Referral to Treatment: The Next Steps

1
Referral to TreatmentThe Next Steps

• Jennifer G. Smith, MD
• Division of General Medicine Primary Care
• John H. Stroger, Jr. Hospital
• Cook County Bureau of Health Services
• jennifer_smith_at_rush.edu

2
Overview

• Addiction is a common, treatable disease but most
  people who have it go untreated
• Treatment for addiction can begin with screening,
  assessment, referral in general healthcare
  settings
• Building a successful continuum of care for
  addiction diseases means change for general
  healthcare and addiction treatment providers
• Taking steps to implement successful referral
  between general healthcare and addiction
  treatment organizations

3
Overview

• Addiction is a common, treatable disease but most
  people who have it go untreated
• Treatment for addiction can begin with screening,
  assessment, referral in general healthcare
  settings
• Building a successful continuum of care for
  addiction diseases means change for general
  healthcare and addiction treatment providers
• Taking steps to implement successful referral
  between general healthcare and addiction
  treatment organizations

4
DSM IV Substance Abuse Disorder(Use with
Consequences)

• Continued substance use, in spite of 1 or more
  recurring negative consequences over one year
• Interference with role obligations
• Risk of physical injury
• Legal problems
• Interpersonal problems

5
DSM IV Substance Dependence Disorder (Alcoholism,
Addiction)

• Continued substance use in spite of 3 or more
  recurring negative consequences over one year
• Tolerance - Increased amounts needed to achieve
  effect
• Withdrawal - Signs of, use to avoid or relieve
• Loss of control over use, compulsive use, craving
  -
• More or longer use than intended
• Unsuccessful attempts to cut down or control use
• Much time spent getting, using, recovering
• Activities given up or reduced to facilitate use
• Use despite knowledge of related problems

6
Addiction is a Brain Disease

• Using drugs repeatedly over time changes brain
  structure and function in fundamental and
  long-lasting ways
• Long-lasting brain changes in the brain's natural
  motivational control circuits are responsible for
  the compulsion to use drugs that is the essence
  of addiction

Leshner AI, JAMA, 282 (1999) 13141316
7
Addiction Treatment is Effective

• Goal of addiction treatment is to return to
  productive functioning
• Treatment reduces substance use by 40-60
• Treatment reduces crime by 40-60
• Treatment increases employment by 40
• Rates of adherence similar to treatment for other
  chronic diseases such as diabetes, asthma,
  hypertension
• Every 1 spent for treatment saves up to 12 in
  reduced health care and crime-related costs

McLellan AT, Lewis DC, O'Brien CP, Kleber HD,
JAMA, 284 (2000) 16891695 NIDA, Principles of
Drug Addiction Treatment A Research-Based Guide,
NIH Bethesda, MD, July 2000
8
90 of People with Active Substance Use Disorders
are Untreated
23.2 million (9.5) of US pop. gt 12 years old
have a current substance use disorder
69 paid with own or family savings 28 public
assistance 45 medicare/medicaid 32 private
insurance
National Survey on Drug Use and Health, SAMHSA,
2005
9
Overview

• Addiction is a common, treatable disease but most
  people who have it go untreated
• Treatment for addiction can begin with screening,
  assessment, referral in general healthcare
  settings
• Building a successful continuum of care for
  addiction diseases means change for general
  healthcare and addiction treatment providers
• Taking steps to implement successful referral
  between general healthcare and addiction
  treatment organizations

10
People with Substance Use Disorders Seek Care in
General Healthcare Settings
Distribution of Persons w/ SUD Treated in
Ambulatory Settings
Narrow et al. Arch Gen Psychiatry. 19935095-107
11
Prevalence of Substance Dependence Disorder among
Primary Care Patients
Patients Men women 18-65 y Men
women 18-65 y Men women mean age 39-47 y
Patients 21,282 482 1,333
Alcohol Dependence 5 2 5-7
women 11-14 men
Illicit Drug Use 5 - -
Study Fleming (1998) Piccinelli (1997) Volk (
1997)
12
Prevalence of Substance Dependence Disorder among
General Hospital Admissions
Facility Patient type 90 Hospitals 18 y, All
Services Univ Hospital 18-49 y, Med/Surg Level
1 Trauma 18 y, Trauma Teaching Hospital 18-85
y, Medicine
Patients 2,040 374 1,118 2,988
Alcohol Dependence 6.3 10.5 24.1 -
Illicit Drug Dependence 10.9 (Drug
Use) 2.5 17.7 4 (Drug Use)
Study Smothers (2003) Brown (1998) Soderstrom (
1997) Canning (1999)
13
At-Risk Dependent Use by Inpatient
ServiceStroger Hospital, 2004-2005
14
Prevalence of Alcohol Dependence by
AgeHospitalized Patients vs. Community
Prevalence
15
Drug Dependence by AgeHospitalized Patients vs.
Community
Prevalence
16
Readiness Ruler How ready are you to make a
change in your use?
Alcohol, Cocaine
Marijuana
Heroin
Not ready
Unsure
Ready
Average response of patients dependent on that
substance
17
Identification Intervention for Substance Use
Disorders among General Healthcare Patients
Patients Identified by MD Team 7-66 20 5
7
Patients with Intervention by MD
Team 35 8 21
Setting, Patients University Hospital Alcohol
screen General Hospital Alcohol Use
Disorder 90 General Hospitals Alcohol Use
Disorder
Study Moore (1989) Hearne (2002) Smothers (20
04)
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Overview

• Addiction is a common, treatable disease but most
  people who have it go untreated
• Treatment for addiction can begin with screening,
  assessment, referral in general healthcare
  settings
• Building a successful continuum of care for
  addiction diseases means change for general
  healthcare and addiction treatment providers
• Taking steps to implement successful referral
  between general healthcare and addiction
  treatment organizations

