1. Referral to Treatment: The 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@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. 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 DSM IV Substance Dependence Disorder (Alcoholism, Addiction)

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. > 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 General medical (ED, MD office)43.3% Specialty mental health42.6% Professional human services19.0% Self-help groups7.9% Specialty addiction6.3% Narrow et al. Arch Gen Psychiatry. 1993;50:95-107 Distribution of Persons w/ SUD Treated in Ambulatory Settings

11. Prevalence of Substance Dependence Disorder among Primary Care Patients Study Fleming (1998) Piccinelli (1997) Volk (1997) 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% -

12. Prevalence of Substance Dependence Disorder among General Hospital Admissions Study Smothers (2003) Brown (1998) Soderstrom (1997) Canning (1999) 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)

13. At-Risk & Dependent Use by Inpatient Service Stroger Hospital, 2004-2005

14. Prevalence of Alcohol Dependence by Age: Hospitalized Patients vs. Community Prevalence %

15. Drug Dependence by Age: Hospitalized Patients vs. Community Prevalence %

16. Readiness Ruler: How ready are you to make a change in your use?” Not ready UnsureReady Heroin Alcohol, Cocaine Marijuana Average response of patients dependent on that substance

17. Identification & Intervention for Substance Use Disorders among General Healthcare Patients Study Moore (1989) Hearne (2002) Smothers (2004) Setting, Patients University Hospital + Alcohol screen General Hospital + Alcohol Use Disorder 90 General Hospitals + Alcohol Use Disorder Patients Identified by MD Team 7-66% 20% 57% Patients with Intervention by MD Team 35% 8% 21%

18. 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 Screening General Health Information Brief Intervention Chemical Dependency Treatment Brief Assessment Assess & Referral Use with Consequences At-Risk Use Low Risk Use Dependent Use State Licensed Treatment Providers CCBHS Hospitals & Health Centers

20. Illinois SBIRT Interventions Screening General Health Information Brief Intervention Chemical Dependency Treatment Brief Assessment Assess & Referral Use with Consequences At-Risk Use Low Risk Use Dependent Use State Licensed Treatment Providers CCBHS Hospitals & Health Centers

21. Outcome of Screening 28 months, 3/30/04 – 7/27/06 Hospitalized Patients N (% of screened) Ambulatory Patients N (% of screened) Low Risk 34,507 (75.3) 5,493 (86.6) At-Risk Use Received Brief Intervention 4,820 (10.5)548 (8.6) Use w/ Consequences Received Brief Intervention 1383 (3.0)106 (1.7) Dependent Use Received BI, offered Referral 5,121 (11.2)195 (3.1) Accepted Referral to Treatment 2,752 (8) (54% of dependent pts) 39 (1) (20% of dependent pts)

22. Patient Placement Criteria for Addiction Treatment ( American Society of Addiction Medicine) Multidimensional Assessment: 1.Acute intoxication, Withdrawal potential 2.Biomedical conditions and complications 3.Emotional/Behavioral/Cognitive conditions and complications 4.Readiness to change 5.Relapse/Continued use/Continued problem potential 6.Recovery environment

23. ASAM PPC Treatment Levels of Service: I.Outpatient Treatment II.Intensive Outpatient and Partial Hospitalization III.Residential/Inpatient Treatment IV.Medically-Managed Intensive V.Inpatient Treatment

24. Illinois SBIRT Interventions Screening General Health Information Brief Intervention Chemical Dependency Treatment Brief Assessment Assess & Referral Use with Consequences At-Risk Use Low Risk Use Dependent Use State Licensed Treatment Providers CCBHS Hospitals & Health Centers REFERRAL COORDINATOR

25. Patients Referred to Treatment 28 months, 3/30/04 - 7/27/06 # Patients Referred Total2,773 Brief Treatment (Individual Counseling)793 Residential921 Methadone Maintenance576 Intensive Outpatient232 Outpatient251

26. Entry into State Funded Treatment within 60 Days from Hospital Discharge Substance Dependent Patients Entered Treatment Accepted Referral to Treatment while Hospitalized 983161 (16%) Did Not Want Referral to Treatment while Hospitalized 2925 (2%) Sample of dependent patients discharged from Stroger Hospital matched with State-funded treatment data base (2004-2005)

27. Illinois SBIRT Interventions Screening General Health Information Brief Intervention Chemical Dependency Treatment Brief Assessment Assess & Referral Use with Consequences At-Risk Use Low Risk Use Dependent Use State Licensed Treatment Providers CCBHS Hospitals & Health Centers Brief Treatment REFERRAL COORDINATOR

28. Time to Treatment “Intake” Appointment Mean 95% CI 4 12 16 208 Modality Brief treatment Intensive outpt Residential Outpatient Methadone Tx Estimated time to beginning of treatment Intake representative of beginning of treatment 0 2842 Days Tx

29. Entry into State Funded Treatment within 60 Days from Hospital Discharge Substance Dependent Patients Entered Treatment Referred to Brief Treatment (with or w/out other traditional modality also intended) 27472 (26%) Referred to Traditional Treatment Modality (without Brief Treatment first) 70989 (13%) Sample of dependent patients discharged from Stroger Hospital matched with State-funded treatment data base

30. Illinois SBIRT Interventions Screening General Health Information Brief Intervention Chemical Dependency Treatment Brief Assessment Assess & Referral Use with Consequences At-Risk Use Low Risk Use Dependent Use State Licensed Treatment Providers CCBHS Hospitals & Health Centers Brief Treatment COMMUNITY CASE COORDINATORS REFERRAL COORDINATOR

31. Outcome of Referrals, Follow-Up from Community Care Coordinators 12 months (4/01/05 – 3/31/06) Patients assigned to CCC after Hospital Discharge 1,072 Followed, know patient entered Treatment 335 (31% of assigned) (55% of followed) Followed, know patient did not enter planned Treatment 262 (24% of assigned) (43% of followed) Followed, patient died9 ( 1% of assigned) Lost to follow-up466 (43% of assigned)

32. Change in Treatment Entry with NO WAIT Mean Days to Tx Entry % in Tx within 60 Days Residential9 days18 % Methadone Maintenance 17 days22 % % in Tx after Referral 87 % 67 % First Year Usual Wait Referred Patients* Same/Next Day Treatment 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

35. (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