1. A System of Care for Substance Use as a Chronic Health Problem Rachel Gonzales Ph.D, Professor Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles www.uclaisap.org rachelmg@ucla.edu Supported by: National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) California Alcohol and Drug Programs (ADP)

2. Understanding addiction as a chronic health problem

3. Demonization Criminalization Psychiatric views Socialization Medicalization Addiction Paradigms Sinful/Immoral Criminal/Illegal Mental Disorder- DSM Learned Behavior/Habit Acute (Brain) Disease Neuro-Science & Longitudinal Research Chronic Illness Leshner, 2001; Anglin et al., 1997

4. Neuroscience Supports Addiction = Chronic Health Problem …with biological, psychological and behavioral components

5. Biological Response How Do Drugs Work?   Interact with neurochemistry (reward pathway of the Brain)   Results: - Feel Good – Euphoria/reward - Feel Better – Reduce negative feelings Like Natural Rewards: Food, Sex

6. Pathway for Understanding Addictive Effects of Drugs on the Brain Reward Pathway

7. 0 0 50 100 150 200 0 0 60 120 180 Time (min) % of Basal DA Output NAc shell Empty Box Feeding Source: Di Chiara et al. FOOD Natural Rewards Elevate Dopamine in the Brain

8. 0 0 100 200 300 400 500 600 700 800 900 1000 1100 0 0 1 1 2 2 3 3 4 4 5 hr Time After Amphetamine % of Basal Release DA DOPAC HVA Accumbens AMPHETAMINE 0 0 100 200 300 400 0 0 1 1 2 2 3 3 4 4 5 hr Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE 0 0 100 150 200 250 0 0 1 1 2 2 3 3 4 4 5hr Time After Morphine % of Basal Release Accumbens 0.5 1.0 2.5 10 Dose (mg/kg) MORPHINE 0 0 100 150 200 250 0 0 1 1 2 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE Drugs Also Bring Reward (via Dopamine)

9. What have we learned through Positron Emission Tomography (PET)?

11. Prolonged Changes In the Brain in Lasting Ways “Healthy” Brain “Cocaine Addict” Brain Addiction leads to….

12. BRAIN CHANGES appear prominently in PET scans of current and past drug users Drug users have far less dopamine activity (right), as is indicated by the depletion (dark red shows disruption), compared to the controls (left) Studies show that this difference contributes to dependence and a diseased brain

13. Behavioral Response How Drugs Work  Loss of control  Continued compulsive use despite harmful use despite harmful consequences consequences  Multiple relapses preceding stable preceding stable recovery recovery

14. Partial Recovery of Dopamine Transporters After Prolonged Abstinence Normal Control Meth user (1 month abstinent) Meth user (36 months abstinent) Why is Continued Treatment Critical?

15. Longitudinal Research Support for Addiction as a Chronic Illness

16. Advancing the notion of Drug Careers and Treatment Careers….  Landmark study: UCLA ISAP researchers (Hser, Anglin et al) followed up a cohort of 581 male heroin addicts admitted to the California Civil Addict Program (1962-64) for over 30 years.  The program was the only major publicly- funded drug treatment program available in California in the 60s. Tx: combo of inpatient and outpatient drug treatment to narcotic-dependent criminal offenders committed under court order. Tx: combo of inpatient and outpatient drug treatment to narcotic-dependent criminal offenders committed under court order.

17. Status of Sample at 3 Interview Points Status of Sample at 3 Interview Points

18. 22% 48% 6% 2% 4% 7% 12% Methadone Maintenance Natural History of Narcotic Addiction Among Sample (N=581)

19. Causes of Death Among Sample (N = 271) a Includes overdose, poisoning, drug dependence, and suicide by drugs b Includes motor vehicle, suicide, firearms, homicide, and falls c Includes alcoholic cirrhosis, alcohol dependence, and poisoning by alcohol d Includes kidney disease, diabetes, GI, and epilepsy seizures e Includes viral hepatitis, AIDS, TB, and staphylococol depticemia a b c d e

