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Substance Use and Mental

Health: Applications of the

interRAI Mental Health Suite

Christopher Perlman, PhDAssistant Professor, University of Waterloo

Waterloo, Ontario, Canada

Fellow, interRAI

April 20, 2017

© C. Perlman, 2017

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Agenda

• Substance Use Assessment using interRAI

• Patterns of Substance Use Among Inpatient Psychiatry

• Clinical characteristics

• Concurrent conditions

• Informing public health policy: Trends in Cannabis Use

• New directions for interRAI screening and assessment

© C. Perlman, 2017

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Substance Use Treatment System in

Ontario

Public-Pay Services

• Hospital-based and physician services

• Community-based MH services

• Community-based addictions services• Ontario Drug Treatment Centres (opiod & some nicotine,

cocaine, alcohol, marijuana)

• Some residential services

Private-Pay (fee for service/charity) Services

• Some residential treatment programs

• Some private counselling and community based services

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Integrated Substance Use Content

Specific Addiction-Related Content:• CAGE Screener

• Patterns of Substance Use, Alcohol, Problem Gambling, Withdrawal

• Intentional misuse of medications

• Substance-use diagnoses

• Substance Use CAP

Indirectly-Related Content• Social relationships and conflict

• Employment/Education

• Criminal involvement

• Trauma

• Mental status

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Substance Use Clinical Assessment Protocol

1. Triggered due to Current Problematic Substance Use• This includes persons who have any of the following:

• used illicit drugs (e.g., inhalants, hallucinogens, cocaine and crack, stimulants, opiates, cannabis) in the last 90 days or

• used injection drugs in the last 30 days or

• consumed 5 or more alcoholic beverages in a single sitting in the last 14 days.

2. Triggered due to Prior History of Problematic Substance Use• history of substance use, no use in the last 90 days but have the potential to

relapse:

• a history of illicit drug use (but no use in the last 90 days)

• a history of injection drug use (but no use in the last 30 days)

• intentional misuse of medication(s) in the last 90 days

• any one of four behavioural indicators of potential substance-related addiction, based on the interRAI-MH addictions screen (CAGE)

• a social environment that facilitates or encourages drug or alcohol use (which is an additional trigger in the community mental health instrument).

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Substance Use in Inpatient Psychiatry

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60

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Proportion of Inpatients Triggering the Substance Use CAP in Ontario, Canada

2006-2015

Current Use History of Use

Inhalants 1%

Hallucinogens 3%

Stimulants 5%

Cocaine/Crack 13%

Opiates 11%

Cannabis 39%

Substances Used in 30-days prior

to Admission:

N= 69,295

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Substance Use in Inpatient Psychiatry

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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Proportion of Inpatients Triggering the Substance Use CAP in Ontario, Canada

2006-2015

Current Use History of Use

N= 69,29533% to 53%

3% 28%

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DSM-IV Diagnoses among Inpatients with

Substance Use Needs

Schizophrenia = 19%

Mood = 32%

Anxiety = 3%

Dementia = 2%

Other (impulse, adjustment, eating, personality) = 10%

Substance Use Disorder

Primary = 32%

Secondary = 21%

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Needs among inpatients triggering the Substance Use CAP

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Pain and Opiate Use

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0 1 2 3 4

Pain Scale (higher = more frequent and severe)

Physical Pain among Patients who have Used Opiates or Abused Medication

Opiate Use Recent Opiate Use Abuse of Medication

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Care Planning with the Person

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Concurrent Substance Use

What are the characteristics of inpatients with different

types of concurrent substance use and mental health

disorders?

N = 23, 991 (across 70 hospitals), 2011

• Schizophrenia and SUD = 4.7%

• Mood and SUD = 8.9%

• Other Concurrent = 2.47%

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0 10 20 30 40 50

No DD

Any DD

Mood Disorders and SUD

Schizophrenia and SUD

Patterns of Concurrent Diagnosis by Age

≥65 45-64 25-44 18-24

© C. Perlman, 2017

Other Concurrent

None

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None

Other

Mood/SUD

SZ/SUD

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60

None Other Mood/SUD SZ/SUD

Substance Use within 30 days of Admission Among Concurrent

Diagnostic Classifications

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Mental Health Service Utilization

