SUD Module C:SUD Module C:

Care ManagementCare Management

or…….

How to not cure anyone& still accomplish something

& go home happy

or…….

How to not cure anyone& still accomplish something

& go home happy

• Current models of addiction treatment do not result in complete and permanent remission of symptoms 100% of the time.

• Current models of addiction treatment do not result in complete and permanent remission of symptoms 100% of the time.

What is the problem?What is the problem?

If we already know this, then what is the problem?If we already know this, then what is the problem?

• Initial models of addiction treatment emphasized the need for total and permanent abstinence (i.e., permanent remission, cure)

• Anything less was a failure (dichotomous outcome criteria)

• Initial models of addiction treatment emphasized the need for total and permanent abstinence (i.e., permanent remission, cure)

• Anything less was a failure (dichotomous outcome criteria)

What is the problem?What is the problem?

• Addiction treatment developed separated from medical and psychiatric treatment

• Psychiatry in particular was excluded

• Any treatment outside of specialized units was considered inadequate or worse (enabling)

• Addiction treatment developed separated from medical and psychiatric treatment

• Psychiatry in particular was excluded

• Any treatment outside of specialized units was considered inadequate or worse (enabling)

Barriers to providing care for chronic addictionBarriers to providing care for chronic addiction

• Programmatic dogmatism and idealism

• Lack of understanding among policymakers, society, and MCOs

• Political and regulatory climate

• Programmatic dogmatism and idealism

• Lack of understanding among policymakers, society, and MCOs

• Political and regulatory climate

Barriers to providing care for chronic addictionBarriers to providing care for chronic addiction

• Lack of training in addiction treatment

• Lack of models for care management

• Goal setting and treatment planning

• Lack of training in addiction treatment

• Lack of models for care management

• Goal setting and treatment planning

• Clients have severe problems

• Programs don’t work, won’t accept clients, or clients won’t go

• If clinicians act, they are accused of enabling, or doing too much w/o results

• If clinicians do not act, they are accused of neglect, doing too little

• Clients have severe problems

• Programs don’t work, won’t accept clients, or clients won’t go

• If clinicians act, they are accused of enabling, or doing too much w/o results

• If clinicians do not act, they are accused of neglect, doing too little

So we needed a new model...So we needed a new model...

A model that:A model that:

• Accepts chronicity

• Recognizes limits of treatment methods

• Is palliative (non-curative) in nature

• Accepts chronicity

• Recognizes limits of treatment methods

• Is palliative (non-curative) in nature

A model that:A model that:

• Stresses long term management (years to decades)

• Treats addiction like other chronic diseases such as bipolar disorder or diabetes

• Stresses long term management (years to decades)

• Treats addiction like other chronic diseases such as bipolar disorder or diabetes

That new model is...That new model is...

Care Management For Chronic AddictionCare Management For Chronic Addiction

Application of CMCAApplication of CMCA

Go to Module C

N

Refer to specialty care with attention to engagement barriers

[J]

Go to Module R

Care Management Rehabilitation

Y

Does patient agree to

referral or is it mandated?

[I]

From Module A

Can treatment plan be implemented in

primary care?[E]

N

From Module R

Y

Is rehabilitation acceptable to the

patient?[E] N Go to Module C

Care Management IndicationsCare Management Indications

• Moderate to extreme severity

• Unwilling to commit to change

• Unable to participate in rehabilitation

• Poor response to multiple attempts at rehabilitation

• Willing to engage in therapeutic relationship

• Moderate to extreme severity

• Unwilling to commit to change

• Unable to participate in rehabilitation

• Poor response to multiple attempts at rehabilitation

• Willing to engage in therapeutic relationship

Continuum of Care for AddictionsContinuum of Care for Addictions

Use &Problems

Modality

None

1º Prevention2º Prevention

Moderate

Severe

Rehabilitation

Extreme

Care Mgmt.

CMCA GoalsCMCA Goals

• Engagement

• Coordination of care

• Reduce suffering

• Treat complications

• Improve motivation to change

• Engagement

• Coordination of care

• Reduce suffering

• Treat complications

• Improve motivation to change

CMCA GoalsCMCA Goals

• Induce remission when possible

• Prevent/limit relapse

• Slow rate of deterioration

• Reduce use of expensive, ineffective services

• Induce remission when possible

• Prevent/limit relapse

• Slow rate of deterioration

• Reduce use of expensive, ineffective services

• Episodic care only• Crisis intervention• Case management• Continue attempts to engage• Involuntary treatment when

indicated• Asset management when

indicated

Is care management

acceptable to the patient?

[B]

Patient in need of care management

[A]

N

Provide episodic attention to

substance useReassess

periodically[I]

Implement/continue care management plan in specialty

care or primary care[See side bar]

[C]

Y

Is care management

acceptable to the patient?

