Implementing pharmacotherapy and recovery support for people with co-occurring disorders (COD) in community mental health settings Elizabeth Bromley, MD, PhD (UCLA, LACDMH), Brian Hurley, MD (LACDHS) Allison J. Ober, MSW, PhD (RAND)
Conflict of Interest Disclosures Elizabeth Bromley, Brian Hurley, M.D., M.D. M.B.A., DFASAM No Disclosures No Disclosures Allison Ober, M.S.W, Ph.D. No Disclosures 2
• Discuss why we’re doing this project • Share what we’ve learned from clinic staff Goals for • Share what we’ve learned from clients Today • Discuss medications for alcohol (MAUD) and opioid use disorders (MOUD) • Review our toolkit • Hear your thoughts and feedback 3
Why are we doing this project? The problem, what we know about it, what we are trying to do about it
Co-occurring substance use and mental health disorders are common Up to 45% of people with a substance use disorder have a co-occurring mental illness Of about two million adults with an opioid use disorder (OUD) in the US, about 29% have co-occurring depression, 22% have anxiety, and 27% have bipolar disorder Of about 25 million people with an alcohol use disorder (AUD) in the US, about 33% SAMHSA, 2018 also have a mental illness (NSDUH 2017) 5 5 Katarzyna Bialasiewicz via Getty Images
Despite the burden among people with mental health disorders, there are still large gaps in treatment 91.7 .7% o of peop ople le wit with CO COD do do not g get tre reatment f for or both h diso disorders SAMHSA, 2018 (NSDUH 2017) 6
Treatment is Effective but Underused for People with COD Medications for OUD (MOUD) can reduce overdose deaths and increase treatment retention and functioning Most people with Co-OUD do not receive treatment for either problem Medication for AUD (MAUD) can reduce cravings and lower heavy drinking days People with a Co-AUD have less 10% chance of getting treatment in a given year 7
Treatment Cascade for Clients with AUD at DMH 2018 (N=8 clinics) To put this in 30000 context, 24267 some 25000 22679 numbers 20000 from 8 clinics 15000 within LA 10000 County DMH 4956 3626 5000 1575 254 0 New DMH Clients Clients With Clients Clients with Clients Clients Screened for Positive Received an AUD Receiving AUD AUDIT-C Brief Clinical Diagnosis Medication Score Intervention for AUD 8
Lack of treatment for people with COD is due to several factors Long waiting lists for • specialty care Medication is not always • available in specialty care Stigma and logistical barriers • Service coordination • challenges Service provider lack of • training to work with people with serious mental illness 9
COD treatment in community mental health centers could help address unmet need Aiming to FULLY treat COD in public mental health settings can address the lack of access to effective treatments for a vulnerable and underserved population, in a setting where they are most likely to access care 10
What should we do about this? We need to increase clinic SUPPLY and client DEMAND for medications and recovery support in mental health settings for people with COD 11
First we learned about barriers to implementing medications and recovery support from DMH providers and staff through • client and staff surveys • interviews and focus groups Now we are using the data to build a web-based toolkit to facilitate implementation of evidence- based COD treatment in community mental health settings 12
8 clinics directly operated by the Los Angeles County Department of Mental Health (DMH) • One in each of the 8 Service Study Sites Planning Areas (SPAs) • Selected large, small, semi-rural, and urban sites • DMH treats 250,000 individuals yearly, covering the 4750 square miles of LA County 13
• We’ve completed data collection on supply and demand for medications and recovery support for people with Study co-occurring AUD (Co-AUD) Status • We are about 80% finished with data collection for co-occurring OUD (co- OUD) • Today we will focus primarily on Co- AUD 14
Understanding Supply Staff perspectives on providing treatment for people with COD in community mental health settings
What are t e the big igges est b barrie iers to p provid idin ing trea eatment w wit ithin in DMH for p peop ople w wit ith co- occurrin oc ing a alcoh ohol ol u use dis disor order ( (Co-AUD) D)? Findings: Administrator • “Treatment of Co-AUD is not in my job description” interviews • No easy way to communicate clinical (N=39) information about specific patients • Clients are not motivated to address AUD; when they are, providers are not prepared to work with them • Lack of awareness of treatment availability and resources 16
Is provid Is idin ing treatment f for peop ople w wit ith Co- AUD a accep eptable a and feasib ible? A Are provider ers p prepared a d and willing? Findings : • Treatment of Co-AUD, including medication, Staff Surveys matches clinic priorities (N=334) • While most clinical staff feel prepared to identify and diagnose AUD, more than half think medications should be prescribed by a specialist from outside DMH • Most prescribing providers are willing to prescribe medications for Co-AUD 17
What are e you our t thoug oughts a about p provid idin ing care f for C Co-AUD? ? Findings: Motivated to address Co-AUD, but: Staff Focus • Lack of trained and available staff Groups (N=16) • Lack of documented procedures for how to provide treatment • Need for collaboration with specialty care for detox/residential treatment • Belief treatment for AUD cannot be billed 18
REFLECTIONS: Do these issues resonate with you? What are some other issues that systems or clinics might encounter? 19
Understanding Demand The client perspective on receiving medications for alcohol use disorders (MAUD) and recovery support in community mental health
• Participants recruited from groups for co-occurring disorders, flyers, and provider referral Participants Participants • Focus groups guided by Health Belief and Model and Methods Methods • Data analyzed using deductive and then inductive techniques • 20% of transcripts double-coded 21
87 total participants Average age: 47 years • 53% female • 47% had a current or past diagnosis of a co- Participants AUD Resul sults ts Results • 65% were currently drinking and Methods • 13% reported not drinking and did not have a current or past co-AUD diagnosis • Three-quarters had not heard of naltrexone, and familiarity with other MAUDs was lower 22
Most clients viewed drinking as a problem of internal locus of control and did not perceive MAUD as potentially helpful “I don’t care what kind of pill they make, “I’m an alcoholic, so that whatever it is….if you don’t deal with the issues (medication) would not that’s making you drink…then that’s useless…” even be a deterrent for me. If I’m not going to feel it, I’m just going to keep drinking, drink until I black An individual’s desire to quit out.” “is definitely the most important thing. You're not going to stop unless you want to. If somebody else forced you to stop, you're not going to stop.” 23
Views of the costs and benefits of MAUD were shaped by presumed impact on internal locus of control Costs a s as Harm o rm or Burden Benefi efit “My thing is I don’t want to become dependent on a pill to make me stop or quit or “Don't think of it as a thing that…is whatever....[H]ow long do I have to take this? I gonna magically cure you of your might not want to take this pill no more, then alcoholism. It's the foundation to what? Am I going to relapse?” helping you, but it's a tool, but you need to put in the hard work “Plus, we don’t want to be taking all different yourself. You need to go to your meetings, you need to go to kind of meds. I’m already on some meds and therapy.” I’m like they’re going to give me this…I’m not willing to do that. It’s a little too much for me.” 24
Clients acknowledged severity of illness and susceptibility to relapse, but these did not influence desire for MAUD Susceptib tibility ility Severity ity “I relapse all the damn time. I do. This is like the longest I haven't relapsed in I don't know “My relationship with alcohol is how much time. I have 40-something days. vital because for me to drink is It's the longest I've had not relapsing.” for me to use drugs, me to come up missing, me to not take care “The worst thing that I've experienced …is of mental health issues, and how socially acceptable it is. And even on that's very important to know for the Today Show …every single morning they yourself because I can't control alcohol, not one drop of it.” have glasses of wine or a new mixed drink.….That is challenging.” 25
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