Implementing pharmacotherapy and recovery support for people with - - PowerPoint PPT Presentation

Implementing pharmacotherapy and recovery support for people with co-occurring disorders (COD) in community mental health settings

Elizabeth Bromley, MD, PhD (UCLA, LACDMH), Brian Hurley, MD (LACDHS) Allison J. Ober, MSW, PhD (RAND)

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Conflict of Interest Disclosures

Allison Ober, M.S.W, Ph.D. No Disclosures Elizabeth Bromley, M.D. No Disclosures Brian Hurley, M.D., M.B.A., DFASAM No Disclosures

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Goals for Today

• Discuss why we’re doing this project
• Share what we’ve learned from clinic staff
• Share what we’ve learned from clients
• Discuss medications for alcohol (MAUD) and
• pioid use disorders (MOUD)
• Review our toolkit
• Hear your thoughts and feedback

Why are we doing this project?

The problem, what we know about it, what we are trying to do about it

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Katarzyna Bialasiewicz via Getty Images

• Up to 45% of people with a

substance use disorder have a co-occurring mental illness 5

Co-occurring substance use and mental health disorders are common

• Of about 25 million people

with an alcohol use disorder (AUD) in the US, about 33% also have a mental illness

• Of about two million adults

with an opioid use disorder (OUD) in the US, about 29% have co-occurring depression, 22% have anxiety, and 27% have bipolar disorder SAMHSA, 2018 (NSDUH 2017)

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Despite the burden among people with mental health disorders, there are still large gaps in treatment

SAMHSA, 2018 (NSDUH 2017)

91.7 .7% o

• f peop
• ple

le wit with CO COD do do not g get tre reatment f for

• r both

h diso disorders

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Treatment is Effective but Underused for People with COD

Medications for OUD (MOUD) can reduce overdose deaths and increase treatment retention and functioning Most people with Co-OUD do not receive treatment for either problem Medication for AUD (MAUD) can reduce cravings and lower heavy drinking days People with a Co-AUD have less 10% chance of getting treatment in a given year

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To put this in context, some numbers from 8 clinics within LA County DMH

24267 22679 4956 3626 1575 254 5000 10000 15000 20000 25000 30000 New DMH Clients Clients Screened for AUD Clients With Positive AUDIT-C Score Clients Received Brief Clinical Intervention Clients with an AUD Diagnosis Clients Receiving Medication for AUD

Treatment Cascade for Clients with AUD at DMH 2018 (N=8 clinics)

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• Long waiting lists for

specialty care

• Medication is not always

available in specialty care

• Stigma and logistical barriers
• Service coordination

challenges

• Service provider lack of

training to work with people with serious mental illness

Lack of treatment for people with COD is due to several factors

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COD treatment in community mental health centers could help address unmet need

Aiming to FULLY treat COD in public mental health settings can address the lack

• f access to effective

treatments for a vulnerable and underserved population, in a setting where they are most likely to access care

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What should we do about this?

We need to increase clinic SUPPLY and client DEMAND for medications and recovery support in mental health settings for people with COD

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Now we are using the data to build a web-based toolkit to facilitate implementation of evidence- based COD treatment in community mental health settings First we learned about barriers to implementing medications and recovery support from DMH providers and staff through

• client and staff surveys
• interviews and focus groups

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8 clinics directly operated by the Los Angeles County Department

• f Mental Health (DMH)
• One in each of the 8 Service

Planning Areas (SPAs)

• Selected large, small, semi-rural,

and urban sites

• DMH treats 250,000 individuals

yearly, covering the 4750 square miles of LA County

Study Sites

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• We’ve completed data collection on

supply and demand for medications and recovery support for people with co-occurring AUD (Co-AUD)

• We are about 80% finished with data

collection for co-occurring OUD (co- OUD)

• Today we will focus primarily on Co-

AUD

Study Status

Understanding Supply

Staff perspectives on providing treatment for people with COD in community mental health settings

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Administrator interviews (N=39)

Findings:

• “Treatment of Co-AUD is not in my job

description”

• No easy way to communicate clinical

information about specific patients

• Clients are not motivated to address AUD;

when they are, providers are not prepared to work with them

• Lack of awareness of treatment availability

and resources What are t e the big igges est b barrie iers to p provid idin ing trea eatment w wit ithin in DMH for p peop

• ple w

wit ith co-

• c
• ccurrin

ing a alcoh

• hol
• l u

use dis disor

• rder (

(Co-AUD) D)?

