Coming Out of the Shadows Addressing Substance Use in Primary Care - - PowerPoint PPT Presentation

Coming Out of the Shadows

Addressing Substance Use in Primary Care

November 12, 2014

We Want To Hear From You!

Type questions into the Questions Pane at any time during this presentation

Patient-Centered Primary Care Institute

Online Modules Webinars Website Learning Collaboratives Trainings TA Network

Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures

• Access to Care “Health care team, be there when we need you”
• Accountability “Take responsibility for making sure we receive the best

possible health care”

• Comprehensive Whole Person Care “Take responsibility for making sure we

receive the best possible health care”

• Continuity “Be our partner over time in caring for us”
• Coordination and Integration “Help us navigate the health care system to get

the care we need in a safe and timely way”

• Person and Family Centered Care “Recognize that we are the most important

part of the care team - and that we are ultimately responsible for our overall health and wellness”

Learn more: http://primarycarehome.oregon.gov

PCPCH Model of Care

Introduce Presenters

Traci Rieckmann, Ph.D. Associate Professor OHSU Department of Public Health and Preventive Medicine Department of Psychiatry UCLA Department of Psychiatry Ariel Singer, MPH Program and Training Director OHSU Northwest Addiction Technology Transfer Center

Learning Objectives

• Review the prevalence of risky substance use in

primary care settings and the impact on chronic conditions commonly managed in primary care

• Define the substance use disorder continuum
• Learn about treatment options, including behavioral

and pharmaceutical interventions

• Receive a brief primer on the specialty substance

use treatment system

• Review system-level barriers and strategies for

primary care and substance use treatment integration

We are moving from saying, “this is a personal failure...” To saying, “there is a light at the end of this tunnel…”

“And if you want to, we can walk towards it together…”

SUD Prevalence and Impact

Prevalence of Substance Use Disorders in US Primary Care Settings Between 6-20% US Hospital Emergency Room and Trauma Centers Over 50% General Adult Population 8-11% Medically Harmful Substance Use Over 40 million adults

Alignment with PCPCH Standards

• Access to Care

– ACA expanded coverage and access – Behavioral health and SUD screening and treatment available in PC – Referral to specialty care

• Accountability

– Evidence based care is available and improves outcomes

• Comprehensive Whole Person Care

– Can’t treat comorbid conditions without addressing the SUD

• Continuity

– Integration, cross-training of providers, interface with specialty care

• Coordination and Integration

– Team Care or Collaborative Chronic Care Models

• Person and Family Centered Care

– Patient informed and engaged decision-making tools – Provider improved communication and engagement

DSM V: 11 Criteria for SUDs

Diagnosis on a Continuum of Severity

• Taking substance in larger amounts for longer than intended
• Wanting to cut down or stop using, but not managing to
• Spending a lot of time getting, using, or recovering from use
• Cravings and urges to use the substance
• Not managing to do what you should at work, home or school
• Continuing to use, even when it causes problems in relationships
• Giving up important social, occupational or recreational activities
• Using again and again, even when it puts the you in danger
• Continuing to use, when you have a physical or psychological problem that could

have been caused or made worse by use

• Needing more of the substance to get desired effect (tolerance)
• Development of withdrawal symptoms; relieved by taking more of the

substance.

Mild (2-3 ) Moderate (4-5) Severe (6+)

SUD: What it is and isn’t

Miguel has been working in the construction industry for the past 25 years. About two years ago, he hurt his back on a job-site and had to have surgery. Miguel doesn’t work as much during the winter and his back doesn’t really bother him too much when he is not on his feet all day. During the summer, he works long hours and has moderate to severe back

• pain. His PCP prescribed him Vicodin to help him manage his pain during those months.

Miguel usually takes two pills at lunch time and two more when he gets home in the

• evening. If his back is hurting more than usual, he takes two more before bed. When the

rainy season starts, he stops taking the Vicodin and notices that he feels more irritable than usual, his muscles are achy and he is sweatier than usual.

What’s going on with Miguel’s use of a narcotic pain medication?

SUD: What it is and isn’t

Jodi works in a grocery store. She has a three year old daughter and a five year old son, and they all live with her mom. Jodi likes to go out with her friends from high school to dance, flirt and blow off some steam. She goes out 3 or 4 nights per week and usually has 5 to 7

• drinks. If someone has cocaine, she likes to use that too.

Her mom is getting concerned about how often Jodi is asking her to watch the kids. Sometimes Jodi is not only out most of the night, but then can’t function all that well to take care of her kids and she has been late to work as well resulting in her boss giving her a two

• ut of three strikes and you’re out warning.

