The Brain Story Certification: Module 18

Module 18: Addiction Treatment, Part C – Improving
Services

Excerpt from “Effectiveness, Quality & Performance”
Thomas McLellan, PhD
Treatment Research Institute

• What is effectiveness?
  • Some use the FDA perspective – a minimum of two randomized clinical trials by separate investigators for effectiveness over placebo.
  • There is FDA-Level evidence for the following psychological interventions:
    • Cognitive Behavioural Therapy (CBT)
    • Motivational Enhancement Therapy (MET)
    • Community Reinforcement and Family Training (CRFT)
    • Behavioural Couples Therapy (BCT)
    • Multi-Systemic Family Therapy (MSFT)
    • 12-Step Facilitation
    • Individual Drug Counseling.
  • Thee is FDA-Level evidence for the following medication interventions
    • Alcohol dependence
      • Disulfiram, Naltrexone, and Accamprosate
    • Opiate dependence
      • Naltrexone, Methadone, and Buprenorphine
    • Cocaine
      • Disulfiram, Topiramate, Vaccines
    • There are not significant FDA treatments for Marijuana or methamphetamine (at the time of the lecture).
  • How do we improve outcomes?
    • Outcomes differ depending on what you expect and when.
    • There are a few differences between:
      • Brief and intensive treatments
      • Inpatient/outpatient treatments
      • Conceptually different treatments
      • “Matched” and “Mismatched” treatments.
      • Gender/Culturally relevant treatments.
    • Pre/post levels higher as opposed to during intervention is examined as a positive outcome – it fails to recognize that post-treatment outcomes are hardly changed.  Looking for a cure for addiction (has it continued to work?) does not sufficiently represent the impacts of interventions.

Excerpt from “Physician Health Programs”
Michael Kaufmann, MD, and Dianne Maier, MD
Ontario Medical Association
Alberta Medical Association

A shared approach to addiction in physicians: chronic disease model components:

• Care – multidisciplinary, with case management
• Continuity – it is a long-run approach for abstinence
• Occupational health principles are applied.
• PHP Model Components (Alberta)
  • Services provided to medical students, residents, physicians, and immediate family.
  • TF telephone assistance in the assessment, referral and support of a client
  • Case coordination services
    • Only for physician spectrum
  • Health promotion and education
• PHP Model Components (Ontario)
  • Services provided to medical students, residents, physicians, and immediate family.
  • Core components:
    • Intake assessment/support
    • Referral for treatment
    • Case management, monitoring and advocacy
    • Health promotion/education
• In Alberta, the biologic monitoring program is not a part of care coordination services.  There is an active liaison between the regulator and the service providers.
• Ontario has biologic monitoring – with random urinalysis, hair testing, and breath testing.
• Physician Health Programs:
  • Primary – Prevention and education
  • Secondary – Access to services for early intervention and treatment
  • Tertiary – Intervention, treatment coordination, case management, and monitoring.
  • Colleagues and participants are viewed through a biopsychosocial-spiritual lens,
• While the medical has its usefulness, there needs to have a comprehensive view of the client’s wellbeing.  We want to move to a more existential and meaning-making realm of work with individuals.  We want to help reestablish the interconnectedness of the client with others.

Excerpt from “Physician Health Programs”
Michael Kaufmann, MD, and Dianne Maier, MD
Ontario Medical Association
Alberta Medical Association

Typical medical management of substance abuse:

• Assessment.
• Trial of abstinence.
• Education regarding low-risk substance use.
• Supportive counselling and treatment of concurrent disorders.
• Monitoring of adherence to a chosen protocol
• Reassessment as needed.

Harm reduction and other programming have a role, depending on the situation the client is in.  We watch – thinking about how the client can adhere.  What happens over time?

Medical treatment of those who have substance dependence:

• Detoxification
• Residential program (4-6 weeks) – often the first-line program in Ontario.
• Aftercare (1-2 years)
• Total abstinence approach (the chronic disease model)
• Psychoeducation.
• Relapse prevention skills.
• Healthy lifestyle counselling.
• Mutual support programs (12-step)
• Peer support groups
• Identification and treatment of co-morbid disorders
• Family programs and support
• Pharmacotherapy – may sometimes be overused.
• Agonist Therapy – not often used.  It is a harm-reduction method but is not recovery or a comprehensive therapy.

This uses a clinically focused approach with biological, behavioural, face-to-face monitoring, monitoring and consideration planning, and contingencies for non-compliance.

PHP case management receives reports from all monitoring components.  There is a review of toxicology reports and coordination and facilitation of communication.  Case management includes liaising and advocating with the workplace and identification of resources as needed.  It also includes prompt responses to relapse in substance use or behaviours, annual review with the client, case conference(s) as required, progress/advocacy reports to third parties as needed, and identification and response to concerns within the family.

