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COURAGE TO CHANGE
VITKA EISEN, MSW, EDD
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OVERVIEW
Intro
Evolution of SUD treatment
Current definitions and interventions
Review of chronic disease management at it applies to SUD
Review collaborative care model for SUD
Changing operating environment in California
Challenges and opportunities
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HEALTHRIGHT 360
Whole person care for low-income adults, youth, and families
• Substance use disorder (SUD) treatment
• Residential
• Outpatient
• Medication Assisted Treatment
• Mental health services
• Primary medical care (FQHC)
• Support services that address the social determinants of health:
• Education,
• Employment prep,
• Housing case management and transitional housing
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HEALTHRIGHT 360
Haight Ashbury
Free Clinics
Walden House
HealthRIGHT360
Lyon Martin Health
Services
Tenderloin Health
Services
Women’s Recovery
Association
Asian America Recovery
Services
North County Serenity
House
Prototypes
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OUR MISSION AND MODEL
Mission: Build health, give hope, and change lives for people in need.
View overall health improvement as our primary purpose—no matter
which point of entry.
5
Client
SUD Tx
MH Tx Medical
Social
Svces
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CORE TREATMENT
PRINCIPLES
Compassionate, non-judgmental, and welcoming services for high need, complex, low-income clients
Evidenced-based interventions
Medication Assisted Treatment where indicated
Trauma informed services
Assessment-driven individualized care
Full integration of substance use, mental health, and primary medical care
Gender responsive services
Culturally and linguistically appropriate care for diverse clients
Clients never fail treatment; treatment fails clients
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HEALTHRIGHT 360
Operates in 10 counties in California, from Solano to San Diego
Provides treatment in 4 state prisons and 2 county jails
38,000 clients treated last fiscal year
Annual revenue of $110M
1,100 employees
House 1,238 people in California every night, either in treatment
bed, interim or permanent housing
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A long strange trip…
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VIEWS OF ADDICTION
Moral failing
Adaptive coping mechanism
Chronic brain condition
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SPECIALTY CARE FOR
SUD
• Aversion therapies
• Institutionalization/incarceration
• Detoxification
• NTPs
• Minnesota Model
• Therapeutic Communities
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CHANGING DEFINITION OF
SUD
National Institute of Drug Abuse:
Addiction is defined as a chronic, relapsing brain disease that is characterized
by compulsive drug seeking and use, despite harmful consequences. It is
considered a brain disease because drugs change the brain; they change its
structure and how it works. These brain changes can be long lasting and can
lead to many harmful, often self-destructive, behaviors.
ASAM:
Addiction is a primary, chronic disease of brain reward, motivation, memory
and related circuitry. Dysfunction in these circuits leads to characteristic
biological, psychological, social and spiritual manifestations. This is reflected
in an individual pathologically pursuing reward and/or relief by substance use
and other behaviors.
Unbroken Brain (Szalavitz):
Addiction is a developmental learning disorder
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SUD PREVALENCE
AND COST
22.7 million individuals in the US with a SUD
2.5 million received treatment
Of the 20.2 million people that did not receive treatment, 19 million
did not think they needed it.
Total social cost of alcohol and drug misuse is $700 billion
annually
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EVIDENCED-BASED
PSYCHOSOCIAL
INTERVENTIONS
Motivational interviewing
Contingency management
Cognitive behavioral therapy
Community reinforcement approach plus vouchers
Trauma informed treatment
Facilitated 12-step
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EVIDENCED BASED
PHARMACOLOGIC
INTERVENTIONS
Medication assisted treatment
• Managing withdrawal and preventing cravings
• Methadone
• Buprenorphine
• Nicotine replacement
• Therapies to manage cravings and/or block euphoric effects
• Naltrexone (oral and injectable)
• Acamprosate
• Disulfiram
• Zyban
• Chantix
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NOT EFFECTIVE OR
LACKING IN EVIDENCE
Acupuncture as sole intervention
Relaxation therapy as standalone
Individual psychotherapy as sole intervention
Unstructured group psychotherapy
Confrontational therapy
Discharging patients for return to drug use
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CHANGING TREATMENT
FRAMEWORKS
Acute/long-term care
Acute/episodic brief care
Chronic care/ongoing support
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WHAT IS CHRONIC
DISEASE MANAGEMENT
An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve quality of life while reducing health care costs by preventing or minimizing the effects of a disease.