20. Implications for the Field  Cannot ignore the chronic nature of addiction and the associated long-term effects of heroin addiction in terms of morbidity, mortality, criminal justice involvement, and overall level of functioning  Compared to a US Population sample, heroin addiction reduces life expectancy by an average of 18 years

21. Other Long-term Outcome Studies  Alcohol: Vaillant et al. conducted multiple long-term follow-up studies with alcoholics (post-tx). Findings repeatedly show that alcoholics experience multiple relapses and re-treatments with only 30-50% achieving stable abstinence.  Cocaine: Hser et al. 10-yr follow-up study of cocaine users post-tx found that fewer than 50% achieve extended periods of abstinence AND most re-enter treatment multiple times.  Methamphetamine: Marinelli-Casey et al. 3-year follow up study (600 MA users post-tx) found that 50% continue to use MA at a moderate or severe level throughout the 36 month period.

22. Re-Addiction Following Prison Re-Addiction Following Prison Vaillant 447 opiate addicts91% Maddux & Desmond 594 opiate addicts 98% Nurco & Hanlon 355 opiate addicts 88% Hanlon & Nurco 237 mixed addicts 70% Other Studies: Simpson, Wexler, Inciardi, Hubbard, Anglin Treatment Research Institute

23. Developing a Treatment System that is Responsive

24. Given the Research, there has been a Paradigm Shift in Treatment Response… Focus has increasingly shifted from an acute, model of tx towards a chronic care model

25. Shift is been important for adequately understanding and managing substance use disorders and the recovery process Are we there Yet?

26. Public Expectations of Substance Abuse Interventions Public Expectations of Substance Abuse Interventions  Safe, complete detoxification “The 28 day cure” “The 28 day cure” Put them in a box, something happens and they come out fixed Put them in a box, something happens and they come out fixed The washing machine model: Put a “dirty addict” in, run the washer, and take out a “clean citizen” The washing machine model: Put a “dirty addict” in, run the washer, and take out a “clean citizen”  Results in: Reduced use of medical services Reduced use of medical services Eliminate crime Eliminate crime Return to employment Return to employment Eliminate family disruption Eliminate family disruption No return to drug use No return to drug use

27. Although, the treatment community is feeling the Shift Let’s Review the process….

28. A Menu of Treatment Services Continuing Care Programs Intensive Outpatient/Psychosocial Behavioral Treatment Sober Living Residence Long-term Residential Treatment Short-term Residential Treatment Detox/ Inpatient Detox/ Outpatient Medication Assisted Treatment

29. Treatment… Acute System Response Admission Client Outcomes Discharge …One Type of Tx From Menu of Services

30. What’s the Problem with this System?   Treatment effects usually don’t last very long after acute treatment stops   Clients who are not in some form of treatment or being monitored are at elevated risk for relapse

31. 2. Begins by voluntary choice: then exacerbated by neurobiological changes that weaken volitional control McLellan et al., 2000 compared substance use disorders with chronic illnesses (such as diabetes, hypertension, and asthma) and identified many similarities

32. Asthma (adult only).35 -.70 Diabetes (insulin dep).70 -.95 (males) Hypertension.25 -.50 (males) How Similar in Heritability? Twin Study Estimates Alcohol (dependence).55 -.65 (males) Opiate (dependence).35 -.50 (males) Eye Color1.00

33. Sneak Peak at Similar Relapse Rates Drug Addiction Type I Diabetes 0 10 20 30 40 50 60 70 80 90 100 Hypertension Asthma 40 to 60% 30 to 50% 50 to 70% Percent of Patients Who Relapse McLellan et al., JAMA, 2000

34. DetoxResidential Outpatient NTPContinuing Care/Support Services Chronic Care Model Response TreatmentRecovery We are well trained in the realm of the treatment stages…

35. Stage of Treatment 1. Detoxification Purpose: Stabilization=Safe/Adequate reduction of withdrawal symptoms -Physical/Emotional stabilization -Promote problem recognition -Engage patient into rehabilitation

36. Effective Strategies During Engagement in Rehabilitation  Counseling to Promote Transfer using NIATx Strategies  Motivational Interviewing  Voucher-Based Techniques  Medications

