Research Science on Substance Use Disorders:Integrated Collaborative Care,
Improved Treatment, Better Outcomes, Increased
Client Experience of Care
Mark Stanford, Ph.D. Division Director, Addiction Medicine & Therapy Services
SCVMC Dept of Alcohol & Drug Services
In just the last 15 years,
advances in science
have revolutionized our
fundamental views of
substance use disorders
and allowed for the
development of
improved treatments!
control Methamphetamine use
control methamphetamine addicted brain
Research shows that . . .
Prolonged Drug Use Changes
the Brain
in Fundamental and Lasting
Ways
And there is scientific evidence that these changes can be
both structural and functional.
Diagnosing Addiction
• Diagnosing Addiction: The 4 “C’s”
– C = Control
– C = Compulsion
– C = Continued use despite consequences
– C = Craving
Koob, G. Scripps. 2014
Risk Factors for SUD
• Biological: Genetics account for 50-75%
• Psychological: Mental illness, temperament
• Ecological: Social networks, employment
status, access
Lembke A, et al. Stanford. 2014. Ling W, et al. UCLA 2012.
Biology/genes
Environment
Biology/
Environment
Interactions
IFH + high tolerance = 60%
IFH + low tolerance = 15%Schuckit M. UCSD. 2002.
We know there’s a genetic contribution to addiction…
overlapping with environmental influences that help
make addiction a complex disease.
Control Addicted
Cocaine
Alcohol
DA
DA
DA DADA
DA
Reward Circuits
DADA DA
DA
DA
Reward Circuits
DA
DA
DA
DA DA
DA
Drug Abuser
Non-Drug Abuser
Heroin
Meth
Dopamine D2 Receptors are Lower in Addiction
DA
The typical drug addict/alcoholic?
Rethinking the “drug abuser”
Persons with SUDs are not a homogenous group of people who use/drink in excess
• More accurately called Substance Use Disorders (SUD),
it describes use along a continuum of severity from mild
misuse, to problem use, to chronic relapsing conditions.
• The most severe form of SUD is a chronic and relapsing
condition much like diabetes, hypertension and asthma.
Treatment success and relapse rates for SUD mirror those
other chronic disorders
• The most severe form of SUD is a primary disease and
not the result of other emotional or psychiatric problems.
How is “addiction” defined after 30 years
of robust scientific study?
American Society of Addiction Medicine,
2011.
The National Institute of Drug Abuse (NIDA), National Institute of
Alcohol Abuse and Addiction (NIAAA), and the Institute of Medicine
(IOM) have each articulated explicit evidence-based standards for
effective SUD treatment services.
The cornerstones of these guidelines are:
Addiction is a chronic disease
Addiction is treatable
Addiction treatment must be on-going and continuous
No single treatment is effective for all individuals
Co-occurring medical and psychiatric conditions must
be addressed
California Society of Addiction Medicine. 2011
The National Quality Forum
The National Quality Forum (NQF), dedicated to
improving the quality of health care in the United States,
has identified and endorsed 8 evidence-based standards of
care for the treatment of substance use disorders:
1. Screening & case finding 5. Withdrawal management
2. Diagnosis & assessment 6. Psychosocial interventions
3. Brief intervention 7. Pharmacotherapy
(methadone, buprenorphine,
naltrexone, acamprosate, etc.)
4. Promoting engagement in 8. Continuing care management
treatment
What Are Evidence-Based Practices?
Institute of Medicine (2001):
Evidence-based practices
“. . . Evidence is comprised of research findings
derived from the systematic collection of data
through observation and experiment and the
formulation of questions and testing of
hypotheses" (www.ebbp.org).
Criteria for EBP Designation for SUD Practices
• The results of the research have been published in a peer-
reviewed journal or documented in a comprehensive evaluation
report
• Sufficient documentation exists in the form of manuals, training
materials, etc. to facilitate dissemination of the approach
• Meets a minimum statistical parameter that determines efficacy
over placebo, treatment as usual, or no treatment at all
• The approach has demonstrated positive outcomes (p < 0.05) in
>1 studies
National Registry of Evidence Based Programs and Practices (NREPP). 2014.
What are the most important evidence-based practices?
Behavioral
• Motivational Interviewing/Brief Intervention
• Contingency Management
• Cognitive-Behavioral Coping Skills Training
• Couples and Family Counseling
• 12 Step Facilitation Therapy (12 step meetings can be important
peer recovery support but themselves are not tx)
• Screening, Brief Intervention and Referral to Treatment (SBIRT )
Addiction Medicines (coupled with behavioral treatment)
• Methadone
• Buprenorphine (Subutex and Suboxone)
• Naltrexone (oral and extended release, i.e. Vivitrol)
• Naloxone (for overdose prevention)
• Campral (acamprosate)
• Antabuse (disulfiram)
40-60%
Compulsive
illicit drug useCriminal
activity
Unemployment
From decades of
outcomes data, we know
that
SUD treatment works!
40-60% 60%
NIDA. 2006.
