A System of Care for Substance A System of Care for Substance

Use as a Chronic Health ProblemUse as a Chronic Health Problem

Rachel Gonzales Ph.D, ProfessorRachel Gonzales Ph.D, ProfessorSemel Institute for Neuroscience and Human BehaviorSemel Institute for Neuroscience and Human Behavior

David Geffen School of MedicineDavid Geffen School of MedicineUniversity of California at Los AngelesUniversity of California at Los Angeles

www.uclaisap.orgrachelmg@ucla.edu

Supported by: National Institute on Drug Abuse (NIDA)

Pacific Southwest Technology Transfer Center (SAMHSA)California Alcohol and Drug Programs (ADP)

Understanding addiction as a chronic health problem

DemonizationCriminalization

Psychiatric viewsSocialization

Medicalization

Addiction Paradigms

Sinful/ImmoralCriminal/Illegal

Mental Disorder- DSMLearned Behavior/HabitAcute (Brain) Disease

Neuro-Science & Longitudinal Research

Chronic Illness

Leshner, 2001; Anglin et al., 1997

Neuroscience SupportsNeuroscience SupportsAddiction = Chronic Health ProblemAddiction = 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

Pathway for Understanding Pathway for Understanding Addictive EffectsAddictive Effects of Drugs on the Brainof Drugs on the Brain

Reward Pathway

00

5050

100100

150150

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00 6060 120120 180180

Time (min)Time (min)

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BoxBox FeedingFeeding

Source: Di Chiara et al.Source: Di Chiara et al.

FOODFOOD

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11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717

ScrScrScrScrBasBasFemale 1 PresentFemale 1 Present

ScrScrFemale 2 PresentFemale 2 PresentScrScr

Source: Fiorino and PhillipsSource: Fiorino and Phillips

SEXSEX

Natural Rewards Elevate Dopamine in the BrainNatural Rewards Elevate Dopamine in the Brain

00100100200200300300400400500500600600700700800800900900

1000100011001100

00 11 22 33 44 5 hr5 hr

Time After AmphetamineTime After Amphetamine

% o

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DADADOPACDOPACHVAHVA

AccumbensAccumbens AMPHETAMINEAMPHETAMINE

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DADADOPACDOPACHVAHVA

AccumbensAccumbensCOCAINECOCAINE

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00 11 22 33 44 5hr5hrTime After MorphineTime After Morphine

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0.50.51.01.02.52.51010

Dose (mg/kg)Dose (mg/kg)

MORPHINEMORPHINE

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00 11 22 3 hr3 hrTime After NicotineTime After Nicotine

% o

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AccumbensAccumbensCaudateCaudate

NICOTINENICOTINE

Drugs Also Bring Reward (via Dopamine)Drugs Also Bring Reward (via Dopamine)

What have we learned through Positron Emission Tomography (PET)?

Prolonged Changes

In the Brain in Lasting

Ways

“Healthy” Brain

“Cocaine Addict” Brain

Addiction leads to….

BRAIN CHANGESBRAIN CHANGES appear appear prominently in PET scans of prominently in PET scans of current and past drug users current and past drug users

Drug users have far less Drug users have far less dopamine activity (dopamine activity (rightright), as is ), as is indicated by the depletion (dark indicated by the depletion (dark red shows disruption), red shows disruption), compared to the controls compared to the controls (left)(left)

Studies show that this Studies show that this difference contributes todifference contributes to dependence and a diseased dependence and a diseased brainbrain

Behavioral ResponseBehavioral ResponseHow Drugs WorkHow Drugs Work

Loss of controlLoss of control

Continued compulsive Continued compulsive

use despite harmful use despite harmful

consequencesconsequences

Multiple relapses Multiple relapses

preceding stable preceding stable

recoveryrecovery

Partial Recovery of Dopamine Transporters After Prolonged Abstinence

Normal Control Meth user(1 month abstinent)

Meth user(36 months abstinent)

Why is Continued Treatment Why is Continued Treatment Critical?Critical?

Longitudinal Research Support for Addiction as a Chronic

Illness

Advancing the notion of Drug Careers and Treatment Careers….