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Findings :

• Treatment of Co-AUD, including medication,

matches clinic priorities

• While most clinical staff feel prepared to

identify and diagnose AUD, more than half think medications should be prescribed by a specialist from outside DMH

• Most prescribing providers are willing to

prescribe medications for Co-AUD Is Is provid idin ing treatment f for peop

• ple w

wit ith Co- AUD a accep eptable a and feasib ible? A Are provider ers p prepared a d and willing?

Staff Surveys (N=334)

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Findings:

Motivated to address Co-AUD, but:

• Lack of trained and available staff
• Lack of documented procedures for how to

provide treatment

• Need for collaboration with specialty care

for detox/residential treatment

• Belief treatment for AUD cannot be billed

What are e you

• ur t

thoug

• ughts a

about p provid idin ing care f for C Co-AUD? ?

Staff Focus Groups (N=16)

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REFLECTIONS: Do these issues resonate with you? What are some other issues that systems or clinics might encounter?

Understanding Demand

The client perspective on receiving medications for alcohol use disorders (MAUD) and recovery support in community mental health

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Participants and Methods

• Participants recruited from groups for

co-occurring disorders, flyers, and provider referral

• Focus groups guided by Health Belief

Model

• Data analyzed using deductive and

then inductive techniques

• 20% of transcripts double-coded

Participants and Methods

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87 total participants Average age: 47 years

• 53% female
• 47% had a current or past diagnosis of a co-

AUD

• 65% were currently drinking
• 13% reported not drinking and did not have a

current or past co-AUD diagnosis

• Three-quarters had not heard of naltrexone,

and familiarity with other MAUDs was lower

Resul sults ts Participants and Methods

Results

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An individual’s desire to quit “is definitely the most important thing. You're not going to stop unless you want to. If somebody else forced you to stop, you're not going to stop.”

Most clients viewed drinking as a problem of internal locus of control and did not perceive MAUD as potentially helpful

“I’m an alcoholic, so that (medication) would not even be a deterrent for

• me. If I’m not going to feel

it, I’m just going to keep drinking, drink until I black

• ut.”

“I don’t care what kind of pill they make, whatever it is….if you don’t deal with the issues that’s making you drink…then that’s useless…”

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Views of the costs and benefits of MAUD were shaped by presumed impact on internal locus of control

“My thing is I don’t want to become dependent

• n a pill to make me stop or quit or

whatever....[H]ow long do I have to take this? I might not want to take this pill no more, then what? Am I going to relapse?” “Plus, we don’t want to be taking all different kind of meds. I’m already on some meds and I’m like they’re going to give me this…I’m not willing to do that. It’s a little too much for me.”

Costs a s as Harm o rm or Burden

“Don't think of it as a thing that…is gonna magically cure you of your

• alcoholism. It's the foundation to

helping you, but it's a tool, but you need to put in the hard work

• yourself. You need to go to your

meetings, you need to go to therapy.”

Benefi efit

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Clients acknowledged severity of illness and susceptibility to relapse, but these did not influence desire for MAUD

“My relationship with alcohol is vital because for me to drink is for me to use drugs, me to come up missing, me to not take care

• f mental health issues, and

that's very important to know for yourself because I can't control alcohol, not one drop of it.”

“I relapse all the damn time. I do. This is like the longest I haven't relapsed in I don't know how much time. I have 40-something days. It's the longest I've had not relapsing.” “The worst thing that I've experienced …is how socially acceptable it is. And even on the Today Show…every single morning they have glasses of wine or a new mixed drink.….That is challenging.”

Severity ity Susceptib tibility ility

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Cues to action and context were viewed as important drivers of demand once individuals perceived a need for help with their drinking

Seeing a person that, “Hey, I’ve been on the pill, I haven’t had a drink in five years and now I’m about to get off the pill” would motivate me to take MAUD.

Cues Cues t to A

• Acti

tion

“Until you’ve actually been in our shoes, you’re never going to really completely fully understand what it’s like to be an alcoholic.”

