Transcript 3I_ Chermack_ VA Screening Tools... for Vets

VA Screening Tools and
Treatment
Options Available to
Stephen Chermack, PhD
Veterans
Chief, Mental Health Service, VA Ann Arbor Healthcare System
Associate Professor, Department of Psychiatry, University of
Michigan
The Science of Addiction
Biological Factors Interact with Environmental Factors
to Produce Addiction
Biology/Gen
es
Biology/
Environmen
t
Interaction
DRU
G
Addictio
Environme
nt
So What Does All This
Mean for
Drug Abuse Service
Delivery?
Relapse Rates for Drug Addiction
are Similar to Other Chronic Medical Conditions
0
2
0
1
00
Drug
Dependenc
e
Type I
Diabetes
Hypertension
50 to 70%
0
4
0
3
50 to 70%
0
6
0
5
30 to 50%
0
8
0
7
40 to 60%
Percent of Patients Who
Relapse
10
09
Asthma
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October
Outcome In Diabetes
Conclusion: Treatment Successful!
Treatment Research Institute
Outcome In Addiction
(Incorrect) conclusion: Treatment NOT successful!
Treatment Research Institute
If we treat a diabetic and symptoms don’t
subside….what do we do?
Would we increase the dose?
Would we change medications?
Would we change treatment approaches?
Would we fail to provide ongoing
treatment for a diabetic?
We need to shift the paradigm of addiction
treatment from an acute to a
chronic care model
Goals of Drug Treatment:
Keeping an Eye on the Target
Functionality in
Family, Work,
and
Community
Effectiveness of Treatment
40-60%
Drug Use
40-60%
Crime
40%
Employment
Cost-Effectiveness of Drug Treatment
• Cost to society of drug abuse = $180 billion/year.
• Treatment is less expensive than incarceration:
- Methadone maintenance = $4,700/yr
- Imprisonment =
$18,400/yr
• Other studies indicate that every $1 invested in
treatment can yield up to $7 in savings.
Recovery from drug addiction requires effective
treatment followed by management of the disorder over
time.
A Chronic Care Approach
to Drug Treatment
“Prescription” for
Services
Screening and Brief Intervention
Initial Services
Sustain & Manage
Recovery/Chronic Care
Management
Clinical
Practices
Assessment
Therapeutic
Interventions
Behavioral Counseling and Medications
Percent
Treatment must last long enough to
produce stable behavioral changes.
In-Prison Treatment Plus Post-Release Aftercare Improve 5 Year
Outcomes in Prison Addicts
Participants 80%
African American
AFTERCARE
is Indispensable
Arrest-Free
Drug-Free
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* p < .05 from Comparison
Martin, Butzin, Saum, Inciardi (2004), Crime and Delinquency
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Assessment is the first step in treatment.
• Nature/extent of drug problem
• Strengths:
• Family support
• Employment history
• Motivation
• Threats to recovery:
• Criminal behavior
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Mental health
Physical health
Family Influences
Employment
Homelessness
HIV/AIDS
Matching services to needs is critical
for treatment to be successful.
Child Care
Services
Family
Services
Housing / TransportationBehavioral Therapy and
Counseling
Services
Vocational Services
Intake Processing /
Assessment
Detoxification
Substance Use
Monitoring
Mental Health Services
Treatment Plan
Clinical and Case
Management
Financial Services
Self-Help / Peer Support
Groups
Pharmacotherapy
Medical
Services
Continuing Care
Legal Services
Educational Services
AIDS / HIV
Services
Drug use during treatment should be
carefully monitored.
• Know that lapses can occur
• Conduct urinalysis
• Provide immediate feedback
• Intensify treatment as needed
Treatment should target factors associated
with criminal behavior.
