Transcript Dr. Howard Padwa - rptif - University of South Carolina

Howard Padwa, Ph.D.
University of California, Los Angeles
Integrated Substance Abuse Programs
Transforming Treatment:
Treating Substance Use Disorders as
Health Conditions
South Carolina Department of Alcohol and Other Drug Abuse Services
University of South Carolina
Recovery Program Transformation & Innovation Fund Conference
September 10, 2015
1
Recovery Program Transformation
& Innovation Fund
• Four priority areas for Planning and
Implementation Grants:
– Medication Assisted Treatment
– Integration of Behavioral Health Services (mental
health, medical)
– Adolescent/family services – forming and strengthening
partnerships
– Infrastructure for accessible, integrated services
• Reflect national and historic trend toward treating
substance use disorders (SUD) like we treat other
health conditions
2
Transformation:
Seeing SUDs as Health Conditions
• Historically, problematic
alcohol/drug use seen as a
vice, moral failing, weakness,
or choice
• Association of substances with
racial, political “enemies”
• Major policy responses:
– Control supply
– Punitive approach to users
3
Transformation:
Seeing SUDs as Health Conditions
• 1940s-2000s: Recognition of SUD as a medical problem
• McLellan et al., “Drug Dependence, A Chronic Medical
Illness” published in JAMA (2000)
• Compared SUD to diabetes, hypertension, asthma
• Similar roles of genetics, personal choice, environment
• Comparable outcomes if managed with behavior
modification, ongoing monitoring, medications
• Clinical argument for increased insurance/primary care
involvement, on par with other medical conditions
4
Transformation:
Bringing Treatment Out Of Isolation
• SUD Treatment Has Been Isolated
– Inebriate Asylums, Narcotic
Farms
– Criminal Justice Settings
– Methadone Clinics
• Peer support emphasis
– 12-Step focus
– Therapeutic Communities
• Most SUD treatment occurred in
places that only focused on SUD
5
Transformation:
Bringing Treatment Out Of Isolation
• 2008 Wellstone-Domenici Mental
Health and Addiction Equity Parity
Act
• 2010 Affordable Care Act
• Assure coverage of SUD in parity
with other health benefits
• Encouraging integration of SUD
services into other health settings,
service systems
• Holding SUD services up to same
standards as other areas of
6
medicine
Transformation of SUD Services
• Two interrelated changes
• Treating SUD like other
medical conditions
• Bringing SUD services
in to the health care
system
7
The Isolation of SUD Treatment
SUD
SYSTEM
MEDICAL
SYSTEM
MENTAL
HEALTH
(MH)
SYSTEM
8
Making Services More
Patient-Centered
• The burden of
coordinating care and
meeting population
needs “should rest on
the system, not the
families or consumers
who are already
struggling because of a
serious illness.”
President’s New Freedom Commission, 2003
9
Making Services More
Patient-Centered
• One of the major goals of health care reform
is to move from services that are systemcentered to ones that are patient-centered.
• Integration can make services more patientcentered.
– For SUD clients
– For people who would benefit from SU services
but do not receive them
10
What Integration Can Do
SUD
SYSTEM
MEDICAL
SYSTEM
MENTAL
HEALTH
(MH)
SYSTEM
11
What Integration Can Do
• Help create a “no wrong door” system that
includes SUD services
12
Why Integrate?
Different Reasons for
Different Populations
SUD
25 million
At Risk
Problematic Use
68 million
Humphreys &
McLellan, 2010
Minimal Risk
Little/No Use
13
SUD
Integration for clients in
treatment
• Treat people, not disorders
• Substance use is rarely
the only problem
• SUD clients have unmet
MH needs
• SUD clients have unmet
medical needs
14
Why Integrate MH Services with
SUD Treatment?
• MH disorders are more prevalent among
individuals with SUDs.
37.8%
16.7%
11.3%
4.0%
Any Mental Health Disorder
Serious Mental Illness
Non-SUD Population
SUD population
SAMHSA 2014, NSDUH Mental Health Findings
15
Co-Occurring MH Disorders Are
Associated With Worse Outcomes
• Increased risk for:
– Suicidal Ideation
– Aggression/Injury
– HIV
– Hepatitis
– Chronic health problems
(cardiovascular, liver, GI)
– Hospitalization
– Social Exclusion
– Homelessness
16
CSAT 2005; Horsfall et al., 2009
Why Integrate MH Services with
SUD Treatment?