Excerpt from “Physician Health Programs”
Michael Kaufmann, MD, and Dianne Maier, MD
Ontario Medical Association
Alberta Medical Association

• CDM responsibility is to the entire population/group with case finding/screening
• PHP has:
  • A discrete population
  • Safety-sensitive occupation
  • Multiple possibilities, such as:
    • Self
    • Family
    • Colleagues within the workplace/treatment
    • Regulator
    • Screening for SUDs and addictions regularly
• PHP does the following:
  • Risk assessment on the first call
    • Substance (mid)use/abuse or dependence of possible concurrent disorder
  • Need for direct interventions
    • Lower threshold for immediate assessment/treatment than the general public
  • Assessment and treatment
    • Frequently at residential treatment centers first
      • Expertise with health practitioners
      • Multiplidisclipinary care
      • Medical and psychiatric care
      • Family support – addiction is a family disease.  Support for both family and family
    • PHP manages the case
      • Occupational health principle applied
      • Case management/coordination:
        • has clinical focus
        • Monitors health and recovery
        • Responds to behaviour and substance
      • Accountability is set through:
        • A clear agreement/contract
        • Contingency plans are clear.
        • Patient safety is at the forefront.
    • Recognition of the significance in the relationship between the PHP team and the client.
    • Community is seen as necessary.
      • Agreements and contracts made post-initial treatment – for 5 years of post-substance dependence.
      • Community-based ongoing treatment for addiction and concurrent disorders.
      • Teams can be multidisciplinary
      • After initial treatment, the PHP can support all service providers with:
        • A perspective of the bigger picture
        • A different form of advocacy than that of the treatment provider
        • Support for health and recovery through monitoring results (including biological indicators)
        • Compliance
        • Ensure additional referrals and resources as needed.
      • Don’t want to silo service-providers.
    • Preserve the confidentiality of the client
    • Coordinate care
    • Liaison and facilitation of communication between the family, treatment providers, workplace, and regulators (as necessary)
  • CDM principles
    • Provide care in the least intrusive setting
    • great in the community before providing more complex services.
    • Primary care provider manages treatment
    • Involves patient in their own care – value in the relationship
    • Support with education and ongoing follow-up
    • It uses a multidisciplinary team that supports family physicians, specialists, and other services.
    • Integrate care across the boundaries of multiple organizations.
• Always ensure the safety and sensitive nation of the medical profession, including:
  • Fiduciary responsibility
  • Accommodations in the work and workplace
  • PHPs are not a treatment provider for participants.
  • Participate in return to work planning with the participant and the workplace
  • Monitor mental health
• It appears that there is a lot of difference between the care of doctors with addictions and services rendered to the general public.
• PHPs do much better over general public interventions – OMA PHP relapse research data over 5 years.
• Relapse risk increases when there was:
  • A concurrent psychiatric disorder
  • Family history of a substance use disorder
  • Previous relapse
  • combination of the above factors
• Things that do not increase relapse risk:
  • Substance of choice
  • Specialty
  • Gender
• Life satisfaction increases year-over-year in PHP data
• Overall wellness, job effectiveness, and relationships with others improve over time in the PHP programs.

Excerpt from “Business Process Improvement”
David Gustafson, PhD
University of Wisconsin, Madison

• Process Improvement:
  • Look at the experiences clients would face in the face of trying to address addiction.
  • Would substance users see this system as accessible?
  • Timing accounts for a lot in the treatment
  • Highly dedicated staff are essential.
  • Business models waste a lot of money but separate patients and staff.
  • How the interactions unfold can be controlled.
• There are 9 key paths to recovery:
  • First contact
  • Intake and assessment
  • Transitions through levels of care
  • Paperwork
  • Scheduling
  • Engagement
  • Social supports
  • Outreach
  • Maximizing revenue
• It is useful to keep it simple, and be okay with doing a process poorly at first, and developing it better with practice.  Organizations may develop learned helplessness – organizations need to feel that they can change now and learn from the experience.

Excerpt from “Business Process Improvement”
David Gustafson, PhD
University of Wisconsin, Madison

• 5 evidence-based principles of organizational improvement:
  • Improvements – help the CEO sleep.  We need to buy into the agenda of the leadership to improve services.
  • Influential change leader.  Needs to be someone with high legitimate and referent power.  Needs to be respected within the organization/community.
  •  Personally experience what customers experience.  Do a walkthrough of intake/service to see what it is like to be a client.  Also, ask the staff what can be done to make things better for staff and clients.
  • Ideas and “pressure” from outside the organization is an essential part of improvements.
  • What distinguishes the successful from their competitors
  • Quality services
  • Rapid-cycle-testing – see what new ideas look like in application and make adjustments as needed.  Identify what does not work, improve it, and improve it again.
• Strategies:
  • Make it simple, with a narrow focus of specific aims, use a few simple measures, and downplay the use of tools.
  • Start small!

Excerpt from “How Should We Integrate Care for Substance Use Disorders into Mainstream Medicine”
Thomas McLellan, PhD
Treatment Research Institute

• There are substance-use disorders that are between “social use” and dangerous use (addiction).  This is called “harmful use.”  Addiction forms from harmful use
• Integrated care could improve general medical care, it could save money, and it is the law to do so.
  • Levels of use below addiction regularly to misdiagnosis, poor adherence to prescribed care
  • interference with commonly used medications
  • increased time with physicians
  • unnecessary medical testing.
  • Low-risk drinking limits -4/day men, and 3/day for women.  No more than 14/ week for men, and 7/week for women.
  • Drinking is a major risk factor from breast cancer – more so than smoking.  Any alcohol raises the risk of relapsing and interferes with radio and chemotherapy.
  • Many prescribed medications have a bad interaction with alcohol consumption – fatal medical errors.  Doctors do not ask what substances a patient is using, not knowing what possible interactions could take place.
  • Doctors should screen for and discuss substance use.
  • Create a patient contract – single doc and pharmacy
  • Patient and family education on safe storage of medication
  • Urine Screening pre and during prescribing (extended test panel) to assess risk.
  • Brief interventions can be useful in harmful substance use.  Intake only needs to be 2-3 questions.  It can be 5-10 minutes in a motivational interviewing format.  This has been shown to create cost-savings in emergency rooms.