1. VA Screening Tools and Treatment Options Available to Veterans Stephen Chermack, PhD Chief, Mental Health Service, VA Ann Arbor Healthcare System Associate Professor, Department of Psychiatry, University of Michigan

2. The Science of Addiction

3. Addictio n DRU G Environme nt Biology/Gen es Biology/ Environmen t Interaction Biological Factors Interact with Environmental Factors to Produce Addiction

4. So What Does All This Mean for Drug Abuse Service Delivery?

5. Relapse Rates for Drug Addiction are Similar to Other Chronic Medical Conditions Relapse Rates for Drug Addiction are Similar to Other Chronic Medical Conditions 0 0 1010 1010 2020 2020 3030 3030 4040 4040 5050 5050 6060 6060 7070 7070 8080 8080 9090 9090 10 0 Drug Dependenc e Drug Dependenc e Type I Diabetes Type I Diabetes Hypertension Asthma 40 to 60% 30 to 50% 50 to 70% Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000. Percent of Patients Who Relapse

6. Treatment Research Institute Outcome In Diabetes Conclusion: Treatment Successful!

7. Treatment Research Institute Outcome In Addiction (Incorrect) conclusion: Treatment NOT successful!

8. If we treat a diabetic and symptoms don’t subside….what do we do? Would we increase the dose? Would we change medications? Would we change treatment approaches? Would we fail to provide ongoing treatment for a diabetic? Would we increase the dose? Would we change medications? Would we change treatment approaches? Would we fail to provide ongoing treatment for a diabetic?

9. We need to shift the paradigm of addiction treatment from an acute to a chronic care model

10. AbstinenceAbstinence Functionality in Family, Work, and Community Functionality in Family, Work, and Community Goals of Drug Treatment: Keeping an Eye on the Target Reduced Criminal Behavior

11. Effectiveness of Treatment 40- 60% Drug Use Crime Employment 40- 60% 40%

12. Cost-Effectiveness of Drug Treatment Cost to society of drug abuse = $180 billion/year. Treatment is less expensive than incarceration: - Methadone maintenance = $4,700/yr -Imprisonment =$18,400/yr Other studies indicate that every $1 invested in treatment can yield up to $7 in savings.

13. Clinical Practices Initial Services Sustain & Manage Therapeutic Interventions Assessment “Prescription” for Services Behavioral Counseling and Medications Recovery/Chronic Care Management Screening and Brief Intervention Recovery from drug addiction requires effective treatment followed by management of the disorder over time. A Chronic Care Approach to Drug Treatment

14. Treatment must last long enough to produce stable behavioral changes. Percent

15. * p <.05 from Comparison In-Prison Treatment Plus Post-Release Aftercare Improve 5 Year Outcomes in Prison Addicts No Treatment CREST Dropouts CREST Completers CREST Completers + Aftercare Drug-Free Arrest-Free No Treatment CREST Dropouts CREST Completers CREST Completers + Aftercare Martin, Butzin, Saum, Inciardi (2004), Crime and Delinquency * * * * * AFTERCARE is Indispensable Participants 80% African American

16. Assessment is the first step in treatment. Nature/extent of drug problem Strengths: Family support Employment history Motivation Threats to recovery: C riminal behavior Mental health Physical health Family Influences Employment Homelessness HIV/AIDS

17. Intake Processing / Assessment Treatment Plan Pharmacotherapy Continuing Care Clinical and Case Management Self-Help / Peer Support Groups Behavioral Therapy and Counseling Substance Use Monitoring Detoxification Child Care Services Vocational Services Medical Services Educational ServicesAIDS / HIV Services Family Services Financial Services Legal Services Mental Health Services Housing / Transportation Services Matching services to needs is critical for treatment to be successful.

