Download Substance Abuse Treatment

Substance Abuse Services
Integration of Care Committee
June 22, 2010
Nina Rothschild, DrPH
Terri Wilder, MSW
Marybec Griffin-Tomas, MA
HIV Planning Council of New York
Care, Treatment, and Housing Program
Bureau of HIV/AIDS Prevention and Control
New York City Department of Health and Mental Hygiene
1
Overview
Background
Definition of US Health Resources and Services
Administration (HRSA) Service Categories
► Definition of the NY EMA Service Category
► Strengths and Challenges of the NY EMA Model
► HRR Contracts and Clients Served
► Literature Review
► Best Practices
► Service Model Recommendations from Needs Assessment
Committee
► DOHMH Recommendations
►
►
2
Background
► In
preparation for the re-bid process, CTHP
has reviewed:
 Epidemiologic data
 Data from existing substance abuse treatment
contracts
 Evidence-based practices for provision of
substance abuse services
 Current HRSA guidance on substance abuse
services
3
Epidemiologic Data
►
Of newly diagnosed cases of HIV in 2006 (N=4,030),
reported to NYC HARS as of September 30, 2009:
 Total substance users=1,109 (27.5%)
 Substance use includes:
► Heroin,
crack/cocaine, methadone, methamphetamine, or
other/unspecified substance abuse; and persons with a history of
injection drug use
► Alcohol use (any)
► Marijuana use (any)
► *Alcohol
and marijuana use do not have measures for frequency or
intensity of use. ANY use of these substances results in this
classification.
►
Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented to Integration of Care
Committee meeting, January 28, 2010
4
Non-Substance Users
Compared with Others
► Compared
with non-substance users…
 Substance users overall: more likely to be male and
Hispanic
 Hard substance users: more likely to be male, Hispanic,
in their 40s or 50s, and Bronx residents, and less likely
to start care within three months of diagnosis
 Alcohol users: more likely to be male, Hispanic, and in
their 50s, and less likely to be Brooklyn residents
►
Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented to
Integration of Care Committee meeting, January 28, 2010
5
HRSA Definition:
Outpatient Substance Abuse Treatment
► Core
service
► Provision of medical or other treatment
and/or counseling to address substance
abuse problems (i.e., alcohol and/or legal
and illegal drugs)
► Outpatient setting by a physician or under
the supervision of a physician, or by other
qualified personnel.
►
Source: HRSA Guidance 8/14/09
6
HRSA Definition:
Residential Substance Abuse Treatment
► Non-core
► Provision
of treatment to address substance abuse
problems (including alcohol and/or legal and illegal
drugs) in a residential health service setting (short
term)
► May not be used for inpatient detoxification in a
hospital setting UNLESS detoxification is offered in
a separate licensed residential setting within the
walls of a hospital.
►
HRSA Guidance 8/14/09
7
HRSA 2010 Clarification of
Outpatient Substance Abuse Treatment
►
Services should be limited to:
 Pre-treatment/recovery readiness programs
 Harm reduction
 Mental health counseling to reduce depression, anxiety and other
disorders associated with substance abuse
 Outpatient drug-free treatment and counseling
 Opiate assisted therapy
 Neuro-psychiatric pharmaceuticals
 Relapse prevention
 Acupuncture therapy provided by a certified or licensed practitioner
and/or program is allowed in substance abuse programs
►
Source: HRSA Guidance 4/8/10
8
NY EMA Definition
Harm Reduction, Recovery Readiness, and Relapse
Prevention Services (HR/RR/RP)
► Easily
accessible harm reduction, recovery
readiness, and relapse prevention services
to individuals who are HIV-positive and
actively using drugs, relapsing, or in
recovery.
9
NY EMA Definition
Harm Reduction, Recovery Readiness, and Relapse
Prevention Services (HR/RR/RP)
►
Service elements include:









Rapid HIV testing
Linkage to HIV primary care*
Outreach in SRO hotels
Individual, family or group harm reduction counseling
Assessment and referral for diagnosis and treatment of sexually
transmitted infections
Screening and referral for substance use treatment
Training and provision for overdose prevention with Narcan
Individual, family, or group low threshold AOD services
Buprenorphine treatment
*Encouraged but not reimbursed. All other services are reimbursed. The EMA is working to
add confirmatory testing and linkage to care for the newly diagnosed to the model of reimbursed
services in August/September 2010.
