VA Screening Tools and Treatment

Options Available to VeteransStephen Chermack, PhD

Chief, Mental Health Service, VA Ann Arbor Healthcare System

Associate Professor, Department of Psychiatry, University of Michigan

The Science of AddictionThe Science of Addiction

Addiction

DRUG

Environment

Biology/Genes Biology/

EnvironmentInteraction

Biological Factors Interact with Environmental Factors to Produce Addiction

So What Does All This So What Does All This Mean for Mean for

Drug Abuse Service Drug Abuse Service Delivery? Delivery?

Relapse Rates for Drug Addiction are Similar to Other Chronic Medical Conditions

Relapse Rates for Drug Addiction are Similar to Other Chronic Medical Conditions

001010

2020

3030

4040

5050

6060

7070

8080

9090

100100

Drug Dependen

ce

Drug Dependen

ce

Type I Diabete

s

Type I Diabete

s

Hypertension

Hypertension

Asthma

Asthma

40

to

60

%4

0 t

o

60

%

30

to

50

%3

0 t

o

50

%

50

to

70

%5

0 t

o

70

%

50

to

70

%5

0 t

o

70

%

Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

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Treatment Research Institute

Outcome In Diabetes

Conclusion: Treatment Successful!

Treatment Research Institute

Outcome In Addiction

(Incorrect) conclusion: Treatment NOT successful!

If we treat a diabetic and symptoms don’t subside….what do we do?If we treat a diabetic and symptoms don’t subside….what do we do?

Would we increase the dose?Would we change medications?Would we change treatment approaches?

Would we fail to provide ongoing treatment for a diabetic?

Would we increase the dose?Would we change medications?Would we change treatment approaches?

Would we fail to provide ongoing treatment for a diabetic?

We need to shift the paradigm of We need to shift the paradigm of addictionaddiction

treatment from an acute to a treatment from an acute to a chronic care modelchronic care model

AbstinencAbstinenceeAbstinencAbstinencee

Functionality Functionality inin

Family, Work,Family, Work,and and

CommunityCommunity

Functionality Functionality inin

Family, Work,Family, Work,and and

CommunityCommunity

Goals of Drug Treatment:Keeping an Eye on the Target

Reduced Criminal

Behavior

Effectiveness of Treatment

40-60%

Drug Use Crime Employment

40-60%

40%

Cost-Effectiveness of Drug Treatment

• Cost to society of drug abuse = $180 billion/year.

• Treatment is less expensive than incarceration: - Methadone maintenance = $4,700/yr- Imprisonment = $18,400/yr

• Other studies indicate that every $1 invested

in treatment can yield up to $7 in savings.

ClinicalPractice

s

Initial Services

Sustain & Manage

TherapeuticInterventions

Assessment

“Prescription” for Services

Behavioral Counseling and Medications

Recovery/Chronic Care Management

Screening and Brief Intervention

Recovery from drug addiction requires effective treatment followed by management of the disorder over time.

A Chronic Care Approach to Drug Treatment

Treatment must last long enough to produce stable behavioral changes.

Per

cent

* p < .05 from Comparison

In-Prison Treatment Plus Post-Release Aftercare Improve 5 Year Outcomes in Prison Addicts

No Tre

atm

ent

No Tre

atm

ent

CREST Dro

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CREST Dro

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CREST Com

plete

rs

CREST Com

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rs

CREST Com

plete

rs +

CREST Com

plete

rs +

Afterc

are

Afterc

are

Drug-FreeDrug-FreeArrest-FreeArrest-Free

No Tre

atm

ent

No Tre

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CREST Dro

pout

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CREST Dro

pout

s

CREST Com

plete

rs

CREST Com

plete

rs

CREST Com

plete

rs +

CREST Com

plete

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Afterc

are

Afterc

are

Martin, Butzin, Saum, Inciardi (2004), Crime and Delinquency

*

*

**

*

AFTERCARE is Indispensable

Participants 80%African American

Assessment is the first step in treatment.

• Nature/extent of drug problem• Strengths:

• Family support• Employment history• Motivation

• Threats to recovery:• Criminal behavior• Mental health• Physical health• Family Influences• Employment• Homelessness• HIV/AIDS

Intake Processing / Assessment

Treatment Plan

Pharmacotherapy

Continuing Care

Clinical and Case Management

Self-Help / Peer Support Groups

Behavioral Therapy and Counseling Substance Use

Monitoring

Detoxification

Child Care Services

Vocational Services

Medical Services

Educational ServicesAIDS / HIV

Services

Family Services

Financial Services

Legal Services

Mental Health Services

Housing / Transportation

Services

Matching services to needs is critical for treatment to be successful.

