First Annual LA SBIRT Network Summit. LA SBIRT Network UCLA Ronald Reagan Medical Center August 22, 2014

Transcription

1 First Annual LA SBIRT Network Summit LA SBIRT Network UCLA Ronald Reagan Medical Center August 22, 2014

2 Goals and Educational Objectives 1. Review current trends in addictive disorders 2. Describe SBIRT practices and approaches 3. Discuss treatment options for addictive disorders

3 Housekeeping CEU process Slides and handouts will be posted on: Worldofsbirt.wordpress.com LASBIRT.com (under construction) SAMHSA Evaluations

4 Today s Agenda 9:30-10 Welcome Current Trends in Addiction Screening (S) 12 1 Lunch / Provider Showcase 1 2:30 Brief Interventions (BI) 3 4 Treatment (RT) 4 4:30 SBIRT Town Hall

5 Lunch Provided by: Connections in Recovery Bridges to Recovery Matrix Institute on Addictions CALGETS (Office of Problem Gambling) The Annenberg Foundation

6 What is SBIRT? Public health approach to the delivery of early intervention and treatment services for people with substance use disorders Developed by SAMHSA ~ 2004

7 What is SBIRT? Screening quickly assesses the severity of substance use and identifies appropriate level of treatment Brief Intervention increases insight, awareness and motivation toward change Referral to Treatment provides access to specialty care

8 Who is doing SBIRT? In addition to MDs Nursing Consortium of Nursing Leaders National push to put into curricula Develop competencies Social Work

9 The Value of SBIRT Makes the invisible visible Identifies a patient is in need of BI/RT; stops progression Gives providers an opportunity to educate and change at risk behaviors Can provide a wake-up call Feasible to screen in primary care

10 Since SBIRT Started ~ 2 million people screened 11% received brief intervention (BI) 6 months after BI Reductions in substance abuse, physical complaints, social and emotional difficulties

11 What SBIRT Can t Do Not likely to change behaviors of severe and complex cases Dually diagnosed Severely mentally ill Unclear how well it works with different drugs of abuse

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13 Pre - LA SBIRT Network UCLA Health System Went to electronic records Winter 2013 Goal is to treat 2 million lives Over 2,000 physicians 6 hospitals Outpatient: UCLA Medical Group >150 offices

14 LA SBIRT Network SAMHSA-funded Project (Medical Professional Training) 9/2013 8/2016 (3 years) 14 other sites nationally Training Project, not Research Project Social Work, Nursing, Medical Residencies (students and providers)

15 Goals of LA SBIRT Network Develop and Deliver SBIRT Trainings Increase adoption of SBIRT Practices Embed SBIRT Training Permanently Build Stakeholders Network Expand workforce capacity Ultimate goal of increasing SBIRT implementation and practices throughout Los Angeles

16 LA SBIRT Network Trainers: Tim Fong, Thomas Freese, Sherry Larkins, Beth Rutkowski, Joy Chudzynski, Sheryl Kataoka USC School of Social Work, UCLA School of Nursing, UCLA DGSOM, UCLA GME Council of Directors and Community Stakeholders

17 LA SBIRT Network Activities LA SBIRT Website LA SBIRT-specific training materials Evidence-based Tailored to appropriate audience Create online LA SBIRT Learning Community LA SBIRT Summit Building community partnerships

18 SBIRT Resources

19 SBIRT App (Google Play) James Bray Baylor

20 SBIRT Screening Cards

21 Will you take the SBIRT Challenge?

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23 Current Trends in Addictive Disorders Timothy Fong MD UCLA Addiction Psychiatry Fellowship UCLA Addiction Medicine Clinic LA SBIRT Network

24 National Trends > 1 million hospitalizations due to drug overdoses Drugged driving > drunk driving Marijuana use increasing 25% of hospital admissions involve complications from substance use 7% of general population require treatment for substance use disorders

25 Addiction is a Disease of the Young Compton, W. M. et al. Arch Gen Psychiatry 2007;64: Copyright restrictions may apply."