• MH Disorders are particularly common among people
in SUD treatment
– More likely to seek treatment if there is a co-occurring MH
disorder
– Approx. 50-70% with lifetime history of MH disorders
– Estimated 40-50% with current MH disorders
• Co-occurring MH disorders should be considered the
rule, not the exception
17
CSAT 2005: Flynn & Brown, 2009
How Do Clients With MH Disorders
Do In SUD Treatment?
• Similar SUD outcomes, worse MH outcomes
• Less satisfied with treatment
– Believe treatment is less clear, less supportive
– More likely to drop out
• Less change in beliefs/relapse prevention skills
– See fewer benefits to quitting
– Less confident they can stay abstinent
– Less likely to develop problem-solving skills
18
Boden & Moos 2009; Horsfall et al., 2009
Why Do COD Clients Struggle with
“Traditional” SUD Treatment?
• Client Level
–
–
–
–
Less motivation to change
Failure to recognize psychiatric symptoms
Self-medication
Cognitive challenges
• Program Level
–
–
–
–
Perceived necessity of sequential treatment
Confrontational approaches
Opposition to psychotropic medication
Suspicion of medical expertise vs lived experience 19
Integration Can Help Address
SUD Clients’ MH Needs
MEDICAL
SYSTEM
SUD
SYSTEM
MENTAL
HEALTH
SYSTEM
20
What are the ways that MH and SUD
services are integrated?
MH/SUD
Consultation
MH/SUD
Coordination
Full
Integration
Integration of services
21
What are the ways that MH and
SUD services are integrated?
• Informal relationships
between SUD and MH
providers.
MH/SUD
Consultation
• Referrals/linkages to
providers of other specialty
when necessary.
• Consultation on client
needs, engagement,
prevention, and early
intervention.
22
What are the ways that MH and
SUD services are integrated?
• Formalized relationships
between SUD and MH
providers
MH/SUD
Coordination
• Specialty MH and SUD
providers will discuss
specific clients.
• More clinically integrated,
with providers working as a
team.
23
What are the ways that MH and
SUD services are integrated?
Full
Integration
• Services to address both
mental health and
substance use disorders
are provided in the same
program.
• Services provided by one
integrated team that has
professionals with expertise
in providing services for
MH, SUD, and COD.
24
What Integrating MH and SUD
Services Can Do
• Benefits of integration
– Improve access to MH services
– Make interventions more focused on client needs
– Transfer burden of care coordination from the client
to the system
• Treatment that addresses both MH and SUD at
the same time associated with less crises
(arrests, hospitalization)
• There is not clear evidence of which integration
model leads to the best outcomes
25
Mangrum 2006; Drake et al., 2008; Sterling et al., 2011
Where should integrated services
be provided?
Severity of SU Disorder
Less Severe
MH, More
Severe SUD
Mauer, 2006
SUD SYSTEM
Less severe
MH, Less
Severe SUD
PRIMARY
CARE
Severe MH and
Severe SUD
INTEGRATED
COD
PROGRAM
More Severe
MH, Less
Severe SUD
MH SYSTEM
Severity of MH Disorder
26
What Is the Goal?
Co-Occurring Capability
• Not all programs need to
offer fully integrated care
• The key is to be cooccurring capable
– Detect MH needs
– Either link to MH services
or treat them
– Provide services that are
sensitive to needs of
clients with mental illness
See SAMHSA’s
DDCAT Version 4.0
for more details
• Dual Diagnosis Capability
in Addiction Treatment
(DDCAT) Index
27
Co-Occurring Capable
Treatment Tools
• Diagnostic Services
• Medications
• Psychoeducation
• Motivational Interviewing
• Contingency Management
• Cognitive Behavioral Therapy
Techniques
• Relapse Prevention Strategies
See the Center for
Substance Abuse
Treatment’s TIP 42 for
more details.
