No Slide Title · Surg, 1999. Estee S, ... Solberg LI, Am J Prev Med, 2008. National Committee on...

©Treatment Research Institute, 2012

6/3/2015

Why Integrate Addiction Care

into Mainstream Medicine?


A. Thomas McLellan Treatment Research Institute

Part I

Closing Thoughts

Substance use disorders” will soon be a

regular part of mainstream healthcare: 1. SUDs are too omnipresent, dangerous &

expensive in healthcare to be ignored

2. Market forces will accelerate integration

o Insurance benefits will bring new meds,

continuing care protocols & other tools

3. Mainstream healthcare can do this!

o Several protocols already fit into the system

Substance Use Among US Adults

Addiction ~ 23,000,000

Harmful – 40,000,000 Use

Little or No Use Little/No

Use

Very

Serious

Use

In Treatment ~ 2,300,000

1

1. Because it will improve

general medical care

2. Because it will save money

3. Because it’s the law.

1


general medical care 2. Because it will save money


Alcohol and drug use below “addiction” lead to:

misdiagnoses,

poor adherence to care,

interference with prescribed meds,

more physician time,

unnecessary medical testing,

poor outcomes

increased costs

Particularly in chronic illness.

Substance Use Impact on Healthcare

Vinson D, Ann Fam Med, 2004. Brown RL, J Amer Board Fam Prac, 2001. Humeniuk R, WHO, 2006. Manwell LB, J

Addict Dis, 1998. Longabaugh R. Alcohol Res Health, 1999. Healthiest Wisconsin 2010, WI DHFS, 2000. USPSTF,

Screening for Alcohol Misuse, 2004. National Quality Forum, National Voluntary Consensus Standards, 2006. Bernstein

J, Drug Alcohol Depend, 2005. Saunders B, Addiction, 1995. Stephens RS, J Consult Clin Psychol, 2000. Copeland J, J

Subst Abuse Treat 2001. Fleming MF, Med Care, 2000. Fleming MF, Alcohol Clin Exp Res, 2002. Gentilello LM, Ann

Surg, 1999. Estee S, Medicaid Cost Outcomes, Interim Report 4.61.1.2007.2, Washington State Department of Social

and Health Services. Yarnall KSH, Am J Public Health, 2003. Solberg LI, Am J Prev Med, 2008. National Committee on

Prevention Priorities, http://www.prevent.org/content/view/43/71/.

6

Systematic Reviews Diabetes:

– Howard et al. Ann Intern Med.

Hypertension:

– McFadden et al. Am J Hypertens.

Chronic pain:

– Martell et al. Ann Intern Med.

Breast cancer:

– Terry et al. Ann Epidemiol.

Sleep:

– Dinges et al. JAMA

Risk of Mortality & Drinks/Day

1.0

1.3

1.2

1.1

1.4

0.6

0.9

0.8

0.7

7 6 5 0 2 1

Drinks per Day

Ris

k o

f M

ort

alit

y

3 4

Di Castelnuovo et al. Arch. Int. Med. 2006;166(22):2437

What Are Low-Risk Drinking Limits?

Source: NIAAA, Rethinking Drinking: Alcohol and Your Health, 2009

Alcohol Use and Breast Cancer

Before Diagnosis – heavy drinkers

1.5 times chance of contracting

2.3 times chance w/BRCa2 gene

After Diagnosis – ANY Drinking

Increases risk of relapse

Interferes radio & chemo therapy

Nati

on

al In

sti

tute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

oli

sm

24

0

5

10

15

20

25

30

35

40

45

In College Not In College

Harmful Drinking Among Young People

10 or more drinks

Age 21-24

Age 18-20 Pe

rce

nt

Phillips, D. P. et al. 2008;168:1561-1566.

Alc/Drg Related

Fatal Errors

FME Death Rate

1983 - 2004

Potential impact on Safety: Fatal Medical Errors

• BU study of 87 patients with undisclosed opioid

use receiving primary care at BU Medical Center.

• 100% received at least one medication with a

significant drug-drug interaction

• Average number of significant interactions = 5

• 15 of 87 patients (17%) were treated by ED for

their interaction ($$$)

Drug-Drug Interactions – Safety Issues

Walley et al., J. Gen Internal Medicine, 24(9): 1007-11, 2009

Causes of Accidental Death

#1 Opioid Overdose

#2 Car Accidents

#3 Accidental Shooting

Source: CDC, 2013

Two Studies of Opioid

Overdose Hall et. Al. JAMA, 2008

Dunn et al. Annals Int. Med, 2009

Study 2 – Dunn et al, Annals 2009

• Prescription Drug Overdose Within a

Managed Care Environment

– Group Health study of overdose incidents and deaths

– 3,000 overdose reports in 2008

– Examined case histories and prescription records

• Death Rate of 11 / 100,000

– Predictors = Male; 30-50; Low SES;

MH/SA; OD history; Bz script; <10 days after script.