Landmark study: UCLA ISAP researchers Landmark study: UCLA ISAP researchers (Hser, Anglin et al) followed up a cohort of (Hser, Anglin et al) followed up a cohort of 581 male heroin addicts admitted to the 581 male heroin addicts admitted to the California Civil Addict Program (1962-64) for California Civil Addict Program (1962-64) for over 30 years.over 30 years.

The program was the only major publicly-The program was the only major publicly-funded drug treatment program available in funded drug treatment program available in California in the 60s.California in the 60s.

Tx: combo of inpatient and outpatient drug Tx: combo of inpatient and outpatient drug treatment to narcotic-dependent criminal offenders treatment to narcotic-dependent criminal offenders committed under court order.committed under court order.

Status of Sample atStatus of Sample at 3 Interview Points 3 Interview Points

38%

56%

41%

30%

40%39%

14%

19%

23%

0

20

40

60

1974-75 1985-86 1996-97

Inactive (neg UA) Active (pos UA & refusal) Incarcerated

Unknown

Dead

Incarcerated

Daily Narcotic Use

Occasional Use

Abstinence

0

10

20

30

40

50

60

70

80

90

100

56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96

Years 1956 through 1996

% o

f S

amp

le

22%

48%

6%2%

4%

7%

12%

Methadone Maintenance

Natural History of Narcotic Addiction Among SampleNatural History of Narcotic Addiction Among Sample(N=581)(N=581)

Causes of Death Among Sample Causes of Death Among Sample (N = 271)(N = 271)

5

9

10

11

12

28

31

35

56

74

0 10 20 30 40 50 60 70 80

Number of Deaths

Infectious Diseases

Cerebrovascular Disease

Liver Disease (Non-Alcoholic)

Lung/Pulmonary Diseases

Other

Heart Disease

Cancer

Alcohol-Related

Accidents and Violence

Drug-Related

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

a

b

c

d

e

Implications for the Field

Cannot ignore the chronic nature of Cannot ignore the chronic nature of addiction and the associated long-term addiction and the associated long-term effects of heroin addiction in terms of effects of heroin addiction in terms of morbidity, mortality, criminal justice morbidity, mortality, criminal justice involvement, and overall level of functioninginvolvement, and overall level of functioning

Compared to a US Population sample, Compared to a US Population sample, heroin addiction heroin addiction reducesreduces life expectancy life expectancy by an by an average of 18 yearsaverage of 18 years

Other Long-term Outcome Studies

AlcoholAlcohol: Vaillant et al. conducted multiple long-term : Vaillant et al. conducted multiple long-term follow-up studies with alcoholics (post-tx). Findings follow-up studies with alcoholics (post-tx). Findings repeatedly show that alcoholics experience multiple repeatedly show that alcoholics experience multiple relapses and re-treatments with only 30-50% achieving relapses and re-treatments with only 30-50% achieving stable abstinence.stable abstinence.

Cocaine: Cocaine: Hser et al. 10-yr follow-up study of cocaine Hser et al. 10-yr follow-up study of cocaine users post-tx found that fewer than 50% achieve users post-tx found that fewer than 50% achieve extended periods of abstinence AND most re-enter extended periods of abstinence AND most re-enter treatment multiple times.treatment multiple times.

MethamphetamineMethamphetamine: Marinelli-Casey et al. 3-year follow : Marinelli-Casey et al. 3-year follow up study (600 MA users post-tx) found that 50% up study (600 MA users post-tx) found that 50% continue to use MA at a moderate or severe level continue to use MA at a moderate or severe level throughout the 36 month period. throughout the 36 month period.

Re-Addiction Following PrisonRe-Addiction Following Prison

• 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

Treatment Research Institute

Developing a Treatment System that is Responsive

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

Shift is been important for adequately understanding and

managing substance use disorders and the recovery process

Are we thereYet?

Are we thereYet?

