Transcript R&A Update - Government Executive

SUBSTANCE ABUSE AND THE WTB:
PERSPECTIVES FROM WALTER REED
Barbara A. Marin, Ph.D.
Clinical Director
Walter Reed Army Medical
Center
Army Substance Abuse
Program
Commercial: 202-782-3969
[email protected]
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WALTER REED ARMY MEDICAL CENTER
ARMY SUBSTANCE ABUSE PROGRAM
Clinical Assets
Barbara A. Marin, Ph.D, LCPC, CADC
Thelma Harris, LICSW, MAC
James Hardin, LCSW-C, MAC
Noel Hannah, LICSW, MAC
Debi Isenstein, LCSW-C
Despina Hangemanole, LGSW
2 Clinical Vacancies
WRAMC DCCS
ASAP Clinical Director (0180)
ADCO Staff (Garrison Assets)
Daryl Hawkins, PhD, ADCO
Sean McMillian, DTC
Richard Phillips, DTC
Myrna Perry, DTC
Kamau Bandele, Prevention Coordinator
Holly Leyo, EAP
LIPS (6 SW)
Administrative Staff:
Anthony Canzater, Health Systems Spec.
Valencia Robinson, WPIII
2
YA-0185-02
Social Workers
1 Clinical
Case Mgr
YA-0185-02
Admin Staff (2)
•1 Health Systems
Specialist (0671)
•1 WPIII contract
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UNCLASSIFIED//FOUO
WTU BDE – 2
WTU BN - 13
Warrior Transition Unit
WTU CO - 20
CBHCO - 9
Landstuhl 221
Heidelberg 34
Bavaria 167
Current WT Population (assigned
or attached to a WTU) is 12,023
Soldiers
WI
Ft. Drum
518
MA
West Point
178
95
Ft. Dix
249
Ft. Lewis
Ft. Riley
682
408
Ft. Carson
Ft. Belvoir
72
WRAMC
Ft. Leavenworth
671
CA
236
613
18
Ft. Lee
201
VA
69
199
UT
Ft. Leonard Wood
Ft Meade
152
73
Ft. Eustis
178
126
Ft. Sill
Ft. Irwin
& Balboa
Ft Huachuca
144
52
124
Ft. Hood
1240
Ft. Richardson
AR
Ft. Campbell
207
673
Ft. Knox
Ft. Bragg
326
736
Ft. Jackson
95
Redstone Arsenal
12
Ft. Gordon
130
407
Ft. Bliss
307
Ft. Stewart
Ft Rucker
Ft. Wainwright
528
18
AL
86
Ft. Sam Houston
Ft. Polk
590
271
TAMC
281
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Source: Dr. Carino, OTSG-WTO \ 703.681.1873
92
FL
139
83
Ft. Benning
3
322
UNCLASSIFIED//FOUO
PR
Last updated: 08 SEP 08
FY08 WRAMC WTB POPULATION
AVERAGE SIZE: 625
Warriors Assigned and Attached
650
634
632
631
626
634
626
626
625
625
630
622
620
611
606 608
600
FY08
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ASAP PATIENT CHARACTERISTICS
SOME BASICS
Largely active duty; accept other beneficiaries as space permits
53% WTB (178 WTB of 341 total patients served in FY08)
47% non-WTB (AD, DAC, FM)
Patient distribution by component:
Regular Army: 108 (61%) as compared with @70% WTB
Reserve: 38 (21%) as compared with 10% WTB
National Guard: 32 (18%) as compared to 20 % WTB
GWOT Workload Comparison:
FY08/FY09
300
250
275
257
232
208
268
215
200
150
100
FY08
50
FY09
0
Oct
Nov
Dec
Jan
Feb
Mar
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GUIDING PRINCIPLES:
CREATING A THERAPEUTIC MILIEU
Promote Team Approach
Frequent meetings: staffing, problem solving, Inter-Disciplinary
Reviews
Group co-facilitation across specialties
Ongoing consultation
Patient-Focused Treatment Planning and Choice Points
Self-help
Psycho-education
Stage of change model for treatment decision-making
Medication Management for Co-occurring Conditions
Psychiatric Evaluations for ASAP patients not under care elsewhere
Medication Management
Staff Consultation
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GUIDING PRINCIPLES:
FOCUSING ON SAFETY
Abstinence Monitoring
Breath testing
Ethyl Glucuronide (ETG)
Other drug testing
NIDA 5
Special Requests
October-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08 May-08 Jun-08
Jul-08
Aug-08
Sep-08
Total Tested
97
85
52
113
106
121
123
291
304
253
311
368
Total Positive
5
10
10
18
14
13
14
33
28
17
38
29
5.15%
11.76%
19.23%
15.93%
13.21%
10.74% 11.38% 11.34%
9.21%
6.72%
12.22%
7.88%
Soldiers Tested
65
56
44
79
64
67
68
78
71
68
81
87
Soldiers Positive
5
9
10
18
11
13
12
15
17
