Substance Use Disorder Services for Returning Veterans

John P. Allen, PhD, MPANational Mental Health Program

Director, Addictive Disorders

Outline of the Presentation

• Nature of patients served in VHA SUD program

• Settings and nature of VHA treatment for SUD

• Relationship of military variables to SUD

• Treatment of SUD and co-morbid PTSD in VHA

• Facility-specific SUD services

Substance Use Disorders in VHA

• Rates/severity of SUD problems for Veterans slightly exceed those in the general population matched for age, gender, and geographic location. (25% of Veterans aged 18 to 25 meet diagnostic criteria for SUD.)

• Over 160, 000 Veterans were treated in FY 2010 in SUD specialty care. Two-thirds of SUD diagnosed patients were treated in primary care or general mental health services only.

• 55% of VA patients in SUD specialty care also have a diagnosis for another mental health problem; 30% have a diagnosis for PTSD.

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Number of Patients Diagnosed with a Substance Use Disorder

SUD Diagnoses Over Time

Drug Diagnoses Over Time

Key Themes in VHA’s Substance Use Disorder (SUD) Program

– Enhance access to SUD care; Particular emphasis on needs of OEF/OIF, women, justice-involved and homeless Veterans

– Resolve SUD problems in early stages– Evidence-based pharmacologic and psychosocial

interventions– Mainstream treatment thru integrating SUD care in

settings where Veterans present for care– Provide a continuum of care– Reduce stigma for SUD care– Objectively measure SUD treatment response

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SUD Services in Primary Care

• About 2/3 of patients with SUD diagnoses are treated in primary care or general mental health only, rather than in SUD specialty services.

• Primary care services for SUD problems consist of:– Screening for excessive use of alcohol– Brief intervention for patients drinking at unhealthy levels– Determination of need for detoxification and referral/medical

oversight– Prescription of medications for SUD approved by the Food and

Drug Administration– Referral of patients with severe problems to SUD specialty care– Follow-up of SUD patients who refuse SUD services

• 96% of VHA patients are screened annually for at-risk drinking.

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Settings for SUD Care• Substance Abuse Residential Rehabilitation Treatment Programs

(N=64)Focused on providing psychosocial treatment. Differ from traditional inpatient programs by having lower numbers of staffing levels and longer lengths of stay. These are dedicated Substance Abuse Residential Rehabilitation Treatment Programs, but all residential treatment programs within the VA offer SUD treatment in some fashion.

• Intensive outpatient programs (N=136 Standalone; 20 Combined with RRTPs) Provide at least three hours of SUD treatment services three days per week. Includes day treatment, partial hospitalization, and intensive outpatient clinic-based programs

• Standard outpatient programs (N=61)--Ambulatory SUD services

• Methadone maintenance programs –In-House (N=39) or contracted with community providers (N=13)

• Non-SUD specialty care --SUD services provided in primary care (including buprenorphine), mental health, PTSD services/teams, etc.

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Selected Characteristics of Patients in VA SUD Treatment Programs

Patient characteristics at intake24-

Hour Care

Intensive Outpatient

Standard Outpatient

Married or in a long-term, marriage-like relationship

28% 30% 38%

Female 5% 5% 4%

Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) Veteran

14% 15% 11%

Homeless or in unstable living arrangements

52% 40% 22%

Met diagnostic criteria for PTSD 30% 29% 32%

Met diagnostic criteria for nicotine dependence

72% 68% 74%

Met diagnostic criteria for opioid dependence

17% 18% 51%

Recent SUD-Related Activities• Award of new SUD specialist positions• SUD Handbook and CPG for treatment of SUD• Webinars for physicians on medical interventions for

SUD• Establishment of Contingency Management as

adjunctive to treatment• Clinical guidance related to patients receiving

medically prescribed marijuana• Clinical guidance issued for SUD specialists assigned

to PTSD teams and services • Assignment of VISN-level SUD Representatives• Patient brochure developed to encourage drug

treatment• Study on use of EtG and EtS inaugurated

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Military Deployment and SUD

• Rate of alcohol behavioral problems double (25% vs 12%) before and after deployment (Wilk et al, 2010). (Among Reserve Component personnel there were twice as many new onsets of heavy weekly drinking, binge drinking, and alcohol-related behavioral problems among deployed personnel than among their non-deployed peers (Jacobson et al, 2008).