Elements*:
• Healthcare delivery system redesign towards preventative care
• Healthcare organizational support/organizational leadership and resources
• Expert informed decision support
• Improve information systems to track and coordinate care
• Fostering patient self-management through coaching, problem solving and peer support
• Linking patients to community by enhancing access to community resources
17McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, McNeely J. Can substance use
disorders be managed using the Chronic Care Model? Review and recommendations from a NIDA
consensus group. Public Health Reviews. 2014; 35(2):2107–6952.
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CHRONIC CARE MODEL
Framework for SUD treatment includes services along a
continuum, matched to patient need, integrated with primary care
18
Team based care
Services embrace evidence-
based guidelines
Person centered
Info sharing
Self-management and recovery
support
Link to community resources
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INTEGRATED CARE
FOR SUD
Refe
rral
• Separate facilities
• Communication key element
Co-locate
d•Physical proximity
•Meet to discuss specific cases
Colla
bora
tive
• Practice transformation
• Team-based care with shared information
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COLLABORATIVE CARE
MODEL FOR SUD
Team driven: Multidisciplinary team includes PCP, SUD care
coordinator, mental health, social worker, nurse, etc. as
indicated
Population focused: Team responsible for the provision of
care and health outcomes of defined population
Measurement guided: Team uses disease-specific as well as
patient reported outcome measures to drive clinical decision
making
Evidenced-based: Team employs scientifically proven
interventions to achieve improved health outcomes
20Dissemination of Integrated Care within Adult Primary Care Setting:
Collaborative Care Model (2016) American Psychiatric Association Academy of
Psychosomatic Medicine.
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POPULATION HEALTH
• A systematic effort to improve health outcomes in sub-
populations that share multiple clinical and social attributes
• Reflects the interdependence of biology, behaviors, social,
cultural, economic and environmental factors that impact well-
being
• Compels providers to envision and develop organized and
integrated systems that deliver the Quadruple Aim:
21Gauthier, P. (2016). Operationalizing Population Health; Population
linked service system. NatCon16. Las Vegas, NV.
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QUADRUPLE AIM
Better healthImproved patient
experience
Improved care team experience
Reduced cost
Healthcare
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POPULATION HEALTH
A systematic effort to improve health outcomes in sub-
populations that share multiple clinical and social attributes
• Patient registries
• Reviewing data in the aggregate (e.g. patients over 50 or
under 25, patients w/history of incarceration, Pacific Islander
patients, etc.)
• Reviewing health outcomes and distributions within a
population
• Reviewing patterns of determinants of the outcomes
23
Gauthier, P. (2016). Operationalizing Population Health;
Population linked service system. NatCon16. Las Vegas, NV.
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POPULATION HEALTH
Reflects the interdependence of biology, behaviors, social,
cultural, economic and environmental factors that impact
well-being
• Efforts to improve population health must address the social
determinants of health
• Such efforts should be focused on both improving the health
of individual patients as well as changing/improving the social
conditions that may impede health improvement
24
Gauthier, P. (2016). Operationalizing Population Health;
Population linked service system. NatCon16. Las Vegas, NV.
