Evidence-based Care for Substance Use Disorders (SUD)

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Evidence-based Care for Substance Use Disorders
(SUD)

• Dan Kivlahan, PhD
• CESATE and SUD QUERI
• P3 Conference
• New Haven, 9/30/09

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Overview

• Selected co-prevalence estimates
• Revised VA/DoD Clinical Practice Guideline
• Pharmacotherapy (abbrev.)
• Psychosocial
• Common factors
• Selected evidence-based SUD treatments with
  potential implications for 3P Veterans?
• Measurement Based Care
• The Brief Addiction Monitor (BAM)
• Common data elements

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Pain and SUD treatment

• In sample of Veterans seeking addiction
  treatment, excluding opioid dependent patients
• 33 reported persistent pain 47 reported
  intermittent pain
• Those with persistent pain
• Received less treatment
• Had poorer abstinence rates at 12 mos
• Had greater service utilization and higher costs
• Caldiero et al., The association of persistent
  pain with outpatient addiction treatment outcomes
  and service utilization. Addiction, 2008, 103,
  1996-2005.

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Diagnosed SUD Among OEF/OIF Veterans with PTSD

• 303,223 new users in OEF/OIF Roster thru FY08
• PTSD 24
• Alcohol Use Disorder 22
• Other Drug Use Disorder 10
• Depression 53
• Cohen, Marmar, Ren, Bertenthal Seal, JAMA 2009.

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Recent SUD-related Hiring
Program of Positions Filled/ Committed Filled/ Committed
SUD-PTSD Clinicians 147 122 83
TOTAL SUD-related Expansion Initiative Hires 914 766 84
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http//www.healthquality.va.gov
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Caveats on Guidelines

• An aid in decision making
• But the strength of evidence is variable
• Where scientific data were lacking ,
  recommendations were based on the clinical
  expertise of the Working Group
• This should not prevent providers from using
  their own clinical expertise in the care of an
  individual patient

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Initiate Addiction-Focused Pharmacotherapy (If
Indicated)

• BACKGROUND
• Addiction-focused pharmacotherapy should be
  considered, available and offered if indicated,
  for all patients with opioid dependence and/or
  alcohol dependence. Addiction-focused
  pharmacotherapy should be provided in addition to
  indicated pharmacotherapy for co-existing
  psychiatric conditions

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Initiate Addiction-Focused Pharmacotherapy (If
Indicated)

• Discuss addiction-focused pharmacotherapy options
  with all patients with opioid and/or alcohol
  dependence.
• Initiate addiction-focused pharmacotherapy if
  indicated and monitor adherence and treatment
  response.

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Initiate Pharmacotherapy for Alcohol Dependence

• 1. Routinely consider oral naltrexone, an opioid
  antagonist, and acamprosate for patients with
  alcohol dependence. Acamprosate is currently
  non-formulary with criteria for use posted at
  http//vaww.national.cmop.va.gov/PBM/Clinical20Gu
  idance/Forms/AllItems.aspx
• 2. Medications should be offered in combination
  with addiction-focused counseling.
• 3. Injectable naltrexone should be considered
  when medication adherence is a significant
  concern in treating alcohol dependence .
  Injectable naltrexone is currently non-formulary
  with criteria for use posted at
  http//vaww.national.cmop.va.gov/PBM/Clinical20Gu
  idance/Forms/AllItems.aspx

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Any Pharmacotherapy for AUD FY07

• No Addiction Care 190,974 1.2
• SUD Specialty Outpatient Only 82,843
  6.4
• Both SUD Opt Residential 7,240
  11.6
• Harris et al (in press) Psychiatric Services

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Pharmacotherapy Initiated for AUD FY07
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Is Opioid Agonist Treatment (OAT) Medication
Appropriate for, and Acceptable to, the Patient?

• BACKGROUND
• Opioid agonist treatment (OAT) is the first line
  treatment for chronic opioid dependence that
  meets DSM-IV-TR criteria.

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Initiate Addiction-Focused Psychosocial
Interventions

• Indicate to the patient and significant others
  that treatment is more effective than no
  treatment
• (i.e., Treatment works).
• Consider the patients prior treatment experience
  and respect patient preference , since no single
  intervention approach has emerged as the
  treatment of choice.

