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Introduction to the Medical System: Facilitating Coordinated Care by Understanding the Medical Issues of Clients with Substance Use Disorders Thomas E.

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Presentation on theme: "Introduction to the Medical System: Facilitating Coordinated Care by Understanding the Medical Issues of Clients with Substance Use Disorders Thomas E."— Presentation transcript:

1 Introduction to the Medical System: Facilitating Coordinated Care by Understanding the Medical Issues of Clients with Substance Use Disorders Thomas E. Freese, PhD Director of Training, UCL A Integrated Substance Abuse Programs

2 Overview The medical system and managed care Factors for successful collaboration Common medical issues in substance using clients Models of integration from real-world settings Discussion

3 Per capita health care spending Source: Organization for Economic Co-operation and Development. OECD Health Data 2006, from the OECD Internet subscription database updated October 10, Copyright OECD 2006,

4 We’re planning on filling in the details later

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6 What is “Primary Care Integration”? Primary care integration is the collaboration between SUD service providers and primary care providers (e.g., FQHC’s, CHC’s) Collaboration can take many forms along a continuum * *Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; MINIMALBASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt Coordinated Co-located Integrated

7 The Primary Care System SUD Care System Minimal Coordination BH and PC providers –work in separate facilities, –have separate systems, and –communicate sporadically. MH Care System

8 The Primary Care System BH And PC providers –Engage in regular communication about shared patients leading to improved coordination Basic AT A DISTANCE SUD Care System MH Care System

9 The Primary Care System BHand PC providers –Still have separate systems –Some services are co-located (e.g., screening, groups, etc). Basic On Site (co-location of services) Referral SBI Counseling SUD Care System MH Services Counseling MH Care System

10 BH and PC providers –Still have separate systems –Primary care services are integrated into BH Settings Basic On Site (reverse co-location) SUD Care System Medical Services The Primary Care System Referral MH Care System Medical Services Referral

11 PC providers –Develop and provide their won services Integrated Care System Integrated The Primary Care System SUD Care System MH Care System MAT

12 BH and PC providers –share the same facility –have systems in common (e.g., financing, documentation –regular face-to-face communication Integrated Care System Integrated The Primary Care System SUD Care System MH Care System

13 The Medical System Managed Care –Any system that manages healthcare delivery with the aim of controlling costs. –Typically a primary care physician acts as gatekeeper for other health services such as specialty medical care, surgery, or physical therapy. –www.medicinenet.com

14 Managed CareTraditional Insurance Choosing a physician Selected from plan listAny Specialty carePrimary care referralAny Quality of Care Insurer determines prior to enrolling the provider Patient responsible for determining Payment for Services Capitation Individual pays fee for service. Gets (partial) reimbursement AdvantagesOverall cost savingsMaximum flexibility DisadvantagesToo few services providedHigh cost Managed and Fee-for-Service Care

15 The Medical System Primary Care The aims of primary care are to provide broad spectrum of care –both preventive and curative; –over a period of time; and –to coordinate all of the care the patient receives. All family physicians and most pediatricians and internists are in primary care. –www.medicinenet.com

16 The Medical System Primary Care Practitioner must possess a wide breadth of knowledge in many areas. Patients consult the same primary care doctor for routine check-ups, and initial consultation about a new complaint. Common chronic illnesses, often treated in primary care, include: –Hypertension-- Diabetes –Asthma and COPD-- Depression and anxiety –Arthritis and other pain

17 Strategies for successful communication It is important to understand the system with which you are working Learn about the medical conditions that bring people to primary care Expand your vocabulary to facilitate communication Stay within your scope of practice in your interactions Make yourself visible and useful

18 Hypertension Common Medical Issues Associated with Substance Use Disorders

19 Hypertension: Clinical Description Blood pressure (BP) is the force against the walls of one’s arteries while blood is pumping. Hypertension is when BP is too high. Example BP: 120/80 mmHg (“120 over 80”) –Systolic (top number): pressure while heart contracts. Normal is 180. –Diastolic (bottom number) pressure while heart relaxes & enlarges. Normal is 80.