Public Expectations of Substance Public Expectations of Substance Abuse InterventionsAbuse Interventions

Safe, complete detoxificationSafe, complete detoxification ““The 28 day cure”The 28 day cure” Put them in a box, something happens and they come out Put them in a box, something happens and they come out

fixedfixed The washing machine model: Put a “dirty addict” in, run the The washing machine model: Put a “dirty addict” in, run the

washer, and take out a “clean citizen”washer, and take out a “clean citizen”

Results in:Results in: Reduced use of medical servicesReduced use of medical services Eliminate crimeEliminate crime Return to employmentReturn to employment Eliminate family disruptionEliminate family disruption No return to drug useNo return to drug use

Although, the treatment community is feeling the Shift

Let’s Review the process….

A Menu of Treatment Services

Continuing Care Programs

Intensive Outpatient/Psychosocial Behavioral Treatment

Sober Living Residence

Long-term Residential Treatment

Short-term Residential Treatment

Detox/Inpatient

Detox/Outpatient

Medication Assisted Treatment

Treatment…

Acute System Response

Admission

Client Outcomes

Discharge…One Type of Tx

From Menu of Services

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

1. Similar Genetic Heritability

4. Both Chronic:

Continued Use&

Relapsing

3. Shared Influence:

Individual &

Environmental

Factors

2. Begins by voluntary choice: then exacerbated by neurobiological changes that weaken volitional control

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

identified many similarities

Asthma (adult only) .35 - .70

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

Hypertension .25 - .50 (males)

How Similar in Heritability?Twin Study Estimates

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

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

Eye Color 1.00

Sneak Peak at Similar Relapse Rates

Drug Addiction

Type I Diabetes

0

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Hypertension Asthma

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McLellan et al., JAMA, 2000

Detox Residential Outpatient NTP Continuing Care/Support Services

Chronic Care Model Response

Treatment Recovery

We are well trained in the realm of the treatment stages…

Stage of TreatmentStage 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 Effective Strategies During Engagement in RehabilitationEngagement in Rehabilitation

Counseling to Promote Transfer using Counseling to Promote Transfer using NIATx StrategiesNIATx Strategies

Motivational InterviewingMotivational Interviewing Voucher-Based TechniquesVoucher-Based Techniques MedicationsMedications

Stage of TreatmentStage 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

Detox Residential Outpatient NTP Continuing Care/Support Services

Chronic Care Model Response

Treatment Recovery

Emphasis on: Continuity of Care

What is Continuity of Care?

Continuing Care/Support Services

DetoxResidential Treatment

Outpatient/Psychosocial Behavioral Treatment

Sober Living Residence

Arrow = Referral/Transf

er

NO Clinical Discharge

Extending treatment beyond acute care

Where is the State of CA in this shift?

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

87.5747765.5

75.888.4

2612.5

2334.524.211.6

0

25

50

75

100>1 TreatmentService

1 TreatmentService

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

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)…

0

500

1000

1500

2000

2500

NTP Detox Detox Residential IntensiveOutpatient

Day Care Rehab

Number of Transfers within the past 30-days following Tx discharge

Total Admissions

Any Transfers

Sonoma

36% 10%6%25%

31%

Tx Modality

*

No.

of

Adm

issi

ons

0

20000

40000

60000

80000

100000

120000

NTP Detox Detox Residential Outpatient Day Care Rehab

Number of Transfers within the past 30-days following Tx discharge

Total Admissions

Any Transfers

Tx Modality

No.

of

Adm

issi

onsStateState

29%11%

13%21%30%

72%

3%

12%

13% 15%

1%

3%

7%

74%

Nothing

Detox

Residential

Outpatient

M aintenance

Destination Treatment Type

FresnoFresnoDetox Total: 962

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

StateStateDetox Total: 26670

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

Maintenance= 126

Transfers from Detox

1%8%

10%

80%

1%

Nothing

Detox

Residential

Outpatient

Day Care Rehab

7%

75%

6%

11% 1%

Destination Treatment Type

*Transfers to NTP Detox = 2, Maintenance= 0 *Transfers to NTP Detox = 46, Maintenance= 98

Residential Total: 41,636Residential Total: 2154SonomaSonoma StateState

Transfers from Residential

Sonoma

0

20

40

60

80

100

120

Rx (Oxycodone)

Heroin Cocaine Meth Alcohol Cannabis Benzo (tranquilizers)

Other*

Retention Days by Primary Drug

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

Drug Category

Mea

n N

o. o

f D

ays

in T

x

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

Sonoma

0

20

40

60

80

100

120

NTP Detox Detox Residential IOP Rehabilitative Maint.

