Mass General s Substance Use Disorder Initiative

Transcription

1 Mass General s Substance Use Disorder Initiative Martha Kane, PhD Sarah Wakeman, MD, FASAM Clinical and Medical Directors, Mass General Hospital Substance Use Disorder Initiative

2 None Disclosures

3 Objectives Understand substance use disorder as a chronic illness Describe effective treatment for substance use disorder Review Mass General s response to the current opioid use disorder & other SUD crisis

4 Initial State Limited benefit from current treatment models High acuity, med + psych + substance dx Limited success in treatment outcome Lack of integrated treatment options, limited evidence based care Significant social needs unmet (social determinants of health) Care is poorly coordinated, short term focus, in silos with limited communication Challenge: How can current models be modified to address needs and break the cycle? 4

5 Drug overdoses now leading cause of death for Americans under 50

6 National Opioid-Related Inpatient Hospitalizations and ED Visits

7 Prevalence of Substance Use Disorder SAMHSA National Survey on Drug Use and Health. Retrieved from

8 As we have seen repeatedly in the history of medicine, science is one of the strongest allies in resolving public health crises. Ending the opioid epidemic will not be any different.

9 Understanding Addiction The question is frequently asked: Why does a man become a drug addict? The answer is that he usually does not intend to. Junk wins by default. I tried it as a matter of curiosity. I drifted along taking shots when I could score. I ended up hooked. You don t decide to be an addict. One morning you wake up sick and you re an addict. William S. Burroughs, Junky (1953)

10 Natural History of Opioid Use Disorder Using to feel good Needing to use more to feel normal Using to keep from getting sick

11 When you can stop you don't want to, and when you want to stop, you can't. Luke Davies, Candy

12 A Disease of Gene-Environment- Development Biology Genes/Development Environment DRUG/ALCOHOL Brain Mechanisms Slide courtesy of Dr. Compton, NIDA Addiction

13 Addiction Primary, chronic brain disease characterized by compulsive drug seeking and use despite harmful consequences Involves cycles of recurrence and remission 40-60% genetic American Society of Addiction Medicine. April 12, NIDA. August,

14 Substance Use Disorder Changes Brain Structure and Function Decreased Heart Metabolism in Coronary Artery Disease High Decreased Brain Metabolism in Substance Use Disorder Healthy heart Diseased Heart Low Healthy Brain Diseased Brain Slide Courtesy of NIDA

15 Volkow et al. J. Neurosci., December 1, 2001, 21(23): Visualizing Recovery

16 A Treatable Disease NIDA. Principles of Drug Addiction Treatment McLellan et al., JAMA, 284: , 2000.

17 What is Effective Treatment? Pharmacotherapy Recovery Supports Psychosocial Interventions

18 Similar to Management of Diabetes No cure Goal is euglycemia and prevention of acute and chronic complications Individualized treatment plans and targets Treatment includes: Medication Lifestyle changes Regular monitoring for complications Behavioral support

19 Short-term Detoxification Ineffective Chutuape et al. Am J Drug Alcohol Abuse Feb;27(1):19-44.

20 What is Effective Treatment? Buprenorphine Maintenance 75% retained in treatment 75% abstinent by toxicology Detoxification 0% retained in treatment 20% died Kakko et al. Lancet Feb 22;361(9358):662-8

21 Treatment Retention Higher Sees et al. JAMA. 2000;283(10):

22 Mortality Decreased All cause mortality rates (per 1000 person years): In methadone treatment: 11.3 Out of methadone treatment: 36.1 In buprenorphine treatment: 4.3 Out of buprenorphine treatment: 9.5 Overdose mortality rates: In methadone treatment: 2.6 Out of methadone treatment: 12.7 In buprenorphine treatment: 1.4 Out of buprenorphine treatment: 4.6 Sordo et al. BMJ 2017;357:j1550

23 Treatment Selection: Belief versus Science We as a society think [people with addiction] should just get off drugs and by strenuously hauling up on their own bootstraps should stay off no matter what. Policymakers and some clinicians continue to promote detoxification as treatment, even though detoxification does nothing to help people stay off drugs. Ling W. J Neuroimmune Pharmacol (2016) 11:

24 Medications for Addiction Treatment Work

25 Long-term Treatment In most cases, treatment will be required in the long term or even throughout life. Such long-term treatment, common for many medical conditions, should not be seen as treatment failure, but rather as a costeffective way of prolonging life and improving quality of life, supporting the natural and long-term process of change and recovery. World Health Organization

