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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