sud module c: care management. or……. how to not cure anyone & still accomplish something...
TRANSCRIPT
or…….
How to not cure anyone& still accomplish something
& go home happy
or…….
How to not cure anyone& still accomplish something
& go home happy
• Current models of addiction treatment do not result in complete and permanent remission of symptoms 100% of the time.
• Current models of addiction treatment do not result in complete and permanent remission of symptoms 100% of the time.
What is the problem?What is the problem?
If we already know this, then what is the problem?If we already know this, then what is the problem?
• Initial models of addiction treatment emphasized the need for total and permanent abstinence (i.e., permanent remission, cure)
• Anything less was a failure (dichotomous outcome criteria)
• Initial models of addiction treatment emphasized the need for total and permanent abstinence (i.e., permanent remission, cure)
• Anything less was a failure (dichotomous outcome criteria)
What is the problem?What is the problem?
• Addiction treatment developed separated from medical and psychiatric treatment
• Psychiatry in particular was excluded
• Any treatment outside of specialized units was considered inadequate or worse (enabling)
• Addiction treatment developed separated from medical and psychiatric treatment
• Psychiatry in particular was excluded
• Any treatment outside of specialized units was considered inadequate or worse (enabling)
Barriers to providing care for chronic addictionBarriers to providing care for chronic addiction
• Programmatic dogmatism and idealism
• Lack of understanding among policymakers, society, and MCOs
• Political and regulatory climate
• Programmatic dogmatism and idealism
• Lack of understanding among policymakers, society, and MCOs
• Political and regulatory climate
Barriers to providing care for chronic addictionBarriers to providing care for chronic addiction
• Lack of training in addiction treatment
• Lack of models for care management
• Goal setting and treatment planning
• Lack of training in addiction treatment
• Lack of models for care management
• Goal setting and treatment planning
• Clients have severe problems
• Programs don’t work, won’t accept clients, or clients won’t go
• If clinicians act, they are accused of enabling, or doing too much w/o results
• If clinicians do not act, they are accused of neglect, doing too little
• Clients have severe problems
• Programs don’t work, won’t accept clients, or clients won’t go
• If clinicians act, they are accused of enabling, or doing too much w/o results
• If clinicians do not act, they are accused of neglect, doing too little
A model that:A model that:
• Accepts chronicity
• Recognizes limits of treatment methods
• Is palliative (non-curative) in nature
• Accepts chronicity
• Recognizes limits of treatment methods
• Is palliative (non-curative) in nature
A model that:A model that:
• Stresses long term management (years to decades)
• Treats addiction like other chronic diseases such as bipolar disorder or diabetes
• Stresses long term management (years to decades)
• Treats addiction like other chronic diseases such as bipolar disorder or diabetes
That new model is...That new model is...
Care Management For Chronic AddictionCare Management For Chronic Addiction
Go to Module C
N
Refer to specialty care with attention to engagement barriers
[J]
Go to Module R
Care Management Rehabilitation
Y
Does patient agree to
referral or is it mandated?
[I]
From Module A
Can treatment plan be implemented in
primary care?[E]
N
From Module R
Y
Is rehabilitation acceptable to the
patient?[E] N Go to Module C
Care Management IndicationsCare Management Indications
• Moderate to extreme severity
• Unwilling to commit to change
• Unable to participate in rehabilitation
• Poor response to multiple attempts at rehabilitation
• Willing to engage in therapeutic relationship
• Moderate to extreme severity
• Unwilling to commit to change
• Unable to participate in rehabilitation
• Poor response to multiple attempts at rehabilitation
• Willing to engage in therapeutic relationship
Continuum of Care for AddictionsContinuum of Care for Addictions
Use &Problems
Modality
None
1º Prevention2º Prevention
Moderate
Severe
Rehabilitation
Extreme
Care Mgmt.
CMCA GoalsCMCA Goals
• Engagement
• Coordination of care
• Reduce suffering
• Treat complications
• Improve motivation to change
• Engagement
• Coordination of care
• Reduce suffering
• Treat complications
• Improve motivation to change
CMCA GoalsCMCA Goals
• Induce remission when possible
• Prevent/limit relapse
• Slow rate of deterioration
• Reduce use of expensive, ineffective services
• Induce remission when possible
• Prevent/limit relapse
• Slow rate of deterioration
• Reduce use of expensive, ineffective services
• Episodic care only• Crisis intervention• Case management• Continue attempts to engage• Involuntary treatment when
indicated• Asset management when
indicated
Is care management
acceptable to the patient?
