Delivery Systems for Substance Abuse Treatment: Integration with Primary Care and Mental Health and Social Services

1
Delivery Systems for Substance Abuse Treatment
Integration with Primary Care and Mental Health
and Social Services

• (Also referred to as)
• Delivery Systems for Substance Abuse Treatment
• An International Conference

2
The Problems

• Misuse of psychoactive substances occurs in all
  societies and has throughout history.
• The nature of the substance use/abuse/misuse/addic
  tion problems vary widely across different
  countries/regions of the world

3
Substance Use-related Problems

• Direct substance use related problems
  intoxication, overdose, abuse, dependence
• Medical problems caused/exacerbated by substance
  misuse lung disease, liver disease infectious
  diseases (including HIV/AIDS and hepatitis)
  other blood borne diseases cardiovascular
  disease neurological/psychiatric disorders
  obstetric complications, etc.

4
Substance Use-related Problems

• Social service problems caused/exacerbated by
  substance misuse employment problems, housing
  problems, family problems, child welfare
  problems.
• Criminal justice system problems international
  narcotic trafficking crime and corruption local
  drug-related crime and violence drug use within
  the prison systems.

5
A Common Reality

• At the present time, it would be difficult to
  identify a country in which adequate resources
  are available and committed to comprehensively
  address all substance use problems in that
  society.
• For this reason, policymakers and health care
  leaders are forced to prioritize which
  populations receive attention, for what problems,
  in what locations in the service delivery system,
  using which treatments.
• Countries who are in early stages of system
  development can learn from countries who now have
  to redesign systems

6
Focus of this Meeting

• Delivering treatment to individuals with
  substance use disorders
• -Who? ( Adults or adolescents? Prisoners or
  pregnant women?
• Sex workers or students)
• -What? (Cigarette smokers or heroin addicts?
• Methamphetamine injectors or
  solvent huffers?)
• -Where? (Primary care clinic or mental health
  center? Specialty
• addiction clinics or welfare
  eligibility office?)
• -How? (Screening and brief interventions?
  Methadone
• maintenance? Behavioral therapies?
  Combination
• approaches?)

7
A Segregated System of Care (eg. USA)

• Mental Health Treatment Services Hospitals,
  clinics, practionner offices. Psychiatrists,
  psychologists, social workers, marriage and
  family therapists

• Primary Care and Public Health System Hospitals,
  Clinics, MD offices Family practice internal
  medicine, other medical specialists, Nursing and
  medical support staff

• Substance Abuse Service System Therapeutic
  communities, Hospital based care, Methadone
  programs, Outpatient clinics Modest number of
  MDs and Ph.D.s Many paraprofessional workers

• Social Service System Agencies to provide
  support for food, housing, child welfare and
  other services. Social workers and
  paraprofessionals

8
Some of the Disadvantages of a Segregated System
of Care

• The primary care/public health service system is
  the largest and sees the most individuals. Many
  people seen in this system have substance abuse,
  mental health and social service system needs
  which go unidentified and unmet.
• Within this system there is a tremendous
  potential to identify substance use disorders and
  initiate a plan for care.
• However, in many cases, MDs are not properly
  trained to recognize these disorders and if they
  do recognize them, do not know how to address
  them.

9
Current Efforts in Countries with Segregated
Systems

• Increase screening and interventions in primary
  care setting.
• Develop dual diagnosis services.
• Integrate infectious disease screening and
  treatment into substance abuse care system.
• Increase linkage between social services and
  substance abuse care.
• Blend the funding streams to promote integrated
  care

10
Integrating Substance Abuse Screening and Other
Services into Primary Care

• Thomas F. Babor, Ph.D., MPH
• University of Connecticut
• School of Medicine
• Farmington, USA

11
Why intervene in Primary Health Care?

• Misuse of alcohol, tobacco and other substances
  is prevalent in PHC settings
• Substance use often linked to presenting symptoms
  (e.g., injuries, hypertension)
• PHC personnel are respected and trusted
• Interventions are effective in many societies
• Stigma can be minimized in PHC setting
• Early intervention and secondary prevention

12
Goals of Screening

• Identify both high risk substance users and those
  likely to be dependent
• Use as little patient/staff time as possible
• Collect information for use in patient education,
  brief advice, referral decisions and prevalence
  estimates

