Relapse Sensitive Care: Changing Systems of Addiction Treatment Stacey C. Conroy LICSW, MPH Richmond VA Medical Center - Supervisory Social Worker Mental Health & Substance Abuse 1
Stacey C. Conroy LICSW, MPH, Disclosures Stacey C. Conroy LICSW, MPH, has no financial relationships to disclose. The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information. 2
Planning Committee, Disclosures AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this module to disclose: PCSSMAT lead contributors Frances Levin, MD and Adam Bisaga, MD; AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; AMERSA staff and faculty Colleen LaBelle, BSN, RN-BC, CARN, Doreen Baeder and AAAP Staff Kathryn Cates-Wessel, Miriam Giles and Blair Dutra. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers will inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3
Accreditation Statement American Academy of Addiction Psychiatry (AAAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. 4
Designation Statement American Academy of Addiction Psychiatry designates this enduring material educational activity for a maximum of one (1)AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity. Date of Release: March 15, 2016 Date of Expiration: March 15, 2019 5
System Requirements In order to complete this online module you will need Adobe Reader. To install for free click the link below: http://get.adobe.com/reader/ 6
Target Audience The overarching goal of PCSS-MAT is to make available the most effective medication-assisted treatments to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings. 7
Educational Objectives At the conclusion of this activity participants should be able to: Identify 2 factors that contribute to supporting a Relapse Sensitive Care model of addiction treatment Assess current practice for relapse sensitive care concepts Develop an action plan to implement relapse sensitive care in current practice Discuss Quality of Life as a potential Outcome Measure for addiction treatment 8
Treatment Completion Matters to Outcomes Patients who completed the treatment program used significantly fewer psychiatric inpatient bed days of care the year after they completed the program, both in comparison to their own prior use and in comparison to program dropouts. Graduates were more likely to be abstinent and less likely to fully relapse or be incarcerated at 6- month follow-up. Wallace, A.E. & Weeks, W.B. (2004). Substance abuse intensive outpatient treatment: Does program graduation matter? Journal of Substance Abuse Treatment, 27-30. 9
Seeking But Not Completing Treatment 56% of those who seek treatment do not complete treatment: Treatment completed: 44 percent Dropped out: 26 percent Transferred for further treatment: 15 percent Terminated by facility: 7 percent Other: 5 percent failed to complete for other reasons Incarcerated: 2 percent Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2011. Discharges from Substance Abuse Treatment Services. BHSIS Series S-70, HHS Publication No. (SMA) 14-4846. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 10
Changing how Addiction is viewed We would hope that the days are numbered in which the addictions field can argue that addiction is a primary health care problem while its clinicians continue to treat the primary symptoms of addiction as bad behavior subject to disciplinary discharge. White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006) It s time to stop kicking people out of treatment. Counselor. 11
A Few Common Administrative Discharge Reasons Failing to participate in service activities, e.g., missing counseling sessions. Possessing contraband in the treatment facility (e.g., illicit drugs, cigarettes, prohibited food items). Using alcohol or non-prescribed drugs. Failing to secure medication for a psychiatric condition. White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006) It s time to stop kicking people out of treatment. Counselor. 12
Honesty What has OR does honesty about relapse lead to? Who created the liars in addiction treatment? Hint: It was Us the providers What incentive do patients have to be honest if discharge is the outcome? 13
Relapse Sensitive Care (RSC) A systemic philosophy of care with the goal of maintaining an individual in addiction treatment to enhance the potential for sustained recovery. In certain settings this systemic philosophy of care can be expanded to encompass an individuals definition of recovery with outcomes based on quality of life and not solely on abstinence. 14
