Referral to Treatment: The Next Steps Jennifer G. Smith, MD Division of General Medicine & Primary...

Referral to Treatment:The Next Steps

Jennifer G. Smith, MDDivision of General Medicine & Primary Care

John H. Stroger, Jr. Hospital

Cook County Bureau of Health Services

[email protected]

Overview

• Addiction is a common, treatable disease but most people who have it go untreated

• Treatment for addiction can begin with screening, assessment, & referral in general healthcare settings

• Building a successful “continuum of care” for addiction diseases means change for general healthcare and addiction treatment providers

• Taking steps to implement successful referral between general healthcare and addiction treatment organizations

DSM IV Substance Abuse Disorder(Use with Consequences)

Continued substance use, in spite of 1 or more recurring negative consequences over one year:

• Interference with role obligations• Risk of physical injury• Legal problems• Interpersonal problems

Continued substance use in spite of 3 or more recurring negative consequences over one year:

• Tolerance - Increased amounts needed to achieve effect• Withdrawal - Signs of, use to avoid or relieveLoss of control over use, compulsive use, craving -• More or longer use than intended • Unsuccessful attempts to cut down or control use• Much time spent getting, using, recovering• Activities given up or reduced to facilitate use• Use despite knowledge of related problems

DSM IV Substance Dependence Disorder(Alcoholism, Addiction)

Addiction is a Brain Disease

• Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways

• Long-lasting brain changes in the brain's natural motivational control circuits are responsible for the compulsion to use drugs that is the essence of addiction

Leshner AI, JAMA, 282 (1999): 1314 1316

Addiction Treatment is Effective

• Goal of addiction treatment is to return to productive functioning– Treatment reduces substance use by 40-60%– Treatment reduces crime by 40-60%– Treatment increases employment by 40%

• Rates of adherence similar to treatment for other chronic diseases such as diabetes, asthma, hypertension

• Every $1 spent for treatment saves up to $12 in reduced health care and crime-related costs

McLellan AT, Lewis DC, O'Brien CP, Kleber HD, JAMA, 284 (2000): 1689 1695NIDA, Principles of Drug Addiction Treatment: A Research-Based Guide, NIH Bethesda, MD, July 2000

90% of People with Active Substance Use Disorders are Untreated

85%

5%

10%

Did not feel need fortreatment

Felt need for treatmentbut did not receive

Received specializedtreatment

23.2 million (9.5%) of US pop. > 12 years old have a current substance use disorder

69% paid with own or family savings28% public assistance45% medicare/medicaid32% private insurance

National Survey on Drug Use and Health, SAMHSA, 2005

Overview





People with Substance Use Disorders Seek Care in General Healthcare Settings

General medical (ED, MD office) 43.3%

Specialty mental health 42.6%

Professional human services 19.0%

Self-help groups 7.9%

Specialty addiction 6.3%

Narrow et al. Arch Gen Psychiatry. 1993;50:95-107

Distribution of Persons w/ SUD Treated in Ambulatory Settings

Prevalence of Substance Dependence Disorder among Primary Care Patients

Study

Fleming(1998)

Piccinelli(1997)

Volk(1997)

Patients

Men & women18-65 y

Men & women18-65 y

Men & womenmean age 39-47 y

# Patients

21,282

482

1,333

Alcohol Dependence

5%

2%

5-7% women11-14% men

Illicit Drug Use

5%

-

-

Prevalence of Substance Dependence Disorder among General Hospital Admissions

Study

Smothers(2003)

Brown(1998)

Soderstrom(1997)

Canning(1999)

FacilityPatient type

90 Hospitals18+ y, All Services

Univ Hospital18-49 y, Med/Surg

Level 1 Trauma 18+ y, Trauma

Teaching Hospital18-85 y, Medicine

# Patients

2,040

374

1,118

2,988

Alcohol Dependence

6.3%

10.5%

24.1%

-

Illicit Drug Dependence

10.9%(Drug Use)

2.5%

17.7%

4%(Drug Use)

