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A System of Care for Substance Use as a Chronic Health Problem. Rachel Gonzales Ph.D, Professor Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles www.uclaisap.org [email protected] Supported by:

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a system of care for substance use as a chronic health problem

A System of Care for Substance Use as a Chronic Health Problem

Rachel Gonzales Ph.D, Professor

Semel Institute for Neuroscience and Human Behavior

David Geffen School of Medicine

University of California at Los Angeles

www.uclaisap.org

[email protected]

Supported by:

National Institute on Drug Abuse (NIDA)

Pacific Southwest Technology Transfer Center (SAMHSA)

California Alcohol and Drug Programs (ADP)

slide3

Addiction Paradigms

Demonization

Criminalization

Psychiatric views

Socialization

Medicalization

Sinful/Immoral

Criminal/Illegal

Mental Disorder- DSM

Learned Behavior/Habit

Acute (Brain) Disease

Neuro-Science & Longitudinal Research

Chronic Illness

Leshner, 2001; Anglin et al., 1997

neuroscience supports addiction chronic health problem
Neuroscience SupportsAddiction = Chronic Health Problem

…with biological, psychological and behavioral components

biological response how do drugs work
Interact with neurochemistry (reward pathway of the Brain)

Results:

- Feel Good – Euphoria/reward

- Feel Better – Reduce negative feelings

Like Natural Rewards:

Food, Sex

Biological ResponseHow Do Drugs Work?
natural rewards elevate dopamine in the brain

FOOD

SEX

200

200

NAc shell

150

150

DA Concentration (% Baseline)

100

100

15

% of Basal DA Output

10

Empty

Copulation Frequency

50

Box

Feeding

5

0

0

Scr

Scr

Scr

Scr

0

60

120

180

Bas

Female 1 Present

Female 2 Present

Mounts

Time (min)

Sample

Number

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

Intromissions

Ejaculations

Source: Di Chiara et al.

Source: Fiorino and Phillips

Natural Rewards Elevate Dopamine in the Brain
drugs also bring reward via dopamine

COCAINE

AMPHETAMINE

Accumbens

1100

Accumbens

400

1000

900

DA

800

DA

300

DOPAC

700

DOPAC

% of Basal Release

HVA

HVA

600

% of Basal Release

500

200

400

300

100

200

100

0

0

0

1

2

3

4

5 hr

Time After Amphetamine

Time After Cocaine

MORPHINE

NICOTINE

250

Accumbens

250

Dose (mg/kg)

200

Accumbens

0.5

200

Caudate

1.0

2.5

% of Basal Release

150

% of Basal Release

10

150

100

0

1

2

3 hr

100

0

1

2

3

4

5 hr

0

0

0

1

2

3

4

5hr

Time After Nicotine

Time After Morphine

Drugs Also Bring Reward (via Dopamine)
slide9

What have we learned through

Positron Emission Tomography (PET)?

slide11

Addiction leads to….

Prolonged Changes

In the Brain

in Lasting Ways

“Cocaine Addict” Brain

“Healthy” Brain

slide12

BRAIN CHANGESappear prominently in PET scans of current and past drug users Drug users have far less dopamine activity (right), as is indicated by the depletion (dark red shows disruption), compared to the controls (left)Studies show that this difference contributes todependence and a diseased brain

behavioral response how drugs work
Behavioral ResponseHow Drugs Work
  • Loss of control
  • Continued compulsive

use despite harmful

consequences

  • Multiple relapses

preceding stable

recovery

why is continued treatment critical
Why is Continued Treatment Critical?

Normal Control

Meth user

(36 months abstinent)

Meth user

(1 month abstinent)

Partial Recovery of Dopamine Transporters After Prolonged Abstinence

advancing the notion of drug careers and treatment careers
Advancing the notion of Drug Careers and Treatment Careers….
  • Landmark study: UCLA ISAP researchers (Hser, Anglin et al) followed up a cohort of 581 male heroin addicts admitted to the California Civil Addict Program (1962-64) for over 30 years.
  • The program was the only major publicly-funded drug treatment program available in California in the 60s.
    • Tx: combo of inpatient and outpatient drug treatment to narcotic-dependent criminal offenders committed under court order.
causes of death among sample n 271
Causes of Death Among Sample (N = 271)