[B]

CMCA PrinciplesCMCA Principles

• Supportive, engaging approach

• Document substance use systematically at each visit

• Supportive, engaging approach

• Document substance use systematically at each visit

Document substance use:• Drinking or using days last 30• Typical # drinks/drinking day• Max # drinks/24 hrs last 30• Bingeing

Implement/continue care management plan in specialty care or primary care

[See side bar][C]

• Monitor substance use

• Monitor biological indicators

• Encourage reduction or abstinence

• Provide motivational support

• Educate about substance use and associated problems

• Recommend self help groups

• Monitor substance use

• Monitor biological indicators

• Encourage reduction or abstinence

• Provide motivational support

• Educate about substance use and associated problems

• Recommend self help groups

• Address social functioning needs

• Address financial and housing needs

• Address nicotine use as appropriate

• Provide opioid agonist therapy if appropriate

• Provide crisis intervention as needed

• Provide care coordination

• Address social functioning needs

• Address financial and housing needs

• Address nicotine use as appropriate

• Provide opioid agonist therapy if appropriate

• Provide crisis intervention as needed

• Provide care coordination

Implement/continue care management plan in specialty care or primary care

[See side bar][C]

Implement/continue care management plan in

specialty care or primary care

[See side bar][C]

Is care management

acceptable to the patient?

[B]

Y

Consider use of addiction focused pharmacotherapy

(Use Module P)

Has stable remission been

achieved?[E]

Reassess progress periodically

Follow up in primary careMonitor substance use

Monitor biological indicatorsEncourage continued reduction

or abstinenceProvide motivational support

[F]

Y

Educate about substance use, associated problems and

prevention of relapse[G]

Has stable remission been

achieved?[E]

CMCA ReassessmentCMCA Reassessment

• Reassess goals periodically

• Long-term, ideal goal remains full remission and improvement in all co-existing conditions

• Refer to rehab when goals change

• Reassess goals periodically

• Long-term, ideal goal remains full remission and improvement in all co-existing conditions

• Refer to rehab when goals change

Is referral to specialty care rehabilitation indicated and acceptable

to the patient?[See side bar]

[H]

Return to Box 3

Go to Module R

Y

N

N

Has stable remission been

achieved?[E]

Return to Box 3

Reassess progress periodically

Implement/continue care management plan in

specialty care or primary care

[See side bar][C]

Application of Care Management:

Application of Care Management:

Medically Ill Heavy DrinkersMedically Ill Heavy Drinkers

Application of Care Management:

Medically Ill Heavy Drinkers

Application of Care Management:

Medically Ill Heavy Drinkers

0

10

20

30

40

50

60

-4 to 0 yr 0-2 yr 2-4 yr

Sick days per person per year

Controls

Intervention

Kristenson et al., 1983

0

500

1000

1500

2000

2500

Total MH GI Acc Alc

Hospital Days After 5 Years

Controls

Intervention

Kristenson et al., 1983

Application of Care Management:Medically Ill Heavy Drinkers

Application of Care Management:Medically Ill Heavy Drinkers

0

40

80

120

160

% Abstinent Days Lst Drnk

IOTCTL

Willenbring and Olson, 1999

IOT 2 Year ResultsIOT 2 Year Results

0

10

20

30

40

50

IOT-Clin CTL-Clin

BL

2 YR

Willenbring and Olson, 1999

IOT ResultsIOT Results

Survival

60

70

80

90

100

0 6 12 18 24Months

Pe

rce

nta

ge

liv

ing

IOT 1

CTL 1

Willenbring, et al., 1994

82

IOT for Medically Ill AlcoholicsIOT for Medically Ill Alcoholics

68

Willenbring and Olson, 1999

IOT for Medically Ill AlcoholicsIOT for Medically Ill Alcoholics

Survival

60

70

80

90

100

0 6 12 18 24Months

Pe

rce

nta

ge

liv

ing

IOT 2

CTL 2

81

70

Application of Care Management:

Application of Care Management:

Coexisting Mental and Addictive Disorders (COMAD)

Coexisting Mental and Addictive Disorders (COMAD)

1

2

3

4

5

Baseline 12 mo 24 mo 36 mo

AUSDUS

Abstinence

SevereDependence

Abuse

Drake et al., 1998

Improvement in COMADImprovement in COMAD

Improvement in COMADImprovement in COMAD

Drake et al., 1998

Using days past 180

0

20

40

60

80

Baseline 24 mo

Alc UseDrug Use

Improvement in COMADImprovement in COMAD

Bartels et al., 1995

0

20

40

60

80

100

Alc d/o Drug d/o

Baseline

7 yrs

Summary

• Care management is a pragmatic approach to treating substance use disorders as a chronic illness.

• Care management can be applied by any professional in any setting

• Evidence to date shows a better long-term prognosis than is commonly appreciated.