Something New Recovery Orientated Systems of Care Development of Network of Community Base Services Fully implemented in a few places May be abstinence based with standard rate of administrative d/c due to substance use Traditionally Abstinence Based Relapse Sensitive Care Development of Internal and External Recovery Supports Single Agency Can be implemented in any size agency or practice Motivational/Values/ Quality-of-Life Based Chronic Disease Management Harm Reduction Often one component of larger agency Restrictions on implementation due to public opinion Does not require that the behavior with the negative outcome stops, simply finds a safer way to engage in behavior while motivation for change develops Public Health / Safety 15
Consider Relapse Sensitive Care Multiple opportunities to engage in treatment, stopping the revolving door of multiple treatment episodes Increase in recovery supports following a relapse while remaining in treatment (not a discharge and referral model) Explores additional measure of treatment success i.e. Quality of Life (QoL) Measures Traditional Care One strike on substance use often leads to discharge Decreases recovery supports through discharge often when a patient relapses they leave treatment which may include loss of housing, emotional supports, freedom due to legal issues Urine Drug Screen is most common measure of treatment success 16
Addiction Behavior or Biology Disease Model of Addiction Not as New as People Think 17
Patients to be Treated 1784 - Dr. Benjamin Rush s Inquire into the effects of Aberrant Sprits on the Human Mind and Body argued that this condition is a disease that physicians should be treating 1810 - Dr. Rush calls for the establishment of a Sober House to care for the confirmed drunkard 1891-1892 - Keeley League Laws must realize a leading fact: Medical not penal treatment reforms the drunkard. White, W. (1998) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington IL: Chestnut Health Systems 18
Public Health Issue 1944 - Marty Mann founds the National Committee for Education on Alcoholism (today the National Council on Alcoholism and Drug Dependence) around the following propositions: 1. Alcoholism is a disease. 2. The alcoholic, therefore, is a sick person. 3. The alcoholic can be helped. 4. The alcoholic is worth helping. 5. Alcoholism is our No. 4 public health problem, and our public responsibility. White, W. (1998) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington IL: Chestnut Health Systems. 19
Specialty Medicine 1954 - Ruth Fox, MD establishes the New York City Medical Society on Alcoholism, today known as the American Society of Addiction Medicine (ASAM). 1967 - The American Medical Association passes resolution identifying alcoholism as a "complex" disease and a "disease that merits the serious concern of all members of the health professions." 1967 - The New York Medical Society alters its mission to become the American Society on Addiction Medicine. White, W. (1998) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington IL: Chestnut Health Systems. 20
Development of Medications Diseases are treated with medications: Methadone 1947 in powder form for compounding; 1973 tablet for suspension; 2010 solution oral Disulfiram (Antabuse) 1951 Buprenorphine,(Suboxone, Subutex) 2002 Acamprosate (Campral) 2004 XR-Naltexone (Vivtrol) 2006 FDA/Center for Drug Evaluation and Research Office of Communications Division of Online Communications Update Frequency: Daily www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=search.search_drug_name 21
Neuroscience Of Cue Induced Relapse AND Reinstatement in Animal Studies 22
Drug Related Cue Literature Review These drug-related cues may be: Visual (seeing words, pictures or silent videos) Auditory (e.g., listening to imagery scripts) Audiovisual (combination of sights and sounds) Tactile or haptic (handling the corresponding paraphernalia) Olfactory or gustatory (smelling or tasting the substance) Increasingly often, multi-sensory drug cues are also employed (e.g., holding a cigarette while watching audiovideos of smoking) Induced Neuroadaptations in the Nac camp second messenger system in relapse Jasinska A.J., Stein E.A.,,Kaiser J.,,Naumer M.J., Yalachkov Y. (2014). Factors modulating neural reactivity to drug cues in addiction: A survey of human neuroimaging studies. NeurosciBiobehavRev 38:1 16. 23
Relapse is Biological Each of these reinstatement relapse concepts has been reproduced in animal studies absent of human psychosocial stressors Discrete cue-induced reinstatement Context-induced reinstatement Discriminative cue-induced reinstatement Reinstatement model Bossert et al, (2013) The reinstatement model of drug relapse: recent neurobiological findings, emerging research topics transitional research. Pharmacology 229: 453-476. 24