• 27% of reports had prior OD incident

Pain Society and State Guidelines for Pain Management

Model policy for the use of opioids in the treatment of pain.

http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf

Gilson AM, Joranson DE, Maurer MA. Improving state pain policies: recent progress and continuing opportunities.

CA Cancer J Clin. 2007;57(6):341–353

1. Screening for & discussing substance use

2. Patient contract – Single doc & pharmacy

3. Patient & family education on safe storage

of medications

4. Urine Screening pre and during

prescribing (expanded test panel)

1



2. Because it will save money 3. Because it’s the law.

Substance Use Cost in Healthcare


“Harmful – 40,000,000

Use”


Use

Very

Serious

Use


$80 B

Yr

$40B

Yr

1



2. Because it will save money


2009 Parity Act “MHPAEA”

“If” a health plan covers MH/SA

benefits should be comparable to

those of similar physical

illnesses”

2010 Affordable Care Act

• SA care is “Essential Service” • SA is firmly part of healthcare

• Funds full continuum of care • Prevent, BI, Meds, Spec Care

• Significant change in benefit • The nature/number of benefits

• The types of eligible providers

SUD Benefits Today


“Harmful – 40,000,000

Use”


Use

Very

Serious

Use


Addiction

• Detoxification – 100%

– Ambulatory – 80%

• Opioid Substitution Therapy – 50%

• Urine Drug Screen – 100%

– 7 per year

1

Medicaid Diabetes benefit

• Physician Visits – 100%

• Clinic Visits – 100%

• Home Health Visits – 100%

• Glucose Tests, Monitors, Supplies – 100%

• Insulin and 4 other Meds – 100%

• HgA1C, eye, foot exams 4x/yr – 100%

• Smoking Cessation – 100%

• Personal Care Visits – 100%

• Language Interpreter - Negotiated

SUD Benefits Under ACA


“Harmful – 40,000,000

Use”


Use

Very

Serious

Use


Benefit

for

“Substance

Use

Disorders”

• Physician Visits – 100%

– Screening, Brief Intervention, Assessment

– Evaluation and medication – Tele monitoring

• Clinic Visits – 100%

• Home Health Visits – 100%

– Family Counseling

• Alcohol and Drug Testing – 100%

• 4 Maintenance and Anti-Craving Meds – 100%

• Monitoring Tests (urine, saliva, other)

• Smoking Cessation – 100%

Pre-Diabetes

Clinically Managed Diabetes

Personally Managed Diabetes

Screening those at risk Motivational education

Behavioral Interventions Electronic Monitoring

Behavioral Interventions Medications

Family/Peer Support Close Monitoring

Electronic Monitoring Social/Environment Services

Family/Peer Supports

What is Needed?

SPECTRUM OF ILLNESS & CONTINUUM OF CARE:

Type 2 Diabetes

Clinically Managed

SUD

Harmful Use

Personally Managed

SUD

Substance Use Disorders

Clinically Managed Care Setting for Substance Use Disorders

1. Traditional Settings/Programs

a. Detox/Stabilization c. Partial Hospital

b. Residential d. IOP/Outpatient

2. Setting placement/transition determined by:

a. Severity, duration, complexity of illness

b. Availability of social supports

Stage 2 – Clinical Management

Goals

Methods

1. Establish/Maintain reductions in substance use 2. Improve general health and social function 3. Educate patient/Family to understand, monitor and

manage substance use problem 4. Engage Patient/Family/Support network into Stage 3 care

1. Individual, Family and Group Behavioral therapies 2. Rational Medication Regimen

a. Anti-craving medications (maintenance?) b. Appropriate meds for psychiatric and physical illness

3. Electronic and personal monitoring – a. Weekly for 1 month – Bi-Weekly for 3 months b. Monthly for six months

Outcomes &

Indicators

1. Elimination or Significant Reduction of Use as Indicated by urine drug screens during monitoring

2. Active engagement in Stage 3 Care

1. Patient acknowledges “relapse” 2. Patient agrees to more intensive monitoring and/or 3. Patient agrees to intensify care

OR

1. Serious relapse or overdose incident 2. Hospital, ER or Residential Treatment

Required

NOTE Stage 2 an be done in Primary, Specialty OPT or

Specialty Residential Settings

Greater severity/complexity/chronicity increases: * need for frequent monitoring and medication

* Need for specialty care, and * Need for protective setting

But Not

Substance Use Among US Adults


“Harmful – 40,000,000

Use”


Use

Very

Serious

Use


Prevention

Early

Intervention

Treatment

Closing Thoughts

Substance use disorders” will soon be a

regular part of mainstream healthcare: 1. SUDs are too common, dangerous & expensive

in healthcare to be ignored

2. Public understanding that addiction is an

illness not a sin

3. Mainstream healthcare can do this!

o Chronic Care Management protocols are appropriate


6/3/2015

Why Should we Integrate Care for

Substance Use Disorders into

Mainstream Medicine?