13
Alcohol, Smoking and Substance Involvement
Screening Test (ASSIST)

• Developed by international group of researchers
• 8 item instrument
• Screens for health risks problems associated
  with any psychoactive substance use
• Provides lifetime and current (past 3 months)
  estimates of substance use and related risks
• Graduated intervention options linked to ASSIST
  score

14
Brief Intervention

• Definition Time-limited (5 minutes to 5 brief
  sessions) behavioral counselling targets a
  specific health behavior (e.g. at-risk drinking
  or drug use)
• Goals a) reduce alcohol/drug consumption
• b) facilitate treatment engagement, if
  needed
• Relies on use of screening data

15
Integration into PHC Transfer Issues

• Training providers of primary health care
• Training the Trainers
• Organizational factors resources, competition,
  administrative support
• Logistical issues time, stigma, staff motivation
• Social marketing
• Reaching the Tipping Point Stickyness, Mavens,
  Salespeople

16
Effectiveness of drug dependence treatment in
prevention of HIV among IDUs

• Michael Farrell1 John Marsden1, Walter Ling3,
  Robert Ali2, Linda Gowing2
• 1 National Addiction Centre, London, United
  Kingdom
• 2 Drug and Alcohol Services Council, South
  Australia, Australia
• 3UCLA, Los Angeles, California,

17
Estimated size of IDU population (1998/2003)
E. Europe C. Asia 3.2m
N. America 1.43m
W. Europe 1.24m
E. Asia Pacific 2.35m
S. S-E Asia 3.33m
MENA0.44m
Caribbean 0.028m
S. Saharan-Africa 0.009m
Australia N. Zealand 0.19m
L. America 0.97m
10.3m (78) in developing/transitional countries
91 of the world adult population (4 billion) is
covered by the data. Information unavailable for
119 countries.
UN Reference Group on HIV/AIDS prevention and
care among IDU

www.idurefgroup.org
18
The global response UN support for good treatment

• WHO/UNODC/UNAIDS position paper Substitution
  maintenance therapy in the management of opioid
  dependence and HIV/AIDS prevention
• Substitution maintenance treatment is an
  effective, safe and cost-effective modality for
  the management of opioid dependence. Repeated
  rigorous evaluation has demonstrated that such
  treatment is a valuable and critical component of
  the effective management of opioid dependence and
  the prevention of HIV among IDUs.

19
Estimated Opiate Dependent Drug Users in
Substitution Treatment per 100,000 population
20
Consequences of drug use within correctional
settings

• Pressures on prison environment
• health services
• prison staff
• security
• HIV, hepatitis B and C
• Tuberculosis
• Recidivism
• use of drugs is a predictor of recidivism

21
Substitution in prisons

• Estimated that over 30 million imprisoned
  annually
• We can confidently estimate that at least 10
  million of those are drug dependent.
• Major risk for blood borne virus spread
• RCT of methadone in prison (Dolan et al)
  demonstrates role in reduction of blood borne
  virus, and general improvement, and post release
  reduction in mortality for those who continue
• Huge challenge for Asia pacific region where
  institutional incarceration standard response to
  opioid dependence
• Consistently 90 relapse to heroin use,
• Mortality risk 70 fold greater in early release
  period

22
What sort of delivery system is required?

• Needs integrated health care system
• Public Health Strategy to achieve maximum
  coverage
• Primary care training in delivery of treatment
• Family Practice Approach
• Prisons based care linked to community ongoing
  treatment

23
Substitute prescribing worldwide

• Enormous variation in treatment worldwide in
• Treatment setting
• Quality of treatment
• Availability of harm reduction, injecting
  equipment
• Treatment for hepatitis and HIV
• Most harm reduction and treatment resources go to
  less than 20 of the worlds IDUs in so called
  developed countries
• Most drug users worldwide have no access to
  treatment, suffer ill-health, violence and prison

24
Summary

• Evidence for major benefits of treatment in
  reducing spread of HIV
• Strongest evidence for maintenance agonist
  treatment with methadone or burprenorphine or
  other mu opoid agonists
• Strongest evidence for treatment in broader
  context of comprehensive social response to
  social problem of drug use, dependence and
  injecting.
• Belief systems are a greater obstacles to
  implementation in many countries than are
  resource limitations.