History, Medicine, and Neuroscience Are Telling Us The messages outward are that: The client is not in control of their alcohol and/or drug intake or its consequences. The client needs professional treatment to reacquire such control. Reacquisition of control over [Alcohol & Other Drugs] AOD use/nonuse decisions takes time and may be preceded by one or more episodes of relapse. Long-term recovery is best supported by patience and support rather than punishment and abandonment. White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006) It s time to stop kicking people out of treatment. Counselor. 25
Back to Honesty Relapse Sensitive Care What would it be like if a patient were honest and remained in treatment following a relapse? How could we support them in their recovery process? Do we know our internal and external sources of recovery supports? 26
Relapse Sensitive Care How to Start Changing a System: Change Can Be Challenging For Patients AND Staff 27
Begin with Assessment of Current Policies and Procedures What happens in our system, facility, or practice if a patient has a positive urine drug screen? d/c? d/c with referral often a requirement for state funded treatment programs? Maintained in treatment with a consequence and support for ongoing treatment? Maintained in treatment with increase in recovery supports? What research supports our current policies and procedures? 28
Recovery Supports Addiction treatment and recovery support services have repeatedly been shown to be effective with many people achieving recovery. As with any chronic disease, however, discrete treatment episodes, supported by continuing recovery support services, are often needed to help people achieve and maintain recovery. Treatment for addictive disorders is not typically a oneshot type of intervention. Kaplan, L., The Role of Recovery Support Services in Recovery-Oriented Systems of Care. DHHS Publication No. (SMA) 08-4315. Rockville, MD: Center for Substance Abuse Services, Substance Abuse and Mental Health Services Administration, 2008. 29
Identify Internal Recovery Supports Do you have groups? Individual counseling? Do you have on site 12 step meetings? Do you have peer mentors? What is your time frame for the additional supports to assist the recovery process? 14 days, 30 days? Recovery supports will not resolve a relapse over night what is the time frame in which change is anticipated? 30
Identify External Recovery Supports Do you have the ability to refer to other providers of group or individual counseling? Will you maintain treatment until referral provider establishes and begins to implement a treatment plan? Can you provide 12 step meeting list? Do you have the ability to explain types of meetings, benefits of meetings, how to utilize meetings, along with explaining the role of sponsors? It is one thing to give a referral or send to meetings, it is another to facilitate the referral with warm handoff 31
Educational Needs What education will be needed to implement Recovery Sensitive Care philosophy within our System of care? 32
First Level of Education Easy to implement (example): Pleasure Unwoven: inexpensive DVD outlining historical and modern concepts of calling addiction a disease staff and patients Increases discussion on the realities why relapse happens despite honest desire for recovery Increases understanding of the biological aspect of addiction and why someone may relapse while in treatment Increase understanding that RSC is part of a disease model of care for a chronic condition McCauley, Kevin (producer) (2009). Pleasure Unwoven: a personal journey about addiction. (DVD) Institute for Addiction Study. 33
Second Level Education Longer implementation process: Basic facts on neuroscience and relapse - reinforce the need for behavioral and social recovery supports to achieve desired recovery Why do I need 12 step meetings Behavioral supports will assist when cravings come from a cue induced response you may not be aware of Why is MAT a good option for my recovery While developing the behavioral and social supports for recovery MAT can assist in reducing neurological triggers for relapse which are a biological occurrence. o Behavioral support will remain important if addiction has been to multiple substances 34