26 Deaths in America 2.4 million people die each year in the US 500,000 due to tobacco-related causes 100,000 due to alcohol-related causes 40,000 due to drug-induced causes 30,000 due to suicide

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28 DSM-5 Update

29 Definition of Terms Harmless Use At-Risk / Misuse Abuse Dependence Addiction

30 Substance-Related and Addictive Disorders Substance Use Disorder Single, dimensional condition Craving / strong desire to use (new) Legal problems removed 11 symptoms

31 Substance Use Disorder 1. is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control use. 3. A great deal of time is spent in activities necessary to obtain, or recover from its effects. 4. Craving, or a strong desire or urge to use 5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of use. 8. Recurrent use in situations in which it is physically hazardous. 9. use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: 1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. 2. A markedly diminished effect with continued use of the same amount of 11. Withdrawal, as manifested by either of the following: 1. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). 2. is taken to relieve or avoid withdrawal symptoms. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

32 Substance Use Disorder Impaired Control (1-4) larger amounts, can t cut down, spends time, craves has there has ever been a time when you had such strong urges to take the drug that they could not think of anything else.

33 Substance Use Disorder Social Impairment (5-8) Failure to fulfill obligations Social/interpersonal problems Reduced activities / given up External damage

34 Substance Use Disorder Risky Use (9) Using in hazardous situations Using despite physical or psychological harm Failure to abstain despite difficulty it is causing to your body or mind Internal damage

35 Substance Use Disorder Pharmacological Criteria (10-11) Tolerance Increased dose to achieve effect Reduced effect with usual dose Differentiate from individual sensitivity Withdrawal Occurs with decline in blood/tissue levels

36 DSM-5 Updates Added: Cannabis Withdrawal Caffeine Withdrawal Tobacco Use Disorder Moved Gambling Disorder Not Added: Hypersexual Disorders

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38 Alcohol Use Patterns 90% Have ever drank 60% Current drinkers 21% At-risk drinking 5% Abuse 4% Dependence (past year) (past year) O Malley 2014

39 Use Problems By age 18: 75% tried alcohol 60% intoxicated 1x Quantities peak in early 20s Then quantities Ongoing quantities problems Onset use to dependence ~ 15yrs 39 O Malley 2014

40 Risk Of Alcoholic Cirrhosis Alcohol Cirrhosis Odds Ratio (drinks/day) (%) for Cirrhosis Teetotaler < > > Bellentani, S. Journal of Hepatology. 2001;35:

41 Clinical assessment and diagnosis NIAAA Clinician s Guide

42 Alcohol Markers A breathalyzer in every office Urine drug screen Not routinely measured Urine monitoring Urine ETG (ethylglucuronide) Urine EtS (ethylsulfate) Blood Peth (Phosphatidylethanol)

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44 Methamphetamine vs. Cocaine Methamphetamine synthetic high lasts 8-24 hours T ½: 12 hours mechanism: mainly DA release limited medical uses Neurotoxic Cocaine plant-derived high lasts minutes T ½: 1 hour mechanism: mainly DA reuptake used medically not directly neurotoxic

45 Trends in Stimulants >8,300 meth labs seized nationally Past month use of meth has declined over the last 7 years but availability and purity are greater

46 Long-term Effects Addiction Psychosis, including: - Paranoia and delusions - Hallucinations - Repetitive motor activity Changes in brain structure and function Memory loss Aggressive or violent behavior Anxiety and mood disturbances Fatigue Severe dental problems High blood pressure Tachycardia Tachypnea Myocardial infarctions Skin lesions Stroke Dehydration Weight loss Death 46

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48 MJ Content THC : (delta-9-tetrahydrocannabinol) Resin, flowering tops, buds 1960s: 1-5% 2012: 5-10% Sensimilla : 15% ¼ of all high school students have used in past 12 months (MTF)

49 Cannabis and Psychosis Strong Association among the most frequent users Moore, THM, Zammit, S, et al, Lancet 2007; 370:319-28

50 Marijuana Trends Since 2008, perception of harm among 12 th graders has decreased (softening) Heavy MJ use <18 results in 8-point drop in IQ Establishing MJ intoxication limits Environmental impact

51 Medical Marijuana Compassionate Use Act (1996) SB 420 (2003) Establishes ID Card and regulation Explosion ( ; 439 in LA) Crackdown (2010) 2013 accepted practice /rites of passage 2014: Recreational legalization

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53 Smoking Prevalence Rates 70% 60% 50% 40% 30% 20% Smoking Rates 10% 0% MDs MI or SUD

54 Smoking in California First state to enact Tobacco control program (1988) Smoke-Free workplace (1994) Indoor smoking bans Current smoking prevalence for adults 13.3% (2008) 22.7% (1988)

55 Smoking in California 972 million packs sold per year (2011) 34 packs per adult per capita per year (2011) 2 nd lowest state consumption of cigarettes (Utah #1) #1 source of litter

56 1-800-NO-BUTTS Self-help materials, referral to local programs, and one-on-one, telephone counseling to quit smoking minute initial counseling Up to 6 follow-up sessions Doubles a smoker s chances of successfully quitting. 6 languages (English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese)

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59 Abused Opiates Prescription Pills Heroin

60 Opioid Sales, Deaths & Addiction Treatment National Vital Statistics System, ; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), ; Treatment Episode Data Set,

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62 Opioid Trends Since 2007, increase in the number of past-year heroin use (~669K) 80% of heroin initiates used prescription opiates previously More deaths from OD than MVA Emerging use of opioid toolkits (should it be standards of practice?)