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MEASURE
Patient outcome measures:
Must be collected frequently to accurately assess recent
clinical picture
Must be reliable and sensitive to change
Must be relatively simple and low cost to implement
Must include patient-reported (not just clinician reported)
data
Should be tightly correlated to diagnosis
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BEHAVIORAL HEALTH
MEASURES
Screening
• CAGE-AID
• DAST
• AUDIT
• PHQ-9
• BSI
• BDI
Assessment
• ASI
• GAIN
• PCL
• ACE-R
26Unlike primary care, SUD has no nationally agreed upon measures
ADAI Library: Substance Use Screening & Assessment
Instruments Database. http://lib.adai.uw.edu/instruments/
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AND MEASURE
Access
Patient engagement
Patient experience
Medication adherence
Transitions in care
Readmission/time to readmission
Quality of Life measures (WHOQOL-BREF)
Other health measures (HEDIS)
Productivity
Utilization
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WHAT WE CAN LEARN
FROM PRIMARY CARE
Team based care
• Medical provider, licensed mental health professional, AOD
professional, client
• Client key member of team
• Each member works to the top of their scope of practice
• Huddles
Quality improvement strategy
• Routine performance measurement to identify opportunities
for rapid cycle improvement
• Use of patient experience data to inform practice
• Population health management
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HR360 MOVING TOWARDS
COLLABORATIVE CARE
Weekly Integrated Care Team Meeting
• Team-
• Psychiatrist, medical provider, mental health clinician, social
worker, AOD counselor
• Co-chaired by BH lead and Director of Addiction Medicine
• Review complex patients and shared patients
• Cross-learning
SBIRT in clinic with referrals for specialty care where indicated
Medical team will participate in residential tx to assess for
withdrawal mgmt and MAT where indicated
Chronic pain pt registry
Soon to develop high-user care team
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CHALLENGES TO OUR
COLLABORATIVE CARE GOAL
FFS payment structure
Technology—separate EHRs
Lack of easy access to data from other points of care—ED,
other clinic systems
Workforce and training
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CURRENT OPERATING
ENVIRONMENT
CHALLENGES
No national set of outcome
measures for SUD
Insurance/payment systems for
SUD treatment do not
necessarily follow patient
needs
Payment models do not follow
collaborative care model
No financial incentives to cover
the cost of population health
mgmt
Workforce
OPPORTUNITIES
Opioid use epidemic has
become a bipartisan national
issue and a part of the national
conversation
Improved MediCal benefit for
treating SUD
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DMC-ODS WAIVER
OPPORTUNITIES
System redesign to allow for continuum of care
Funding less county/local tax contingent
Telemedicine
Medical-incident to
More mobility
CHALLENGES
Shorter LoS
Strict definition of
episode
Will rates cover
increased cost?
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FUTURE DIRECTIONS
Technologies
Medications
Cognitively impaired clients (TBI, Dementia, FASD)
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TECHNOLOGIES
Technology delivered CBT
Smart-phone based video counseling and recovery supports
Avatar-facilitated motivational interventions
Stress reduction and mindfulness-based apps
GPS/geolocation interventions
Brain-training software designed to remediate executive
function impairment associated with SUD
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No FDA-approved
pharmacological
interventions for stimulant
use disorder.
Several under investigation
Haglund, M., Ling, W., Mooney, L. (2014). Treating
methamphetamine abuse disorder: Experience
from research and practice. Current Psychiatry ;
13(9):36-42, 44
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COGNITIVELY
IMPAIRED PATIENTS
DMC-ODS waiver requires system of care to treat ASAM Level 3.3: patients with cognitive impairment
Include brief neurocognitive assessment as part of intake process
Modify treatment accordingly*:
• Cognitive enhancement, eg memory training, problem solving training
• Decrease session length
• Repetition
• Multi-modal
• Appt books and reminders
• Simple language/check for understanding
• Practice skills in multiple settings
36Grossman, D., & Onken, L. (2003). Developing Behavioral Treatments for Drug Abusers with Cognitive
Impairments. NIDA.
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THE FACES OF FASD
FASD is an umbrella term describing the range of effects that can occur in an individual with prenatal alcohol exposure (PAE)
Effects may include
• Physical dysmorphology
• Intellectual/learning disabilities
• Neurobehavioral/social functioning
• Secondary emotional/mental health disorders
Effects are a result of damage to the developing fetus and they are permanent.
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PRENATAL ALCOHOL
EXPOSUREFor a developing fetus:
• Alcohol is a known teratogen and there is no known “safe”
amount of exposure for a developing fetus.
• National surveys show that about 1 in 2 women of child-bearing
age (i.e., aged 18–44 years) drink alcohol, and 18% of women
who drink alcohol in this age group binge drink.
• Among pregnant women, 1 in 10 reported alcohol use and 1 in
33 reported binge drinking in the past 30 days
Tan, C. H., Denny, C. H., Cheal, N. E., Sniezek, J. E., & Kanny, D. (2015). Alcohol use and binge drinking among
women of childbearing age — United States, 2011–2013. MMWR. Morbidity and Mortality Weekly Report MMWR
Morb. Mortal. Wkly. Rep., 64(37), 1042-1046. doi:10.15585/mmwr.mm6437a3
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PRIMARY CHALLENGES
FROM FASD
• Executive function:
• Problem-solving and planning
• Abstract reasoning
• Ability to switch cognitive strategies in response to feedback
• Verbal and nonverbal fluency
• Working memory
• Ability to generalize from one setting or situation to another
• Attention deficits
• Social cognition
• Learning disability – especially with math
• Impulsivity
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SECONDARY CHALLENGES
FROM FASD
AND
Substance use disorders
mental health issuesproblems in daily living
(hygiene, health and diet)
disrupted school experience trouble with the law
interpersonal relationship
challenges
increased likelihood for
other health conditions (i.e.
joint issues, ear infections)
unplanned
pregnancies/parenting
challenges
maintaining housing,
employment
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FASD PREVALENCE
FASD prevalence in US estimated between 2%-5% (CDC,
2014).