a

b

c

d

e

aIncludes overdose, poisoning, drug dependence, and suicide by drugsbIncludes motor vehicle, suicide, firearms, homicide, and fallscIncludes alcoholic cirrhosis, alcohol dependence, and poisoning by alcoholdIncludes kidney disease, diabetes, GI, and epilepsy seizureseIncludes viral hepatitis, AIDS, TB, and staphylococol depticemia

implications for the field
Implications for the Field
  • Cannot ignore the chronic nature of addiction and the associated long-term effects of heroin addiction in terms of morbidity, mortality, criminal justice involvement, and overall level of functioning
  • Compared to a US Population sample, heroin addiction reduces life expectancy by an average of 18 years
other long term outcome studies
Other Long-term Outcome Studies
  • Alcohol: Vaillant et al. conducted multiple long-term follow-up studies with alcoholics (post-tx). Findings repeatedly show that alcoholics experience multiple relapses and re-treatments with only 30-50% achieving stable abstinence.
  • Cocaine: Hser et al. 10-yr follow-up study of cocaine users post-tx found that fewer than 50% achieve extended periods of abstinence AND most re-enter treatment multiple times.
  • Methamphetamine: Marinelli-Casey et al. 3-year follow up study (600 MA users post-tx) found that 50% continue to use MA at a moderate or severe level throughout the 36 month period.
re addiction following prison
Re-Addiction Following Prison

Treatment Research Institute

  • Vaillant
    • 447 opiate addicts 91%
  • Maddux & Desmond
    • 594 opiate addicts 98%
  • Nurco & Hanlon
    • 355 opiate addicts 88%
  • Hanlon & Nurco
    • 237 mixed addicts 70%
  • Other Studies: Simpson, Wexler, Inciardi, Hubbard, Anglin
given the research there has been a paradigm shift in treatment response
Given the Research, there has been a Paradigm Shift in Treatment Response…

Focus has increasingly shifted from an acute, model of tx towards a chronic care model

slide25
Shift is been important for adequately understanding and managing substance use disorders and the recovery process

Are we there

Yet?

public expectations of substance abuse interventions
Public Expectations of Substance Abuse Interventions
  • Safe, complete detoxification
    • “The 28 day cure”
    • Put them in a box, something happens and they come out fixed
    • The washing machine model: Put a “dirty addict” in, run the washer, and take out a “clean citizen”
  • Results in:
    • Reduced use of medical services
    • Eliminate crime
    • Return to employment
    • Eliminate family disruption
    • No return to drug use
although the treatment community is feeling the shift let s review the process
Although, the treatment community is feeling the ShiftLet’s Review the process….
a menu of treatment services

Detox/

Inpatient

Detox/

Outpatient

Short-term Residential Treatment

Long-term Residential Treatment

Sober Living Residence

Intensive Outpatient/Psychosocial Behavioral Treatment

Medication Assisted Treatment

Continuing Care Programs

A Menu of Treatment Services
slide29

Acute System Response

Admission

Treatment…

Discharge

…One Type of Tx

From Menu of Services

Client

Outcomes

what s the problem with this system
What’s the Problem with this System?
  • Treatment effects usually don’t last very long after acute treatment stops
  • Clients who are not in some form of treatment or being monitored are at elevated risk for relapse
slide31

McLellan et al., 2000 compared substance use disorders with chronic illnesses (such as diabetes, hypertension, and asthma) and identified many similarities

slide32

How Similar in Heritability?

Twin Study Estimates

Eye Color 1.00

Asthma (adult only) .35 - .70

Diabetes (insulin dep) .70 - .95 (males)

Hypertension .25 - .50 (males)

Alcohol (dependence) .55 - .65 (males)

Opiate (dependence) .35 - .50 (males)

slide33

100

90

80

70

60

Percent of Patients Who Relapse

50

40

30

50 to 70%

50 to 70%

40 to 60%

30 to 50%

20

10

0

Drug

Addiction

Type I

Diabetes

Asthma

Hypertension

Sneak Peak at Similar Relapse Rates

McLellan et al., JAMA, 2000

slide34

Chronic Care Model Response

Treatment

Recovery

Detox Residential OutpatientNTP Continuing Care/Support Services

Weare well trained in the realm of the treatment stages…

slide35

Stage of Treatment

1. Detoxification

Purpose: Stabilization=Safe/Adequate reduction of withdrawal symptoms

-Physical/Emotional stabilization

-Promote problem recognition

-Engage patient into rehabilitation

effective strategies during engagement in rehabilitation
Effective Strategies During Engagement in Rehabilitation
  • Counseling to Promote Transfer using NIATx Strategies
  • Motivational Interviewing
  • Voucher-Based Techniques
  • Medications
slide37

Stage of Treatment

2. Rehabilitation

Purpose: Sustain stable abstinence

-Teach self-management skills

-Identify & reduce threats to progress

-Medications (maintenance and relapse prevention)

-Engage patient in continuing care

slide38

Chronic Care Model Response

Treatment

Recovery

Detox Residential OutpatientNTP Continuing Care/Support Services

Emphasis on: Continuity of Care

what is continuity of care
What is Continuity of Care?