14
19
17
7.69%
16.07%
22.73%
22.78%
17.19%
19.40% 17.65% 19.23% 23.94% 20.59%
23.46%
19.54%
Percent of Total Positive
Percent of Soldiers Positive
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GUIDING PRINCIPLES:
FOCUSING ON SAFETY
Lower threshold for intervention (Sample: 341 patient seen in
FY08)
ADAPT (12%)
Extended Evaluation: Exploring Change (26%)
Enrolled (62%)
Building Bridges with the Chain of Command
Rehabilitation Team Meetings
Cadre Trainings
Weekly Interdisciplinary Meetings
Formal and informal communications
Clinical Case Manager is KEY
Immediate reporting of No-Shows
Building strong relationships with WTB TRIAD members 8
GUIDING PRINCIPLES:FOCUSING ON SAFETY
IMPLEMENTATION OF SG DIRECTIVE FOR SOLE PROVIDER
PROGRAM (EFFECTIVE 14 APRIL 2009):
“Assigning WTs to a sole provider may help deter patients from harming
themselves through accidental overdose of narcotics and/or other
high-risk medications.”
Baseline medication review and reconciliation on every assigned WT
within 24 hours of arrival
PCM for every WT and dedicated Clinical Pharmacist to support WTUs
Risk Assessments on all WTs; Soldiers deemed high risk will be
entered into SPP
If high risk/SPP, Soldier will receive no more than 7-day supply of
controlled or non-controlled medications; restricted to use of only one
pharmacy
Only Soldier’s sole provider or authorized alternate is allowed to modify
existing sole provider arrangement.
CURRENT INITIATIVE: EXTENDING SOLE PROVIDER TO NON-WTB
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WRAMC Warrior Population (n=630, 1/1/09)
1st QTR 1st QTR % Population
4th QTR
4th QTR % Population
TBI
181
28%
237
26%
PTSD
125
19%
97
10%
Depression
119
18%
196
21%
Cognitive Disorder
106
16%
118
13%
Substance Abuse
67
10%
122
13%
7
1%
16
2%
7
1%
10
1%
Amputee
99
15%
112
12%
Acute Stress Disorder
29
4%
55
6%
Spinal Cord Injury
37
6%
32
3%
Cardiac Condition
13
2%
21
2%
Cancer
5
1%
3
.3%
295
45%
326
35%
PSYCH, NOT PTSD
Personality
Disorder
Other
Patients on Narcotics
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1st QTR Data as of 31 December
ASAP PATIENT CHARACTERISTICS
Co-Morbidities (Data from FY09, Third Quarter)
Substance Use Profiles
69% Alcohol (41/59)
31% Other Drugs (18/59)
THC (5)
Opiates (4)
Cocaine (3)
Sedative Hypnotics(2)
Polydrug dependence (2)
PCP (1)
Co-occurring Conditions:
Mental health and substance
use disorders (36/59 or 61%)
PTSD and SUD: 29%
(17/59)
Other co-occurring
conditions: MDD, Bipolar
Disorder, GAD, ADHD
TBI and substance use
disorder
13/59 or 22%
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Works in Progress
Pain Management and Addiction
Suboxone Clinic under consideration
Close Coordination with Pain Clinic, PM&R, Anesthesia, PCMs
Sole Provider Designations and Tracking
TBI and Substance Abuse
Special Treatment Considerations
Training Needs
Future Directions
Cranial Electrotherapy Stimulation as adjunctive therapy
IOP Development
New Evidenced Based approaches: ex. Seeking Safety
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SPECIAL CONSIDERATIONS FOR WTB WO
Need for Rapid Response to:
No Shows
Changes in Mental Status
Indications of medication
reactions
Need for Close coordination
with:
Chain of Command
Case Managers
Other Medical Services
Other Behavior Health
Services
Pain Clinic and PM&R
Pharmacy
Conclusion: Communication is KEY
ASAP clinical case manager is an essential function
Proactive interdisciplinary communication: AHLTA not yet approved
for SUD treatment in Army
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CONTACT INFORMATION
WALTER REED ARMY MEDICAL
CENTER
ARMY SUBSTANCE ABUSE PROGRAM
COMMERCIAL: 202-782-3969
DSN: 662-3969
FAX: 202-782-7589
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