Drug use during treatment should be carefully monitored.

• Know that lapses can occur • Conduct urinalysis• Provide immediate feedback• Intensify treatment as needed

Treatment should target factors associatedwith criminal behavior.

• Criminal thinking• Antisocial values• Anger/hostility• Problem solving• Conflict resolution skills• Attitudes toward school/work• Mental health problems • Family functioning• Barriers to care • Alcohol/drug problems

Effective Treatments Include:• Cognitive Behavioral Therapy• 12 step facilitation• Motivational Interviewing• Contingency Management• Behavioral Couples Therapy• Opiate Substitution• Addiction Psychopharmacology• Contingency Management• Problem Service Matching

VA Addiction and MH Services• Uniform Mental Health Services Handbook- released in 2008,

specified “essential components of the the mental health program that is to be implemented nationally, to ensure that all veterans, wherever they obtain care in VHA, have access to needed mental health services.”

• 2012- VA National SUD Handbook- further specified requirements for provision of SUD services at all VA treatment facilities

• VA invests in several staff training initiatives for best practices in mental health care

VA Addiction and MH Services• VA is a highly accountable healthcare organization (includes

performance and quality of care monitoring and feedback)

• VA emphasizes empirically supported treatment approaches

• VA funds innovative research to improve healthcare for veterans, including studies of addiction treatment (e.g., interventions to prevent violence and relapse, treating chronic pain among vets in addiction treatment, improve “aftercare” engagement post-hospitalization, etc.).

VA Medical CentersAnn Arbor:

• VA Ann Arbor Healthcare System • Outpatient & Intensive Outpatient

Battle Creek:• Battle Creek VA Medical Center

• Outpatient, Intensive Outpatient, Residential

Detroit: • John D. Dingell VA Medical Center

• Outpatient, Intensive Outpatient & Opiate Treatment Program

Iron Mountain: • Oscar G. Johnson VA Medical

Center • Outpatient & Intensive Outpatient

Saginaw: • Aleda E. Lutz VA Medical Center

• Outpatient & Intensive Outpatient

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Community Based Outpatient Clinics

Alpena: Clement C. Van Wagoner Outpatient Clinic Bad Axe: Bad Axe Community Based Outpatient Clinic Benton Harbor: Benton Harbor VA Outpatient Clinic Cadillac: Cadillac Community Based Outpatient Clinic Clare: Clare Community Outpatient Clinic Flint: Flint VA Outpatient Clinic Gaylord: Gaylord VA Outpatient Clinic Grand Rapids: Grand Rapids VA Outpatient Clinic Grayling: Grayling Community Based Outpatient Clinic Hancock: Hancock Clinic Ironwood: Ironwood Clinic Lansing: Lansing VA Outpatient Clinic

Mackinaw City: Cheboygan County Community Based Outpatient Clinic Manistique: Manistique Outreach Clinic Marquette: Marquette Clinic Menominee: Menominee Clinic Michigan Center: Jackson VA Outpatient Clinic Muskegon: Muskegon VA Outpatient Clinic Oscoda: Oscoda VA Outpatient Clinic Pontiac: Pontiac VA Outpatient Clinic Saginaw: Saginaw VA Healthcare Annex Sault Ste. Marie: Sault Ste. Marie Clinic Traverse City: Traverse City VA Outpatient Clinic Yale: Yale VA Outpatient Clinic

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Levels of Care and other SUD services

• Residential Rehabilitation Treatment Program• Currently only at Battle Creek• Typical length of stay = 4 weeks

• Intensive Outpatient Program• At each medical center • Length of stay typically 4-6 weeks

• Outpatient Specialty Care• At each medical center and very large CBOC• Varied services including therapy and pharmacotherapy

• Opiate Treatment Program• Only at Detroit (Offering Methadone and Suboxone)• Suboxone offered at some other sites

• Other outpatient SUD services• Some available at each facility in person, telehealth, or fee-basis

Access to Care• New veterans requesting or referred for services receive an initial

evaluation within 24 hours (usually by phone) and a comprehensive diagnostic and treatment planning evaluation within 14 days

• Waiting times for all services for established veterans are less than 30 days from the desired date of appointment

• Telemental Health Services is a mechanism to meet requirements and provide convenience for veterans

• Medical Centers and very large CBOCs offer a range of services during evening hours at least 1 day per week and on at least one weekend day.

