Transcript Slide 1

Substance Use Disorder
Services for Returning Veterans
John P. Allen, PhD, MPA
National Mental Health Program
Director, Addictive Disorders
Outline of the Presentation
• Nature of patients served in VHA SUD
program
• Settings and nature of VHA treatment for
SUD
• Relationship of military variables to SUD
• Treatment of SUD and co-morbid PTSD in
VHA
• Facility-specific SUD services
Substance Use Disorders in VHA
• Rates/severity of SUD problems for Veterans slightly
exceed those in the general population matched for age,
gender, and geographic location. (25% of Veterans aged
18 to 25 meet diagnostic criteria for SUD.)
• Over 160, 000 Veterans were treated in FY 2010 in SUD
specialty care. Two-thirds of SUD diagnosed patients were
treated in primary care or general mental health services
only.
• 55% of VA patients in SUD specialty care also have a
diagnosis for another mental health problem; 30% have a
diagnosis for PTSD.
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Number of Patients Diagnosed with a
Substance Use Disorder
500,000
8.3%
8.4%
450,000
7.8%
400,000
7.3%
6.8%
350,000
7.0%
6.7%
6.5%
6.4%
300,000
250,000
200,000
150,000
100,000
50,000
-
FY02
FY03
FY04
FY05
FY06
FY07
FY08
FY09
FY10
SUD Diagnoses Over Time
300,000
Number of Patients
250,000
200,000
150,000
100,000
50,000
0
FY02
FY03
FY04
Alcohol Only DX
FY05
FY06
Drug Only DX
FY07
FY08
FY09
Both Alc and Drug DX
FY10
Drug Diagnoses Over Time
90,000
80,000
70,000
Number of Patients
60,000
50,000
40,000
30,000
20,000
10,000
0
FY02
FY03
FY04
FY05
Cocaine
FY06
Opioids
FY07
Cannabis
FY08
Amphetamines
FY09
FY10
Key Themes in VHA’s Substance Use
Disorder (SUD) Program
– Enhance access to SUD care; Particular
emphasis on needs of OEF/OIF, women,
justice-involved and homeless Veterans
– Resolve SUD problems in early stages
– Evidence-based pharmacologic and
psychosocial interventions
– Mainstream treatment thru integrating SUD care
in settings where Veterans present for care
– Provide a continuum of care
– Reduce stigma for SUD care
– Objectively measure SUD treatment response13
SUD Services in Primary Care
• About 2/3 of patients with SUD diagnoses are treated in primary
care or general mental health only, rather than in SUD specialty
services.
• Primary care services for SUD problems consist of:
– Screening for excessive use of alcohol
– Brief intervention for patients drinking at unhealthy levels
– Determination of need for detoxification and referral/medical
oversight
– Prescription of medications for SUD approved by the Food and
Drug Administration
– Referral of patients with severe problems to SUD specialty care
– Follow-up of SUD patients who refuse SUD services
• 96% of VHA patients are screened annually for at-risk drinking.
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Settings for SUD Care
•
Substance Abuse Residential Rehabilitation Treatment Programs
(N=64)
Focused on providing psychosocial treatment. Differ from traditional
inpatient programs by having lower numbers of staffing levels and longer
lengths of stay. These are dedicated Substance Abuse Residential
Rehabilitation Treatment Programs, but all residential treatment
programs within the VA offer SUD treatment in some fashion.
•
Intensive outpatient programs (N=136 Standalone; 20 Combined with
RRTPs) Provide at least three hours of SUD treatment services three
days per week. Includes day treatment, partial hospitalization, and
intensive outpatient clinic-based programs
•
Standard outpatient programs (N=61)--Ambulatory SUD services
•
Methadone maintenance programs –In-House (N=39) or contracted
with community providers (N=13)
•
Non-SUD specialty care --SUD services provided in primary care
(including buprenorphine), mental health, PTSD services/teams, etc.
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Selected Characteristics of Patients in VA SUD
Treatment Programs
Patient characteristics at intake
24Hour
Care
Married or in a long-term, marriage-like
relationship
28%
30%
38%
Female
5%
5%
4%
Operation Enduring Freedom (OEF) or
Operation Iraqi Freedom (OIF) Veteran
14%
15%
11%
Homeless or in unstable living
arrangements
52%
40%
22%
Met diagnostic criteria for PTSD
30%
29%
32%
Met diagnostic criteria for nicotine
dependence
72%
68%
74%
Met diagnostic criteria for opioid
dependence
17%
18%
51%
Intensive
Standard
Outpatient Outpatient
Recent SUD-Related Activities
• Award of new SUD specialist positions
• SUD Handbook and CPG for treatment of SUD
• Webinars for physicians on medical interventions for
SUD
• Establishment of Contingency Management as
adjunctive to treatment
• Clinical guidance related to patients receiving
medically prescribed marijuana
• Clinical guidance issued for SUD specialists assigned
to PTSD teams and services
• Assignment of VISN-level SUD Representatives
• Patient brochure developed to encourage drug
treatment
• Study on use of EtG and EtS inaugurated
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Military Deployment and SUD
• Rate of alcohol behavioral problems double (25% vs
12%) before and after deployment (Wilk et al, 2010).