20 Consequences of Hypertension (HTN) Increased risk of: –Stroke –Blood vessel damage (arteriosclerosis) –Heart attack –Tearing of heart’s inner wall (aortic dissection) –Vision loss –Brian damage (NIH, 2010)

21 Blood Pressure Link to SUD Three or more drinks per day increases BP & risk of hypertension in both women and men (Sesso, 2008). Decreasing alcohol consumption associated with dose-dependent reduction in BP (Xin, 2001). Stimulants like cocaine or amphetamines can cause HTN and other acute and chronic cardiovascular diseases. (McMahon, 2010). HTN risk associated with quantity of cigarettes smoked daily and the duration of smoking (Orth, 2004). –Former smokers have higher rates of hypertension than those who never smoked (Orth, 2004).

22 Hypertension & Your Clients HTN can be well controlled in primary care for most patients (Williams 2004). –Some many need help finding transportation. –Some may need help finding free or low-cost clinics. Ask about alcohol consumption. Encourage limiting to 2 or less drinks per day. If client smokes, give advice and support to quit smoking (NICE, 2006). Encourage weight loss and salt reduction. –Losing 10kg (22 lbs) can reduce systolic BP by 10 points (Cappuccio, 2007).

23 Endocarditis Common Medical Issues Associated with Substance Use Disorders

24 Endocarditis: Basic Description Endocarditis is inflammation of the inside lining of the heart chambers and heart valves (endocardium) Usually caused by bacterial infection but can also be fungal. ullsize/18142.jpg (NIH, 2010)

25 Risk factors Injection drug use increase risk: Particulate matter in injected drugs Poor injection hygiene (e.g., not cleaning skin before injecting) Using unsterile equipment. Contaminated drug solutions. Physiological responses to certain drugs. –E.g., cocaine causes blood vessels to constrict (vasospasm) and damages cardiac tissue. –Many studies shows speedball (heroin and cocaine together) injection is a significant risk factor of bacterial infections (Phillips, 2010).

26 Signs & Symptoms Symptoms can develop slowly (subacute) or suddenly (acute ). –Common Chills Excessive sweating Fever –Abnormal urine color (bloody or dark) –Fatigue/weakness –Red, painless skin spots on the palms and soles (Janeway lesions) –Red, painful nodes in the pads of the fingers and toes (Osler's nodes) –Joint pain, muscle aches and pains –Nail abnormalities (splinter hemorrhages under the nails) –Swelling of feet, legs, abdomen

27 Endocarditis & Your Clients Clinical manifestations in injection drug users: –2/3 of patients do not display evidence of underlying heart disease. –Only 35% of IDUs demonstrate heart murmurs on admission (Baddour, 2005). Treatment is intensive but largely successful. –Most patients need to be hospitalized. –Cure rates are high (85%) for right-sided endocarditis. –Treatment cures infection relatively quickly (about 4 weeks). Severe cases exhibiting heart valve damage, stroke, or heart failure may require valve replacement (NIH, 2010)

28 Chronic Obstructive Pulminary Disease (COPD) Common Medical Issues Associated with Substance Use Disorders

29 COPD Overview (Chronic Obstructive Pulmonary Disease) Progressive disease that makes it hard to breathe Cigarette smoking is the leading cause of COPD COPD includes 2 main conditions: Emphysema: walls between air sacs are damaged decreasing the amount of gas in the lungs Chronic Bronchitis: lining of the airways is constantly irritated and inflamed causing the lining to thicken. Thick mucus forms in the airways, making it hard to breathe

30 Signs & Symptoms Signs of Emphysema Shortness of breath, especially during physical activities Wheezing Chest tightness Signs of chronic bronchitis include Having to clear your throat first thing in the morning, especially if you smoke A chronic cough that produces yellowish sputum Shortness of breath in the later stages Frequent respiratory infections

31 Build-up of fluid in the lungs (acute pulmonary edema) has been reported due to use of inhaled crack cocaine and methamphetamines (Wesselius, 1997). Emphysema has been shown to develop secondary to IV drug use (Wesselius, 1997). Individuals are 3 times more likely to develop COPD when tobacco is used in conjunction with marijuana but studies are limited and evidence is inconclusive (ScienceDaily, 2009). COPD Link to SUD

32 Treatment depends on severity and general medical condition. It is usually managed in a primary care setting. Encourage your clients to stop smoking and using drugs. Provide them with smoking cessation and drug counseling options. Encourage compliance with medications, home oxygen therapy, and pulmonary rehabilitation (MayoClinic, 2010). COPD & Your Clients