63 Synthetic Designer Drugs

64 Synthetics MTF Survey of 12 th Graders (2011) 8 % used synthetic cannabinoids 1% used synthetic cathinones No urine drug testing Several high profile media reports

65 Emerging Synthetics Synthetic Cannabinoids K2, Spice Synthetic Cathinones Bath Salts Synthetics Hallucinogens 2-C, NBOMe

66 Cannabis vs. Synthetic Cannabinoids Most symptoms are similar to cannabis intoxication: Tachycardia Reddened eyes Anxiousness Mild sedation Hallucinations Acute psychosis Memory deficits Symptoms not typically seen after cannabis intoxication: Seizures Hypokalemia Hypertension Nausea/vomiting Agitation Violent behavior Coma SOURCES: Hermanns-Clausen et al. (In Press), Addiction; Rosenbaum et al. (2012). Journal of Medical Toxicology; Forrester et al. (2011). Journal of Addictive Disease; Schneir et al. (2011). Journal of Emergency Medicine. 66

67 Synthetic Cathinones vs. Classic Stimulants Mephedrone originally thought to be more like MDMA than amphetamine but dopamine release more like amphetamine à greater abuse liability In and out of brain faster than MDMA à greater potential for repeated binge use MDPV: greater self-administration than even MA SOURCE: Doris Payer, #CHSF

68 Gambling Disorder (Pathological Gambling)

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70 California Prevalence Study (2005) n=7,121 respondents, 18 years and older Problem gambling 2.2% Pathological gambling 1.5% ~1,000,000 problem/pathological cases Highest Risk: African-Americans, Disabled, Unemployed

71 1-800-GAMBLER problemgambling.ca.gov

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73 Consequences of Pathological Gambling Financial Ave. debt = $45,000 Relationships Time Crime Substance use disorders Medical Divorce, child abuse 25 hrs/wk Non-violent 4x risk Worse health

74 Office of Problem Gambling

75 Contact Information Timothy Fong MD UCLA Addiction Medicine Clinic (appts) (office) uclagamblingprogram.org

76 Referring Patients to Effective Addiction Treatment Timothy Fong MD UCLA Addiction Psychiatry Fellowship UCLA Addiction Medicine Clinic

77 2M people (0.8%) receiving treatment* 21M people (7%) have problems needing treatment, but not receiving it* 60-80M people ( 20-25%) using at risky levels US Popula*on: 307,006,550 US Census Bureau, PopulaLon Division July 2009 eslmate *NSUDH, 2008

78 How do I find an effective addiction treatment program?

79 The Referral Process Assisting a patient with accessing specialized treatment Navigate treatment barriers such as cost or lack of transportation. The manner in which a referral is provided can have tremendous impact on whether the client shows up!

80 Referral to Treatment: Keys Accessible Location Culturally Financially Availability Effective / Credible

81 Classic Method Give handout Refer to Social Work Tell patient to go to AA Tell patient to google it Refer to programs that you know

82 Newer Methods Psychology Today Facebook Groups Addiction Professionals Group Mental Health Professionals Group Addiction Professionals Networking Group Yelp Craigslist Angie s List

83 Professional Organizations AAAP Membership Directory CSAM Membership Directory SAMHSA Treatment Locator California ADP Website APA Membership Directory

84 What should patients and referring providers look for in a treatment program?

85 Addiction Treatment Settings Office-based Intensive Outpatient Partial Hospital Program Detox Program (Inpatient) Residential Treatment Settings

86 Licensure vs. Certifications The Department of Health Care Services provides licenses when programs: detoxification, group sessions, individual sessions, educational sessions, or alcoholism or drug abuse recovery or treatment planning. DHCS also provides certifications to programs exceeded minimum levels of quality

87 Treatment in California Nearly 500 SUD treatment programs in LA County alone (DHCS licensed) Unlicensed organizations Private practitioners Non-profit organizations Academic center Religious and spiritual organizations

88 Psychosocial Treatments Residential Treatment Programs (30- day) Intensive Outpatient Programs Family Treatment Individual Counseling 12-step support

89 A quick word on Sober Living Homes House does not provide treatment services on site No structured schedule is required Non-licensed Not subject to regulation or oversight Can be the foundation place of recovery

90 Examples of How Referrals to Treatment Work

91 The Warm Hand-Off From some of your answers on this questionnaire, it looks as if you may be feeling down lately. I have a colleague who I work with who can give you some ideas of ways to help with this. Her/His office is just down the hall, is it okay with you if my nurse walks you there after we are done so you can talk for a minute?