28
Integration Can Help Address
SUD Clients’ Medical Needs
MEDICAL
SYSTEM
SUD
SYSTEM
MENTAL
HEALTH
SYSTEM
29
Why Integrate Medical Care with
SUD Treatment?
• Behavioral risks
– More tobacco use: breathing problems/cancer
– Injections: collapsed veins, infections
– Intoxication leads to more risky sex behaviors
– Violence (pharmacological, systemic)
– Poverty
– Underutilization of healthcare services
30
Boles 2003, McCoy 2001, NIDA 2012
Why Integrate Medical Care with
SUD Treatment?
• Direct medical consequences of substances
–
–
–
–
–
–
Effects on heart rate/heart attacks
Decreases lung functioning
Stomach inflammation
Liver damage
Kidney damage/failure
Increased blood pressure/stroke
• Substance use and SUD contribute to over 70
conditions that require medical care
• 1/3 of people with SUD have a chronic physical
condition or disease
31
NIDA 2012, Reif 2011; NCASA 2012
Substance use shortens life…
Substance Use
Disorder
Premature
Death
Premature
Death from
Natural Causes
Percentage of
Premature
Deaths Not
Accident/OD
Alcohol
1.97 times the 1.7 times the
Dependence
risk
risk
66%
Opioid
Dependence
47%
Harris 1998
6 times the
risk
4 times the
risk
32
…especially in the public SUD system
• People who receive public SUD services:
– Live 26.1 years less than the general
population
– If they have co-occurring MH disorders, they
live 34.5 years less
– Nearly two-thirds of deaths are due to medical
causes
33
ODHS 2008
Common Medical Conditions in the
SUD Population: HIV
• Transmitted through sexual contact
or blood
• Destroys CD4 cells leading to
Acquired Immunodeficiency
Syndrome (AIDS), leaving body
vulnerable to infections and cancers
• Injection drug users account for
30% of new cases outside of subSaharan Africa
• 30-40% of injection drug users in
US are HIV positive
Des Jarlais & Semaan 2008, Harris 1998, Clark 2010
http://www.niaid.nih.gov/topics/hivaids/understan
ding/howhivcausesaids/pages/howhiv.aspx
34
Common Medical Conditions in the
SUD Population: Hepatitis C
• Virus that leads to liver inflammation
• 60%-85% of cases lead to chronic
infection, leading to increased risk of
cirrhosis.
• High risk of transmission through
injection drug use or needle sharing
• Most common infectious disease
among injection drug users (60-90%)
https://nccih.nih.gov/health/hepatiti
sc/hepatitiscfacts.htm
• Injection drug users are largest group
infected with Hepatitis C in the US
35
Edlin 2002, Clark 2010
Common Medical Conditions in the
SUD Population: Endocarditis
• Inflammation of lining inside
heart valves and chambers
• Usually caused by infection or
fungus
• Increased risk from injection
drug use:
–
–
–
–
–
Particulates in drugs
Poor injection hygiene
Unsterile equipment
Contaminants
Risk is higher with cocaine
injection
http://www.nlm.nih.gov/medlineplus/e
ncy/imagepages/18142.htm
Schwartz 2010
36
Common Medical Conditions in the
SUD Population: Lung Disease
• Damaged airways and sacs in
lungs, causing breathing difficulty
• Inhalation of stimulants can cause
buildups in lungs
• Emphysema associated with IV
drug use
• Association with tobacco use
http://nihseniorhealth.gov/copd/wh
atiscopd/01.html
• Asthma twice as prevalent among
individuals with SUD
37
Wesselius 1997, Mertens 2003
Common Medical Conditions in the
SUD Population: Hypertension
• High blood pressure
increases risk of stroke,
heart attack, brain damage,
vision loss
• Three drinks per day
increases risk
• Caused by stimulants
• Twice as prevalent in SUD
population
https://www.nlm.nih.gov/medlineplus/highblo
odpressure.html
38
Sesso 2008, MacMahon 2010, Mertens 2003
Common Medical Conditions in the
SUD Population: Type 2 Diabetes
• Prevents cells from receiving sugar,
leading to buildup in blood
• Can lead to blindness, heart
disease, stroke, kidney failure,
amputation
• Binge drinking increases risk
• Substance use associated with
earlier age of onset
• Alcohol worsens diabetes health
outcomes
39
Pietraszek 2010, Johnson 2001, Emanuele 1998
Common Medical Conditions in the
SUD Population: Arthritis
• Inflammation of tissue lining
joints, leading to breakdown
of cartilage
• Causes pain, stiffness,
swelling, reduced mobility
• Septic arthritis caused by
infection, associated with
injection drug use
• Arthritis almost three times as
prevalent among people with
SUD
https://www.nlm.nih.gov/medlineplus/ency/imag
epages/17128.htm
40
Mertens 2003
Over One-Half of SUD Clients Do
Not Receive Regular Medical Care
• Among them:
– 12% have liver disease
– 16% have hypertension
– 20% have asthma or COPD
– 6% have hepatitis
– 3% have HIV/AIDS
– 47% have sexually transmitted infections
41
De Alba 2004
Integration with medical services
improves clients’ health…
• Decreases hospitalization
rates
• Decreases number of
inpatient days
• Decreases ED visits
• Increases adherence to HIV
antiretroviral therapy
• Can cut total medical costs
in half
Parthasarathy 2003, Weisner 2001, Parry 2007
42
…and it makes treatment more
effective!!!!