33 Diabetes Common Medical Issues Associated with Substance Use Disorders

34 Type 2 Diabetes Overview Basic Overview: –Metabolic disease. –Hyperglycemia (too much sugar) due to insulin resistance and defects in insulin secretion. –Diabetes can lead to: blindness heart & blood vessel disease stroke kidney failure amputations nerve damage. 2/how-to-reduce-impact-type-2- diabete.html

35 Type 2 Diabetes Relationship with SUD –Heavy alcohol consumption can increase risk factors including: body-mass index, low HDL (“good”) cholesterol and cigarette smoking (Tsumura, 1999). –A history of substance use is associated with earlier age of onset of diabetes (Johnson, 2001). –SUD is associated with increased mortality in diabetics (Jackson, 2007). Societal Significance –In 2006, it was the seventh leading cause of death, although likely underestimated (National Diabetes Statistics, 2007). –In 2007, diabetes cost the US $174 billion in medical costs, loss of productivity, disability costs (American Diabetes Association, 2007).

36 Sign & Symptoms Often no symptoms at all. Most common symptoms include: –Blurred vision –Erectile dysfunction –Fatigue –Frequent or slow- healing infections –Increased appetite –Increased thirst –Increased urination content/uploads/2009/03/symptoms-for- type-2-diabetes.gif

37 Type 2 Diabetes & Your Clients Medical services available on-site better link clients in SUD treatment to medical services compared to those with outside referrals (Friedmann, 1999). Social support for abstinence can increase linkage to medical services. (Saitz, 2004). Encourage activities that improve diabetes: –Better diet. –Reduce simple carbohydrate intake (i.e. potatoes, white bread, corn, soda, candy, sweets). –More exercise. –Maintain regular appointments with doctor overseeing diabetes treatment.

38 Importance of Hemoglobin A1c Test (HbA1c) The hemoglobin A1c test is used to determine how diabetes is being controlled. HbA1c provides an average of your blood sugar control over a six to 12 week period. When blood sugar is too high, sugar builds up in your blood and combines with your hemoglobin, becoming "glycated." For people without diabetes, the normal range for the HbA1c test is 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than 7%. Retest should occur every three months to determine level of control.

39 Cellulitis Common Medical Issues Associated with Substance Use Disorders

40 Cellulitis: Clinical Description Cellulitis is a common, potentially serious bacterial skin infection (MayoClinic, 2010). Infection can be due to trauma or underlying dermatitis. –Otherwise harmless bacteria on surface of skin penetrate dermis causing inflammation. If left untreated, infection may spread to lymph nodes or blood stream becoming very dangerous and complicated (Humphrey, 2009).

41 Symptoms of Cellulitis –Redness to skin or swelling that gets larger –Warm to the touch –Tight, glossy look to skin –Pain or tenderness –Quickly spreading skin rash Formation of blisters Oozing yellow pus from skin –Signs of infection Fever, chills, muscle aches (NIH, 2010)

42 Cellulitis Link to SUD Cellulitis symptoms in intravenous drug users are often unusual. –This is because the skin, venous, and lymphatic systems are damaged by frequent needle sticks causing mild infections (Stanway, 2002). Complications can occur leading to development of: –Abscesses –Skin ulcers –Necrotizing Fasciitis (flesh eating disease) May lead to death and/or amputation –Blood clots (Stanway, 2002)

43 Cellulitis & Your Clients Cellulitis can be easily managed in primary care for most patients if caught early (Stanway, 2002). –Some may need help finding free or low-cost clinics. –May require extensive follow-up and intense medication regiments if condition is advanced or patient is immunocompromised. Ask about IV drug use history and emphasize the focus on concern for their health. Reassure the patient that their information is confidential to reduce the stigma and embarrassment associated with IV drug use (Humphrey, 2009).