10
NY EMA: Service Families
►
The NY EMA HRR service category has
four service families:
1.
2.
3.
4.
►
Rapid HIV Testing
Medical Services
AOD Services
Low Threshold AOD Services
Each service family has one or more
service types
11
Service Family: Rapid Testing
► Service
Type and Description:
 Rapid HIV testing includes the provision of preand post-test counseling, completion of consent
and Provider Report Forms (PRF), provision of
or referrals to confirmatory testing, in
accordance with state regulations.
12
Service Family: Medical Services
► Service
Type and Description:
 Medical Outreach in SROs
► Making
contact with SRO residents to encourage, promote and
support utilization of and decrease barriers to medical care,
substance use treatment options and harm reduction services.
 Buprenorphine Initial Visit
► The
induction phase of buprenorphine treatment, including
prescribing and administering dose as well as conducting inoffice observation for up to two hours.
 Buprenorphine Routine Visit
► Follow-up
visits to assess clients and adjust dosage through the
stabilization and maintenance phases of buprenorphine
treatment.
13
Service Family: AOD Services (1)
► Service
Type and Description:
 Family Counseling
► Counseling
and education provided to a family unit regarding
substance use, abuse and harm reduction. Includes sexual risk
reduction, IDU risk reduction, HIV and/or Hepatitis C secondary
prevention, medical treatment plan adherence.
 Group Counseling
► Group
counseling and education session conducted with a
group of at least three Ryan White clients on the same range of
subjects as in Family Counseling - AOD
 Individual Counseling
► Individual
counseling and education conducted with an
individual client on same range of subjects as in Family
Counseling - AOD
14
Service Family: AOD Services (2)
► Service
Type and Description:
 Assessment for STI
►Assessment
of client’s risk for STIs and (if
appropriate) referral to screening and treatment
programs
15
Service Family: AOD Services (3)
► Service
Type and Description:
 Overdose Prevention Training – Group
► Overdose
prevention education and training, including risk
reduction, assessment, response, and reversal, and prescribing
and dispensing Narcan conducted with a group of at least three
Ryan White clients
 Overdose Prevention Training – Individual
► One-on-one
overdose prevention education, otherwise identical
to Overdose Prevention Training - Group
 Substance Use Assessment
► Screening
and (if appropriate) referral for substance use
treatment for syringe exchange, ESAP, buprenorphine,
methadone, detox, peer community support
16
Service Family:
Low Threshold AOD Services (1)
►
Service Type and Description:
 Low Threshold AOD Services – Family
► Services
provided to a family unit (the client plus at least one other
family member or significant other) to encourage testing and
enrollment into primary care. Some examples are stress reduction,
supportive counseling, activities of daily living kits, and drop-in
activities
 Low Threshold AOD Services – Group
► Conducted
with a group of at least three Ryan White participants.
Otherwise identical to Low Threshold AOD Services - Family
 Low Threshold AOD Services – Individual
► Conducted
with an individual client (or a family member within the first
90 days of the family member’s enrollment). Otherwise identical to
Low Threshold AOD Services - Family
17
Service Family:
Low Threshold AOD Services (2)
► Service
Type and Description
 Low Threshold Assessment and Referral for STI
►Assessment
of client’s risk for STIs and (if
appropriate) referral to screening and treatment
programs
 Low-Threshold Screening and Referral for
Substance Use Treatment
►Screening
and (if appropriate) referral for substance
use treatment for syringe exchange, ESAP,
buprenorphine, methadone, detox, peer community
support
18
Service Family:
Low Threshold AOD Services (3)
►
►
►
Low threshold services are the AOD/HR services available
to individuals who may not know their HIV status to
encourage testing and enrollment into primary care.