At-Risk & Dependent Use by Inpatient ServiceStroger Hospital, 2004-2005

Cocaine

0

10

20

30

Trauma HIV Med-Surg OB

Heroin

0

10

20

30

Trauma HIV Med-Surg OB

Marijuana

0

10

20

30

Trauma HIV Med-surg OB

Dependent At-Risk

Alcohol

0

10

20

30

Trauma HIV Med-surg OB

Prevalence of Alcohol Dependence by Age:Hospitalized Patients vs. Community

0

5

10

15

20

25

18-24 25-34 35-44Years

45-54 55-64 > 65

Alcohol Dependence in Hospitalized Patients, CCBHS

Alcohol Dependence in Community Members, Illinois

Pre

vale

nce

%

Drug Dependence by Age:Hospitalized Patients vs. Community

0

5

10

15

20

25

18-24 25-34 35-44Years

45-54 55-64 > 65

Cocaine Dependence in Hospitalized Patients, CCBHS

Heroin Dependence in Hospitalized Patients, CCBHS

Any Drug Dependence in Illinois Community

Pre

vale

nce

%

Readiness Ruler: How ready are you to make a change in your use?”

Not ready Unsure Ready

Her

oin

Alc

oh

ol,

Co

cain

e

Mar

iju

ana

Average response of patients dependent on that substance

Identification & Intervention for Substance Use Disorders among General Healthcare Patients

Study

Moore(1989)

Hearne(2002)

Smothers(2004)

Setting, Patients

University Hospital+ Alcohol screen

General Hospital+ Alcohol Use Disorder

90 General Hospitals+ Alcohol Use Disorder

Patients Identified

by MD Team

7-66%

20%

57%

Patients with Interventionby MD Team

35%

8%

21%

Overview





Illinois SBIRT Interventions

Screening

General HealthInformation

BriefIntervention

ChemicalDependencyTreatment

BriefAssessment

Assess &Referral

Use withConsequences

At-Risk Use

Low Risk Use

Dependent Use

State Licensed Treatment Providers

CCBHS Hospitals& Health Centers

Outcome of Screening 28 months, 3/30/04 – 7/27/06

Hospitalized Patients

N (% of screened)

Ambulatory Patients

N (% of screened)

Low Risk 34,507 (75.3) 5,493 (86.6)

At-Risk UseReceived Brief Intervention

4,820 (10.5) 548 (8.6)

Use w/ ConsequencesReceived Brief Intervention

1383 (3.0) 106 (1.7)

Dependent UseReceived BI, offered Referral

5,121 (11.2) 195 (3.1)

Accepted Referral to Treatment

2,752 (8)(54% of dependent pts)

39 (1)(20% of dependent pts)

Patient Placement Criteria for Addiction Treatment(American Society of Addiction Medicine)

Multidimensional Assessment:

1. Acute intoxication, Withdrawal potential

2. Biomedical conditions and complications

3. Emotional/Behavioral/Cognitive conditions and complications

4. Readiness to change

5. Relapse/Continued use/Continued problem potential

6. Recovery environment

ASAM PPCTreatment Levels of Service:

I. Outpatient Treatment

II. Intensive Outpatient and Partial Hospitalization

III. Residential/Inpatient Treatment

IV. Medically-Managed Intensive

V. Inpatient Treatment


Screening


BriefIntervention


BriefAssessment

Assess &Referral


At-Risk Use

Low Risk Use

Dependent Use



REFERRALCOORDINATOR

Patients Referred to Treatment 28 months, 3/30/04 - 7/27/06

# Patients Referred

Total 2,773

Brief Treatment (Individual Counseling) 793

Residential 921

Methadone Maintenance 576

Intensive Outpatient 232

Outpatient 251

Entry into State Funded Treatmentwithin 60 Days from Hospital Discharge

Substance Dependent

Patients

Entered Treatment

Accepted Referral to Treatment while Hospitalized

983 161 (16%)

Did Not Want Referral to Treatment while Hospitalized

292 5 (2%)