(Among Reserve Component personnel there were twice
as many new onsets of heavy weekly drinking, binge
drinking, and alcohol-related behavioral problems among
deployed personnel than among their non-deployed
peers (Jacobson et al, 2008).
• Post deployment military personnel with SUD problems
are rarely referred for care (134 referrals/6669 positive
alcohol screens on PDHRA for active duty and 179/4787
for reserve component) (Milliken et al, 2007)
Combat Exposure and SUD
• Combat exposure is associated with increased
rates of weekly heavy drinking, binge drinking,
and alcohol-related problems. This is
particularly true for personnel aged 24 or
younger (Jacobson, et al, 2008).
• The threat of death or personal injury is most
associated with post-deployment alcohol
problems. This relationship is independent of
the relationship of these threats to other mental
health problems (Wilk et al, 2010)
SUD and PTSD
• Co-morbidity of the two conditions ranges
from 25 to 50% in OEF/OIF personnel
(Gulliver & Steffen, 2010).
• Prognoses for both conditions are worse
when the conditions are co-morbid than
when they occur independently
(Bernhardt, 2009).
Recommendations for Treatment of
SUD in Veterans with PTSD
(Based on Findings of Subject Matter Expert Panel in
November, 2009)
• Treatments for the two conditions should be coordinated and
generally the treatments should be done simultaneously. There
should be a single treatment plan.
• The VA-DoD Clinical Practice Guidelines should be followed for
each condition.
• A community of practice for SUD-PTSD specialists should be
created.
• Patients should be regularly monitored to ensure that the treatment
plan is responsive to their needs.
• Family involvement can be very helpful to the treatment of both
conditions.
• The Clinical Recommendations of the Panel should be
revisited/revised on the basis of new research and the actual
experiences of the SUD-PTSD specialists.
Percent of OEF/OIF Veterans with Diagnoses of
Substance Use Disorder by Year Seen
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
Issues in Treating SUD in OEF/OIF Veterans
• Enhance attractiveness of VHA SUD services.
• Capitalize on characteristics of VA care system.
• Distinguish developmentally-related aspects of
substance abuse from risk of chronic effects.
• Develop more computerized aids to enhance
SUD services
• Integrate services to address complexity of
problems presented - combinations of SUD with
traumatic brain injury, chronic pain,
homelessness, PTSD, nicotine dependence,
community/family readjustment
• Reduce concerns over confidentiality
5
Uniform Mental Health Services Handbook
as Related to Treatment of Substance Use
Disorders
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Screening and Assessment
• Universal screening for alcohol misuse in new
patient encounters, according to presenting
problem, and at least once a year
• Targeted screening for other substance-related
problems
• Follow-up for positive screens with a
multidimensional evaluation if substance use
disorder has been diagnosed
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Interventions (1)
• Emergency department services that include
provisions for 23 hour observation
• Medically managed withdrawal--Inpatient and
ambulatory, as needed
• Brief interventions in primary care or general
mental health
• Intensive outpatient services and/or residential
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care substance use services
Interventions (2)
• Dual diagnosis programs or coordination of
mental health and substance use disorder care
• Evidence-based psychosocial interventions to
prevent relapse
• Opiate agonist treatment (methadone and/or
buprenorphine)
• Evidence-based pharmacotherapy for alcohol
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dependence
Interventions (3)
• Long term monitoring and maintenance
treatment
• Interim services to address the needs of
patients waiting for specific programs
• Active follow-up for those who refuse referral
to SUD services
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Mental Health Services
Percent of Patients Participating in Various Treatment
Activities
24-Hour
Care
Intensive
Outpatient
Standard
Outpatient
Clinical diagnostic
interview
Individual therapy
related to mental health
problems
Group therapy related
to mental health
problems
83%
84%
82%
31%
34%
31%
42%
35%
12%
Medications for mental
health problems
61%
53%
52%
Treatment Activity
32
Medical and Support Services
(Average Percent of Patients Participating in Treatment Activities)
Treatment Activity
24-Hour
Care
Intensive
Outpatient
Standard
Outpatient
Hepatitis C screening and
testing
65%
47%
48%
HIV counseling and testing
55%
36%
44%
Medication for opioid
detoxification
2%
3%
5%
Medication for alcohol
detoxification
10%
9%
4%
Consultation/collaborative care
for patients with spinal cord
injury
2%
6%
0%
Referral to another program
for mental health services
26%
30%
24%
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SUD Services for Special Populations
(Average Percent of Patients Participating in Treatment Activities)
24-Hour
Care
Intensive
Outpatient
Standard
Outpatient
OIF/OEF focused group
therapy or other services
6
3
3
Women-specific groups or
other services
7
2
2
Integrated therapy for PTSD &
SUD
28
21
11
Treatment Activity
33