• Post deployment military personnel with SUD problems are rarely referred for care (134 referrals/6669 positive alcohol screens on PDHRA for active duty and 179/4787 for reserve component) (Milliken et al, 2007)

Combat Exposure and SUD

• Combat exposure is associated with increased rates of weekly heavy drinking, binge drinking, and alcohol-related problems. This is particularly true for personnel aged 24 or younger (Jacobson, et al, 2008).

• The threat of death or personal injury is most associated with post-deployment alcohol problems. This relationship is independent of the relationship of these threats to other mental health problems (Wilk et al, 2010)

SUD and PTSD

• Co-morbidity of the two conditions ranges from 25 to 50% in OEF/OIF personnel (Gulliver & Steffen, 2010).

• Prognoses for both conditions are worse when the conditions are co-morbid than when they occur independently (Bernhardt, 2009).

Recommendations for Treatment of SUD in Veterans with PTSD

(Based on Findings of Subject Matter Expert Panel in November, 2009)

• Treatments for the two conditions should be coordinated and generally the treatments should be done simultaneously. There should be a single treatment plan.

• The VA-DoD Clinical Practice Guidelines should be followed for each condition.

• A community of practice for SUD-PTSD specialists should be created.

• Patients should be regularly monitored to ensure that the treatment plan is responsive to their needs.

• Family involvement can be very helpful to the treatment of both conditions.

• The Clinical Recommendations of the Panel should be revisited/revised on the basis of new research and the actual experiences of the SUD-PTSD specialists.

Percent of OEF/OIF Veterans with Diagnoses of Substance Use Disorder by Year Seen

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2001 2002 2003 2004 2005 2006 2007 2008 2009

Issues in Treating SUD in OEF/OIF Veterans

• Enhance attractiveness of VHA SUD services. • Capitalize on characteristics of VA care system. • Distinguish developmentally-related aspects of

substance abuse from risk of chronic effects.• Develop more computerized aids to enhance

SUD services• Integrate services to address complexity of

problems presented - combinations of SUD with traumatic brain injury, chronic pain, homelessness, PTSD, nicotine dependence, community/family readjustment

• Reduce concerns over confidentiality

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Uniform Mental Health Services Handbook as Related to Treatment of Substance Use

Disorders

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Screening and Assessment

• Universal screening for alcohol misuse in new patient encounters, according to presenting problem, and at least once a year

• Targeted screening for other substance-related problems

• Follow-up for positive screens with a multidimensional evaluation if substance use disorder has been diagnosed

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Interventions (1)

• Emergency department services that include provisions for 23 hour observation

• Medically managed withdrawal--Inpatient and ambulatory, as needed

• Brief interventions in primary care or general mental health

• Intensive outpatient services and/or residential care substance use services

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Interventions (2)• Dual diagnosis programs or coordination of mental

health and substance use disorder care

• Evidence-based psychosocial interventions to prevent relapse

• Opiate agonist treatment (methadone and/or buprenorphine)

• Evidence-based pharmacotherapy for alcohol dependence

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Interventions (3)

• Long term monitoring and maintenance treatment

• Interim services to address the needs of patients waiting for specific programs

• Active follow-up for those who refuse referral to SUD services

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Mental Health Services Mental Health Services Percent of Patients Participating in Various Treatment

Activities

Treatment Activity 24-HourCare

IntensiveOutpatient

StandardOutpatient

Clinical diagnostic interview

83% 84% 82%

Individual therapy related to mental health

problems31% 34% 31%

Group therapy related to mental health

problems42% 35% 12%

Medications for mental health problems

61% 53% 52%

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Medical and Support ServicesMedical and Support Services

((Average Percent of Patients Participating in Treatment Activities)

Treatment Activity 24-HourCare

IntensiveOutpatient

StandardOutpatient

Hepatitis C screening and testing

65% 47% 48%

HIV counseling and testing 55% 36% 44%

Medication for opioid detoxification

2% 3% 5%

Medication for alcohol detoxification

10% 9% 4%

Consultation/collaborative care for patients with spinal cord

injury2% 6% 0%

Referral to another program for mental health services

26% 30% 24%33

SUD Services for Special PopulationsSUD Services for Special Populations

((Average Percent of Patients Participating in Treatment Activities)

Treatment Activity 24-HourCare

IntensiveOutpatient

StandardOutpatient

OIF/OEF focused group therapy or other services

6 3 3

Women-specific groups or other services

7 2 2

Integrated therapy for PTSD & SUD

28 21 11

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