This number may be low because:
• Diagnosis requires confirmed maternal alcohol use during
pregnancy, + neurodevelopmental and/or intellectual deficits
OR
• Facial dysymorphology + neurodevelopmental and intellectual
deficits
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FASD PREVALENCE (CONTINUED)
Only 17% of individuals with FASD have facial
dysmorphology and maternal confirmation may be
impossible to obtain.
And, it can be very difficult to get confirmation of PAE,
particularly for adults
So, if no facial dysmorphology and no maternal confirmation
of PAE, then NO diagnosis.
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SUD PREVALENCE AMONG
PATIENTS WITH FASD
Of the individuals with a FASD age 12 and over, the prevalence of alcohol or drug problems was 35%.
Of the adults with PAE, 53% of males and 70% of females experienced substance use problems. This is more than 5 times that of the general population.
Streissguth, A.P., Barr, H.M., Kogan, J. & Bookstein, F. L. (1996). Understanding the Occurrence of Secondary
Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (PAE). Final Report to the Centers for
Disease Control and Prevention (CDC). Seattle: University of Washington, Fetal Alcohol & Drug Unit, Tech. Rep. No. 96-
06
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Most FASD is undiagnosed…
and individuals with FASD are at increased risk of
substance use disorders…
and treatment programs do not
routinely screen for FASD, or modify
treatment programming…
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THEN…IT IS LIKELY THAT:
a) FASD MAY BE FOUND AT A HIGHER RATE AMONG
OUR CLIENTS THAN THE GENERAL POPULATION.
b) WE ARE FAILING TO IDENTIFY CLIENTS WITH FASD
OR OTHER BRAIN INJURIES WITHIN OUR
TREATMENT PROGRAMS.
c) WE ARE FAILING TO PROVIDE ADEQUATE SUPPORT
FOR OUR CLIENTS WHO MAY HAVE A FASD.
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TREATMENT
MODIFICATIONS
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NEXT STEPS
Research needed to better screen
Develop and test interventions
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REFERENCES
ADAI Library: Substance Use Screening & Assessment Instruments Database. http://lib.adai.uw.edu/instruments/
Dissemination of Integrated Care within Adult Primary Care Setting: Collaborative Care Model (2016) American Psychiatric Association Academy of Psychosomatic Medicine.
Gauthier, P. (2016). Operationalizing Population Health; Population linked service system. NatCon16. Las Vegas, NV.
Grossman, D., & Onken, L. (2003). Developing Behavioral Treatments for Drug Abusers with Cognitive Impairments. NIDA.
Haglund, M., Ling, W., Mooney, L. (2014). Treating methamphetamine abuse disorder: Experience from research and practice. Current Psychiatry ; 13(9):36-42, 44
Kiluck, B.D., & Carroll, K.M. (2013). New Developments in Behavioral Treatments for Substance Use Disorders. Current Psychiatry Report.
McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, McNeely J. Can substance use disorders be managed using the Chronic Care Model? Review and recommendations from a NIDA consensus group. Public Health Reviews. 2014; 35(2):2107–6952.
Streissguth, A.P., Barr, H.M., Kogan, J. & Bookstein, F. L. (1996). Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (PAE). Final Report to the Centers for Disease Control and Prevention (CDC). Seattle: University of Washington, Fetal Alcohol & Drug Unit, Tech. Rep. No. 96-06
Tan, C. H., Denny, C. H., Cheal, N. E., Sniezek, J. E., & Kanny, D. (2015). Alcohol use and binge drinking among women of childbearing age — United States, 2011–2013. MMWR. Morbidity and Mortality Weekly Report MMWR Morb. Mortal. Wkly. Rep., 64(37), 1042-1046. doi:10.15585/mmwr.mm6437a3
Volkow, N.D., Koob, G.F., McLellan, T. (2016) Neurobiologic Advances from the disease model of addiction. New JAMA,374;4
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