integrated substance use disorder treatment program overview · 2021. 4. 4. · ‐completes...
TRANSCRIPT
Road To Recovery
Integrated Substance Use Disorder Treatment Program Overview
Donna Kalauokalani, MD, MPHDeputy Medical Executive
Complex Patient Populations
Board of Parole Hearings TrainingApril 21, 2021
Objectives
Understand SUD as a Disease
Mission of the Department & ISUDT Program Goals
Recognize Major Components & Staffing of ISUDT Program
Describe Populations Served
Why Care About Addiction?
Big Problem Nationally 21 Million in US suffer from an Addiction 70,000 Overdose Deaths in 2019 & Climbing
Big Problem Locally # 1 Cause of Injury‐Related Death
Huge Problem for CDCR Affects Majority of People Incarcerated
Definition of Addiction
Addiction is a disease of the brain circuitry involved with reward, motivation, and memory characterized by: Compulsive Use Despite Harms To Self & Others Dysfunctional Emotional Responses/Judgement/Decision Making Cycles of Relapse and Remission Without Treatment Can Progress to Disability or Premature Death
Effective Treatment is Available
Medication Assisted Treatment (MAT) for OUD
•Reduce Overdose Deaths•Reduce Illicit Drug Use•Reduce Criminal Activity• Increase Retention in Treatment• Improve Health and Lower Healthcare Costs
CDCR Mission
To facilitate the successful reintegration of the individuals in our care back to their communities equipped with the tools to be drug‐free, healthy, and employable members of society by providing education, treatment, rehabilitative, and restorative justice programs, all in a safe and humane environment.
Goals:Save Lives, Improve Life
Staff Satisfaction/Retention
Support Personal/Public Safety
Reduce Recidivism
Avoid Unnecessary Costs/Better ROI
Promote Healthy Families/Communities
ISUDT Program
Major Components of ISUDT Program
Screening ‐ NIDA Quick Screen
Assessment ‐ NIDA Modified Assist +/‐ ASAM Criteria
Treatment ‐ Behavioral, Pharmacologic, Supportive Housing
Transition Services ‐ Connection to Community Resources
Screening - NIDA Quick Screen
Assessment - NIDA Modified Assist
Alcohol
+Alcohol
Assessment - ASAM Criteria
1)Acute Intoxication and/or Withdrawal Potential
2)Biomedical Conditions and Complications
3)Emotional, Behavioral, Cognitive Conditions & Complications
4)Readiness to Change
5)Relapse, Continued Use, or Continued Problem Potential
6)Recovery/Living Environment
Treatment - Behavioral
ASAM Score MCC Code Level of Care CBI Scheduling
> 2.0 T1 Intensive Outpatient 9‐20 hours of service/week
1.0‐2.0 T2 Outpatient Services 3‐9 hours of service/week
<1.0 T3Psychoeducation /Relapse Prevention
Minimal CBI; Brief intervention via classes/groups
Peer support groups ‐ Inmate Leisure Time Activity Groups (ILTAG) Ex. White Bison, Alcoholics Anonymous, and Celebrate Recovery
• Allow a patient to anchor to others who are like‐minded
• Focus on ongoing relationships and support networks• Supports honing coping strategies
HOW A PATIENT JOINS A PEER SUPPORT GROUP:
Patient completes CDCR Form 22 & submits to Community Resource Office
If accepted, he/she will receive a ducat indicating time, date & place for group
Treatment - Behavioral
Treatment - Supportive Housing
Substance Abuse Criminal Behavior Mental Health Symptoms
Goals: Identify Designated Supportive Housing Unit(s) For:
• Phase I: At Least 250 Participants at Each Institution
• Phase II: Increases to 500 Participants
MEDICATION FORMULATION PATIENTS (%)
Acamprosate Oral tab 0.3%
Buprenorphine/ Naloxone Sublingual Film 97%
Methadone* Oral tab 0.1%
Naltrexone Oral Oral tab 2.6%
* Dosing provided by licensed NTP beyond 3‐day bridge
Treatment - Pharmacologic
Safe• Partial Opioid Agonist
• “Ceiling Effect” – No Respiratory Depression
• Less Prone to Abuse & Overdose
Buprenorphine Pharmacology
Effective Reduces Increases• Recidivism • Treatment Retention
• HCV/ HIV Transmission • Employment• Overdose Death
Buprenorphine Use
• Use for Detoxification vs Abuse or Euphoria
• Reduce Withdrawal Symptoms
• Stop Using Other Opioids
• Waiting for Treatment
Increasing Access Decreases Diversion
Monitoring - Urine Drug Screens
VITAL SIGN
• Monitoring for Relapse
• Compliance with Prescribed Medication
• ~Equivalent to a Blood Glucose Level