44 Hetapatis C Common Medical Issues Associated with Substance Use Disorders

45 Hepatitis C: Basic Description Hepatitis C is a virus (HCV) that leads to inflammation of the liver (NIH, 2010). Injection drug users (IDUs) are the largest group infected with HCV in the US (Edlin, 2002). Most new infections occur in drug users. Treatment goals: –Remove HCV virus from the blood. –Reduce risk of cirrhosis and liver cancer. Developing cirrhosis of liver significantly increases mortality. interferon-based-therapy-slows-progression-of-liver-cirrhosis-in- hepatitis-c-patients.html

46 Risk factors –Usually spread through blood infected with HCV. –Injection drug use and/or sharing needles with someone infected with HCV. –Unprotected sex with an infected partner (less common). –Can be passed from mother to baby during childbirth (less common). –HCV is the most common infectious disease among injection drug users (Backmund, 2001) htm

47 Signs & Symptoms Most people recently infected do not show symptoms. 10% of recently infected have jaundice that improves spontaneously. Possible symptoms: –Upper-right abdominal pain. –Abdominal swelling –Bleeding in esophagus or stomach (caused by varicies = dilated veins) –Dark urine –Fatigue –Fever –Itching –Jaundice –Loss of appetite –Nausea –Pale or clay-colored stools –Vomiting consequences-of-hepatitis-c.cfm~pageid~1614

48 HCV & Your Clients Former IDUs usually allowed HCV treatment only after months of being drug-free (Backmund, 2001). –Helping clients maintain abstinence through this period is crucial. Treatment is effective in IDU clients, even if a patient relapses (Dalgard, 2002). Treatment adherence often lower in SUD clients, but in groups experienced with SUD, they often have adherence rates exceeding 80% (Edlin, 2002). Essential to find a physician with expertise in hepatology and SUD; –Essential for MD to have experience developing strong relationships with patients to continue treatment even if drug relapse occurs (Edlin 2002).

49 Dental Problems Common Medical Issues Associated with Substance Use Disorders

50 Dental problems: Basic Description Dental problems are common in substance abusers, with the most common problem being “meth mouth” (Myers, 2007). These problems can include dry mouth, caries (cavities), halitosis (bad breath), necrotizing gingivitis, brux (tooth grinding), and periodontal disease that can lead to loose or cracked teeth. Dental problems may occur due to: –Apathy or patient neglect of dental health –Poor diet –Stress –Corrosive substances added to drugs Photo%20Gallery.htm

51 Risk factors & Outcomes –Smoking or snorting substances such as methamphetamines or cocaine. Substance goes down to the posterior nasal pharynx, drains in the back of the throat and bathes the teeth with corrosive substances. –Dry mouth (xerostomia ) Occurs due to decrease in the salivary flow, which contributes to an increased decay rate –Carious lesions & Periodontal Disease Large, dark in color and appears at the gum line. Result of corrosive agents added while making the drugs (such as ether, Freon, & paint thinners) (Peterson, 2008). – Acute Necrotizing Ulcerative Gingivitis Redness, swelling, and erosion of gums Painful Foul smelling

52 Signs & Symptoms Possible symptoms: –Broken teeth –Rampant tooth decay –Recurrent necrotizing ulcerative gingivitis –Bad breath –White, painful coating on tongue (yeast infection) –Painful, bleeding, infected gums –Bruxing (grinding) teeth –Yellowing of teeth –Tooth abscesses –Headaches, jaw pain, neck pain

53 Dental Problems & Your Clients Assessment and referrals to proper health professionals. –Patients may be reluctant to admit to others and themselves that they have a problem and need help. –Genuine, empathic, nonjudgmental, and educated concern is expressed in terms of overall health and well being by health care professionals, the impact can be significant (Newman, 2003). Drugs such as cocaine, methamphetamine and ecstasy have been shown to have dangerous interactions with common dental anesthetics. –These, in turn, could cause major hypertensive episodes or other health problems (Peterson, 2008).

54 Arthritis Common Medical Issues Associated with Substance Use Disorders

55 Arthritis: Clinical Description Arthritis is the inflammation of the tissue lining the joints which leads to the breakdown of cartilage that normally protects the joints (NIH, 2010). Joints are the places where two bones meet, such as the elbow or knee. Cartilage is a tough, elastic, fibrous connective tissue found in various parts of the body. There are over 100 different types of arthritis.