How do treatment outcomes compare?
McLellan et al., JAMA, 2000
Chronic Illness Relapse Rates(after diagnosis, treatment and stabilization)
SCVMC
Dept of Alcohol & Drug Services
MISSION STATEMENT
To develop and operate a seamless Continuum of Care for
the prevention and treatment of substance abuse problems
in the community that is appropriate for the diverse
populations of the County and that is accountable for its
services
Director Research
& Evaluation
Children, Family &
Community Services
Fiscal &
AdministrationPrevention and
Treatment Services
Addiction Medicine Psychosocial Treatment
Quality Improvement
& Data Support
--Gateway
--Outpatient
--Residential
--Clinical Standards
--Case Management
--Justice Services
--Medication-assisted treatment
--Medical Services
--Psychiatric Services
--HIV Intervention Program
--Integrated Services Initiatives
--Medical Homes
--Women’s/Perinatal
--THU
--CoCentrix EHR
--Data Analysis
--CalOMS
--Care Coordination/UM
Medical Director
-- Budget
-- Contracts
-- Personnel
-- Administrative Support
-- Prevention Services
-- School-linked Services
-- Learning Institute
-- Adolescent Treatment
Medication-assisted
Treatment
Integrated Care
Partnerships
ADULT SYSTEM OF CARE: DADS management staff. Reviews the
operational aspects of the adult managed system of care.
INNOVATIVE PARTNERSHIP (IP): A collaborative between DADS
and the community-based agencies. Monitors the continuous quality
improvement of the managed system of care.
CLINICAL SUPERVISORS: Consists of the clinical supervisor staff
from both DADS and the community-based agencies. The focus is on reviewing
and making recommendations to EG on the clinical performance aspects of the
system of care.
COMMITTEES: There are various on-going and ad hoc committees that are
task-specific. Review specific issues related to the system of care and develop
recommendations to EG. Committees include Compliance, Forms, Contracts,
Quality Improvement, Performance Measures and others.
DADS Leadership and Management Structure
DADS has also developed and implemented several innovative
promising practices including:
1. Client-Directed Outcome-Informed therapy (CDOI)
2. Continuous Recovery Monitoring (CRM)
3. Expansion of medication-assisted recovery
4. Consult service for mental health and primary care providers in
Addiction Medicine
5. Screening, Brief Intervention and Referral to Treatment
(SBIRT) for primary and specialty care
6. Training the network of providers in Trauma Informed Care and
NiaTX.
DADS Innovative and Promising Practices
DADS manages a coordinated System of Care for the
delivery of services and ensures that the client is in the
right level of care at the right time.
Determining the Level of Care and client placement is, in part,
obtained by using the American Society of Addiction Medicine -
Patient Placement Criteria (ASAM PPC 2-R)
Adult System of Care
Managed Care without the Negatives
• One System, single entry point, levels of care
• Standardized procedures, processes, forms
• All speaking the same language: assessment
dimensions, severity ratings, level of care
• Integrated service delivery
• “Managing” care: paying attention, monitoring and
evaluating provider performance and client outcomes
• Continuous Quality Improvement
SANTA CLARA VALLEY HEALTH & HOSPITAL SYSTEM
Department of Alcohol & Drug Services (DADS)
A Managed Coordinated System of Care
INDIVIDUAL
Detoxification Residential Treatment
Outpatient Treatment:
Addiction Medicine
Psychosocial Outpatient,
Perinatal Services
Transitional Housing
Ancillary Services:
• Psych Services
• Transitional HousingGateway Services:
• Screening & Referral
• Prevention Referral
GATEWAY
1-800-488-9919
Adult System of Care Themes
• Using limited resources wisely
• Matching intensity of service to severity of illness
(one size does not fit all)
• Just the right dose, at the right time, in the right
setting, for each individual client
• Client-driven, not program-driven, treatment
• Individualized, focused treatment
• Partnering with other Systems: Criminal Justice,
Department of Corrections, Social Services, Child
Welfare, Mental Health, Primary Care and VMC
Levels of Care
– Social Model Detox
– Residential
– Psychosocial Outpatient
– Addiction Medicine & Therapy Program including Integrated Medical Services
– Perinatal Outpatient & Women’s Treatment
– Transitional Housing Units
System of Care
Treatment Services
System of Care
Ancillary Services
• Psychiatric Evaluation & Medication
Consultations
• Transitional Housing
Confidentiality and
Privacy Rights
42 CFR Compliant
Competency Training and
Continuing Education
DADS places an emphasis on training and
continuing education
1. The Learning Partnership
2. Required Trainings: Safety, Confidentiality, Compliance,
Dual Relationships, Law and Ethics, Infectious/Contagious
Diseases, Best Practices, Trauma Informed Treatment,
Medication-Assisted Recovery
Also, visit the DADS web page at:
www.sccdads.org
For more information about integrating Primary Care and
Behavioral Health, visit:
SAMHSA – HRSA: Center for Integrated Health Solutions
http://www.integration.samhsa.gov/