• Therapeutic Conversation Opportunity
Transitions Services
• Enroll & Activate Medi‐CAL• Secure Housing• Schedule Health Care Appointments
• Transportation Arrangements
• Engage Family & Peer Support• Transitional Guidance as Needed
• Finances• Employment• Education
Whole Person CareCare Management & Care Coordination forSuccessful Reintegration Back to Community
Patient
RCRN
PCRN
ResourceRN
SRN II
LCSW
CC III PCP
AOD
AMCT
SupportStaff
ISUDT Treatment Team Composition
PharmD
MH
•Initial Health Screen (incl. NIDA QuickScreen)•Release of Information•If on Methadone, NTP order (transport)
RCRN•NIDA QS for EPRD 15‐24 Mo.•If +, referral to LCSW for NIDA Modified Assist/ASAMPCRN•Coordinator of all transitions between primary care teams, jails, counties, parole, probation, LCSW•NIDA Modified Assist
Resource RN
•Oversees program components for Whole Person CareSRN II
•Screens 7362
•If on MAT, Alert Resource RN•Referrals for AMCT & LCSW
ISUDT Nursing Roles
•Assess patients arriving on MAT using ASAM•Assess patients with SUD complications using NIDA MA/ ASAM •Assess patients with EPRD 15‐24 months using NIDA MA •Refer to DRP’s certified AOD Counselor for CBI
•T1 ‐ Intensive Outpatient•T2 ‐ Outpatient•T3 ‐ Other non‐SUD CBI
•Refer to Provider if MAT eligible
LCSW
ISUDT LCSW Roles
•Case managers who work with patients toward their goals in rehabilitation•Assists with developing relapse‐prevention plans•Provide counseling, teaches job skills, and encourages education
Correctional Counselor(CC‐III)
ISUDT DRP Counselor Roles
•Provide unbiased emotional support for individuals going through treatment•Conduct group therapy (CBI) sessions that help to get to the root of addiction •Helps to provide insight into a patient‘s recovery while participating in CBI
Alcohol & Other Drug Counselor (AOD)
•Process & Approve Methadone Bridge Orders
•Assists with Medication Reconciliation (Transfers)
•Assure Prescriber X‐waivers for Buprenorphine Orders
•Dispense 30‐day Medication Prescriptions upon Release
•Arrange Naloxone on Release via Standing Order
PharmD
ISUDT Pharmacy Roles
•Consideration for Alternative Agent Authorizations•Provide Consultation and Technical Support for PCP•Complex Care for Complicated PatientsAMCT
ISUDT Provider Roles
•Identify SUD Related Complications•Evaluate for and Initiate MAT•Ongoing Management and Monitoring•Refers to LCSW and AMCT
PCP
• The Goals of the New ISUDT Program Align with the Broad Mission of Rehabilitation within CDCR
• The ISUDT Team is Multidisciplinary & Integrated Across Multiple Divisions and Types of Service
• Team Members Have Specific Roles and Responsibilities in Delivering Major Components of the Program Including Screening, Assessment, Treatment, and Transitional Services
Take Away Points-Program Components & Staffing
Leaving
Already Here
Arriving
• EPRD 15‐24 mo
• SUD‐Related Complication• Self‐Referral
• Already on MAT
Population Served
Leaving • 15‐24 Months
Population Served
Standardize
d Mortality Ratio
Overdose Deaths Among Persons Released from Prison Compared to California Population*
*Adjusted for age and sex by post‐release period
Released Patients California Population
Community Transitions are High Risk
Patients Leaving (EPRD 15-24 mo)
PCRN ‐ Screening ‐ NIDA QuickScreen
LCSW Assessment ‐ NIDA Modified Assist +/‐ ASAM
AOD ‐ Treatment CBI CC‐III ‐ Develops Relapse Prevention PlanAMCT – MAT Initiation & MonitoringAssignment to Supportive Housing
Resource RN ‐ Transition Services PharmD – Dispense 30‐day Meds & Naloxone on Release
Already Here
Population Served
• SUD‐Related ComplicationsOverdoseInfections related to IVDU
• Self‐Referrals (7362)
Self-Referrals (7362)
• PCRN Triages 7362 and Alerts/Co‐Consults with PCP
• PCP Sends Referral to LCSW for NIDA MA; Orders UTOX• Depending on NIDA MA/ Lab results: CBI referral Possible Evaluation for MAT
Patients Already in CDCR
NO SCREENING NECESSARY
LCSW Assessment ‐ NIDA Modified Assist
AOD ‐ Treatment CBI CC‐III ‐ Develops Relapse Prevention PlanProvider Evaluates and Treats with MATAssignment to Supportive Housing
Arriving • Already on MAT
Population Served
Patients Arriving on MAT
RCRN ‐ Screening for Patients on MAT‐ Completes Release of Information (Form 7385)‐ Orders Labs & Consults for LCSW and AMCT‐ Places NTP (transport) Order if Patient on Methadone