These services “meet the clients where they’re at” and
include counseling and education related to HR, stress
reduction, ADL counseling, provision of hygiene kits, etc.
Although low threshold services are primarily accessed by
HIV status unknown clients, some programs allow HIV+
clients to access them.
19
Service Family:
Low Threshold AOD Services (4)
► HIV
status unknown clients may only access low
threshold AOD services for a maximum of 90 days.
► Low threshold AOD services for HIV status
unknown clients are primarily used to help with
substance use issues, promote safer sex practices,
and engage the client in HIV testing services.
► After 90 days, if a client still has not been tested
or has tested negative, he or she must be referred
to another program as he/she is no longer eligible
to receive RW funded services.
► Clients who test HIV positive are then eligible for
the entire spectrum of RW services.
20
Service Family:
Low Threshold AOD Services (5)
►
►
►
HIV positive clients may access any service offered by the
HRR agency (both low threshold AOD and AOD services).
Low threshold services are sometimes designed to engage
new HIV positive clients in services (i.e., talking about risk
reduction, decision making skills, etc.) or to support HIV
positive clients who have been enrolled in HRR services for
a longer time and are stabilized and in the process of
transitioning out of HRR services (i.e., they have
‘graduated’ or no longer need the services).
AOD services are designed to help HIV positive clients
manage their HIV diagnosis, reduce their substance use,
and/or reduce risk behaviors.
21
Strengths of the HRR Model
► Provides
counseling in a variety of settings
and methods (individual, group, family)
► Flexibility of the ‘sobriety requirement’
 Clients do not have to be completely abstinent
► Few
payer of last resort issues
22
Challenges of the HRR Model
►
Counseling services are misunderstood and underutilized
 Almost no agencies serve eligible entities such as client families
►
►
Retaining clients is challenging due to transient and often
chaotic nature of the population
Focus is on services for opiate users
 Does not include similar interventions for more prevalent crack,
cocaine, crystal meth, and alcohol users
►
►
Maintaining staff with prescribing privileges (MDs, NPs,
PAs) is expensive
Low threshold AOD services for clients with unknown HIV
status
23
HRR Service Contracts in FY 2009
►
►
►
Planning Council ranked HRR as Priority #4
HRSA Service Category: Core
Approximately 11% of the total RW budget is allocated to
HRR
 Service category allocation: $11,232,026
 Modified spending plan: $10,993,517
►
The HRR program funds 26 programs in NYC
 Projected units of service: 93,059
 Actual units of service: 94,105
►
The portfolio was newly re-bid in 2007
 The HRR service category has been part of the NYC EMA RW Part A
portfolio since at least 1994
Source: Service Category Scorecards 6/15/10
24
HRR Clients Served in FY 2009
20,409 Clients Received Services in FY 2009
►
HIV Status
 18% HIV+ (non-AIDS), 8% CDC-defined AIDS, 54% HIV-, 18% Unknown
Status/Pending, 11% Family Member/Significant Other
►
Gender
 43% Female, 59% Male, 1% Transgender
►
Race and Ethnicity
 52% Black, 35% Hispanic, 7% White, 1% Asian/Pacific Islander, 3% Other/Unknown
►
Age
 3% 0-19 Years of Age, 19% are 20-29 Years of Age, 19% are 30-39 Years of Age,
31% are 40-49 Years of Age, 28% Ages 50+
►
Special Populations
 1% Young MSM of Color, 12% LGBT, 37% Women of Color, 2% Immigrants
Source: Service Category Scorecards 6/15/19
*=Among the total clients served in FY 2009, 54% were HIV-negative. However, these clients cycle through every 90
days and often leave care. HIV+ clients, by contrast, remain in care. Although the number of HIV-clients is high,
they filter through the programs more rapidly.
25
2009 Consumer Focus Group Results
► According
to the report from the 2009
consumer focus groups in the New York
EMA:
 Substance use is an important issue.
 Substance abuse treatment assisted entry into
and engagement in HIV treatment.
 Services are useful and easily accessible.