56 Consequences & Types of Arthritis In many cases the inflammation goes away on its own or with treatment. If it does not there is increased risk of (NIH, 2010): –Long-term pain (Chronic arthritis) –Deformity –Lifestyle restrictions Types of Arthritis (NIAMS, 2010) –Osteoarthritis Most common type Usually occurs due to aging Affects fingers, knees, and hips Can be due to injury –Rheumatoid Arthritis Less common, usually affecting hands and feet Commonly due to autoimmune disorders (i.e. Lupus)

57 Arthritis Link to SUD One common type of arthritis related to IV drug use is Septic Arthritis where there is an infection in the affected joint secondary to bacteria being introduced during injection (MayoClinic, 2010). IV drug users commonly develop septic arthritis in the arms, legs and knees. –Symptoms include (MayoClinic, 2010): Fever/warmth in affected joint Pain, swelling, and redness of affected joint –Treatment Antibiotics Drainage of fluid from affected joint

58 Arthritis & Your Clients Arthritis can be treated by a primary care physician if the cause is identified and managed if there is no curable cause (A.D.A.M, 2010). –Some may need help finding free or low-cost clinics –Need consistent follow-ups by physician Ask about IV drug use and encourage reduction in this method of substance use. Encourage rest and adherance to medication regimes in order to improve treatment outcomes (MayoClinic, 2010).

59 HIV Common Medical Issues Associated with Substance Use Disorders

60 HIV: Basic Description Human Immunodeficiency Virus (HIV). It attacks the body’s immune system, specifically CD4+ T cells in the blood. HIV can lead to Acquired Immune Deficiency Syndrome (AIDS). forum/understanding-hiv

61 Risk factors –Clients with psychiatric illnesses have 4 times higher prevalence of HIV compared to general US population. –Clients with a SUD (or co-occuring SUD & MHD) have an even higher risk than clients with solely mental health disorder (Des Jarlais et al., 2007). –Gay, bisexual, and other men who have sex with men (MSM) are the population most affected by HIV. Infection rates in MSM have steadily increased since 1990s (CDC MSM & HIV, 2010). –Women also have rising infection rates, which will soon lead to more women than men with HIV. African Americans have highest risk among women. After heart disease and cancer, AIDS is second highest cause of death among women (CDC Women, 2010).

62 Signs & Symptoms After infection, symptoms usually don’t develop for up to 10 years. –Patient can infect others during this time. It can take up to 3 months for HIV to be detected in blood after infection. Symptoms usually stem from secondary infections, including: –Diarrhea –Fatigue –Fever –Frequent vaginal yeast infections –Headache –Mouth sores, including yeast infection (thrush) –Muscle stiffness or aching –Rash of different types –Sore throat –Swollen lymph glands

63 HIV & Your Clients SUD treatment can lower chances of blood-borne HIV infection, in addition to hepatitis B and C (CDC, 2002). –IDUs not receiving treatment are 6 times more likely to become HIV+ than those who enter and stay in treatment. –SUD can reduce inhibitions, which raise frequency of high-risk drug practices (e.g. using non-sterile needles) and high-risk sexual behaviors (e.g. sex without condoms). Treatment agencies are a good location to access many IDUs to provide education in reducing risky behavior or increasing self-care if currently infected. In opiate users, beginning methadone maintenance treatment (MMT) reduces the mortality rate to lower than 1/3 of risk before treatment. Risk-reduction education crucial because some may not be successfully achieve complete abstinence from injection drug use. –MMT relapses after treatment are common (up to 50% of clients). –Extra challenges at agencies that consider complete abstinence as the only acceptable outcome because risk-reduction education may be contradictory.

64 Linking HIV & SUD Services Potential integration approaches: –As part of SUD treatment, provide HIV testing and counseling on-site. –In SUD education and counseling, add HIV prevention education (both sexual behavior risks and drug use risks). –HIV-prevention outreach programs can also encourage IDUs to access SUD treatment. –Current needle exchange/access programs can encourage linkage to health and SUD services. –Incorporate family/partner counseling to educate patients' sex partners and children. (CDC-IDU &HIV, 2002).