19
Illinois SBIRT Interventions
General Health Information
Low Risk Use
Screening
At-Risk Use
Brief Assessment
Brief Intervention
Use with Consequences
Assess Referral
Dependent Use
Chemical Dependency Treatment
CCBHS Hospitals Health Centers
State Licensed Treatment Providers
20
Illinois SBIRT Interventions
General Health Information
Low Risk Use
Screening
At-Risk Use
Brief Assessment
Brief Intervention
Use with Consequences
Assess Referral
Dependent Use
Chemical Dependency Treatment
CCBHS Hospitals Health Centers
State Licensed Treatment Providers
21
Outcome of Screening 28 months, 3/30/04 7/27/06
22
Patient Placement Criteria for Addiction
Treatment(American Society of Addiction Medicine)

• Multidimensional Assessment
• Acute intoxication, Withdrawal potential
• Biomedical conditions and complications
• Emotional/Behavioral/Cognitive conditions and
  complications
• Readiness to change
• Relapse/Continued use/Continued problem potential
• Recovery environment

23
ASAM PPCTreatment Levels of Service

• Outpatient Treatment
• Intensive Outpatient and Partial Hospitalization
• Residential/Inpatient Treatment
• Medically-Managed Intensive
• Inpatient Treatment

24
Illinois SBIRT Interventions
General Health Information
Low Risk Use
Screening
At-Risk Use
Brief Assessment
Brief Intervention
Use with Consequences
REFERRAL COORDINATOR
Assess Referral
Dependent Use
Chemical Dependency Treatment
CCBHS Hospitals Health Centers
State Licensed Treatment Providers
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Patients Referred to Treatment 28 months,
3/30/04 - 7/27/06
26
Entry into State Funded Treatmentwithin 60 Days
from Hospital Discharge
Sample of dependent patients discharged from
Stroger Hospital matched with State-funded
treatment data base (2004-2005)
27
Illinois SBIRT Interventions
General Health Information
Low Risk Use
Screening
At-Risk Use
Brief Assessment
Brief Intervention
Use with Consequences
REFERRAL COORDINATOR
Brief Treatment
Assess Referral
Dependent Use
Chemical Dependency Treatment
CCBHS Hospitals Health Centers
State Licensed Treatment Providers
28
Time to Treatment Intake Appointment
Modality Brief treatment Intensive
outpt Residential Outpatient Methadone
Mean 95 CI
Tx
Tx
28
42 Days
12
20
8
4
16
0
Tx Estimated time to beginning of treatment
Intake representative of beginning of treatment
29
Entry into State Funded Treatmentwithin 60 Days
from Hospital Discharge
Sample of dependent patients discharged from
Stroger Hospital matched with State-funded
treatment data base
30
Illinois SBIRT Interventions
General Health Information
Low Risk Use
Screening
At-Risk Use
Brief Assessment
Brief Intervention
Use with Consequences
REFERRAL COORDINATOR
Brief Treatment
Assess Referral
Dependent Use
COMMUNITY CASE COORDINATORS
Chemical Dependency Treatment
CCBHS Hospitals Health Centers
State Licensed Treatment Providers
31
Outcome of Referrals, Follow-Up from Community
Care Coordinators12 months (4/01/05 3/31/06)
32
Change in Treatment Entry with NO WAIT
Same/Next Day Treatment Referred Patients
First Year Usual Wait Referred Patients
Sample of dependent patients discharged from
Stroger Hospital matched with State-funded
treatment data base, 2004-2005
33
Overview

• Addiction is a common, treatable disease but most
  people who have it go untreated
• Treatment for addiction can begin with screening,
  assessment, referral in general healthcare
  settings
• Building a successful continuum of care for
  addiction diseases means change for general
  healthcare and addiction treatment providers
• Taking steps to implement successful referral
  between general healthcare and addiction
  treatment organizations

34
Challenges for Healthcare Providers, Chemical
Dependency (CD) Treatment Providers, Regulators
Funders

• Implement universal screening in general
  healthcare settings and provide further
  assessment for substance use disorder as part of
  general healthcare!
• Establish referral relationships between CD
  treatment and general healthcare settings
• Identify common community resources

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(Challenges continued)

• Establish procedures to coordinate care between
  healthcare CD treatment organizations
• Address confidentiality and clinical information
  sharing
• Identify inter-institutional roles and
  responsibilities
• Coordinate to continue care initiated in general
  healthcare setting (example Methadone to control
  withdrawal in hospital ? methadone maintenance)
• Provide CD treatment to patients with other
  significant medical conditions

36
(Challenges continued)

• Adapt usual CD treatment intake procedures to
  accept patients referred from general healthcare
  settings
• Accept referral from intermediary rather than
  patient
• Give date for initiation of treatment
• Focus on transferring therapeutic alliance at
  first visit to CD treatment provider
• Downsize required regulatory paperwork for first
  visit
• First visit a counseling session not intake
  session

37
(Challenges continued)

• Make CD treatment available with no wait
• Provide support to patients waiting for CD
  treatment
• Incorporate motivational counseling strategies to
  foster retention at all steps

38
Taking Steps

• Engage decision-makers
• Assess current practice, need, potential
  benefits
• Assess readiness identify support
• Assess strategize to minimize barriers
• Engage community resources, partners
• What resources are available?
• Who/what will maintain resource connections
  partnerships?
• Engage workplace teams
• Who will provide assessment?
• Who will refer patients to specific treatment?
• How will assessment and referral fit into usual
  care processes?
• Provide ongoing feedback (data) for incentive,
  improvement, and sustainability
• What information should be monitored?
• Who will collect and feedback information?
• Who needs information feedback?

Smith J, McQueen K, Brown R, Girard C, AMERSA
National Conference, 2005