Title: Delivery Systems for Substance Abuse Treatment: Integration with Primary Care and Mental Health and Social Services
1Delivery 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
2The 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
3Substance 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.
4Substance 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.
5A 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
6Focus 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?)
7A 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
8Some 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.
9Current 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
10Integrating Substance Abuse Screening and Other
Services into Primary Care
- Thomas F. Babor, Ph.D., MPH
- University of Connecticut
- School of Medicine
- Farmington, USA
11Why 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
12Goals 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
13Alcohol, 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
14Brief 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
15Integration 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
16Effectiveness 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,
17Estimated 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
18The 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.
19Estimated Opiate Dependent Drug Users in
Substitution Treatment per 100,000 population
20Consequences 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
21Substitution 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
22What 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
23Substitute 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
24Summary
- 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.
25Substance Abuse Treatment and HIV in Iran
- Azarakhsh Mokri MD
- Iranian National Center for Addiction Studies
(INCAS) - Tehran University of Medical Sciences
- Tehran, Iran
26Integrating 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
27Individuals 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)
28Approaches 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
29Four-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
30Conclusions
- 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
31Outcome 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
32Overview
- 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.
33Integrating 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
34Disposition
- - 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
35Social services can be such a context
- high density of substance use disorders in social
services - early detection possible
- (Miller Weisner 2002)
36Social 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
38Results 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
39Conference 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.