65 Crack/Cocaine Users and Access to Medical Care HIV-positive crack users are: –More likely than their HIV-negative counterparts to have never been in HIV primary care –Less likely to have access to basic medical services –Less likely to have a regular healthcare provider –Less likely to initiate medical care and treatment SOURCES: Metsch LR et al., 2009; Cunningham, CO et al.,

66 Crack/Cocaine Increases HIV Risk 1,084 HIV-negative injecting drug users –137 (~13%) were HIV+ at follow-up –HIV risk increased over time –Daily crack smoking increased throughout study period. –Increased HIV risk from smoking crack was independent of other risk factors, such as: Needle sharing Sex work, and Unprotected sex –Wounds that develop around the mouth while smoking crack can increase HIV transmission risk while sharing crack pipes or performing oral sex. SOURCE: DeBeck et al. (2009). CMAJ, 181 (9):

67 HIV risk behaviors in 637 crack, powder cocaine and heroin users in central Harlem: –Injectors (OR = 2.5) –Engaged in fraud/cons (OR = 2.6) –Separated/divorced/widowed (OR = 2.2) –Multiple sex partners (OR = 1.7) –Females (OR = 1.7) SOURCE: Davis et al., 2006, AIDS Care. Crack/Cocaine Increases HIV Risk 67

68 Crack/Cocaine Use and HIV Disease Progression – Women Study sample: 1,686 HIV-seropositive women (29% used crack during study period) recruited between 1996 and Finding #1: Persistent crack users and intermittent users in active phases showed greater CD4 cell loss and higher HIV-1 RNA levels SOURCE: Cook, JA et al. (2008). Crack-cocaine, disease progression, and mortality in a multi-center cohort of HIV-1 positive women. AIDS, 22(11):

69 Crack/Cocaine Use and HIV Disease Progression – Women Finding #2: Persistent crack users were over three times as likely as nonusers to die from AIDS-related causes Finding #3: Persistent and intermittent crack users were more likely than nonusers to develop new AIDS-defining illnesses SOURCE: Cook, JA et al. (2008). Crack-cocaine, disease progression, and mortality in a multi-center cohort of HIV-1 positive women. AIDS, 22(11):

70 Cocaine and HIV Antiretrovirals According to the latest research, there are NO known drug interactions between cocaine and HIV antiretrovirals (e.g., NNRTIs, NRTIs, Protease Inhibitors, CCR5 Inhibitors, or Integrase Inhibitors) In general, cocaine may increase rate of HIV viral replication in vitro, and is associated with: –Hypertension, cardiac dysrhythmias, myocardial infarction, seizures, depression, and anxiety. SOURCE: NY/NJ AIDS Education and Training Center. 70

71 Methadone and HIV Medications Changes to a patient’s methadone regimen or HIV medications should be reported to both providers to ensure potential interactions are identified. Several HIV antiretroviral medications decrease methadone levels; so use of methadone and certain HIV medications requires an increase in methadone dose. Certain medications that are used to treat HIV (and some psychiatric conditions) may impact metabolism and can cause clinically significant increases or decreases in serum and tissue levels of opioid medications. Refer to the NY/NJ AETC’s product entitled, “Recreational Drugs and HIV Antiretrovirals: A Guide to Interactions for Clinicians, 2009” for a full listing of HIV medications that may interact with methadone. You may also refer to: Drug Interactions Associated With HAART: Focus on Treatments for Addiction and Recreational Drugs. AIDS Reader 13(9): , Available at:

72 Buprenorphine & HIV Medications Data are limited on interactions between buprenorphine and antiretroviral drugs. Studies have found no interaction with zidovudine. Efavirenz has been found to lower buprenorphine levels but with no clinical impact. Protease inhibitors may increase buprenorphine levels Providers should be alert to the possible need for dose adjustment.

73 Pain Common Medical Issues Associated with Substance Use Disorders

74 Progress in the Management of Prescription Opiate Use Disorders Karen Miotto, MD Integrated Substance Abuse Programs Dept. of Psychiatry, UCLA

75 The Fateful Triangle Under treatment of pain Increasing availability of opioid analgesics Increased production and distribution Increase in the number of prescriptions filled Increased internet availability Increase in abuse of prescription opioids

76

77 Prescription Drug Misuse Any prescription drug can be “misused” Misuse = “non-medical use” = Any use that is outside of medically prescribed regimen: –Non-compliance –Taking different dose –Sharing –Obtaining from non-medical source –Taking for psychoactive effects –Taking for effects not indicated –Use with alcohol or other substances

78 Risks of Becoming Addicted Broad availability of prescription drugs –e.g., via the medicine cabinet, family, friends, Internet, and physicians Misperceptions about their safety Focus on a pill for every ill (cultural trend, media) High rates of other substance use including abuse cigarettes, drugs and alcohol Childhood history of abuse, trauma and neglect High rates of depression and anxiety