26
Literature Review
►
►
►
Harm reduction psychotherapy (HRP) is based on the
principle that individuals can become healthier even when
they are still consuming drugs.
HRP does not penalize individuals for their choices about
drug use but instead supports them in an open discussion.
HRP employs Stages of Change and Motivational
Interviewing and focuses on diminishing resistance and
traversing stumbling blocks.
Source: P. Denning, “Harm Reduction Psychotherapy: An Innovative Alternative to Classical Addictions Theory”
American Clinical Laboratory May 2002: 16-18.
27
Literature Review
► Benefits
of harm reduction:
 Diminish the damage of illegal drug use on families,
neighborhoods, and society
 Decrease deaths from overdoses
 Diminish the number of new cases of infections such
as HIV and hepatitis
 Lessen drug-connected injuries and trips to EDs
 Enhance the number of individuals who are able to
obtain treatment
 Lower the number of disturbances to family life from
imprisonment, child abuse and mistreatment, and
domestic fighting
Source: “Harm Reduction” in The New York Academy of Medicine
28
Literature Review
►Harm
reduction techniques:
 Syringe exchange*
 Preventing death from overdose with
Narcan provision
 Fostering access to physical and
mental health care for drug users
Source: “Harm Reduction” in The New York Academy of Medicine
*The EMA does not currently fund syringe exchange and is waiting to hear from
HRSA whether Ryan White dollars can be used for syringe exchange programs.
29
Literature Review
►
Engaging in alcohol and illegal drug use can increase the
likelihood of risky behaviors and HIV transmission and may
complicate adherence.
►
Addressing drug dependency with the help of
pharmacological treatment is key. Medications for
addressing substance use problems include:
 Opioid dependence: methadone, buprenorphine, naltrexone
 Alcohol dependence: naltrexone, acamprosate, disulfiram
 Other drugs: the FDA has not endorsed any medications to treat
usage of other illegal drugs, including cocaine, methamphetamine,
cannabis, or sedative/hypnotics.
Source: RD Bruce, TF Kresina, EF McCance-Katz, “Medication-Assisted Treatment and HIV/AIDS:
Aspects in Treating HIV-Infected Drug Users” in AIDS 2010, Vol. 24.
30
Literature Review
 Treatment for substance abuse, mental health, and primary care
are best incorporated and managed together
 Client retention and engagement in treatment is crucial
 Fostering a therapeutic partnership is key for long-term mental
health and recovery goals
 Incorporation of vocational rehabilitation and general
enhancement of functioning support lasting sobriety
 Continuing education is key for professional staff
 Treatment should incorporate motivational interviewing, group
and individual psychodynamic and cognitive-behavioral
approaches
Source: R Futterman, M Lorente, SW Silverman, “Beyond Harm Reduction: A New Model of
Substance Abuse Treatment Further Integrating Psychological Techniques,” Journal of
Psychotherapy Integration, Vol. 15, No. 1, pp. 3-18.
31
Literature Review
►
Outreach approaches to HIV-infected substance users
include:
 Use of peer advocates to engage and retain clients in care
 Actively involving recent releasees from jail/prison and linking them
with services
 Offering services via mobile units
 Drop-in facilities
 Transitional housing for people who are using drugs but also
participating in harm reduction focused groups
Source: C. Tobias, S. Wood, M-L Drainoni, “Ryan White Title I Survey: Services for
HIV-positive Substance Users” in AIDS Patient Care, Vol. 20, No. 1, 2006, pp. 58-67.
32
Literature Review
► In
a population of triply-diagnosed patients
(mental illness, substance use, HIV infection):
 45% of patients taking ARVs stated that they missed
medications in previous three days
 Issues connected with non-adherence included:
► Abuse
of drugs and alcohol at the present time
► Heightened emotional distress
► Poorer compliance with medical appointments
► Not taking psychiatric medications
► Lower spirituality (self-report)
Source: CA Mellins, JF Havens, C McDonnell et al., “Adherence to Antiretroviral
Medications and Medical Care in HIV-Infected Adults Diagnosed with Mental and
Substance Abuse Disorders” in AIDS Care, Vol. 21, No. 2, 2009, pp. 168-177.