• Criminal thinking
• Antisocial values
• Anger/hostility
• Problem solving
• Conflict resolution skills
• Attitudes toward school/work
• Mental health problems
• Family functioning
• Barriers to care
• Alcohol/drug problems
Effective Treatments Include:
• Cognitive Behavioral Therapy
• 12 step facilitation
• Motivational Interviewing
• Contingency Management
• Behavioral Couples Therapy
• Opiate Substitution
• Addiction Psychopharmacology
• Contingency Management
• Problem Service Matching
VA Addiction and MH Services
• Uniform Mental Health Services Handbook- released in 2008,
specified “essential components of the the mental health program
that is to be implemented nationally, to ensure that all veterans,
wherever they obtain care in VHA, have access to needed mental
health services.”
• 2012- VA National SUD Handbook- further specified requirements
for provision of SUD services at all VA treatment facilities
• VA invests in several staff training initiatives for best practices in
mental health care
VA Addiction and MH Services
• VA is a highly accountable healthcare organization (includes
performance and quality of care monitoring and feedback)
• VA emphasizes empirically supported treatment approaches
• VA funds innovative research to improve healthcare for veterans,
including studies of addiction treatment (e.g., interventions to
prevent violence and relapse, treating chronic pain among vets in
addiction treatment, improve “aftercare” engagement posthospitalization, etc.).
VA Medical Centers
Ann Arbor:
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• VA Ann Arbor Healthcare System
• Outpatient & Intensive Outpatient
Battle Creek:
• Battle Creek VA Medical Center
• Outpatient, Intensive Outpatient,
Residential
Detroit:
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• John D. Dingell VA Medical Center
• Outpatient, Intensive Outpatient &
Opiate Treatment Program
Iron Mountain:
• Oscar G. Johnson VA Medical Center
• Outpatient & Intensive Outpatient
Saginaw:
• Aleda E. Lutz VA Medical Center
• Outpatient & Intensive Outpatient
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Community Based
Outpatient Clinics
Alpena: Clement C. Van Wagoner Outpatient Clinic
Bad Axe: Bad Axe Community Based Outpatient Clinic
Benton Harbor: Benton Harbor VA Outpatient Clinic
Cadillac: Cadillac Community Based Outpatient Clinic
Clare: Clare Community Outpatient Clinic
Flint: Flint VA Outpatient Clinic
Gaylord: Gaylord VA Outpatient Clinic
Grand Rapids: Grand Rapids VA Outpatient Clinic
Grayling: Grayling Community Based Outpatient Clinic
Hancock: Hancock Clinic
Ironwood: Ironwood Clinic
Lansing: Lansing VA Outpatient Clinic
Mackinaw City: Cheboygan County Community Based Outpatient Clinic
Manistique: Manistique Outreach Clinic
Marquette: Marquette Clinic
Menominee: Menominee Clinic Michigan Center: Jackson VA Outpatient Clinic
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Levels of Care and other SUD
services
• Residential Rehabilitation Treatment Program
• Currently only at Battle Creek
• Typical length of stay = 4 weeks
• Intensive Outpatient Program
• At each medical center
• Length of stay typically 4-6 weeks
• Outpatient Specialty Care
• At each medical center and very large CBOC
• Varied services including therapy and pharmacotherapy
• Opiate Treatment Program
• Only at Detroit (Offering Methadone and Suboxone)
• Suboxone offered at some other sites
• Other outpatient SUD services
• Some available at each facility in person, telehealth, or fee-basis
Access to Care
• New veterans requesting or referred for services receive an initial
evaluation within 24 hours (usually by phone) and a comprehensive
diagnostic and treatment planning evaluation within 14 days
• Waiting times for all services for established veterans are less than 30 days
from the desired date of appointment
• Telemental Health Services is a mechanism to meet requirements and
provide convenience for veterans
• Medical Centers and very large CBOCs offer a range of services during
evening hours at least 1 day per week and on at least one weekend day.
Care Transitions
• Facilities ensure continuity of care during transitions from one
level of care to another
• Veterans discharging from inpatient or residential are given
appointments for follow up at time of discharge.
• Follow up includes evaluations within 1 week of discharge.
