Transcript Making Successful Referrals for Substance Use Disorders

Making Successful Referrals
for Substance Use
Disorders
UCSF Collaborative Education Project
Elinore McCance-Katz, MD, PhD
Learning Objectives
1.
2.
3.
4.
Compare and contrast the different levels of
care available for substance use disorders.
Determine the appropriate level of care
required based on severity of use, availability
of resources, and patient willingness.
Understand the process of making referrals to
specialty care for substance use disorders.
Be able to successfully refer patients to Bay
Area treatment facilities and programs.
Outline





Levels of care for substance use
disorders (SUD)
How to assess appropriate level of care
How to make a referral
Local resources
Best practices, clinical tips
Acute Care Continuum




Inpatient medical withdrawal: For use with alcohol,
benzodiazepines, complicated opioid withdrawal (i.e.:
with other co-occurring illnesses such as polysubstance
dependence, HIV, or other significant medical illness)
Outpatient medical withdrawal: For use with opioids
(uncomplicated), stimulants (cocaine/ amphetamines)
Residential treatment: Often can undertake medical
withdrawal and other medical needs while providing
ongoing substance abuse treatment after initial
withdrawal is completed
Intensive outpatient treatment: Usually takes those
without acute medical needs, but with the need for
intensive treatment of substance use disorder (any of
the abuse disorders (i.e.: abuse of any substance that
does not rise to level of substance dependence)) or nonphysiological substance dependence
Chronic Care Continuum
(After any medical withdrawal needs have been attended to)
Type of Treatment Key Features
Intensive Outpatient
Programs (IOP)
Defined as at least 2 hours of treatment per day;
at least 3 days/wk; treatment is usually for about
12 weeks
Partial Hospital/Day
Treatment Programs
Usually for patients with more severe illness often
defined by co-occurring mental illness; 5 d/wk with
varying hours depending on patient needs
Residential Facilities
24 h facility; patient resides there; usually has
skilled medical staff available 24/7; up to 90 days
of treatment
Individual or Group
Counseling; Addiction
Psychiatry
For those with less severe substance abuse
problems; or often used as a referral for ongoing
treatment after completion of more intensive
programs such as IOP or residential
12 Step Mutual Help
Groups
Supportive groups, abstinence based for the most part; sponsors
available to provide support to individuals; big advantage is that
these groups are free of charge; are available for lifetime; can go
multiple times a day every day if wanted; can be the basis of a new
and healthier support system for patient
Overview: Continuum of Care for
Substance Use Disorders


Substance abuse treatment modalities may be mixed; i.e.: include
multiple types of treatment interventions in each setting
Inpatient short term (days to a few weeks); Residential (30-90 days);
IOP (approx. 12 wks) Will include multiple modalities:













Medical management
Medical withdrawal
Psychiatric assessment/treatment if needed
Psychological testing
Individual assessment and therapy
Group therapy
Family therapy
12 Step groups
Vocational assessment
Once inpatient, residential or IOP program is completed; a patient will
be referred for a less intensive, but ongoing treatment:
“Aftercare” – usually low intensity 1/wk individual or group therapy
Those without a sober living environment to return to may need longterm residential:
Half-way house: a group residential facility where recovering people
can get support for sobriety from each other. Not staffed by addiction
professionals. Not a treatment program.
6
But Does Treatment
Even Work?

Providers sometimes feel discouraged about referring pts for
SUD treatment. Sometimes it seems like it just isn’t worth the
effort. But relapse rates are really no different than other
chronic diseases:
http://www.nida.nih.gov/PODAT/faqs.html#Comparison
Referral
Algorithm/Guidelines

So how do you maximize the likelihood of success? You
must first know what level of care you should be
referring to.
 Determine if patient is drug or alcohol dependent
(and needs medical withdrawal) (inpatient) or is a
substance abuser (outpatient unless has other risk
factors)
 Determine if patient has other risk factors that would
make them better candidates for inpatient treatment
than outpatient treatment:



Co-occurring mental illness (may need a psych consult)
Polysubstance use and dependence on multiple
substances
Serious medical illnesses that may be exacerbated
when substance use changes (i.e.: when the patient
stops abusing); e.g.: HIV/AIDS, active HCV, cirrhosis,
other serious illnesses)
Other Factors to Consider