92 Improving the Referral Process Same-day appointments Automatically scheduling appointments with a treatment specialist PRIOR to discharge UC Tobacco Automatic Referral Call from NO-BUTTS Incentives to complete referrals

93 After the referral is made, what should be expected?

94 What Works in Office-Based Treatment Individualized treatment plans Biopsychosocial approach FDA-approved meds Evidenced-based psychotherapies Prescription Drug Monitoring Programs Improving health care education Proper disposal methods

95 What Doesn t Work Non-compliance with recommendations Lack of monitoring No urine drug testing Not using meds in conjunction with full menu of recovery services Off-label use without scientific evidence

96 A sample of Evidence-Based Treatments Matrix Model Motivational Interviewing Relapse Prevention Therapy Cognitive-Behavioral Therapy Contingency Management 12-Step Facilitated Groups

97 FDA-Approved Medications Drugs of Abuse Brand Name Generic Name Alcohol Antabuse Disulfiram Vivitrol Naltrexone Revia Campral Naltrexone Acamprosate

98 FDA-Approved Medications Drug of Abuse Brand Name Generic Name Nicotine Nicotine Replacement Therapies Chantix Patches, Lozenge, Inhalers, Gums Varenicline Zyban Bupropion

99 FDA-Approved Medications Drug of Abuse Brand Name Generic Opiates Suboxone Subutex Buprenorphine Methadone Revia Vivitrol Naltrexone Naltrexone

100 FDA-Approved Medications Addictive Disorder Brand Name Generic Name Cocaine - - Methamphetamine - - Marijuana - - Gambling - - Behavioral Addictions - -

101 On the horizon... Medication-assisted treatment in ACA programs / clinics CBT 4 CBT (online therapy) Smartphone apps Integrated treatment systems (financial, legal, social, companionship)

102 Reimbursement for SBIRT CPT (Commercial Insurance) ($33) Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes ($65) >greater than 30 minutes

103 SBIRT Documentation Positive screening by a standardized SUD screening tool Document time spent discussing use Document where referral was made to and medically necessary reasons why Document at next visit whether or not client completed referral and, if not, why not.

104 UCLA Health Programs Hospital-Based Ronald Reagan Medical Center Resnick Neuropsychiatric Hospital No dedicated detox facility Resnick Partial Hospital Program No formalized Addiction Consultation Hospital Service (yet)

105 UCLA Health Programs Intensive Outpatient Programs UCLA Dual Diagnosis Program Matrix Institute on Addictions UCLA Freedom from Smoking

106 UCLA Health Programs Office-Based / Outpatient UCLA Addiction Medicine Clinic Center for Behavioral Medicine UCLA Addiction Physicians UCLA Behavioral Health

107 Other Ways to Find Addiction Treatment SAMHSA Treatment Locator HELP NIDA Clinical Trials Network American Academy of Addiction Psychiatry American Society of Addiction Medicine

108 Further Reading National Institute on Drug Abuse National Institute on Alcoholism American Academy of Addiction Psychiatry Substance Abuse and Mental Health Service Administration

109 Contact Information Timothy Fong MD UCLA Addiction Medicine Clinic (appts) (office) uclagamblingprogram.org

110 SBIRT Town Hall

111 SBIRT Issues to Ponder Which patient groups respond best to SBIRT? How do clinics implement SBIRT? Which addictive disorders respond to SBIRT practices? How important is training, how much training is necessary?

112 LA SBIRT Network Wishlist Boost online community LA SBIRT Podcasts / Newsletters Link up providers and groups Secure diverse source of funding Highlight SBIRT implementers and innovators

113 Where we go from here: Track SBIRT Implementation What / where are the treatment needs? Document those gaps and needs Establish permanent training curriculum and culture Contact us if you want SBIRT training!

114 Thank You and Evaluations, Please For Further Information and to Request additional SBIRT Training: