Coming Out of the Shadows Addressing Substance Use in Primary Care November 12, 2014
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PCPCH Model of Care Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures Access to Care “Health care team, be there when we need you” • Accountability “Take responsibility for making sure we receive the best • possible health care” Comprehensive Whole Person Care “Take responsibility for making sure we • receive the best possible health care” Continuity “Be our partner over time in caring for us” • Coordination and Integration “Help us navigate the health care system to get • the care we need in a safe and timely way” Person and Family Centered Care “Recognize that we are the most important • part of the care team - and that we are ultimately responsible for our overall health and wellness” Learn more: http://primarycarehome.oregon.gov
Introduce Presenters Traci Rieckmann, Ph.D. Ariel Singer, MPH Associate Professor Program and Training Director OHSU Department of Public Health OHSU Northwest Addiction and Preventive Medicine Technology Transfer Center Department of Psychiatry UCLA Department of Psychiatry
Learning Objectives • Review the prevalence of risky substance use in primary care settings and the impact on chronic conditions commonly managed in primary care • Define the substance use disorder continuum • Learn about treatment options, including behavioral and pharmaceutical interventions • Receive a brief primer on the specialty substance use treatment system • Review system-level barriers and strategies for primary care and substance use treatment integration
We are moving from saying, “this is a personal failure...” To saying, “there is a light at the end of this tunnel…”
“And if you want to, we can walk towards it together…”
SUD Prevalence and Impact Prevalence of Substance Use Disorders in US Primary Care Settings Between 6-20% US Hospital Emergency Room and Trauma Centers Over 50% General Adult Population 8-11% Medically Harmful Substance Use Over 40 million adults
Alignment with PCPCH Standards • Access to Care – ACA expanded coverage and access – Behavioral health and SUD screening and treatment available in PC – Referral to specialty care • Accountability – Evidence based care is available and improves outcomes • Comprehensive Whole Person Care – Can’t treat comorbid conditions without addressing the SUD • Continuity – Integration, cross-training of providers, interface with specialty care • Coordination and Integration – Team Care or Collaborative Chronic Care Models • Person and Family Centered Care – Patient informed and engaged decision-making tools – Provider improved communication and engagement
DSM V: 11 Criteria for SUDs Diagnosis on a Continuum of Severity Taking substance in larger amounts for longer than intended • Wanting to cut down or stop using, but not managing to • Spending a lot of time getting, using, or recovering from use • Cravings and urges to use the substance • Not managing to do what you should at work, home or school • Continuing to use, even when it causes problems in relationships • Giving up important social, occupational or recreational activities • Using again and again, even when it puts the you in danger • Continuing to use, when you have a physical or psychological problem that could • have been caused or made worse by use Needing more of the substance to get desired effect (tolerance) • Development of withdrawal symptoms; relieved by taking more of the • substance. Mild (2-3 ) Moderate (4-5) Severe (6+)
SUD: What it is and isn’t Miguel has been working in the construction industry for the past 25 years. About two years ago, he hurt his back on a job-site and had to have surgery. Miguel doesn’t work as much during the winter and his back doesn’t really bother him too much when he is not on his feet all day. During the summer, he works long hours and has moderate to severe back pain. His PCP prescribed him Vicodin to help him manage his pain during those months. Miguel usually takes two pills at lunch time and two more when he gets home in the evening. If his back is hurting more than usual, he takes two more before bed. When the rainy season starts, he stops taking the Vicodin and notices that he feels more irritable than usual, his muscles are achy and he is sweatier than usual. What’s going on with Miguel’s use of a narcotic pain medication?
SUD: What it is and isn’t Jodi works in a grocery store. She has a three year old daughter and a five year old son, and they all live with her mom. Jodi likes to go out with her friends from high school to dance, flirt and blow off some steam. She goes out 3 or 4 nights per week and usually has 5 to 7 drinks. If someone has cocaine, she likes to use that too. Her mom is getting concerned about how often Jodi is asking her to watch the kids. Sometimes Jodi is not only out most of the night, but then can’t function all that well to take care of her kids and she has been late to work as well resulting in her boss giving her a two out of three strikes and you’re out warning. Jodi visits her primary care doctor to get a refill for her birth control pills and participates in an annual screening for risky drug and alcohol use. What’s going on with Jodi’s substance use and what kind of discussion might her primary care team have with her?
Caring for the Whole Person
Primary Care Identification of SUD Universal Most effective for at-risk (not dependent) users Can be conducted in a variety of ways Screening Brief Intervention Referral to Treatment
Primary Care Response to SUD • Brief Intervention and brief treatment – Most effective for at-risk or harmful use – Motivational Interviewing Approach – Targeted, time-limited • Medication Assisted Treatment – Opioid dependence: buprenorphine, methadone, naltrexone (tablet and injectable) – Alcohol dependence: Naltrexone (Vivitrol), disulfiram, acamprosate, • Recovery check-ups
Chronic Disease Management • Team and Collaborative Interdisciplinary Care • Core Elements – Healthcare delivery system redesign – Organizational level support – Expert-informed/consultation and decision support – Enhanced clinical information systems – Patient self-management – Link or referral/collaboration with local community
The Treatment Landscape
Tools for Providing the Right Care American Society of Addiction Medicine Criteria
ASAM Dimensions for Patient Placement Criteria Description Goals of Care Dimension Acute Assess type and intensity of withdrawal management • 1 Intoxication services and/or Avoid potential harm from sudden discontinuation of • Withdrawal use of alcohol and/or drugs Potential Engage and facilitate completion of withdrawal • management and connect patient to continued treatment, self-help or recovery support services Promote patient dignity and reduce discomfort during • withdrawal process Dimension Biomedical Assess the need for physical health services, including • 2 Conditions and acute and chronic care Complications Dimension Emotional, Assess the need for mental health services, including • 3 Behavioral, or addressing trauma-related conditions, cognitive Cognitive conditions and other psychiatric conditions or disorders Conditions and Complications
ASAM Dimensions for Patient Placement Criteria Description Goals of Care Dimension 4 Readiness to Change Assess need for motivational • interventions to engage in treatment and recovery Respond appropriately using • Prochaska and DiClemente’s Stages of Change Model Dimension 5 Relapse, Continued Use, or Assess the need for relapse • Continued Problem Potential prevention or risk of continued use Focus on previous period of sobriety • or wellness Dimension 6 Recovery/Living Environment Assess need for family or significant • other support services Assess need for housing, financial, • vocational, legal, transportation or child care services
Tools for Providing the Right Care Options for Substance Use Disorder Treatment
The Treatment Landscape Treatment Setting Description Detox Monitored by medical personnel; may be supported by medication Substances of abuse have different levels of withdrawal risk Supports safe and effective withdrawal Average length of service: 3-7 Days Outpatient May consist of group and individual counseling, conducted on a weekly basis Usually 1-2 times per week, less than 9 hours per week total Length of treatment based on individual treatment plan Intensive Outpatient May consist of group and individual counseling, conducted on a weekly basis Usually 3 times per week , total of 9-19 hours per week Average Length of Treatment: 2-3 months Residential/Inpatient Combination of group and individual services, may include medication, case management and follow up care planning May be community or hospital-based Average length of treatment: 28 days, varies significantly
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