Extending treatment beyond acute care

Detox

Residential Treatment

Outpatient/Psychosocial Behavioral Treatment

Arrow =Referral/Transfer

NO Clinical Discharge

Sober Living Residence

Continuing Care/Support Services

to find out
To find out…
  • One place to start is with the data:
    • What % of your clients who complete your treatment program are being referred/transferred to another level of care (continuity of care)?
continuity of care patterns in ca
Continuity of Care Patterns in CA

Majority of clients only receive 1 service (level of care)

what about the county of sonoma
What about the county of Sonoma?
  • What do you think?
    • In terms of the % of clients who complete treatment and are referred/transferred to another level of care (continuity of care)…
slide44

Sonoma

No. of Admissions

31%

25%

6%

10%

36%

Tx Modality

*

slide45

State

No. of Admissions

11%

29%

21%

13%

30%

Tx Modality

slide46

Transfers from Detox

Fresno

State

Detox Total: 962

Detox Total: 26670

Destination

Treatment Type

*Transfers to NTP Detox = 4, Day Care Rehab = 71,

Maintenance= 126

*Transfers to NTP Detox = 0, Day Care Rehab = 0

slide47

Sonoma

Residential Total: 2154

Transfers from Residential

State

Destination Treatment Type

Residential Total: 41,636

*Transfers to NTP Detox = 46, Maintenance= 98

*Transfers to NTP Detox = 2, Maintenance= 0

slide48

Sonoma

Mean No. of Days in Tx

(N=184) (N=636) (N=194) ( N=1191) ( N=2957) (N=706) (N= 6) (N=49)

Drug Category

*Other = barbiturates, PCP, inhalants, ecstasy, hallucinogens, club drugs, and other stimulants and tranquilizers

slide49

Sonoma

Mean No. of Days in Tx

(N=320) (N=2400) (N=983) (N=1970) (N=116) (N=134)

Type of Tx Modality

what does this pattern mean
What Does this pattern mean?

These statistics highlight one of the most prominent challenges faced by the addiction treatment field today…

…many people who enter treatment do not complete the necessary course of treatment required for success

Why is this a backward approach?

much research supports the success of a chronic illness treatment model
Much Research Supports the Success of a Chronic Illness Treatment Model
  • When treated as a chronic illness, the relapse rates of substance dependence are as good or better than other chronic illnesses (McLellan et al., 2005)
  • So, continuity of care (or client transitions between levels of care) is important for keeping the client engaged in their recovery and preventing relapse
  • Continuity of care has been shown to be successful in leading to better “long-term” outcomes (compared to acute care):
    • Abstinence
    • Addiction-related health illnesses
    • Family relationships
    • Legal status
    • Psychiatric issues (including service utilization)
given this issue work with your group brainstorm about
Given this issue, work with your group & brainstorm about…

What you (treatment programs) can do to improve these rates?

slide54
Strongly encourage client engagement in continued treatment
  • Actively “hand-off” clients to the other level of care (establish client-counselor linkages)
  • Be prepared: to bypass barriers
    • Identify what needs to be done (steps) for making the link (transfer), such as obtaining pre-authorization or what type of transfer paperwork is involved
  • Address client uncertainty about what to expect
    • Ensure that clients are informed (by alumni or staff) about the expectations and requirements of the next level of care
slide55
Building “connected care” – developing relationships with other levels of care programs…

…This means – sharing clinical (client) information to enable continuity of care

How can you prepare for connected care?

how can you begin to make connected care a reality
How can you begin to make “connected care” a Reality?
  • Examine your current processes for collecting and managing clinical (client) information within your program
  • Consider the ways clinical (client) information can be shared more efficiently (with other programs).
  • Understand your technology platform -- is it flexible and adaptable enough to support “connected care”
  • Map your community -- identify addiction stakeholders in your community who your program can collaborate with to build connected care
  • Start the external communications process – develop some outreach tools that will enable your program to stay connected to referral/transfer sources within the addiction community (in your neighborhood)?
slide57

Short-term Res Care

Recovery Coaches/ Centers

Outpt

Tx

Detox

Long-term

Res Care

Recovery

Services

Intensive

OtptTx

Methadone

Maintenance

NTP

Detox

Telephone Continuing Care

Recovery Services

Treatment/Intervention

Recovery

what about looking at the of clients who get
What about looking at the % of clients who get…
  • Recovery Services

Continuing Care

OR

Support Services

what is continuing care
What is Continuing Care?