Insurance coverage










Private: must check with insurer to determine what kind of
treatment and what facilities they will pay for
Public: Medi-CAL/City/County: Refer to public treatment
facilities in city or county where the patient resides
Language ability/cultural competence
Treatment history (have they failed outpatient treatment in
past?)
Location/transportation: can the patient and their family easily
access the treatment facility
Family support
Can the facility treat both substance use disorders and mental
illness?
Can the facility treat both substance use disorders and medical
illness?
Does the facility offer/support pharmacotherapy for
maintenance of abstinence?
Does the facility have a good record of keeping referring
medical staff informed of patient progress and ongoing needs?
Assessment Domains for
Treatment Planning
Determining the appropriate level of care, requires a multilevel
assessment of many factors. These factors include:

Severity:
 substance type
 amount, frequency, duration

Alcohol “at risk” or “hazardous”= drinking
Men: >5 drinks/day; >14 drinks/wk
Women: >4 drinks/day; >7 drinks/wk
Route of administration
 Consequences of use
Comorbidity:
 Medical
 Psychiatric
Social support/environment/triggers for relapse (i.e.: will they
need a sober living facility after finishing treatment?)
Motivation
External obstacles: insurance, location of treatment program





10
Case Study

Paul is a 35 y.o. man with two children aged 12 and 15. He has
been your patient for the past 2 years and has seen you for
regular healthcare/physical examinations. He has no ongoing
medical problems noted. He drinks nightly after work, as has
been his habit for many years and has reported drinking 1-3
drinks per sitting. He presents today asking if there is a
medication he can take for his nerves as he has noticed that
he is losing his temper with his children more often. He
recently got into a physical fight with his 15 y.o. after several
drinks that resulted in a neighbor calling police. Other
complaints include problems with sleep—he notes that he often
falls asleep after 4-5 beers in the evening, but wakes up at 2
or 3 AM and has problems returning to sleep. He sometimes
feels anxious and at times has sweats in the mornings and
wonders if he is “going crazy”. Physical examination is normal
except for increased blood pressure at 150/92 and heart rate
of 95 bpm. His last drink was at 10 PM the night before and
you are seeing him at 3 PM. He admits that his drinking has
increased “some” since you saw him last and he thinks he now
drinks about 5 beers daily.
Case Study

What is the likely diagnosis and where should he be sent for
treatment?

Diagnosis: Alcohol dependence. Physical examination shows
only mild hypertension which could occur as a result of alcohol
withdrawal (it has been 17 hours since his last drink). Although
he could also have a mental disorder and this should be
evaluated further as should the hypertension once medical
withdrawal is completed, his current symptoms are most
consistent with alcohol dependence. Based on his history of
withdrawal symptoms, he is a good candidate for care at a
substance abuse treatment program that can offer inpatient
medical withdrawal or this can be accomplished at a local
inpatient hospital (psychiatry may take such a patient given
the question of depression and anxiety with consequences
(i.e.:police involvement, social work involvement needed)). His
symptoms indicate that he is likely to need medication to
assist with withdrawal symptoms. After medical withdrawal he
will need ongoing substance abuse treatment, most likely in an
IOP setting.
After the Assessment:
Nuts and Bolts




Who do you call? see Provider Listing in attached excel
file for this module.
What form do you fill out? May use a standard UCSF
specialist referral form or you may be able to give a
verbal report to the receiving institution
Need to get authorization? You will likely not do this; but
if you do the actual referral you may be asked what
insurance the patient has—the facility will know
immediately if they can take the patient or not; if they
can’t they may be able to direct you to another facility
that will take the patient’s insurance.
What support staff can help? Clinic nursing or
administrative staff may be able to help with
determination of insurance and whether a facility would
be able to take the patient. Medical information will need
to come from the clinician.
The Referral “Package” (1)

A strong referral to appropriate specialty care is key but that’s
not all…



How will you interact/communicate with the specialist? Have
the patient sign a release of information form before they go to
substance abuse treatment.
What is your follow-up plan with the patient? Arrange follow-up
contacts and appointments with you since there may be a
waitlist for specialty care.
What ongoing management strategies will you use? Monitor
labs? Look for medical symptoms of ongoing use? (Look for
physical/psychological symptoms and use POS urine drug
screens) Medication to reduce cravings ? (speak with
treatment facility to determine need and type of
pharmacotherapy) Make plan for harm reduction? (Determine
patient’s goals (do they intend to stay abstinent? “controlled”
use? Be prepared to counsel regarding whether “controlled”
use is possible given extent of their disease; realize SUDs are
chronic, relapsing diseases and the patient may need more
than a single treatment—so you may, at some point, have to
reassess and refer to treatment again)
The Referral Package (2)

Encourage continued use of 12 step programs or support
groups as well as ongoing group and/or individual therapy.