Connecting Old and New Concepts for 12 step concepts are well established connecting traditional learning to newer neuroscience concepts may enhance the buy-in for having RSC in place People Places Things Staff and Patients Cue induced drug-seeking and or craving o Visual, audio, multisensory Cue induced drug-seeking and or craving o Visual, audio, olfactory multisensory Stress induced drug-seeking and or craving o Visual, audio, olfactory, multisensory 35
Provider Role We often know if a patient is a frequent flyer -what do we offer this patient? How do we as providers adjust treatment for the at-risk patient? Bill Wilson, co-founder of Alcoholics Anonymous, and Marty Mann, founder of the National Council on Alcoholism and Drug Dependence, were both treatment recidivists (ten prior treatments between them before finding sobriety). White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006) It s time to stop kicking people out of treatment. Counselor. 36
Change is a Process for Treatment Providers MAT treatment was once considered to be outside of the mainstream of addiction treatment- though in recent years it has gained wider acceptance as Evidence Based Practice. Relapse Sensitive Care may be the Next Change keeping those who seek treatment engaged to improve outcomes. BUT what constitutes a desired Outcome? 37
Outcomes? If Negative Urine Drug Screens is Not the Outcome Measure then What Is? Quality of Life QoL 38
Quality of Life as a Recovery Outcome SAMHSA has established a working definition of recovery that defines recovery as a process of change through which individuals improve their health and wellness, live selfdirected lives, and strive to reach their full potential. Recovery is built on access to evidence-based clinical treatment and recovery support services for all populations. SAMHSA's Working Definition of Recovery Pub id: PEP12-RECDEF, Publication Date: 2/2012, Format: Brochure SAMHSA s Working Definition of Recovery 2012. 39
Quality of Life as Treatment Outcome Mitchell et al (2015) Measures Findings were statistically significant (all ps <.001). Continued treatment enrollment was significantly associated with improved psychological, environmental and social aspects 6 months into treatment Quality of Life measure (QoL) Overall improvement Psychological Environmental Social Change at six month follow up during treatment 10.8% increase 7.6% increase 8.5% increase 11.2% increase Mitchell, S.G., Gryczynski, J., Robert P. Schwartz, R.P., Myers, C.P., O Grady, K.E., Olsen, Y.K., & Jaffe, J.H. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use, Journal of Psychoactive Drugs, 47:2, 149-157. 40
QoL as treatment outcome measure Dhawan, A., & Chopra, A. (2013) Examined QoL scores: Continued treatment enrollment was associated with significant increases in four Quality of Life measures at 9 months, including the physical, social, psychological and environmental QoL domains. (p<.001) QoL measure Baseline data 9 month follow up during treatment Physical 50.3 61.3 Social 45.8 56.2 Psychological 43.6 57.9 Environmental 42.3 54.3 Dhawan, A., & Chopra, A. (2013). Does buprenorphine maintenance improve the quality of life of opioid users? The Indian Journal of Medical Research, 137(1), 130 135. 41
QoL and Evidenced Based Practices Outcome data from a Quality of Life measure can be incorporated into SAMHSA Evidence Based Practices: Motivational Interviewing: Reviewing readiness and confidence scales with patients in context of QoL measures during treatment Acceptance and Commitment Therapy: Focusing on valued direction in life, psychological flexibility energies/tasks moving you towards QoL, towards your valued outcomes Miller, W. R., and Rollnick, S. (2013) Motivational Interviewing: Helping people change (3 rd ed.). New York, NY: Guilford Press. Wilson, K.G. and DuFrene, T. (2012) The wisdom to know the difference an acceptance and commitment therapy workbook for overcoming substance abuse. Oakland, CA: New Harbinger Publications. 42
Safety Matters Medical based safety will still need to be considered especially in MAT. Drug interactions or potential for accidental OD Discharging a patient for reason other than medical safety should be done only after several attempts to engage them in treatment have been made o This includes barrier identification to maintaining recovery o Naloxone OD prevention recourses for every discharge based on medical safety 43
Safety Matters Residential program may consider RSC in context of type of relapse: In the community vs. bring drugs/alcohol into the program o Returning to the program under the influence is a symptom and not the equivalent to bringing drugs/alcohol into the program An assault is a legal issue and constitutes a choice to end treatment 44