79 Pain: “ Define yourself, then we shall converse ”-- Voltaire Pain: An unpleasant sensory and emotional experience arising from the actual or potential tissue damage or described in terms of such damage It is always subjective. Each individual learns the application of the word through experiences related to injury in early life (International Association for the Study Pain [IASP]) Early life – historical Experience—learned Subjective—private Individual--unique

80 Reciprocal Nature: Depression-Pain Relationship 65% of patients with depression experience pain 75% of primary care patients with depression present only with physical complaints and do not attribute their pain to depression 0 or 1 physical symptom - 2% were found to have depression ≥ 9 physical symptoms – 60% were depressed 5% to 85% of patients with pain have depression Increasing pain severity, frequent pain episodes, diffuse pain, and treatment resistant pain are associated with more severe depression In patients with pain, depression is associated with more pain complaints, greater intensity, longer duration of and greater likelihood of nonrecovery Bair MJ et al, ARCH INTERN MED, 2003

81 Grief and Pain Kowalski & Bondmass (2008) study of pain and grief correlation in widows Self-reported physical symptoms included: –Pain –Gastro-intestinal problems –Medical/surgical conditions –Sleep disturbances –Neurological/circulatory issues Psychological symptoms: –Depression –Anxiety –Loneliness Of the 173 women in the sample, about two-thirds the sample reported at least one physical complaint following spousal loss Kowalski & Bondmass, 2008

82 Drug Use Disorders Among Seriously Injured Trauma Patients 1220 recruited, 1118(91.6%) consented 54.2% had a diagnosis of a SUD in their lifetime 24.1% alcohol dependent (men 28%; women, 15%) 17.7% dependent on drugs (men, 20%;women, 11%) 54.3% blood alcohol-positive alcohol dependent 38.7% positive urine drug test drug dependent Soderstrom et al JAMA Jun 11;277(22):

83 The Dilemma Need to accurately diagnose disease and provide effective analgesia Some illnesses have no diagnostic test, but are frequently cited as reasons for pain syndromes needing medication treatment(s) Headache Low back pain Pelvic pain Arthritis Fibromyalgia Chronic Fatigue Syndrome Has contributed to misuse of pain pills and addiction

84 Diagnosing Addiction Opioid-maintained Pain Patients No validated diagnostic criteria for addiction in pain patients; only “at risk” behaviors: –Control –Compulsive use –Continue use despite harm –Craving Identifying “at risk” patients: –History –Screening instruments –Behavioral checklists –Therapeutic maneuver

85 Opioid Risk Tool (ORT) Mark each box that applies: Female Male 1.Family history of substance abuse Alcohol1 3 Illegal drugs2 3 Prescription drugs4 4 2.Personal history of substance abuse Alcohol3 3 Illegal drugs4 4 Prescription drugs5 5 3.Age (mark box if between years)1 1 4.History of preadolescent sexual abuse3 0 5.Psychological disease ADO, OCD, bipolar, schizophrenia2 2 Depression1 1 Scoring totals: Scoring 0-3: low risk (6%) 4-7: moderate risk (28%) > 8: high risk (> 90%) Administration On initial visit Prior to opioid therapy Webster, et al. Pain Med. 2005;6:432.

86 Aberrant Drug-Taking Behaviors Probably more predictive Selling prescription drugs Prescription forgery Stealing or borrowing another patient’s drugs Injecting oral formulation Obtaining prescription drugs from non-medical sources Concurrent abuse of related illicit drugs Multiple unsanctioned dose ↑ s Recurrent prescription losses Probably less predictive Aggressive complaining about need for higher dose Drug hoarding during periods of reduced symptoms Requesting specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation 1 – 2 times Unapproved use of the drug to treat another symptom Reporting psychic effects not intended by the clinician Passik and Portenoy, 1998

87 Pain tolerance Opioid-induced analgesia Opioid-induced hyperalgesia Hyperalgesia (Increased sensitivity to pain) can be opioid induced

88 Four A’s of Pain Management Analgesia Activities of Daily Living Adverse Effects Aberrant Drug- Taking Behavior Baxter J., 2009 Drug of Abuse Testing