25
Substance Abuse Treatment and HIV in Iran

• Azarakhsh Mokri MD
• Iranian National Center for Addiction Studies
  (INCAS)
• Tehran University of Medical Sciences
• Tehran, Iran

26
Integrating Substance Abuse and Mental Health
Services for Individuals with Co-occurring
Disorders
Christine Grella, Ph.D. UCLA Integrated Substance
Abuse Programs Delivery Systems for Substance
Abuse Treatment Istanbul, Turkey September 5,
2005
Funded by NIDA-R01-DA11966
27
Individuals with COD Seek Treatment in Both AOD
and MH Programs

• Over half of AOD outpatients had probable MH
  disorder (Watkins et al., 2004)
• Clients with COD in AOD and MH settings showed
  minimal differences in severity and type of
  disorders (Havassy, Alvidrez, Owen, 2004)
• National data in U.S. show that 30 of
  individuals with AOD disorders either used or
  perceived an unmet need for MH services in past
  year (Mojtabai, 2005)

28
Approaches to Services Integration

• Incorporate MH services into AOD treatment
  programs
• assessment and diagnosis
• pharmacotherapy, med management
• psychotherapy
• Incorporate AOD services into MH programs
• psychoeducation
• contingency management
• motivational interviewing
• relapse prevention
• 12-step groups
• Develop specialized programs for COD that are
  fully integrated

29
Four-Quadrant Framework for COD
High severity
More severemental disorder/more severe
substanceabuse disorder
Less severemental disorder/more severe
substanceabuse disorder
Less severemental disorder/less severe
substanceabuse disorder
More severemental disorder/less severe
substanceabuse disorder
High severity
Lowseverity

• Source NASMHPD, NASADAD, 1998 NY State Ries,
  1993 SAMHSA Report to Congress, 2002

30
Conclusions

• Integration of specialized services for COD in
  AOD treatment increases services utilization,
  which positively benefits client outcomes
• Staff training is critical to increasing access
  to services for COD

31
Outcome and Economic Considerations of Service
Integration

• Constance Weisner, DrPH, MSW
• University of California at San Francisco and
• Division of Research, Northern California Kaiser
  Permanente
• Delivery Systems for Substance Abuse Treatment
• Istanbul, Turkey
• 5-7 September, 2005

32
Overview

• Alcohol and drug abuse are costly to society and
  related to mortality, morbidity, and social
  problems.
• Alcohol and drug problems cover the spectrum of
  moderate to severe problems. A specialty
  treatment system cannot serve all those who could
  benefit from services.
• Health and social service agencies have high
  prevalence of alcohol and drug problems.
• A cost-effective approach to treating alcohol and
  drug problems includes integrating services in
  health and social systems.

33
Integrating substance abuse treatment in the
social services

• Paper presented for the International Conference
  on Building Delivery Systems for Substance Abuse
  Treatment,
• Istanbul, September 5-7, 2005
• by Kerstin Stenius, Ph.D.,
• SoRAD, Stockholm University, Sweden and
• Stakes, Helsinki, Finland

34
Disposition

• - On the role of social work and social support
  in substance abuse treatment
• - Sweden as a case formative moments,
  implications of this integration, present
  challenges
• - Integrating health care addiction treatment and
  social services Results from a Stockholm study

35
Social services can be such a context

• high density of substance use disorders in social
  services
• early detection possible
• (Miller Weisner 2002)

36
Social services can provide social support to
substance abusers

• Defending human and social rights of substance
  users
• Giving support to families and other important
  networks around substance users
• Providing respectful, available and continous
  relations

37

• Social services can be the primary frame for
  substance abuse treatment, as in Sweden
• Detoxification and acute medical care of
  substance use takes place within mental health
  care, but the main responsibility for providing
  care lies with the social services
• On any given day 60 of clients in social
  services, 40 in health care

38
Results Clients' perception of treatment

• Patients/clients from integrated system finds it
  easier to get into treatment and experiences
  treatment as more coherent and continous
• This holds true controlling for drug dependence
  and drug related life area problems
• As a whole about 85 says that they have someone
  in the treatment system they can turn to with
  their problems

39
Conference Summary

• It is possible and desirable to integrate
  substance abuse services with other human service
  systems.
• Service integration can improve care and reduce
  costs.
• These systems can include
• Primary care services
• Mental health services
• Social services
• This is a particularly important concept to
  countries who are newly developing substance
  abuse services.