1. Integrating Substance Use Treatment into Primary Care: You can do it! Aaron Fox, MD, MS, Assistant Professor of Medicine Albert Einstein College of Medicine/Montefiore Medical Center; Attending Physician, Comprehensive Health Care Center Beth Hribar, MPP, Program Director Institute of Advanced Medicine of the Mount Sinai Health System Martha A. Sparks, PhD, Associate Director Mental Health Services, Spencer Cox Center for Health, Institute of Advanced Medicine of the Mount Sinai Health System Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # C6b, Period 6 October 17, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: 1.Identify at least one reason primary care settings provide an ideal location for implementing substance use treatment 2.Understand the regulatory and credentialing requirements for providing both medical and psychosocial interventions in substance use treatment. 3.Understand at least one common barrier to retention for individuals with substance use issues, and will identify a harm- reduction principle or intervention to support patient reengagement. 4.Identify at least one successful intervention that can be implemented in a primary care setting of a standard clinic.

4. Select References Bernstein, J. et. Al. (2015). Recreational drug use among primary care patients: Implications of a positive self-report. Annals of Family Medicine, 13(3). Buck, J. A. (2011). The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs, 30(8). Institute for Clinical Systems Improvement. (2013). Patients with risky substance use in primary care settings. Retrieved from: https://www.icsi.org/_asset/s769qd/RSU- prevalent-in-PC---FINAL.pdf United States Department of Health and Human Services. (2015). Essential health benefits. Retrieved from https://www.healthcare.gov/glossary/essential-health- benefits/ United States Department of Health and Human Services. (2014). Results from the 2013 national survey on drug use and health: Summary of national findings. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/N SDUHresults2013.htm#7.2

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Outline 1.Introduction 2.Integrated care: A primary care physician’s perspective 3.Integrated care: A behavioral specialist’s perspective 4.Integrated care: Policy and regulatory issues 5.Practical recommendations

7. Substance use is common among primary care patients

8. There is a large treatment gap Total number of individuals in need of treatment: 22.7 million Location of substance use treatment (2.5 million unique individuals)

9. Our perspective Substance use disorders are chronic relapsing conditions Neurobiological disease with genetic, psychosocial, environmental contributions Responsibility to meet patient needs Patient centered care Medications are underutilized Harm reduction vs. traditional model of care

10. Implementing substance use treatment into primary care: The medical provider perspective

11. Primary care: an ideal setting for substance use treatment PCPs have experience in longitudinal care for chronic conditions Address risky/problem behavior early Reduce stigma Reduce barriers to care Possibly, improved outcomes (vs. specialty settings)

12. Treatment services delivered in primary care Screening and brief intervention Medication assisted treatment Relapse prevention strategies Harm reduction counseling

13. Case example: Montefiore Medical Center

14. Group Buprenorphine Treatment Team members: MD and MSW Patient selection: need for more intensive counseling Timing: 90 minutes, twice monthly Group Activities: self-disclosure, feedback, trauma-informed group therapy (Seeking Safety), psycho-education, guided relaxation, pizza Lessons Learned: confidentiality, voluntary, logistic support

15. Implementing substance use treatment into primary care: The Behavioral Health Perspective

16. Benefits of behavioral health in primary care Coordinated care team Shared EMR Case conferences Reduced stigma

17. Treatment services provided in behavioral health in primary care Individual therapy Group therapy Case management Patient navigation Treatment for comorbidities Psychopharmacology EMR Case Conference

18. Case example: Morningside Clinic

19. Integrating substance use treatment into primary care: Administration, regulation, and policy

20. Administrative and regulatory considerations Credentialing for treatment providers (CASAC v. Masters-level and higher clinicians) Buprenorphine training and panel size Licensing requirements from state offices of substance use services Clinician discomfort with and stigma surrounding patients with SUDs Effective screening and referral to care

21. The Affordable Care Act Substance use treatment is an “essential health benefit” Mental health care also an “essential health benefit” o Substance use interventions in the context of therapy can be billed under behavioral health and not SAMHSA Referrals to residential treatment limited by Medicaid law o No reimbursement for programs with more than 16 beds Insurance companies often limit the number of days in treatment, or require re-authorization (though not more restrictive than medical or surgical benefits)

22. Practical Recommendations 1.Implement routine screening using the EMR 2.Educate providers about medication assisted treatments - identify a site champion 3.Retention in care IS an important goal 4.Mental health problems and substance use can be treated concomitantly 5.With your training and expertise, you can do it!

23. Acknowledgements Mariel Gallego, Teresa Hurst, Hannah Wolfe, Emily Gertz, and the entire team at the Morningside Clinic Maritza Casillas, Angela Giovanniello, and our patients at the Comprehensive Health Care Center Dr. Fox is supported by K23 DA034541

24. PRIMECare 1.Ask – screen for alcohol use 2.Assess – relapse risk (PRECURSORS) 3.Advise – brief counseling 4.Assist – pharmacotherapy or strategy to manage high-risk situations 5.Arrange – regular appointment Friedmann JGIM 2006