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Initiate Addiction-Focused Psychosocial
Interventions

• Regardless of the particular psychosocial
  intervention chosen, use motivational
  interviewing style during therapeutic encounters
  with patients and emphasize the common elements
  of effective interventions
• enhancing patient motivation to stop or reduce
  substance use,
• improving self-efficacy for change,
• promoting a therapeutic relationship,
• strengthening coping skills,
• changing reinforcement contingencies for
  recovery, and
• enhancing social support for recovery.

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Initiate Addiction-Focused Psychosocial
Interventions

• Emphasize that the most consistent predictors of
  successful outcome are retention in formal
  treatment and/or active involvement with
  community support for recovery.
• Use strategies demonstrated to be efficacious to
  promote active involvement in available mutual
  help programs
• (e.g., Alcoholics Anonymous, Narcotics
  Anonymous).

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Initiate Addiction-Focused Psychosocial
Interventions

• Based on locally available expertise, initiate
  addiction-focused psychosocial interventions with
  empirical support. Consider the following
  interventions that have been developed into
  published treatment manuals and evaluated in
  randomized trials

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Menu of Options

• Behavioral Couples Therapy
• Cognitive Behavioral Relapse Prevention
• Community Reinforcement
• Contingency Management/Motivational Incentives
• Motivational Enhancement Therapy
• Twelve-Step Facilitation Network Support for
  Recovery
• http//vaww.sites.lrn.va.gov/vacatalog/cu_detail.a
  sp?id25544

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Behavioral Couples Therapy

• OFarrell, T.J. Fals-Stewart, W. (2006).
  Behavioral couples therapy for alcoholism and
  drug abuse. New York Guilford Press.

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Behavioral Couples Therapy

• Purpose of BCT is to support abstinence and
  improve relationship functioning
• Medium effect in meta-analysis of 12 studies -
  Powers et al, 2008
• BCT also reduces interpersonal violence, social
  costs, child distress
• Website www.addictionandfamily.org
• Web-based training www.neattc.org
• (under Distance Education)

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• Rewarding Early Abstinence and treatment
  Participation
• An SUD QUERI Effectiveness Trial

R E A P
Funded by VA HSRD (IIR SUT 03-120) P.I. Hildi
Hagedorn, Ph.D. (Minneapolis) Site P.I. Daniel
Kivlahan, Ph.D. (Seattle)
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Motivational Incentives

• Participants randomly assigned to
• Usual Care Standard care provided at the clinic
  breath and urine testing 2x/week for 8 weeks.
• Incentives Usual care draw for incentives (VA
  canteen vouchers) when negative samples are
  submitted. Drawing chances increase with each
  consecutive week of abstinence.

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Urine Test Cup (iCup) with temperature strip and
adulterant panel
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Attendance rate across 16 visits significantly
higher for IIP participants (plt.001)
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2- and 6-Month Follow-UpPercent Days Abstinence
for Total Sample
p.02
p.10
N164/group
N136/group
UC N119 73 IIP N127 77
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6-Month Follow-Up Participants with Any Use(UC
n40 IIP n40)
p.01
p.004
p.05
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Supply Costs
Vouchers M 99 (range 0 to 271)
Rapid Urine Test Cups M 68.25 (5.25/cup X 13 visits)
Alco Sensor mouthpieces M 3.12 (0.24/piece X 13 visits)
Mean per patient 170.37
Max per patient 358.84
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Motivational Incentives(REAP)

• Clinically feasible and relatively low cost
• Well received by patients and most staff.
• Incentives increased attendance during treatment
  and improved 6-month clinical outcomes.
• Intervention associated with significantly
  reduced use among the minority of patients who
  relapsed.
• Working on national policy support for use of
  Medical Care

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Network Support for Recovery

• Mark Litt, PhD.
• Ronald Kadden, PhD.
• Elise Kabela-Cormier, PhD.
• The University of Connecticut Health Center
• Funded by NIH grants R01-AA12827, R21-AA014202
  and
• General Clinical Research Center grant
  M01-RR06192

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Role of Social Network

• A treatment that encourages a change of social
  network, from one that is supportive of drinking
  to one that is supportive of sobriety, may be
  effective.
• AA may be a useful adjunct to treatment, but for
  many it cannot be the only alternative.