Care Transitions

• Facilities ensure continuity of care during transitions from one level of care to another

• Veterans discharging from inpatient or residential are given appointments for follow up at time of discharge.

• Follow up includes evaluations within 1 week of discharge.

Veteran-Centered requirements• Appropriate services addressing the broad spectrum of

substance use conditions including tobacco use disorders are available

• Interventions for SUD are provided when needed in a manner sensitive to the needs of veterans and specific populations including but not limited to homeless, ethnic minorities, women , geriatric veterans, veterans with PTSD or other mental health conditions, veterans w/infectious diseases, TBI, and service-connected conditions.

• SUD is never be a barrier for treatment of other conditions or vice versa.

Screening for SUD in Veterans• During new encounters and at least annually, veterans

seen in medical or mental health settings are screened for alcohol misuse using the AUDIT-C (frequency, quantity, frequency of heavy drinking)

• Targeted case finding strategies are used to identify those with illicit drug use or misuse of prescriptions

• Those screening positive for SUD receive further assessment to determine level of misuse and establish diagnosis.

Assessment within SUD treatment • Veterans presenting for SUD care receive a multidimensional, biopsychosocial assessment to guide treatment planning for SUD and comorbid conditions

• All veterans with Alcohol Use disorder, Opiate Use Disorder, and other Axis 1 Mental Health disorders are evaluated by a physician for medication consideration.

• Veterans complete the Brief Addiction Monitor (BAM)

• Outcomes are monitored throughout the care episode in order to inform ongoing treatment planning.

• Note: VA also screens veterans for depression, PTSD, Military Sexual Trauma, Suicide Risk

Assessment within SUD treatment

• Brief Addiction Monitor (BAM):• recent alcohol and drug use• mental health conditions• sleep problems• Cravings• self-efficacy• self-help participation• social support, • risky situations• Spirituality• structured time,• social stressors,• financial situation,• satisfaction with recovery progress.

Psychosocial Services • Motivational counseling is available to veterans who need it to

support initiation of SUD treatment.

• At least 2 of the following empirically validated psychosocial interventions are available for veterans with SUD:

• Motivational Enhancement therapy/ Motivational Interviewing• Cognitive Behavioral Therapy• Twelve step Facilitation • Contingency Management• Behavioral Couples Therapy for SUD

• When PTSD and other MH conditions co-occur with SUD, interventions for other conditions is made available when not contraindicated.

Cognitive Behavioral Coping Skills

• Based on social learning theory• Substance use is functionally related to other problems• Emphasizes learning of coping skills• Initiation and mastery of skills through practice, role

playing, and extra-sessions tasks

Functional AnalysisFunctional Analysis

• Exploration of substance use in relationship to antecedents and consequences

• Identify and match cognitive and behavioral coping tools based on functional analysis

Withdrawal / Detoxification• Medically supervised withdrawal management is available at

all facilities (or through referral/transfer) as needed based on assessment of symptoms and risk of serious adverse consequences of alcohol , sedatives, hypnotics, or opioids.

• Although withdrawal management can often be ambulatory, inpatient is available.

• Withdrawal management alone is not treatment and must be linked to further SUD Treatment. Appointments for follow up are completed within 1 week of discharge.

Opiate Pharmacotherapy• Pharmacotherapy (e.g., Suboxone or methadone) is available

to veterans with opiate dependence when indicated.

• Pharmacotherapy is provided in addition to and linked to psychosocial treatment and support.

• When agonist treatment is contraindicated or declined, antagonist medication is available and considered.

• Suboxone is prescribed only by waivered prescribers in an office based environment or in an Opiate Treatment program.

Alcohol & Other Pharmacotherapy

• Pharmacotherapy for alcohol dependence is offered and available when not contraindicated. Pharmacotherapy must be prescribed with and linked to psychosocial Tx and support.

• Most common pharmacotherapy for alcohol includes naltrexone and disulfiram; however, alternatives are also prescribed.

• Medications are available for Tobacco use Disorder

• Medications for other mental health concerns are also provided for veterans