26 Hospitals Have Opportunity to Initiate Treatment Initiating methadone in hospital: 82% present for follow-up addiction care Buprenorphine vs. detox among inpatients: Bupe: 72.2% enter into treatment after discharge Detox : 11.9% enter treatment after discharge Buprenorphine vs. referral in ED: Bupe: 78% engaged in treatment at 30 days Referral: 37% engaged in treatment at 30 days J Gen Intern Med. Aug 2010; 25(8): ; JAMA Intern Med 2014 Aug;174(8): ; D'Onofrio et al. JAMA 2015 Apr 28;313(16):

27 A Monumental Lost Opportunity USE n-research/reports/national-survey- primary-care-physicians-patients-

28 SUDs Initiative Mission To improve the quality, clinical outcomes and value of addiction treatment for all MGH patients with SUD. To accomplish this mission, patients must have access to evidence based treatment that is readily available and standardized across the system.

29 Solution: Modify treatment structure and approach Decision Support: Decision support tools Evidence based guidelines Care Delivery System: Treatment on demand access to evidence based treatment MAT Evidence based Behavioral Health tx Psychopharmacology Relapse expected, treated Chronic Care Model HIV/AIDS Self-Management/Community Involvement: Patient centered care, patient driven Peer based services integrated into all levels of care Effective linkage to non-medical supports Navigation services - connection, connection, connection Clinical Information Systems: Registries Outcomes measured Treatment plans modified based on outcomes 29 29

30 Developing a True Continuum of Care Recovery Coaches Inpatient (ACT) Bridge Clinic Outpatient Community Prevention, Education & Evaluation

31 An Example of a Health System Response Inpatient Addiction Consult Team Outpatient Addiction Champion Teams The MGH Substance Use Disorder Initiative Urgent Bridge Clinic Recovery Coaches

32 1 Among patients with SUD Dx code on floors where ACT available; Controlled for type of substance, gender, age 2 remained statistically significant in intention-to-treat analysis and after controlling for age, gender, employment status, smoking status, and baseline days abstinent (p=0.02) Patients Seen by Addiction Consult Team Have Lower Readmission Rates, Increased Abstinence ACT Consults: 3815consults on 2563 patients 32% involved opioids 70% male, mean age Change in Days Abstinent Intervention Patients seen by ACT have lower 30-day readmission (14.6% vs 17.7%) Initial 30 Day Follow-Up

33 Bridge Clinic Provided 4,039 On Demand Visits for 459 Patients Flexible model crucial: 50% visits not scheduled ahead Support for ED, providing same day or next day medication for OD patients; served 55 patients to date Expanding to 7 day/wk coverage For recent inpatients, 10.4% readmitted within 30 days Overall, 16% of Bridge Clinic patients had subsequent inpatient stay, 33% had ED visit

34 Outpatient: Transforming Care In 8 health center/primary care practices Multidisciplinary SUDs champions teams, risk rounds 38 physicians waivered to prescribe buprenorphine in CHCs 546 patients currently receiving buprenorphine treatment in CHCs Behavioral health services Embedded in PCP practices Expanded behavioral health capacity via training for existing staff Treatment for family members 34

35 Patients with Recovery Coaches Have Fewer Inpatient Admissions 10 Recovery Coaches and 1 Recovery Coach manager 1028 patients touched 10% reduction hospitalizations, increase in primary care & MH visits Patients report Improved patient experience Facilitated access to social services Ongoing social support

36 Improving Quality of Life If you think you're going to have a bad day, the best thing is try to get [the coach] first and then say, Look, I'm having a bad day. Is it possible you could come and sit in with me? Patient I guess she [recovery coach] has family who has gone through, who had endocarditis and stuff, so I felt a sense of relation that opened the door that I don't feel with the doctors. Patient Had my first overdose after 20 years of IV drug use. I can describe my thought and feelings, after being saved by narcan in one word along grateful! This medication/drug is saving lives. Thank God. God bless. Keep the faith. Today is my birthday and I have received the best present ever... Another chance at life. So grateful for my family, so grateful for my health, so grateful for this program [Bridge Clinic]. And a grateful heart will never relapse. -Patient

37 What s Next? Extending model to new settings: Pediatrics: Champions Embedded BH care Family care Oncology Tumor Board for SUD Enhanced psychiatric services OB/GYN HOPE Clinic Review of rules about reporting Extending access: Bridge Clinic open 7 days/week Inpatient Addiction Consult support available 24/7 37

38 What s Next? Continued integration throughout primary care IMA, BMG Recovery coaches, multidisciplinary clinical rounds Education and Support Training for Buprenorphine waiver Mentoring for new Buprenorphine prescribers Professional Training Addiction Medicine fellowship CARN 38