37. Stage of Treatment 2. Rehabilitation Purpose: Sustain stable abstinence -Teach self-management skills -Identify & reduce threats to progress -Medications (maintenance and relapse prevention) -Engage patient in continuing care

38. DetoxResidential Outpatient NTPContinuing Care/Support Services Chronic Care Model Response TreatmentRecovery Emphasis on: Continuity of Care

39. What is Continuity of Care? Continuing Care/Support Services Detox Residential Treatment Outpatient/Psychosocial Behavioral Treatment Sober Living Residence Arrow = Referral/Transfer NO Clinical Discharge Extending treatment beyond acute care

40. Where is the State of CA in this shift?

41. To find out…   One place to start is with the data: What % of your clients who complete your treatment program are being referred/transferred to another level of care (continuity of care)?

42. Continuity of Care Patterns in CA Majority of clients only receive 1 service (level of care)

43. What about the county of Sonoma?   What do you think? In terms of the % of clients who complete treatment and are referred/transferred to another level of care (continuity of care)…

44. Sonoma 36% 10%6% 25% 31% Tx Modality * No. of Admissions

45. Tx Modality No. of Admissions State 29% 11% 13% 21% 30%

46. Destination Treatment Type Fresno Detox Total: 962 *Transfers to NTP Detox = 0, Day Care Rehab = 0 State Detox Total: 26670 *Transfers to NTP Detox = 4, Day Care Rehab = 71, Maintenance= 126 Transfers from Detox

47. Destination Treatment Type *Transfers to NTP Detox = 2, Maintenance= 0 *Transfers to NTP Detox = 46, Maintenance= 98 Residential Total: 41,636 Residential Total: 2154SonomaState Transfers from Residential

48. Sonoma (N=184) (N=636) (N=194) ( N=1191) ( N=2957) (N=706) (N= 6) (N=49) Drug Category Mean No. of Days in Tx *Other = barbiturates, PCP, inhalants, ecstasy, hallucinogens, club drugs, and other stimulants and tranquilizers

49. Sonoma (N=320) (N=2400) (N=983)(N=1970) (N=116) (N=134) Mean No. of Days in Tx Type of Tx Modality

50. What Does this pattern mean? These statistics highlight one of the most prominent challenges faced by the addiction treatment field today… …many people who enter treatment do not complete the necessary course of treatment required for success Why is this a backward approach?

51. Much Research Supports the Success of a Chronic Illness Treatment Model   When treated as a chronic illness, the relapse rates of substance dependence are as good or better than other chronic illnesses (McLellan et al., 2005)   So, continuity of care (or client transitions between levels of care) is important for keeping the client engaged in their recovery and preventing relapse   Continuity of care has been shown to be successful in leading to better “long-term” outcomes (compared to acute care): Abstinence Addiction-related health illnesses Family relationships Legal status Psychiatric issues (including service utilization)

52. What you (treatment programs) can do to improve these rates? Given this issue, work with your group & brainstorm about…

53. Some promising practices for increasing client movement between levels of care

54.   Strongly encourage client engagement in continued treatment   Actively “hand-off” clients to the other level of care (establish client-counselor linkages)   Be prepared: to bypass barriers Identify what needs to be done (steps) for making the link (transfer), such as obtaining pre-authorization or what type of transfer paperwork is involved   Address client uncertainty about what to expect Ensure that clients are informed (by alumni or staff) about the expectations and requirements of the next level of care

55.   Building “connected care” – developing relationships with other levels of care programs… …This means – sharing clinical (client) information to enable continuity of care How can you prepare for connected care?

56. How can you begin to make “connected care” a Reality?   Examine your current processes for collecting and managing clinical (client) information within your program   Consider the ways clinical (client) information can be shared more efficiently (with other programs).   Understand your technology platform -- is it flexible and adaptable enough to support “connected care”   Map your community -- identify addiction stakeholders in your community who your program can collaborate with to build connected care   Start the external communications process – develop some outreach tools that will enable your program to stay connected to referral/transfer sources within the addiction community (in your neighborhood)?