In a chronic care paradigm, it is considered an important level of careforpromoting successful transitions from clinical services to recovery

types of continuing care
Types of Continuing Care
  • Traditional approaches
    • Self/mutual help programs
    • Regular counseling visits
  • Newer approaches:
    • Medications
    • Recovery “check-ups”
    • Telephone-based methods
recovery check ups
Recovery Check-ups
  • Developed by Researchers from Chestnut Group (Dennis, Scott et al.)
  • Involves contacting clients every quarter for 2 yearsto ask about:
      • Use of alcohol or drugs on > 2 weeks
      • Being drunk or high all day on any days
      • Alcohol/drug use led to not meeting responsibilities
      • Alcohol/drug use caused other problems
      • Withdrawal symptoms

…If +++, client referred to linkage manager

  • Provides:
    • Personalized feedback
    • Explores possibility of returning to treatment
    • Schedules an intake assessment
telephone based methods
Telephone based methods
  • Convenient for client
  • Reduces stigma of weekly trips to the treatment program
  • Individualized attention
  • Can be automated
  • Lower costs of ongoing care
measurement challenges
Measurement Challenges
  • Currently, we don’t have a method for measuring the extent to which clients are getting continuing care or support services.
  • What we do know (anecdotally) – it’s grim
why so many clients don t get continuing care support services
Program Level

May never get the referral

Logistical/financial disincentives

Resources

Views it as the client’s responsibility

Client Level

Low motivation

Treatment fatigue

(ready to be finished)

Why So Many Clients Don’t Get Continuing Care/Support Services
what about recovery services
What about Recovery Services?
  • What is your county currently doing to promote or provide recovery services…
removing confusion outcomes vs performance
Removing Confusion:Outcomes vs Performance
  • Outcomes:OUTCOME MEASURES ARE USED AT THE PATIENT LEVEL AND MEASURE CHANGES IN PATIENT BEHAVIOR OR FUNCTIONING OVER TIME
  • Performance: PERFORMANCE MEASURES ARE USED AT THE TREATMENT PROGRAM LEVEL TO EXAMINE THE FUNCTIONING OF THE TREATMENT PROGRAM
treatment completion is an outcome
Treatment Completion is an OUTCOME

Definition: Per CALOMS discharge, do people complete treatment

treatment initiation engagement
Treatment Initiation/Engagement

Definitions:

Initiation: Do people who enter treatment receive at least 2 treatment visits in the first 2 weeks?

Engagement: Do people who enter treatment receive at least 4 sessions in the first 30 days/

  • Meaningful: Yes
  • Clearly Defined: Yes
  • Reliability and Validity of Measures: Yes
  • Readily Accessible Data for Measures: ????
treatment retention
Treatment Retention

Definition:

  • Retention: Number of days between admission and discharge.
  • Meaningful: Yes
  • Clearly Defined: Yes
  • Reliability and Validity of Measures: Yes (maybe)
  • Readily Accessible Data for Measures: Yes
continuity of care
Continuity of Care

Definition:

  • Do individuals who enter treatment proceed through multiple service sets (levels of care)
  • Meaningful: Yes
  • Clearly Defined: Yes
  • Reliability and Validity of Measures: Yes
  • Readily Accessible Data for Measures: Yes
system change requirements
YES -- $$$

BUT ALSO

Strong Leadership

Motivated staff at all levels

Implementation Team

Infrastructure development (training)

Communication

Collaboration

Patience & Perseverance

System Change Requirements
building interactive service systems
Building Interactive Service Systems

To create a treatment system that produces the best outcomes for patients,

it is necessary for AOD services within a county to be delivered in a “system of care” rather than a “bunch of isolated programs”.

strategies for improving aod program performance
Strategies for improving AOD program performance
  • Reduce staff turnover
  • Increase staff knowledge of other forms of care to promote a “system of care” rather than isolated programs
  • Increase staff knowledge and use of evidence-based practices
  • Employ process improvement (NIATx)
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