• Primary care reduces drinking and
drug use by people with SUD
• 2-10 primary care visits/year triples
chances of SUD remission after five
years
• Integrated SUD/medical services
reduces SUD severity after 12
months; off-site referral does not
Saitz et al 2005, Friedmann 2003, Mertens 2008
43
Changes Bringing Greater
Integration with Medical Care
MEDICATION
USE
FDA
APPROVAL
Buprenorphine
Acamprosate
Naltrexone
(Ext. Release)
Opioid Use Disorder
Alcohol Use Disorder
Alcohol Use Disorder
Opioid Use Disorder
2002
2004
2006
2010
• Safe and highly effective when used with other services
• Less than half of SUD programs have a physician who
can prescribe these medications
• Integrating with medical care can improve access to
medications
44
SAMHSA 2012
Changes Bringing Greater
Integration with Medical Care
• Newly insured population
expected to have high levels of
SUD need
• SUD services among essential
benefits under the ACA
• Insurance reimbursement will
lead to greater links with
primary care (like other
specialties)
45
Why Integrate?
Different Reasons for
Different Populations
SUD
25 million
At Risk
Problematic Use
68 million
Humphreys &
McLellan, 2010
Minimal Risk
Little/No Use
46
SUD
Integration for people who need
SUD treatment but don’t get it
Adults Needing SUD Treatment
11%
Not in Treatment
In Treatment
89%
SAMHSA 2014
47
Integration Can Improve Access to
SUD Services
MEDICAL
SYSTEM
SUD
SYSTEM
MENTAL
HEALTH
SYSTEM
48
SUD
SUD in Mental Health Settings
• Self medication to alleviate
stress, anxiety, depression
• Mental health disorders
increase likelihood of
substance use, dependence
• SUDs over three times as
common in individuals with
mental illness
• 25-50% of people in MH
treatment have SUD
49
Weiss 1992, Robinson 2011, SAMHSA 2010; CSAT 2005
SUD
SUD in Medical Settings
• Almost 38% of older
problem drinkers use
alcohol to manage pain
• 9%-41% of chronic pain
patients abuse opioids
• Approx. 22% of
healthcare patients misuse
substance
•Over 7.5 million ED visits
annually due to alcohol
Brennan 2005, Machikanti 2006, , McDonnald III 2004; TRI 2010
50
At Risk
Problematic
Use
Integration for people who
don’t need treatment…yet
• Excessive drinking and drug use
cause changes in brain that can
lead to SUD
• Use mental health and medical
visits as a “teachable moment” to
facilitate behavior change
– Educate about risks associated with
substance use, including SUD
– Briefly use motivational interviewing
and cognitive behavior techniques
McLellan 2000, Madras 2009
51
At Risk
Problematic
Use
Integration for people who
don’t need treatment…yet
Screening
Brief
Intervention
Referral to
Treatment
Madras 2009; Saitz 2015
• Pre-post studies have shown
reductions in alcohol/drug use
•More rigorous trials showed
effect for risky drinking, but not
heavy drinking or drug use
• Major Challenges:
• How “brief” can “brief
interventions” be?