Retention Days by Treatment Type

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

Mea

n N

o. o

f D

ays

in T

x

Type of Tx Modality

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

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)

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

Given this issue, work with your group & brainstorm about…

Some promising practices for increasing client movement

between levels of care

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

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?

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)?

Recovery Services

Treatment/Intervention

Recovery

Telephone Continuing Care

Recovery Coaches/ Centers

Recovery Services

Outpt Tx

Detox

Intensive Otpt Tx

Long-term Res Care

Short-term Res Care

Methadone Maintenance

NTPDetox

What about looking at the % of clients who get…

Recovery Services

Continuing Care

OR

Support Services

What is Continuing Care?

In a chronic care paradigm, it is considered an important level of care for promoting successful

transitions from clinical services to recovery

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 Developed by Researchers from Chestnut Group

(Dennis, Scott et al.) Involves contacting clients every quarter for 2 years

to 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

Convenient for client

Reduces stigma of weekly trips to the treatment program

Individualized attention

Can be automated

Lower costs of ongoing care

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)

What about Recovery Services?

What is your county currently doing to promote or provide recovery services…

Are we making progress?

Removing Confusion:Removing Confusion:Outcomes vs PerformanceOutcomes vs Performance

Outcomes:Outcomes: OUTCOME MEASURES ARE USED AT OUTCOME MEASURES ARE USED AT THE PATIENT LEVEL AND MEASURE CHANGES IN THE PATIENT LEVEL AND MEASURE CHANGES IN PATIENT BEHAVIOR OR FUNCTIONING OVER TIMEPATIENT BEHAVIOR OR FUNCTIONING OVER TIME

PerformancePerformance: : PERFORMANCE MEASURES ARE PERFORMANCE MEASURES ARE USED AT THE TREATMENT PROGRAM LEVEL TO USED AT THE TREATMENT PROGRAM LEVEL TO EXAMINE THE FUNCTIONING OF THE TREATMENT EXAMINE THE FUNCTIONING OF THE TREATMENT PROGRAMPROGRAM

Treatment Completion is an Treatment Completion is an OUTCOMEOUTCOME

Definition: Per CALOMS discharge, do Definition: Per CALOMS discharge, do people complete treatment people complete treatment

Treatment Initiation/EngagementTreatment Initiation/Engagement

Definitions: Definitions: InitiationInitiation: Do people who enter treatment receive : Do people who enter treatment receive

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

receive at least 4 sessions in the first 30 days/receive at least 4 sessions in the first 30 days/

Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes Readily Accessible Data for Measures: ????Readily Accessible Data for Measures: ????

Treatment RetentionTreatment Retention

Definition: Definition: Retention: Number of days between admission Retention: Number of days between admission

and discharge.and discharge.

Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes

(maybe)(maybe) Readily Accessible Data for Measures: YesReadily Accessible Data for Measures: Yes

Continuity of CareContinuity of Care

Definition: Definition: Do individuals who enter treatment Do individuals who enter treatment

proceed through multiple service sets proceed through multiple service sets (levels of care)(levels of care)

Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes Readily Accessible Data for Measures: Readily Accessible Data for Measures:

YesYes

System Change Requirements

YES -- $$$

BUT ALSO

Strong Leadership

Motivated staff at all levels

Implementation Team

Infrastructure development (training)

Communication

Collaboration

Patience & Perseverance

Building Interactive Service Building Interactive Service SystemsSystems

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

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

Strategies for improving AOD Strategies for improving AOD program performanceprogram performance

Reduce staff turnoverReduce staff turnover Increase staff knowledge of other forms of Increase staff knowledge of other forms of

care to promote a “system of care” rather care to promote a “system of care” rather than isolated programsthan isolated programs

Increase staff knowledge and use of Increase staff knowledge and use of evidence-based practicesevidence-based practices

Employ process improvement (NIATx)Employ process improvement (NIATx)

Thank YouThank You

rachelmg@ucla.eduwww.uclaisap.org