89 MEDICATION/PSYCHOSOCIAL

90 Mountain Park Health Center Integrated Behavioral Health From Co-Location to Fully Integrated Care Bill Rosenfeld

91 Primary Care BH Phase 1 Goal: Established a Horizontal Platform Behavioral Health Consultant (BHC) placed in medical clinic Considered a member of the primary care team Provides consultation (not therapy) Goal of immediate access, minimal barriers Emphasizes psychoeducation, population mgmt Focus on improving QOL, quality of health care

92 Pitfalls to Avoid Allowing the BHC “Office Hermit” to go on too long Clinician’s housed outside of medical providers service delivery area. Implementing a co-location model

93 Improved Health Outcomes Diminished HbA1c across the board Diminished Missed School Days Diminished rate of Patients asked to leave practice Patient Confidence in self-care enhanced Ratio of SM Goals set and education attended enhanced

94 Impact of Program on Providers  All PCPs reported:  Satisfaction with the BHC service  Access to BHC as “immediate” and “very helpful”  Better able to address behavioral problems  Recommend the service for other medical providers  A majority (> 80%) said because of BHC:  Have greater confidence in how BH issues are treated within the collaborative framework  Able to see more patients in 20 minutes  Better recognize patient behavioral issues

95 Patient Satisfaction 90% said visit length “Very Good”, or “Excellent” 88% rated quality of BHC care as “Very Good” or “Excellent” 94% would recommend BHC to family or friends 89% said it was helpful to meet w/ BHC 82% felt BHC involvement resulted in improved health status

96 Hidden Benefits MPHC dismisses 75% fewer patients from our practice since socially embedding a BHC in Internal Medicine Positive impact on recruitment of medical providers Broad range of staff training possibilities

97 HTN Relaxation Skills Training, Diaphragmatic Breathing, Problem Solving Diabetes Promote Self Mgt. Goal Identification and Attainment, Enhance mood stability, Identify and restructure alarmist thinking and hopelessness, Stress Reduction Obesity Promote Self Mgt. Goal Identification and Attainment, Behavioral Modification, Support Healthy Lifestyle Attainment, Motivational Change, Diet/Exercise Goal Identification and Attainment, Motivation for Change Chronic Pain (multiple presentations), including fibromyalgia syndrome Promote the use of Attention Diversion techniques, Diminish tension through relaxation skills, Stages of Pain psycho education, Values Clarification Insomnia; Sleep Disturbances Sleep Hygiene, Relaxation Skills Training Fatigue/Malaise Sleep Hygiene, Motivation for Change, Lifestyle Assessment and Planned Activity Guidance Asthma Identifying Triggers, Trigger Removal or Mgt., Daily Monitoring, Action Planning Headache Headache impact log, Trigger Identification Pregnancy Stress mgt., augment positive support, promote emotional and physical self care Noncompliance with Medical Treatment Motivational Interviewing, Strengths Identification, Strengths utilization, Values Inventory/Utilization Hypercholesterolemia Lifestyle Mgt., Diet/Exercise Goal Identification and Attainment, Motivation for Change BEHAVIORAL HEALTH UTILIZATION Medical Diagnosis Behavioral Health Intervention

98 BEHAVIORAL HEALTH UTILIZATION FOR OB/GYN Medical Diagnosis Behavioral Health Intervention PregnancyStress mgt., augment positive support, Emotional/Physical Self Care Teen PregnancySafety assessment, Resource assessment, Assessment of emotional/support needs Post Partum VisitAssessment and support for Post Partum Depression and adjustment issues Gestational DiabetesPromote Self Mgt. Goal Identification and Attainment, Enhance mood stability, Identify and restructure alarmist thinking and hopelessness, Stress Reduction Low LibidoRelaxation skills, Stress management, Relationship skills training, Communications skills training, ObesityPromote Self Mgt. Goal Identification and Attainment, Behavioral Modification, Support Healthy Lifestyle Attainment, Motivational Change, Diet/Exercise Goal Identification and Attainment, Motivation for Change InfertilityStress Management, Relationship skills training, Grief work Tobacco/ Substance UseTobacco cessation, Connection to substance abuse programs, Motivational Interviewing Noncompliance with Medical Treatment Motivational Interviewing, Strengths Identification, Strengths utilization, Values Inventory/Utilization

99 Thanks for Bill Rosenfeld for providing this information Bill Rosenfeld at or

100 Contact information Thomas E. Freese, PhD Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs


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