33
Best Practices for Screening
► All
infectious disease clinics/providers,
should be screening for STDs and substance
abuse with HIV-infected persons. Those in
need of services should be referred to
substance abuse programs.
►
*Seth Kalichman, June 1, 2010
34
Screening
► Alcohol
screening and treatment is largely
forgotten but very important when treating
HIV-infected individuals, especially
individuals who are co-infected with HCV
► No single tool is consistently used for
alcohol screening, but most providers use
the AUDIT (or AUDIT-C)* or CAGE or a
combination of them
►
*Alcohol Use Disorders Identification Test
35
Screening
►
Recommended: Use the AUDIT-C followed by a brief intervention
modeled after WHO motivational interviewing (MI) protocol. Focus of
brief intervention is to use MI to determine client’s motivation and
readiness for harm reduction, outpatient substance abuse treatment,
or inpatient substance abuse treatment
►
The Drinker’s Pyramid is a good tool to translate AUDIT findings into
clinical practice.
►
The Drug Abuse Screening Test (DAST-10) is a valid and reliable
instrument that can be used in conjunction with the AUDIT-C.
►
►
Strauss SM, Rindskopf DM, “Screening Patients in Busy Hospital-based HIV Care Centers for Hazardous and Harmful
Drinking Patterns: The Identification of an Optimal Screening Tool” in Journal of the International Association of
Physicians in AIDS Care, Vol.8, No. 6, 2009, pp. 347-353.
Conversation with Seth Kalichman, PhD, June 1, 2010
36
Best Practices for
Care and Treatment
► Coordinated
systems needed for HIV care
and treatment. “One-stop shop” model
works best because clients who are
dependent on drugs and/or alcohol will not
make multiple visits to multiple providers.*
►
*Seth Kalichman, June 1, 2010
37
Needs Assessment Committee
Service Model Recommendations (1)
► Drug
and alcohol, mental health, and
medical services should be co-located in
order to provide one-stop shopping.
► Clients receiving AOD services should be
systematically and formally screened for
mental health needs using a standardized
screening tool.
38
Needs Assessment Committee
Service Model Recommendations (2)
► Programs
should be required to have a
working relationship with clients’ case
managers to ensure the coordination of all
medical and support services needed for the
treatment of addiction.
39
Needs Assessment Committee Service
Model Recommendations (3)
Services should include risk/harm reduction (behavior
change) and risk/removal approaches (medication-assisted
treatment such as Buprenorphine/Methadone for opioid
dependence, Modafinil and Bupropion for
methamphetamine addiction) and psychosocial therapies
provided by mental health and/or behavioral therapists to
address AOD behavioral change and other mental health
issues such as depression.
► Harm reduction programs should use low threshold models
such as street outreach and peer workers supervised by a
trained professional staff member.
► Programs can fund smoking cessation but need to be
mindful that Ryan White is the payer of last resort.
►
40
Needs Assessment Committee
Service Model Recommendations (4)
► Tools
to screen for and assess levels of
alcohol and drug use respectively should be
systematically employed (e.g., every six
months) with all clients.
41
Needs Assessment Committee
Service Model Recommendations (5)
►
►
►
►
Programs that provide outreach to individuals at risk for
problematic alcohol and drug use should include a focus on
youth.
Programs providing services to youth should be able to
demonstrate cultural and linguistic competence, particularly
in the area of sexual orientation, and have a history of
successfully working with the target population.
Programs treating homeless adolescents for substance use
should include a drop-in center for daytime and for nights.
The safety of places offering youth a place to stay
overnight should be carefully investigated to ensure that
youth will not be endangered or exploited.
Peer-to-peer outreach is a particularly useful technique
with youth populations.
42
Needs Assessment Committee
Service Model Recommendations (6)
► While
the EMA awaits word from HRSA
about funding for syringe exchange
programs (SEPs), injection drug using
clients can be referred to non-Ryan Whitefunded syringe exchange programs.
43
Thank You!
50