interventions
Low Risk Use
Screening
General Health
Information
At-Risk Use
Brief
Assessment
Brief
Intervention
Use with
Consequences
Dependent Use
CCBHS Hospitals
& Health Centers
REFERRAL
COORDINATOR
Assess &
Referral
COMMUNITY CASE
COORDINATORS
Brief
Treatment
Chemical
Dependency
Treatment
State Licensed
Treatment Providers
Outcome of Referrals, Follow-Up from
Community Care Coordinators
12 months (4/01/05 – 3/31/06)
Patients assigned to CCC
1,072
after Hospital Discharge
335 (31% of assigned)
Followed, know patient
entered Treatment
(55% of followed)
262 (24% of assigned)
Followed, know patient did
not enter planned Treatment
(43% of followed)
Followed, patient died
Lost to follow-up
9 (1% of assigned)
466 (43% of assigned)
Change in Treatment Entry with NO WAIT
Same/Next Day
First Year
Treatment
Usual Wait
Referred Patients* Referred Patients
Mean
% in Tx
Days to within 60
Tx Entry
Days
% in Tx
after Referral
Residential
9 days
18 %
87 %
Methadone
Maintenance
17 days
22 %
67 %
*Sample of dependent patients discharged from Stroger Hospital
matched with State-funded treatment data base, 2004-2005
Overview
• Addiction is a common, treatable disease but most
people who have it go untreated
• Treatment for addiction can begin with screening,
assessment, & referral in general healthcare settings
• Building a successful “continuum of care” for addiction
diseases means change for general healthcare and
addiction treatment providers
• Taking steps to implement successful referral between
general healthcare and addiction treatment organizations
Challenges for Healthcare Providers, Chemical
Dependency (CD) Treatment Providers,
Regulators & Funders
• Implement universal screening in general
healthcare settings and provide further
assessment for substance use disorder as part
of general healthcare!
• Establish referral relationships between CD
treatment and general healthcare settings
– Identify common community resources
(Challenges continued)
• Establish procedures to coordinate care
between healthcare & CD treatment
organizations
– Address confidentiality and clinical information
sharing
– Identify inter-institutional roles and responsibilities
– Coordinate to continue care initiated in general
healthcare setting (example: Methadone to control
withdrawal in hospital  methadone maintenance)
• Provide CD treatment to patients with other
significant medical conditions
(Challenges continued)
• Adapt usual CD treatment “intake” procedures to
accept patients referred from general healthcare
settings
– Accept referral from intermediary rather than patient
– Give date for initiation of treatment
• Focus on transferring therapeutic alliance at first
visit to CD treatment provider
– Downsize required regulatory paperwork for first visit
– First visit a counseling session not “intake” session
(Challenges continued)
• Make CD treatment available with “no wait”
– Provide support to patients waiting for CD treatment
• Incorporate motivational counseling strategies to
foster retention at all steps
Taking Steps*
• Engage decision-makers
– Assess current practice, need, potential benefits
– Assess readiness & identify support
– Assess & strategize to minimize barriers
• Engage community resources, partners
– What resources are available?
– Who/what will maintain resource connections & partnerships?
• Engage workplace teams
– Who will provide assessment?
– Who will refer patients to specific treatment?
– How will assessment and referral fit into usual care processes?
• Provide ongoing feedback (data) for incentive,
improvement, and sustainability
– What information should be monitored?
– Who will collect and feedback information?
– Who needs information feedback?
*Smith J, McQueen K, Brown R, Girard C, AMERSA National Conference, 2005