Veteran-Centered requirements
• Appropriate services addressing the broad spectrum of
substance use conditions including tobacco use disorders are
available
• Interventions for SUD are provided when needed in a manner
sensitive to the needs of veterans and specific populations
including but not limited to homeless, ethnic minorities, women ,
geriatric veterans, veterans with PTSD or other mental health
conditions, veterans w/infectious diseases, TBI, and serviceconnected conditions.
• SUD is never be a barrier for treatment of other conditions or
vice versa.
Screening for SUD in Veterans
• During new encounters and at least annually, veterans seen in
medical or mental health settings are screened for alcohol
misuse using the AUDIT-C (frequency, quantity, frequency of
heavy drinking)
• Targeted case finding strategies are used to identify those with
illicit drug use or misuse of prescriptions
• Those screening positive for SUD receive further assessment to
determine level of misuse and establish diagnosis.
Assessment within SUD treatment
• Veterans presenting for SUD care receive a multidimensional, biopsychosocial
assessment to guide treatment planning for SUD and comorbid conditions
• All veterans with Alcohol Use disorder, Opiate Use Disorder, and other Axis 1
Mental Health disorders are evaluated by a physician for medication
consideration.
• Veterans complete the Brief Addiction Monitor (BAM)
• Outcomes are monitored throughout the care episode in order to inform ongoing
treatment planning.
• Note: VA also screens veterans for depression, PTSD, Military Sexual Trauma,
Suicide Risk
Assessment within SUD treatment
• Brief Addiction Monitor (BAM):
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recent alcohol and drug use
mental health conditions
sleep problems
Cravings
self-efficacy
self-help participation
social support,
risky situations
Spirituality
structured time,
social stressors,
financial situation,
satisfaction with recovery progress.
Psychosocial Services
• Motivational counseling is available to veterans who need it to support
initiation of SUD treatment.
• At least 2 of the following empirically validated psychosocial interventions
are available for veterans with SUD:
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Motivational Enhancement therapy/ Motivational Interviewing
Cognitive Behavioral Therapy
Twelve step Facilitation
Contingency Management
Behavioral Couples Therapy for SUD
• When PTSD and other MH conditions co-occur with SUD, interventions for
other conditions is made available when not contraindicated.
Cognitive Behavioral Coping
Skills
• Based on social learning theory
• Substance use is functionally related to other problems
• Emphasizes learning of coping skills
• Initiation and mastery of skills through practice, role playing,
and extra-sessions tasks
Functional Analysis
• Exploration of substance use in relationship to
antecedents and consequences
• Identify and match cognitive and behavioral coping
tools based on functional analysis
Withdrawal / Detoxification
• Medically supervised withdrawal management is available at all
facilities (or through referral/transfer) as needed based on
assessment of symptoms and risk of serious adverse
consequences of alcohol , sedatives, hypnotics, or opioids.
• Although withdrawal management can often be ambulatory,
inpatient is available.
• Withdrawal management alone is not treatment and must be linked
to further SUD Treatment. Appointments for follow up are
completed within 1 week of discharge.
Opiate Pharmacotherapy
• Pharmacotherapy (e.g., Suboxone or methadone) is available to
veterans with opiate dependence when indicated.
• Pharmacotherapy is provided in addition to and linked to
psychosocial treatment and support.
• When agonist treatment is contraindicated or declined, antagonist
medication is available and considered.
• Suboxone is prescribed only by waivered prescribers in an office
based environment or in an Opiate Treatment program.
Alcohol & Other Pharmacotherapy
• Pharmacotherapy for alcohol dependence is offered and available
when not contraindicated. Pharmacotherapy must be prescribed
with and linked to psychosocial Tx and support.
• Most common pharmacotherapy for alcohol includes naltrexone
and disulfiram; however, alternatives are also prescribed.
• Medications are available for Tobacco use Disorder
• Medications for other mental health concerns are also provided for
veterans