COURAGE TO CHANGE

VITKA EISEN, MSW, EDD

1

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

2

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

3

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

4

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

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

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

7

A long strange trip…

8

VIEWS OF ADDICTION

Moral failing

Adaptive coping mechanism

Chronic brain condition

9

SPECIALTY CARE FOR

SUD

• Aversion therapies

• Institutionalization/incarceration

• Detoxification

• NTPs

• Minnesota Model

• Therapeutic Communities

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

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

EVIDENCED-BASED

PSYCHOSOCIAL

INTERVENTIONS

Motivational interviewing

Contingency management

Cognitive behavioral therapy

Community reinforcement approach plus vouchers

Trauma informed treatment

Facilitated 12-step

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

15

CHANGING TREATMENT

FRAMEWORKS

Acute/long-term care

Acute/episodic brief care

Chronic care/ongoing support

16

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.

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

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

19

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.

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.

QUADRUPLE AIM

Better healthImproved patient

experience

Improved care team experience

Reduced cost

Healthcare

22

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.

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.

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/

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

28

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

30

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

31

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?

32

FUTURE DIRECTIONS

Technologies

Medications

Cognitively impaired clients (TBI, Dementia, FASD)

33

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

34

35

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

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.

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.

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

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

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

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

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.

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

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…

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.

TREATMENT

MODIFICATIONS

NEXT STEPS

Research needed to better screen

Develop and test interventions

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QUESTIONS?

veisen@healthright360.org

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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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