A. Thomas McLellan Treatment Research Institute

What will it take to Integrate

Part II

1

SBI in Breast Cancer Care

Background

Prominent University Medical Center in Philadelphia

• CEO of Healthcare System – “JCAH wants this – whatever it is – I want it in the whole system.

Start with whichever clinic raises their hand.”

• Cancer center administrator raises his hand –

currying favor

41

Meeting 1 With Cancer Staff

• With Docs - ready to discuss procedures

• Go through slides – NO Questions

• Immediate Result

• Letter to Dean – “ Why do we have to do

Psychiatry’s work….trolling for addicts is not part of our mission”

42


• Bring in the research

• Alcohol is significant predictor of susceptibility to BC

• Alcohol at any dose accelerates tumor growth

• BI reduces alcohol use among non-dependent drinkers

• BI is paid for

• Re-set Expectations

• NOT here FOR a favor – here to DO a favor

• If not good for cancer treatment – we leave – no problem

43


• Surprised but convinced by the research

• New concerns – fit and clinical value in work setting

• Training and Time (Rotations every 12 weeks)

• Workflow - Who, When, How

• What exactly to say – What exactly to do

• Patient Neg Reactions – “Probing into their

lifestyle”

• Electronic Health Record (EHR)

44

45

Active problem of patient is entered into the patient’s problem list (this example

is breast cancer)

SBI and EPIC

EARLY Results

• No Patient Problems/Complaints

• No Intrusion into Workflow/Routine

• No “Alcoholism” – 10% drink above thresh.

• Cancer Center gets CQI credit/prize

– CQI adds SBI as a “performance measure”

• SBI is now part of regional cancer training

• Reduced drinking, better cancer care ???

46

1

SBI in Middle & High School

A Partnership Between TRI and

Phoenix House

Background

• Suburban NYC School System

• MANY Drug Probs

• School Superintendant – “We need help,

teachers can’t teach, getting dangerous …”

• Other tiny little issues

• School is broke – no money for new interventions

• Teacher’s Union will not allow teachers to do more

• School Board is furious w/Superintendant (Property Values)

48

Issues

• What MIGHT work?

• SBI

• Who should do health screening – can they pay?

• Education – NO – Hell NO – Absolutely NO

• Health Department – Yes, part of recurring budget

• But ONLY in “Registered Health Clinic”

• Who should do the BI and RT?

• SA Treatment program – but only if it is reimbursed

• Why would a kid self disclose substance use?

• PERHAPS if it were engaging, useful, confidential 49

Solutions Round 1 • Create a “Health Clinic” in the School –

• Get architect and builder and inspector

• Get license and billing authorization - Phoenix House

• Get agreement that this is Prevention

• No need for Parent consent

• No record of “substance abuse treatment”

• Credit – NYC DoH (OASAS) & DoE

50

Solutions Round 2 • Create an engaging, anonymous screen

• Begin with CRAFFT – NYC regulations

• Use computer – private, multi-language, audio

• Tailored Software

• Anonymous & Confidential

• Personalized Feedback (BAC)

• Provide Tailored Guidance to Counselor for BI

• Develop detailed clinical protocol – manual – billing

Solutions Round 3 • Create tailored BI sessions and decision criteria

• 1 - Kids with no problems

• 2 – Kids with emerging use – to problem use

• 3 – Kids with significant problems

• Fundamentally different – Parent Involvement

• Develop confidentiality protections

• Develop billing and administrative procedures

Alpha Testing – 2 months

• Insurance problems

• Ultimately need parental consent - insurance

• School scheduling problems – too much time out

• Screen only during non-academic classes

• Computer problems

• Better, faster forms generation

• Training problems

• Two counselors could not learn MI

53

Beta Testing – 12 Months

• No teacher, admin or parent problems – BUT

absolutely NO teacher or parent involvement

• Screened 480 kids – 16 weeks

• Over-reporting of substance use (53%)

• 42 % students received 2 MI sessions

• 4 students & 9 parents referred to treatment

• Financially viable at 2 counselors @ 5-6 per day in

schools of 500+

• Now want depression, bullying, diabetes screens 54

No Slide Title · Surg, 1999. Estee S, ... Solberg LI, Am J Prev Med, 2008. National Committee on...

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