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2-yr Outcomes 90-Day Abstinence
NS gt NSCM CaseM NSCM CaseM
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Network Support Study

• Network Support Tx outcomes remained good over 2
  years posttreatment
• NS resulted in increases in support for
  abstinence, but no decreases in support for
  drinking
• Support for abstinence, incl. participation in
  AA, partly responsible for decreased drinking
• Contingency management did not help
• The addition of 1 abstinent friend to the social
  network increased the probability of being
  abstinent for the next year by 27

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Manage General Medical and Psychiatric
Co-occurring Conditions

• 1. Prioritize and address other medical and
  psychiatric co-occurring conditions.
• 2. Recommend and offer tobacco cessation
  treatment to patients with nicotine dependence.
• 3. Treat concurrent psychiatric disorders
  consistent with VA/DoD clinical practice
  guidelines (e.g., Post Traumatic Stress)
  including concurrent pharmacotherapy.

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Variable response to SUD TX

• Many patients do well and others do not
• Even with standardized treatment delivery
• and good adherence
• Some patients do well at first, but then
  deteriorate
• Very hard to predict who will do well in advance

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Assess Response to Treatment / Monitor Biological
Indicators

• Reassess response to treatment periodically and
  systematically,
• using standardized and valid self report
  instrument(s)
• laboratory tests.
• Indicators of treatment response include ongoing
  substance use, craving, side effects of
  medication, emerging symptoms, etc.

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Key Questions

• What is the Plan B for patients who dont
  respond to initial approach?
• How to determine when it is time to
  offer/encourage Plan B?

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Measurement Based Care(McKay 2009)

• Establish standardized baseline
• Assess treatment response early
• during treatment for most
• perhaps re-engage some patients
• Timely adjustment of tx plan for non-responders
• More distal clinical outcomes could justify
  status quo practices or prompt quality
  improvement efforts

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Brief Addiction Monitor (BAM)

• Need efficient system to monitor patient progress
  and assess outcomes
• Assess substance use, along with other indicators
  of relapse risk and recovery-oriented behaviors
• Incorporate in CPRS and prompt follow-up with a
  clinical reminder

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Development of BAM

• 17 items - 5 minutes to complete
• Pilot study in Phil., administered to 150
  patients at intake
• Repeated 3 months later
• Initial analyses indicate
• Sensitive to change
• Composed of 3 reliable factors
• substance use
• risk factors for use
• pro-recovery behaviors,

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BAM Questions on Use
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BAM Items
Substance Use Risk Factors Protective Factors
Any alcohol use Physical health Self-efficacy
Heavy alcohol use Sleep problems Self-help
Drug use Mood/Angry/Upset Religion/spirituality
Craving Risky situations Work, school
Family/social conflict Income/Housing
Satisfied w Recovery Social supports for recovery
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Implementing BAM

• Expand pilot testing to several additional VAMCs
• Explore timing/frequency of assessment
• while most patients still in treatment
• Gradual progress on getting the monitor into the
  electronic medical record
• Clinical Reminder template
• Mental Health Assistant
• MyHealtheVet

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BAM in CPRS
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http//www.dcoe.health.mil/cde.aspx
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Common data elements Alcohol

• Core
• AUDIT-C (3-items)
• AUDIT (10-items)
• Report both total score (0-40) and AUDIT-C total
  score (0-12)
• Related but distinct factors

• Advanced
• Consequences
• Short Index of Problems (15-items)
• Drinker Inventory of Consequences (50-items)
• Days of any/heavy use
• Timeline Follow-back
• Days of alcohol-related problems
• DSM-IV Checklist
• Blood Alcohol Level within 24 hours of injury

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Common data elements Tobacco use

• Core
• Cigarettes/tobacco products per day
• Time to first tobacco use (within 30 minutes)

• Advanced/Extended
• Last use
• Fagerstrom Test of Nicotine Dependence (5-item)
• Saliva cotinine
• Lifetime pack years

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Gaps for future consideration

• Common Data Elements for non-alcohol SUD
• Priority prescription medication misuse
• Definitions of recovery, remission, good
  clinical outcome
• Alcohol use as factor in TBI recovery
• Natural history
• Response to treatment
• Developmental influences prior to injury/trauma
  exposure on risk and recovery
• Relapse to tobacco use in theater

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Conclusions

• Revised VA/DoD Clinical Practice Guideline
• Pharmacotherapy AND Psychosocial Interventions
• Common factors, including respecting patient
  preference
• Evidence-based Treatments
• Menu of options
• Measurement-based care
• Common Data Elements
• Implementation and De-Implementation challenges
• daniel.kivlahan_at_va.gov