Summary Relapse Sensitive Care: Supported by Disease Model Supported by Neuroscience which provides evidence on biological reasons for relapse Treatment engagement, not punitive measures for return of biological-based symptoms Supports the SAMHSA definition of recovery which includes, health, wellness, and self determination Supports Quality of Life as an outcome rather than solely on negative urine drug screens 45
Summary Relapse Sensitive Care Implementation: Assessment of current policies and procedures Current recovery support resources Internal and external Education Patients and Staff Incorporating Quality of Life as on outcome measure QoL patient data incorporated into EBPs 46
References Bossert et al, (2013) The reinstatement model of drug relapse: recent recent neurobiological findings, emerging research topics transitional research. Pharmacology 229: 453-476. Dhawan, A., & Chopra, A. (2013). Does buprenorphine maintenance improve the quality of life of opioid users? The Indian Journal of Medical Research, 137(1), 130 135. FDA/Center for Drug Evaluation and Research Office of Communications Division of Online Communications Update Frequency: Daily www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=search.search_drug_name Jasinska A.J., Stein E.A.,,Kaiser J.,,Naumer M.J., Yalachkov Y. (2014). Factors modulating neural reactivity to drug cues in addiction: A survey of human neuroimaging studies. NeurosciBiobehavRev 38:1 16. Kaplan, L., The Role of Recovery Support Services in Recovery-Oriented Systems of Care. DHHS Publication No. (SMA) 08-4315. Rockville, MD: Center for Substance Abuse Services, Substance Abuse and Mental Health Services Administration, 2008. McCauley, Kevin (producer) (2009). Pleasure Unwoven: a personal journey about addiction. (DVD) Institute for Addiction Study. 47
References Miller, W. R., and Rollnick, S. (2013) Motivational Interviewing: Helping people change (3 rd ed.). New York, NY: Guilford Press. Mitchell, S.G., Gryczynski, J., Robert P. Schwartz, R.P., Myers, C.P., O Grady, K.E., Olsen, Y.K., & Jaffe, J.H. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use, Journal of Psychoactive Drugs, 47:2, 149-157. SAMHSA's Working Definition of Recovery Pub id: PEP12-RECDEF, Publication Date: 2/2012, Format: Brochure SAMHSA s Working Definition of Recovery 2012. Self, D. W.; Nestler, E. J. (1998) Relapse to drug-seeking: neural and molecular mechanisms. Drug and alcohol dependence 51: 49-60. Shannon Gwin Mitchell Ph.D., Jan Gryczynski Ph.D., Robert P. Schwartz M.D., C. Patrick Myers M.A., Kevin E. O Grady Ph.D., Yngvild K. Olsen M.D. & Jerome H. Jaffe M.D. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use, Journal of Psychoactive Drugs, 47:2, 149-157. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 48
References Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2011. Discharges from Substance Abuse Treatment Services. BHSIS Series S-70, HHS Publication No. (SMA) 14-4846. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Wallace, A.E. & Weeks, W.B. (2004). Substance abuse intensive outpatient treatment: Does program graduation matter? Journal of Substance Abuse Treatment, 27, 27-30. White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006) It s time to stop kicking people out of treatment. Counselor. White, W. (1998) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington IL: Chestnut Health Systems. Wilson, K.G. and DuFrene, T. (2012) The wisdom to know the difference an acceptance and commitment therapy workbook for overcoming substance abuse. Oakland, CA: New Harbinger Publications. 49
PCSS-MAT Mentoring Program PCSS-MAT Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction. PCSS-MAT Mentors comprise a national network of trained providers with expertise in medication-assisted treatment, addictions and clinical education. Our 3-tiered mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available, at no cost to providers. For more information on requesting or becoming a mentor visit: pcssmat.org/mentoring 50
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PCSSMAT is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society of Addiction Medicine (ASAM) and Association for Medical Education and Research in Substance Abuse (AMERSA). For More Information: www.pcssmat.org Twitter: @PCSSProjects Funding for this initiative was made possible (in part) by Providers Clinical Support System for Medication Assisted Treatment (5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, 52 commercial practices, or organizations imply endorsement by the U.S. Government.
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