Amount of time hospitalized

None in last 2yrs 70.46 70.10 69.06 58.19

30 days or less 19.97 21.96 22.12 27.55

31 days to 1 year 8.13 6.42 7.65 13.02

More than 1 year 1.43 1.52 1.17 1.24

Contact with Community Health

No contact in the last year 50.86 56.42 56.09 48.27

31 days or more 15.41 16.05 15.82 19.04

30 days or less 33.73 27.53 28.09 32.68

Category

Patients, %

Non-

Concurrent

Other MI/

SUD

Mood /

SUD

Schizophrenia

/ SUD)

Number of Psychiatric Admissions

(Recent)

None 70.46 70.10 69.06 58.19

1 to 2 22.15 23.31 24.92 28.70

3 or more 7.38 5.69 6.02 13.11

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Evaluating Policy: Trends in Cannabis Use

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Cannabis Use Among Adults in

Inpatient Psychiatry, Ontario, Canada:

2006 to 2015

Inpatient admissions in Ontario, Canada

• N = 147,550

Recent Cannabis Use = reported use within 30 days prior to

admission

• 18.3% (25% had any cannabis use in prior year)

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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Perc

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Trends in Cannabis Use Within 30-days of Admission to Inpatinet Psychiatry(2006-2015)

© C. Perlman, 2017

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2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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Trends in Cannabis Use Among All Age Groups (2006-2015)

Age=65+ Age=55-64 Age=45-54 Age=35-44

Age=25-34 Age =18-24 Age = <18

© C. Perlman, 2017

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0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Perc

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Trends in Cannabis Use among Patients by Selected Primary Diagnoses and Concurrent Substance Use

Substance-Related Disorders (Q1d) Schizophrenia (Q1e)

Mood Disorders (Q1f) Anxiety Disorders (Q1g)

Concurrent

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What other drugs are used by those

using cannabis?

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35

Perc

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Concurrent Substance

10% of Cannabis Users had no

concurrent substance use

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Implications of interRAI for Cannabis

Policy

• Prescribed vs. Recreation Use?

• Mechanism for evaluating trends and impact of policy

• Do age limits and restrictions on potency impact admissions to inpatient psychiatry?

• Increase in first-episode psychosis?

• Opportunity to monitor longitudinal trends for youth into adulthood

interRAI Children & Youth Mental Health interRAI MH/CMH

© C. Perlman, 2017

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Improving assessment and screening:

The interRAI Addictions Supplement

Canada:Chris Perlman: interRAI & University of Waterloo

Nancy Curtin-Telegdi: interRAI & University of Waterloo

John Hirdes: interRAI & University of Waterloo

Shannon Stewart: interRAI & Western University

Carol Anne Wight: Director, Western Health, Newfoundland

Nawaf Madi: Canadian Institute for Health Information

Jennifer Berger: Canadian Institute for Health Information

ChileBert Kempfe: Psychologist, Santiago, Chile

South AfricaDuncan Laurenson: Physician, Cape Town, SA

© C. Perlman, 2017

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interRAI Content vs. Other

Addictions Screens

• RAI-MH/CMH vs. Addictions Severity Index (396 items)

• RAI-CMH items directly or indirectly about 46% of ASI items

• E.g., 22 CMH questions related to the 106 ASI questions on Alcohol

and Drugs

• ASI missing bout 50% of CMH item content

• RAI-MH/CMH vs. GAIN

• 41% of Full GAIN items not on RAI-MH

• 59% of RAI-MH/CMH items not on the Full GAIN

© C. Perlman, 2017

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Addictions Supplement v1.0

• 1.5 pages (18 items)

• History of addictions issues/services

• Expanded oral and physical health status

• Video gaming and internet use

• Expanded sections on patterns and risk associated with use

• Readiness, need, and support for change

• Additional page on subjective usability ratings (for Pilot Study)

• Subjective rating of severity

• Content ratings for clinical utility

• Suggestions for missing content

• Time to complete

© C. Perlman, 2017

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Current Pilot• Canada

• Integrated into 1 of 14 health regions in Ontario for use in all hospital and community-based mental health services

• Hospital-based services in Manitoba

• Community-based services in Western Newfoundland

• Chile• Integrated into use with interRAI Community Mental Health

Assessment

• U.S.• Integrated into interRAI Community Mental Health Assessment

for New York State

© C. Perlman, 2017

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Applications

• Full range of clinical, psychosocial, and health services

information to support:

• Advanced care planning

• Levels of care decision support

• Outcome monitoring

• Quality indicators

© C. Perlman, 2017

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Dank je wel - Merci - Thank you

Christopher Perlman

Twitter: @Chris_Perlman

[email protected]

substance use and mental health: applications ... - ku leuven...eureka! using the rai-mh to support...

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