LCSW ‐ Assessment with ASAM
AOD ‐ Treatment CBI CC‐III ‐ Develops Relapse Prevention PlanPCP ‐ Bridging Orders, Medical Hold, Check CURESAMCT ‐ Consultation/ Continuation of MATAssignment to Supportive Housing
• The Populations served include all individuals in CDCR
• The Patients Leaving CDCR Currently Comprise the Largest Group of Patients Enrolling into the ISUDT Program
• Transition Services Provides Linkages to Social and Clinical Services to Help Mitigate Risk
Take Away Points -Population Served
0
10
20
30
40
50
60
70
2015 2016 2017 2018 2019 2020
CCHCS Overdose Deaths
Overdose Deaths – CA & US
DRAFT VERSION
DRAFT VERSION
Summary
•SUD is a Treatable Chronic Relapsing Disease
•Relapse Rates Similar to Other Chronic Conditions
• ISDUT Program Offers Evidenced Based Treatments
•Success is a Lifelong Journey on the Road to Recovery
Life Transformations…reflect on where I would be at or who I could have become if I would have had this program injected into my life 37 years ago! I am a 49 year old addict. I have never received treatment or any counseling to deal with my appetite for drugs and this lifestyle that put me here behind bars for the rest of my life.
If this program would have been introduced to me from the first time that I used drugs I would have been saved from this lifetime of destruction. It breaks my heart that I cause so many other people that have crossed my path thru out my lifetime so much pain.
I have hit rock bottom plenty of times. I even pulled out a shovel and have dug a hole beyond rock bottom.
I’m still new to this MAT program but I know there is a difference happening in my thoughts and actions since I have started following the doctor’s orders and talking to the staff here. I know I have a long way to go. I’m still at war with this monstrous addiction that is in me.
All I want to say is Thank You, thank you for making me feel that there is hope and that life is worth it man! I don’t know what I have to offer or where my life is heading to but today for the first time in 37 years I can shout out to the stars I’ve been clean & sober for 45 days.
Appreciation
Well since I’m not too good with words and with verbally explaining my sentiments towards others. I decided to sit down and write to you this letter of appreciation for blessing me with the tools that I needed in order to combat the war that’s been within me all these years. And sadly I had lost that war time after time throughout most of my teen and adult life.
Hope
There’s a future out there that’s mine to be made, I’ve learned
to love myself and am capable of loving others. I’m no longer
afraid to live. I want to thank you for everything this program
has done. I share this with so many others and tell them what
lies ahead when on this program. Thank you.
Mission Accomplished
So I just wanted to say that if this program was designed and intended to save
lives mission accomplished. With my disease being treated so well, there’s no
doubt in my heart or head that I’m going to make it. No matter how bad things
get, and I know they will, I’m going to be okay. The demon that destroyed me is
being dealt with. So if you’ve ever wanted to make a difference in this world, in
somebody’s life, you have.
• “The science and the evidence of the benefit is overwhelming. Study after study documenting the clear benefits of Suboxone, changing lives and saving lives…So I changed my view and decided to get involved with the MAT program. It was the best career decision I have every made!”
• “What I love is I am now truly helping my patients, making a real difference in their lives. My patients share their successes and failures, and it is so gratifying to hear about how their lives are changing for the better, and how they are rebuilding family relationships.”
• “Being a provider for the MAT program has absolutely changed the way I practice and has allowed me to participate in a truly life‐changing program for our patients.”
• “My practice has changed in a positive way. I enjoy very much seeing these patients realize that they can be successful making the changes needed to gain control over their addiction.”
Provider Letters