Sample of dependent patients discharged from Stroger Hospital matched with State-funded treatment data base (2004-2005)


Screening


BriefIntervention


BriefAssessment

Assess &Referral


At-Risk Use

Low Risk Use

Dependent Use



BriefTreatment

REFERRALCOORDINATOR

Time to Treatment “Intake” Appointment

Mean 95% CI

4 12 16 208

Modality

Brief treatment

Intensive outpt

Residential

Outpatient

Methadone

Tx Estimated time to beginning of treatment

Intake representative of beginning of treatment

0 28 42 Days

Tx

Tx

Entry into State Funded Treatmentwithin 60 Days from Hospital Discharge

Substance Dependent

Patients

Entered Treatment

Referred to Brief Treatment (with or w/out other traditional modality also intended)

274 72 (26%)

Referred to Traditional Treatment Modality (without Brief Treatment first)

709 89 (13%)

Sample of dependent patients discharged from Stroger Hospital matched with State-funded treatment data base


Screening


BriefIntervention


BriefAssessment

Assess &Referral


At-Risk Use

Low Risk Use

Dependent Use



BriefTreatment

COMMUNITY CASECOORDINATORS

REFERRALCOORDINATOR

Outcome of Referrals, Follow-Up from Community Care Coordinators

12 months (4/01/05 – 3/31/06)

Patients assigned to CCC after Hospital Discharge

1,072

Followed, know patient entered Treatment

335 (31% of assigned)

(55% of followed)

Followed, know patient did not enter planned Treatment

262 (24% of assigned)

(43% of followed)

Followed, patient died 9 (1% of assigned)

Lost to follow-up 466 (43% of assigned)

Change in Treatment Entry with NO WAIT

Mean Days to Tx Entry

% in Tx within 60

Days

Residential 9 days 18 %

Methadone Maintenance

17 days 22 %

% in Tx

after Referral

87 %

67 %

First YearUsual Wait

Referred Patients*

Same/Next DayTreatment

Referred Patients

*Sample of dependent patients discharged from Stroger Hospital matched with State-funded treatment data base, 2004-2005

Overview





Challenges for Healthcare Providers, Chemical Dependency (CD) Treatment Providers,

Regulators & Funders

• Implement universal screening in general healthcare settings and provide further assessment for substance use disorder as part of general healthcare!

• Establish referral relationships between CD treatment and general healthcare settings

– Identify common community resources

(Challenges continued)

• Establish procedures to coordinate care between healthcare & CD treatment organizations– Address confidentiality and clinical information

sharing

– Identify inter-institutional roles and responsibilities

– Coordinate to continue care initiated in general healthcare setting (example: Methadone to control withdrawal in hospital methadone maintenance)

• Provide CD treatment to patients with other significant medical conditions


• Adapt usual CD treatment “intake” procedures to accept patients referred from general healthcare settings

– Accept referral from intermediary rather than patient

– Give date for initiation of treatment

• Focus on transferring therapeutic alliance at first visit to CD treatment provider

– Downsize required regulatory paperwork for first visit

– First visit a counseling session not “intake” session


• Make CD treatment available with “no wait”

– Provide support to patients waiting for CD treatment

• Incorporate motivational counseling strategies to foster retention at all steps

Taking Steps*• Engage decision-makers

– Assess current practice, need, potential benefits– Assess readiness & identify support– Assess & strategize to minimize barriers

• Engage community resources, partners– What resources are available?– Who/what will maintain resource connections & partnerships?

• Engage workplace teams– Who will provide assessment? – Who will refer patients to specific treatment?– How will assessment and referral fit into usual care processes?

• Provide ongoing feedback (data) for incentive, improvement, and sustainability– What information should be monitored?– Who will collect and feedback information?– Who needs information feedback?

*Smith J, McQueen K, Brown R, Girard C, AMERSA National Conference, 2005

Referral to Treatment: The Next Steps Jennifer G. Smith, MD Division of General Medicine & Primary...

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