18. Drug use during treatment should be carefully monitored. Know that lapses can occur Conduct urinalysis Provide immediate feedback Intensify treatment as needed

19. Treatment should target factors associated with criminal behavior. Criminal thinking Antisocial values Anger/hostility Problem solving Conflict resolution skills Attitudes toward school/work Mental health problems Family functioning Barriers to care Alcohol/drug problems

20. Effective Treatments Include: Cognitive Behavioral Therapy 12 step facilitation Motivational Interviewing Contingency Management Behavioral Couples Therapy Opiate Substitution Addiction Psychopharmacology Contingency Management Problem Service Matching

21. VA Addiction and MH Services Uniform Mental Health Services Handbook- released in 2008, specified “essential components of the the mental health program that is to be implemented nationally, to ensure that all veterans, wherever they obtain care in VHA, have access to needed mental health services.” 2012- VA National SUD Handbook- further specified requirements for provision of SUD services at all VA treatment facilities VA invests in several staff training initiatives for best practices in mental health care

22. VA Addiction and MH Services VA is a highly accountable healthcare organization (includes performance and quality of care monitoring and feedback) VA emphasizes empirically supported treatment approaches VA funds innovative research to improve healthcare for veterans, including studies of addiction treatment (e.g., interventions to prevent violence and relapse, treating chronic pain among vets in addiction treatment, improve “aftercare” engagement post- hospitalization, etc.).

23. VA Medical Centers Ann Arbor: VA Ann Arbor Healthcare System Outpatient & Intensive Outpatient Battle Creek: Battle Creek VA Medical Center Outpatient, Intensive Outpatient, Residential Detroit: John D. Dingell VA Medical Center Outpatient, Intensive Outpatient & Opiate Treatment Program Iron Mountain: Oscar G. Johnson VA Medical Center Outpatient & Intensive Outpatient Saginaw: Aleda E. Lutz VA Medical Center Outpatient & Intensive Outpatient * * * * *

24. Community Based Outpatient Clinics Alpena: Clement C. Van Wagoner Outpatient Clinic Bad Axe: Bad Axe Community Based Outpatient Clinic Benton Harbor: Benton Harbor VA Outpatient Clinic Cadillac: Cadillac Community Based Outpatient Clinic Clare: Clare Community Outpatient Clinic Flint: Flint VA Outpatient Clinic Gaylord: Gaylord VA Outpatient Clinic Grand Rapids: Grand Rapids VA Outpatient Clinic Grayling: Grayling Community Based Outpatient Clinic Hancock: Hancock Clinic Ironwood: Ironwood Clinic Lansing: Lansing VA Outpatient Clinic Mackinaw City: Cheboygan County Community Based Outpatient Clinic Manistique: Manistique Outreach Clinic Marquette: Marquette Clinic Menominee: Menominee Clinic Michigan Center: Jackson VA Outpatient Clinic Muskegon: Muskegon VA Outpatient Clinic Oscoda: Oscoda VA Outpatient Clinic Pontiac: Pontiac VA Outpatient Clinic Saginaw: Saginaw VA Healthcare Annex Sault Ste. Marie: Sault Ste. Marie Clinic Traverse City: Traverse City VA Outpatient Clinic Yale: Yale VA Outpatient Clinic * * * * *

25. Levels of Care and other SUD services Residential Rehabilitation Treatment Program Currently only at Battle Creek Typical length of stay = 4 weeks Intensive Outpatient Program At each medical center Length of stay typically 4-6 weeks Outpatient Specialty Care At each medical center and very large CBOC Varied services including therapy and pharmacotherapy Opiate Treatment Program Only at Detroit (Offering Methadone and Suboxone) Suboxone offered at some other sites Other outpatient SUD services Some available at each facility in person, telehealth, or fee-basis

26. Access to Care New veterans requesting or referred for services receive an initial evaluation within 24 hours (usually by phone) and a comprehensive diagnostic and treatment planning evaluation within 14 days Waiting times for all services for established veterans are less than 30 days from the desired date of appointment Telemental Health Services is a mechanism to meet requirements and provide convenience for veterans Medical Centers and very large CBOCs offer a range of services during evening hours at least 1 day per week and on at least one weekend day.