[B]
Patient in need of care management
[A]
N
Provide episodic attention to
substance useReassess
periodically[I]
Implement/continue care management plan in specialty
care or primary care[See side bar]
[C]
Y
Is care management
acceptable to the patient?
[B]
CMCA PrinciplesCMCA Principles
• Supportive, engaging approach
• Document substance use systematically at each visit
• Supportive, engaging approach
• Document substance use systematically at each visit
Document substance use:• Drinking or using days last 30• Typical # drinks/drinking day• Max # drinks/24 hrs last 30• Bingeing
Implement/continue care management plan in specialty care or primary care
[See side bar][C]
• Monitor substance use
• Monitor biological indicators
• Encourage reduction or abstinence
• Provide motivational support
• Educate about substance use and associated problems
• Recommend self help groups
• Monitor substance use
• Monitor biological indicators
• Encourage reduction or abstinence
• Provide motivational support
• Educate about substance use and associated problems
• Recommend self help groups
• Address social functioning needs
• Address financial and housing needs
• Address nicotine use as appropriate
• Provide opioid agonist therapy if appropriate
• Provide crisis intervention as needed
• Provide care coordination
• Address social functioning needs
• Address financial and housing needs
• Address nicotine use as appropriate
• Provide opioid agonist therapy if appropriate
• Provide crisis intervention as needed
• Provide care coordination
Implement/continue care management plan in specialty care or primary care
[See side bar][C]
Implement/continue care management plan in
specialty care or primary care
[See side bar][C]
Is care management
acceptable to the patient?
[B]
Y
Consider use of addiction focused pharmacotherapy
(Use Module P)
Has stable remission been
achieved?[E]
Reassess progress periodically
Follow up in primary careMonitor substance use
Monitor biological indicatorsEncourage continued reduction
or abstinenceProvide motivational support
[F]
Y
Educate about substance use, associated problems and
prevention of relapse[G]
Has stable remission been
achieved?[E]
CMCA ReassessmentCMCA Reassessment
• Reassess goals periodically
• Long-term, ideal goal remains full remission and improvement in all co-existing conditions
• Refer to rehab when goals change
• Reassess goals periodically
• Long-term, ideal goal remains full remission and improvement in all co-existing conditions
• Refer to rehab when goals change
Is referral to specialty care rehabilitation indicated and acceptable
to the patient?[See side bar]
[H]
Return to Box 3
Go to Module R
Y
N
N
Has stable remission been
achieved?[E]
Return to Box 3
Reassess progress periodically
Implement/continue care management plan in
specialty care or primary care
[See side bar][C]
Application of Care Management:
Application of Care Management:
Medically Ill Heavy DrinkersMedically Ill Heavy Drinkers
Application of Care Management:
Medically Ill Heavy Drinkers
Application of Care Management:
Medically Ill Heavy Drinkers
0
10
20
30
40
50
60
-4 to 0 yr 0-2 yr 2-4 yr
Sick days per person per year
Controls
Intervention
Kristenson et al., 1983
0
500
1000
1500
2000
2500
Total MH GI Acc Alc
Hospital Days After 5 Years
Controls
Intervention
Kristenson et al., 1983
Application of Care Management:Medically Ill Heavy Drinkers
Application of Care Management:Medically Ill Heavy Drinkers
0
40
80
120
160
% Abstinent Days Lst Drnk
IOTCTL
Willenbring and Olson, 1999
IOT 2 Year ResultsIOT 2 Year Results
Survival
60
70
80
90
100
0 6 12 18 24Months
Pe
rce
nta
ge
liv
ing
IOT 1
CTL 1
Willenbring, et al., 1994
82
IOT for Medically Ill AlcoholicsIOT for Medically Ill Alcoholics
68
Willenbring and Olson, 1999
IOT for Medically Ill AlcoholicsIOT for Medically Ill Alcoholics
Survival
60
70
80
90
100
0 6 12 18 24Months
Pe
rce
nta
ge
liv
ing
IOT 2
CTL 2
81
70
Application of Care Management:
Application of Care Management:
Coexisting Mental and Addictive Disorders (COMAD)
Coexisting Mental and Addictive Disorders (COMAD)
1
2
3
4
5
Baseline 12 mo 24 mo 36 mo
AUSDUS
Abstinence
SevereDependence
Abuse
Drake et al., 1998
Improvement in COMADImprovement in COMAD
Improvement in COMADImprovement in COMAD
Drake et al., 1998
Using days past 180
0
20
40
60
80
Baseline 24 mo
Alc UseDrug Use
Improvement in COMADImprovement in COMAD
Bartels et al., 1995
0
20
40
60
80
100
Alc d/o Drug d/o
Baseline
7 yrs