Con

• ntextual F

xtual Fact ctors

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Conclusions

• When medications were seen as supporting

internal locus of control, demand increased

• When medications were seen as undermining

internal locus of control, demand declined

• Contextual factors and cues to action shaped

demand after a person had accepted the need for help

• Familiarity with MAUD was low; individuals

who had tried MAUD expressed the most

• ptimism about its effectiveness

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Framing MAUD as a tool to build self-control over drinking appears to be a promising strategy for increasing the acceptability of, and demand for MAUD among individuals with co-occurring SMI and AUDs Implications for Practice

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• Data from one mental health system
• Focus groups can generate hypotheses,

not test them

• Mix of individuals with and without a

co-AUD

• Learned little about views on specific

medications Limitations

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REFLECTIONS How do you think clients perceive MAUD? How can we use this information to increase demand for MAUD?

Medications for Alcohol Use Disorder

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There are several medications appropriate for treating alcohol use disorder

• Naltrexone (Oral)  REVIA
• Naltrexone (Long Acting Injection)

VIVITROL

• Acamprosate CAMPRAL
• Disulfiram  ANTABUSE

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Each medication works differently

• Naltrexone  reduces cravings for alcohol and

mitigates reinforcement during alcohol consumption; fewer drinking days and reduced volume of alcohol consumption on drinking days

• Acamprosate  reduces cravings for alcohol; fewer

drinking days

• Disulfiram  causes acetylaldehyde reaction when

alcohol is consumed

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Project COMBINE compared the effects of naltrexone to placebo and a cognitive behavioral intervention (CBI)

Anton, R. F., O’Malley, S. S., Ciraulo, D. A., Cisler, R. A., Couper, D., Donovan, D. M., ... & Longabaugh, R. (2006). Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. Jama, 295(17), 2003-2017.

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There is evidence that long-acting injectable naltrexone results in fewer heavy drinking days

Garbutt, J. C., Kranzler, H. R., O’Malley, S. S., Gastfriend, D. R., Pettinati, H. M., Silverman, B. L., ... & Vivitrex Study Group. (2005). Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. Jama, 293(13), 1617-1625.

Development of a Toolkit for Implementing COD Treatment in County Mental Health Clinics

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A collection of resources to help clinics implement their vision

What’s in the Toolkit?

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Section 0: Toolkit Rationale

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Section 1: Create a shared vision for your system/ clinic

2

Section 2: Review and adapt the workflow template to your system/ clinic

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Section 3: Assess readiness and develop your implemen- tation plan

4

Section 4:

Build clinical skills

5

Section 5: Client and family resources

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Section 6: Launch & monitor your program

Toolkit Overview

Today we’ll dive into Sections 1, 2, & 6

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Section 1 Create a Shared Vision for Your System/Clinic

Audience: System/clinic leadership Contents:

• Create a system-level or clinic vision for

integrated pharmacotherapy and recovery support for people with Co- AUD/OUD

• How to obtain staff buy-in for the vision
• How to identify champions
• How to create a change team

Slide 40

Exercise: What is your vision for integrated COD care?

Instructions: Form groups of 4-5 people each Each group comes up with its own vision for integrated pharmacotherapy and recovery support in mental health (or other) settings Write the vision on the paper provided Share your vision!

Slide 41

One possible vision

Every adult served by XX County/Clinic with a co-occurring opioid or alcohol use disorder will be assessed, and if appropriate, offered and provided treatment with medication, along with recovery support services in a client centered manner

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DISCUSS: What are your thoughts about this vision? Is anything missing? What would you change? Could this work in your county/clinic?

Slide 43

Section 2 Review and Adapt the Workflow and Guidelines

• Audience: Clinic leadership; change

team

• Contents:
• Overview of the Co-AUD/OUD

workflow template

• Workflow guidelines templates
• How to adapt the workflow and

guidelines to meet system/clinic needs

Treatment and Follow-Up

Screen for co-AUD

Co-Occurring Alcohol Use Disorder (co-AUD) Clinical Process Map TEMPLATE (Adapt this for your system or clinic)

Yes No

Determine client appropriateness for AUD medication as part of regular psychiatric assessment Conduct brief intervention

Assessment Services

New client begins DMH assessment or current client identified with alcohol use Screen positive ? Conduct co-AUD comprehensive assessment* Meets diagnosti c criteria for co- AUD?