27. Care Transitions Facilities ensure continuity of care during transitions from one level of care to another Veterans discharging from inpatient or residential are given appointments for follow up at time of discharge. Follow up includes evaluations within 1 week of discharge.

28. Veteran-Centered requirements Appropriate services addressing the broad spectrum of substance use conditions including tobacco use disorders are available Interventions for SUD are provided when needed in a manner sensitive to the needs of veterans and specific populations including but not limited to homeless, ethnic minorities, women, geriatric veterans, veterans with PTSD or other mental health conditions, veterans w/infectious diseases, TBI, and service- connected conditions. SUD is never be a barrier for treatment of other conditions or vice versa.

29. Screening for SUD in Veterans During new encounters and at least annually, veterans seen in medical or mental health settings are screened for alcohol misuse using the AUDIT-C (frequency, quantity, frequency of heavy drinking) Targeted case finding strategies are used to identify those with illicit drug use or misuse of prescriptions Those screening positive for SUD receive further assessment to determine level of misuse and establish diagnosis.

30. Assessment within SUD treatment Veterans presenting for SUD care receive a multidimensional, biopsychosocial assessment to guide treatment planning for SUD and comorbid conditions All veterans with Alcohol Use disorder, Opiate Use Disorder, and other Axis 1 Mental Health disorders are evaluated by a physician for medication consideration. Veterans complete the Brief Addiction Monitor (BAM) Outcomes are monitored throughout the care episode in order to inform ongoing treatment planning. Note: VA also screens veterans for depression, PTSD, Military Sexual Trauma, Suicide Risk

31. Assessment within SUD treatment Brief Addiction Monitor (BAM): recent alcohol and drug use mental health conditions sleep problems Cravings self-efficacy self-help participation social support, risky situations Spirituality structured time, social stressors, financial situation, satisfaction with recovery progress.

32. Psychosocial Services Motivational counseling is available to veterans who need it to support initiation of SUD treatment. At least 2 of the following empirically validated psychosocial interventions are available for veterans with SUD: Motivational Enhancement therapy/ Motivational Interviewing Cognitive Behavioral Therapy Twelve step Facilitation Contingency Management Behavioral Couples Therapy for SUD When PTSD and other MH conditions co-occur with SUD, interventions for other conditions is made available when not contraindicated.

33. Cognitive Behavioral Coping Skills Based on social learning theory Substance use is functionally related to other problems Emphasizes learning of coping skills Initiation and mastery of skills through practice, role playing, and extra-sessions tasks

34. Functional Analysis Exploration of substance use in relationship to antecedents and consequences Identify and match cognitive and behavioral coping tools based on functional analysis

36. Withdrawal / Detoxification Medically supervised withdrawal management is available at all facilities (or through referral/transfer) as needed based on assessment of symptoms and risk of serious adverse consequences of alcohol, sedatives, hypnotics, or opioids. Although withdrawal management can often be ambulatory, inpatient is available. Withdrawal management alone is not treatment and must be linked to further SUD Treatment. Appointments for follow up are completed within 1 week of discharge.

37. Opiate Pharmacotherapy Pharmacotherapy (e.g., Suboxone or methadone) is available to veterans with opiate dependence when indicated. Pharmacotherapy is provided in addition to and linked to psychosocial treatment and support. When agonist treatment is contraindicated or declined, antagonist medication is available and considered. Suboxone is prescribed only by waivered prescribers in an office based environment or in an Opiate Treatment program.

38. Alcohol & Other Pharmacotherapy Pharmacotherapy for alcohol dependence is offered and available when not contraindicated. Pharmacotherapy must be prescribed with and linked to psychosocial Tx and support. Most common pharmacotherapy for alcohol includes naltrexone and disulfiram; however, alternatives are also prescribed. Medications are available for Tobacco use Disorder Medications for other mental health concerns are also provided for veterans