• How to make the “RT” work
52
At Risk
Problematic
Use
Integration for people who
don’t need treatment…yet
Screening
Brief
Intervention
Referral to
Treatment
• SBIRT is feasible and
potentially beneficial in places
outside of the medical system
• Largest potential benefit in
places where there are at-risk
populations or high levels of
substance use
• Schools and Universities
• Juvenile Justice
• Jails
53
• Social Services
Severity of MH/SU Disorder
How Can Integration Happen?
High MH/SUD
Low Physical
High MH/SUD
High Physical
SPECIALTY BH IN
COORDINATION
WITH PC
SPECIALTY BH
AND PC WITH
COORDINATORS IN
BOTH SETTINGS
Low MH/SUD
Low Physical
PC EITHER BY
MEDICAL OR
ONSITE BH STAFF
High Physical
Low MH/SUD
PC WITH ONSITE
BH STAFF
Severity of Physical Disorder
Mauer 2006
54
What Does High MH/SUD,
High Primary Care Look Like?
• There have been early adopters across the
country
– Been developing integrated care for a long time
– Have a lot of resources
• For details see:
– Treatment Research Institute “Forum on
Integration” (2010)
– SAMHSA “Innovations in Addiction Treatment:
Addiction Treatment Providers Working With
Integrated Primary Care Services (2012)
55
SUD/Medical Integration
California (2011-2012)
• 43 of 44 California
counties surveyed reported
SUD/PC integration
• Two most common models:
– Behavioral health in
primary care
– Primary care in SUD
settings
• There is no clear evidence
of which integration model
is “best”
56
How Does Integration Happen?
• Behavioral Health in
Primary Care
– BH staff trained in SUD
treatment conducts SBIRT
– BH staff works as member
of primary care team in
coordination with medical
doctor
– BH staff provides
counseling, other services
for 3-5 sessions
• Experience shows this can
lead to more focus on MH
than SUD
PRIMARY
CARE
Behavioral
Health
57
How Does Integration Happen?
• Primary Care in SUD
Treatment
– Medical staff provide
services onsite in SUD
treatment facilities.
– Give physicals, screen for
chronic diseases, refer to
medical specialists
– SUD treatment staff screen
for physical problems, refer
as necessary
SUD
Treatment
Medical
Care
58
Integrating Isn’t Always Easy
“Integrated…care is like a pomegranate:
overwhelmingly people say they like it, but
few buy it.”
Cummings, 2009
59
Common Barriers to Integration
DOCUMENTATION
• Incompatible Systems
• Confidentiality/Privacy Concerns
FUNDING
• Silos
• Poor Reimbursement
• Sustainability
ORGANIZATIONAL • Reluctance to Change
CHARACTERISTICS • Lack of implementation resources
(space, time)
• Poor role clarity
PROVIDER
• Reluctance to deliver new services
CHARACTERISTICS • Divergent service philosophies
• Different work paces/styles
60
Common Facilitators of Integration
FUNDING
• Flexible or dedicated funding
• Develop/utilize EHRs that facilitate
DOCUMENTATION integration
• Client consents to share information
LEADERSHIP
(SYSTEM AND
CLINIC LEVEL)
• Enhance buy-in
• Use a provider “champion” to lead
change
•Foster strong collaborative
relationships (individuals, agencies)
• Training, technical assistance
• Quality improvement
• Flexibility, freedom to experiment
61
Take Away Points
• SUD services are being integrated into the
mainstream of the US health care system
• Integration with mental health and medical
services can help:
– Better address whole-person needs of clients
in treatment
– Facilitate access to most modern, evidencebased approaches to SUD care
– Close the SUD treatment gap
62
Take Away Points
• SUD integration can/should be not only with
medical services, but other places where
there are likely to be high levels of risk or
need
• The benefits of integration are clear, but
some questions remain:
– How can integrated services be enhanced to
have maximum benefit ?
• Funding and leadership that support service
integration can help overcome barriers to
implementation
63
QUESTIONS?
64
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Howard Padwa, Ph.D.
[email protected]
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