Yes

Place AUD in diagnosis list and in initial treatment plan Team collaborates and develops treatment plan

Assigned Clinician Nursing Staff Psychiatrist/NP Multidisciplinary Team

Deliver long-acting injectable naltrexone, if applicable Consult with addiction sub- specialist, if needed Prescribe and deliver AUD medication Annual: Team collaborates and updates treatment plan Urgent withdrawal management needed?

Yes No

AUD medication appropriate & desired?

Yes

Assess and send for withdrawal management (includes nursing) Shared decision- making with client on treatment plan

START

Peer Support

*Some clinics may choose to do an abbreviated diagnostic assessment here

No

Screen annually or as clinically indicated

FINISH

Link to peer and family support Link to SUD counselor; provides information about resources Collect AUD lab set *Some clinics may choose to collect this later Provide peer and family support Provide individual + group co-AUD counselling Provide group + individual treatment for co-AUD and mental health condition Conduct co- AUD comprehensiv e assessment (if not already completed)

SUD Counselor No

“Click” on each box for a workflow guideline

Conduct Brief Intervention

• Goal: Provide feedback to the client on their alcohol use

and determine next steps

• Procedure description: Provide targeted feedback about

alcohol use; elicit readiness to change; negotiate an initial change plan

• Who conducts this: Clinician who conducts the full

assessment for AUD

• When conducted: Any time after the diagnostic

assessment for OUD/AUD is made

• What to do:

– Deliver a brief intervention (Step-by-Step instructions for delivering a BI are provided in the guideline) – Document discussion in session notes, e.g., conducted brief intervention, discussed treatment options

“Click” on each box of the workflow for a workflow guideline

Exercise: Create your

• wn workflow

Instructions:

• Form groups of 5-6 people
• Review the workflow poster and

discuss:

– Would this work in your clinic? – What is missing? – What should change?

• Share your key points with everyone

Slide 47

Section 6: Launch and Monitor Your Program

• Audience: Clinic leadership and change

team

• Contents:

– Use your implementation plan to: Confirm Resources are in Place Confirm Personnel are in Place – Orient all staff to the COD-AUD program – Create a quality metrics monitoring plan – Develop a program implementation (monitoring) plan

Slide 48

How will you know your program is working? Possible quality metrics for monitoring an MAUD and recovery support program Data from LA County Department Mental Health (N=8 clinics)

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Quality Metric 1: % Screened % of clients screened for hazardous alcohol use

95% 89% 97% 93% 95% 97% 97% 98% 99% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% All Clinics Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8

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Quality Metric 2: % Received Brief Intervention % of clients with hazardous alcohol use who received a brief intervention

47% 56% 43% 35% 54% 47% 46% 38% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% All Clinics Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8

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Quality Metric 3: % Diagnosed % of clients who screened positive who were diagnosed with co-occurring alcohol use disorder

7% 3% 6% 9% 15% 6% 7% 6% 8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% All Clinics Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8

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Quality Metric 4: % Initiated Treatment % initiated any mental health treatment within 14 days of screening positive for co-AUD

47% 29% 43% 49% 31% 71% 39% 64% 47% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% All Clinics Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8

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Quality Metric 5: Engaged in Treatment % who engaged in any treatment within 34 days of initiating treatment

25% 14% 34% 20% 15% 51% 18% 33% 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% All Clinics Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8

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Quality Metric 6: % Taking Medication % of clients with co-occurring alcohol use disorder taking medication

5% 2% 16% 2% 1% 4% 11% 6% 9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% All Clinics Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8

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DISCUSS: What are your thoughts about these metrics? What do they tell us about needs at DMH? What else would you look at?

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What questions do you have for us about the project? About the toolkit? About the medications for AUD and OUD?

More Questions?

Email us! Ebromley@mednet.ucla.edu bhurley@dhs.lacounty.gov Ober@rand.org

Elizabeth Bromley, MD, PhD (UCLA, LACDMH), Brian Hurley, MD (LACDHS) Allison J. Ober, MSW, PhD (RAND)