Remember that giving the patient a list of local 12 step
meetings is far more effective that just vaguely suggesting
they go. You can find updated SF meeting lists at
www.aasf.org. Ask for commitment to attend a specific
meeting on a specific day.
Impress on receiving facility that you want regular updates
starting with their assessment of the patient’s needs and the
treatment they provide as well as their plan for ongoing care
after the patient leaves their facility. Note: Most substance
abuse treatment programs and providers are eager to provide
ongoing input about your patient. They realize that you are
looking to them to effectively treat the substance use disorder
and to make a comprehensive discharge plan. They are also
aware that you can refer to a number of facilities (and they
usually are appreciative of your referral), so they will try to
give you the updates and information you need to so that you
can make sure that the patient’s ongoing treatment needs are
met. If you refer to a facility that does not provide you
updates; don’t refer to them again.
So What’s Available
Locally?

See the Attached Listing for SF Bay Area
Treatment Facilities (excel file in the folder for
this module)
Provides type of facility
 Services offered
 Medicare/Medi-Cal acceptance
 Languages/special populations served
 Differentiates public and private facilities
 Websites for many 12 step and self-help groups

Preparing the Pt for the
Referral



Assess the appropriate level of care
needed and finding the right facility is
really just half the battle. All that work
will be lost if the pt is unable or
unwilling to follow through.
What would you do to help prepare the
pt for treatment?
Would this differ depending on the level
of care?
Preparing the Pt for the
Referral: Our Suggestions








Motivation – recall the discussion of motivation (and how to build it) in
Module 6. Be sure the pt is motivated and willing to attend before
making the referral.
Ask the pt to “look ahead” and identify any potential obstacles or
roadblocks. Do some advance problem-solving on how to address
these issues.
Ask the pt to share his/her worries or what they imagine treatment will
be like. Provide corrective information.
Use testimonials from other pts, use the weight of your professional
opinion and your relationship with the pt.
Normalize anxiety and ambivalence.
Remind pt that he/she has choice. If one program doesn’t fit, try
another. There are many options.
Reassure pt you won’t abandon them regardless of how tx turns out.
Enlist the support of family members to help get the patient to
treatment (obtain releases of information to be able to speak with
family members the patient identifies as important in their lives).
Common Mistakes
1.
2.
3.
4.
5.
PCP rushes into “action” and makes a tx referral when
the pt isn’t interested.
PCP refers to an overfull program or to a program that
doesn’t take the pt’s insurance. Pt feels unheard and
frustrated.
PCP doesn’t create a referral “package” – i.e. other
strategies/programs or homework the pt can try while
they are on a tx program waitlist.
PCP doesn’t consider pharmacotherapy to reduce
cravings and/or reduce suffering.
PCP gets frustrated and sees the pt as “resistant” or
“self-sabotaging” instead of having a difficult chronic
disease.
What could you do to avoid each of these mistakes? How
will you assess your success?
Take Home Points




Substance abuse treatment works and there
are ways to maximize the likelihood of a
successful referral.
Substance abuse treatment occurs on a
continuum with several modalities overlapping
in multiple treatment settings
Level of care is determined by severity of
illness: is patient dependent or do they have
substance abuse. Comorbidities?
Inpatient treatment reserved for those with
more serious illness (dependence, more than
one substance, medical/psychiatric illness cooccurring)
Take Home Points



Substance abuse treatment facilities should provide you
ongoing updates with a valid release of information; if
they do not; don’t refer to them again
Substance abuse treatment facilities should provide you
with a structured discharge plan discussing the patient’s
ongoing treatment needs and making specific
recommendations as to what and where the patient
might access those interventions
Addiction is a chronic relapsing illness; continued
monitoring after substance abuse treatment is needed
and you may have to refer to substance abuse treatment
more than one time for any particular patient
Related Tools and
Resources

See Excel Spreadsheet Listing for Local Alcohol
and Drug Treatment Facilities and Programs



SF County Treatment Access Program 1-800750-2727
CA ADP resource website listings:


SF Bay Area
http://www.adp.ca.gov/Treatment/index.shtml
SAMHSA Treatment Facility Locator Tool

http://findtreatment.samhsa.gov/