57. Recovery Services Treatment/Intervention Recovery Telephone Continuing Care Recovery Coaches/ Centers Recovery Services Outpt Tx Detox Intensive Otpt Tx Long-term Res Care Short-term Res Care Methadone Maintenance NTP Detox

58. What about looking at the % of clients who get…   Recovery Services Continuing Care OR Support Services

59. What is Continuing Care? In a chronic care paradigm, it is considered an important level of care for promoting successful transitions from clinical services to recovery

60. Types of Continuing Care   Traditional approaches Self/mutual help programs Regular counseling visits   Newer approaches: Medications Recovery “check-ups” Telephone-based methods

61. Recovery Check-ups   Developed by Researchers from Chestnut Group (Dennis, Scott et al.)   Involves contacting clients every quarter for 2 years to ask about: Use of alcohol or drugs on > 2 weeks Being drunk or high all day on any days Alcohol/drug use led to not meeting responsibilities Alcohol/drug use caused other problems Withdrawal symptoms …If +++, client referred to linkage manager   Provides: Personalized feedback Explores possibility of returning to treatment Schedules an intake assessment

62. Telephone based methods   Convenient for client   Reduces stigma of weekly trips to the treatment program   Individualized attention   Can be automated   Lower costs of ongoing care

63. Measurement Challenges   Currently, we don’t have a method for measuring the extent to which clients are getting continuing care or support services.   What we do know (anecdotally) – it’s grim

64. Why So Many Clients Don’t Get Continuing Care/Support Services Program Level   May never get the referral   Logistical/financial disincentives   Resources   Views it as the client’s responsibility Client Level - - Low motivation - - Treatment fatigue (ready to be finished)

65. What about Recovery Services?   What is your county currently doing to promote or provide recovery services…

66. Are we making progress?

67. Removing Confusion: Outcomes vs Performance  Outcomes: OUTCOME MEASURES ARE USED AT THE PATIENT LEVEL AND MEASURE CHANGES IN PATIENT BEHAVIOR OR FUNCTIONING OVER TIME  Performance: PERFORMANCE MEASURES ARE USED AT THE TREATMENT PROGRAM LEVEL TO EXAMINE THE FUNCTIONING OF THE TREATMENT PROGRAM

68. Treatment Completion is an OUTCOME Definition: Per CALOMS discharge, do people complete treatment

69. Treatment Initiation/Engagement Definitions: Initiation: Do people who enter treatment receive at least 2 treatment visits in the first 2 weeks? Engagement: Do people who enter treatment receive at least 4 sessions in the first 30 days/  Meaningful: Yes  Clearly Defined: Yes  Reliability and Validity of Measures: Yes  Readily Accessible Data for Measures: ????

70. Treatment Retention Definition:  Retention: Number of days between admission and discharge.  Meaningful: Yes  Clearly Defined: Yes  Reliability and Validity of Measures: Yes (maybe)  Readily Accessible Data for Measures: Yes

71. Continuity of Care Definition:  Do individuals who enter treatment proceed through multiple service sets (levels of care)  Meaningful: Yes  Clearly Defined: Yes  Reliability and Validity of Measures: Yes  Readily Accessible Data for Measures: Yes

72. System Change Requirements   YES -- $$$   BUT ALSO   Strong Leadership   Motivated staff at all levels   Implementation Team   Infrastructure development (training)   Communication   Collaboration   Patience & Perseverance

73. Building Interactive Service Systems  To create a treatment system that produces the best outcomes for patients, it is necessary for AOD services within a county to be delivered in a “system of care” rather than a “bunch of isolated programs”. it is necessary for AOD services within a county to be delivered in a “system of care” rather than a “bunch of isolated programs”.

74. Strategies for improving AOD program performance  Reduce staff turnover  Increase staff knowledge of other forms of care to promote a “system of care” rather than isolated programs  Increase staff knowledge and use of evidence-based practices  Employ process improvement (NIATx)

75. Thank You rachelmg@ucla.edu www.uclaisap.org rachelmg@ucla.edu www.uclaisap.org rachelmg@ucla.edu www.uclaisap.org