Jodi visits her primary care doctor to get a refill for her birth control pills and participates in an annual screening for risky drug and alcohol use.

What’s going on with Jodi’s substance use and what kind of discussion might her primary care team have with her?

Caring for the Whole Person

Primary Care Identification of SUD

Most effective for at-risk (not dependent) users Can be conducted in a variety of ways

Screening  Brief Intervention  Referral to Treatment

Universal

Primary Care Response to SUD

• Brief Intervention and brief treatment

– Most effective for at-risk or harmful use – Motivational Interviewing Approach – Targeted, time-limited

• Medication Assisted Treatment

– Opioid dependence: buprenorphine, methadone, naltrexone (tablet and injectable) – Alcohol dependence: Naltrexone (Vivitrol), disulfiram, acamprosate,

• Recovery check-ups

Chronic Disease Management

• Team and Collaborative Interdisciplinary Care
• Core Elements

– Healthcare delivery system redesign – Organizational level support – Expert-informed/consultation and decision support – Enhanced clinical information systems – Patient self-management – Link or referral/collaboration with local community

The Treatment Landscape

Tools for Providing the Right Care American Society of Addiction Medicine Criteria

ASAM Dimensions for Patient Placement

Criteria Description Goals of Care Dimension 1 Acute Intoxication and/or Withdrawal Potential

• Assess type and intensity of withdrawal management

services

• Avoid potential harm from sudden discontinuation of

use of alcohol and/or drugs

• Engage and facilitate completion of withdrawal

management and connect patient to continued treatment, self-help or recovery support services

• Promote patient dignity and reduce discomfort during

withdrawal process Dimension 2 Biomedical Conditions and Complications

• Assess the need for physical health services, including

acute and chronic care Dimension 3 Emotional, Behavioral, or Cognitive Conditions and Complications

• Assess the need for mental health services, including

addressing trauma-related conditions, cognitive conditions and other psychiatric conditions or disorders

ASAM Dimensions for Patient Placement

Criteria Description Goals of Care Dimension 4 Readiness to Change

• Assess need for motivational

interventions to engage in treatment and recovery

• Respond appropriately using

Prochaska and DiClemente’s Stages

• f Change Model

Dimension 5 Relapse, Continued Use, or Continued Problem Potential

• Assess the need for relapse

prevention or risk of continued use

• Focus on previous period of sobriety
• r wellness

Dimension 6 Recovery/Living Environment

• Assess need for family or significant
• ther support services
• Assess need for housing, financial,

vocational, legal, transportation or child care services

Tools for Providing the Right Care Options for Substance Use Disorder Treatment

Treatment Setting Description Detox Monitored by medical personnel; may be supported by medication Substances of abuse have different levels of withdrawal risk Supports safe and effective withdrawal Average length of service: 3-7 Days Outpatient May consist of group and individual counseling, conducted on a weekly basis Usually 1-2 times per week, less than 9 hours per week total Length of treatment based on individual treatment plan Intensive Outpatient May consist of group and individual counseling, conducted on a weekly basis Usually 3 times per week , total of 9-19 hours per week Average Length of Treatment: 2-3 months Residential/Inpatient Combination of group and individual services, may include medication, case management and follow up care planning May be community or hospital-based Average length of treatment: 28 days, varies significantly

The Treatment Landscape

Strategies to Promote Integration

• Training for skills, attitude and cultural understanding
• Focus on shared system and patient-level goals
• Work together to resolve workflow and care

coordination issues and to understand differing cultural norms

• Practice patience

Challenges to Integration

• Stigma relating to substance use
• Substantial cultural differences between care

systems

• Differing pace of care delivery
• 42CFR/barriers to health information sharing
• Concerns about scope of practice on both

sides

Systems Change

Key Training Topics (and how ATTC can help!)

Primary Care Professionals

• Substance Use Disorder as a

chronic disease

• SBIRT
• Motivational Interviewing

and harm reduction

• Medication-assisted

Treatment

• Understanding what happens

in treatment

• Operating as part of

extended PCMH team SUD Professionals

• Health effects of substances
• f abuse on prevalent chronic

conditions

• Motivational Interviewing

and harm reduction

• Outreach and engagement

for moderate risk patients

• Operating as part of

extended PCMH team

Questions?

Type questions into the Questions Pane at any time during this presentation

Resources & Thanks!

• http://www.attcnetwork.org/home/
• http://www.integration.samhsa.gov/
• http://www.oregon.gov/oha/amh/Pages/sbirt.aspx

Thanks for your time and participation today! Please complete post-webinar survey.