User login
Medicare going in ‘right direction’ on opioid epidemic
About 174,000 Medicare beneficiaries received such a medication – either buprenorphine or naltrexone – to help them with recovery in 2018, according to the Office of Inspector General in the Department of Health & Human Services.
In addition, prescriptions for naloxone – the drug that can reverse an opioid overdose – spiked since 2016, rising 501% – and that is likely an underestimate because it doesn’t include doses of the nasal spray Medicare members might have received through local programs, the OIG said.
“For now, the numbers are going in the right direction,” said Miriam Anderson, lead investigator on the report. “But this is a national crisis and we must remain vigilant and continue to fight this epidemic and ensure that opioids are prescribed and used appropriately.”
During the 2 years studied, the threat of new addictions appeared to slow. Prescriptions for an opioid through Medicare Part D decreased by 11%. The numbers of the beneficiaries considered at serious risk for misuse or overdose ― either because they received extreme amounts of opioids or appeared to be “doctor shopping” – dropped 46%. And there were 51% fewer doctors or other providers flagged for prescribing opioids to patients at serious risk from 2016 to 2018.
The report says the OIG and other law enforcement agencies will investigate the highest-level prescribers for possible fraud and signs that some providers operate pill mills. The report mentions a physician in Florida who provided 104 high-risk Medicare patients with 2,619 opioid prescriptions.
It will be up to Medicare to follow up with patients whose opioid use suggests addiction, recreational use, or resale. In one case, a Pennsylvania woman received 10,728 oxycodone pills and 570 fentanyl patches from a single physician during 2018. A Medicare member in Alabama acquired 56 opioid prescriptions from 25 different prescribers within 1 year.
In a statement, the Centers for Medicare & Medicaid Services said: “Fighting the opioid epidemic has been a top priority for the Trump administration. We are encouraged by the OIG’s conclusion which finds significant progress has been made in our efforts to decrease opioid misuse while simultaneously increasing medication-assisted treatment in the Medicare Part D program.”
The agency points to recent efforts to curb opioid misuse including a 7-day limit on first-time opioid prescriptions, pharmacy alerts about Medicare beneficiaries who receive high doses of pain medication, and drug management programs that may restrict a patient’s supply. CMS says it does not use a “one-size-fits-all” approach. Medicare patients in long-term care facilities or hospice care and those in cancer treatment are exempt from the opioid-prescribing restrictions.
The opioid-prescribing limits are raising alarms among some Medicare recipients, especially those who qualify based on a long-term disability and deal with severe, chronic pain.
Jae Kennedy, PhD, a disability policy expert at Washington State University, Spokane, said cutting back on opioid prescriptions is generally a good development.
“But we hear from people in the disability community who feel like they’re being victimized by this new, very stringent set of dispensing limits,” said Dr. Kennedy. “People have been managing their pain, in some cases for many years without a problem, and now they’re being kind of criminalized by this new bureaucratic backlash.”
Ms. Anderson said the OIG agrees that “some patients need opioids and they should receive those needed for their condition. This report raises concerns that some patients may be receiving opioids above and beyond those needs.”
While most Medicare beneficiaries are 65 years or older, the 15% who are under 65 and disabled may be the key piece of this report. Dr. Kennedy’s research shows they are up to three times more likely to describe persistent pain than are other adults and 50% more likely to report opioid misuse. A 2017 OIG report found that 74% of Medicare beneficiaries at serious risk for addiction and overdose deaths were under age 65 years.
Dr. Kennedy said it’s good to see Medicare expanding access to medication-assisted treatment, known as MAT, for addiction, but the agency needs to make sure that more buprenorphine prescribers accept all patients, not just the ones who are easiest to manage. Patients with disabilities often need many different medications for multiple physical and mental health conditions.
“Saying, ‘Well, because you’ve got schizophrenia or manic depressive disorder, we can’t treat you,’ I think is discriminatory,” Dr. Kennedy said. “It’s happening with private buprenorphine prescribers in this country because there are so few.”
Americans 65 years or older have the lowest rates of opioid overdose deaths. Even so, the Centers for Disease Control and Prevention says the number of deaths among seniors increased by 279% from 1999 to 2017.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. WBUR, a public radio station owned by Boston University, is a member station of NPR.
About 174,000 Medicare beneficiaries received such a medication – either buprenorphine or naltrexone – to help them with recovery in 2018, according to the Office of Inspector General in the Department of Health & Human Services.
In addition, prescriptions for naloxone – the drug that can reverse an opioid overdose – spiked since 2016, rising 501% – and that is likely an underestimate because it doesn’t include doses of the nasal spray Medicare members might have received through local programs, the OIG said.
“For now, the numbers are going in the right direction,” said Miriam Anderson, lead investigator on the report. “But this is a national crisis and we must remain vigilant and continue to fight this epidemic and ensure that opioids are prescribed and used appropriately.”
During the 2 years studied, the threat of new addictions appeared to slow. Prescriptions for an opioid through Medicare Part D decreased by 11%. The numbers of the beneficiaries considered at serious risk for misuse or overdose ― either because they received extreme amounts of opioids or appeared to be “doctor shopping” – dropped 46%. And there were 51% fewer doctors or other providers flagged for prescribing opioids to patients at serious risk from 2016 to 2018.
The report says the OIG and other law enforcement agencies will investigate the highest-level prescribers for possible fraud and signs that some providers operate pill mills. The report mentions a physician in Florida who provided 104 high-risk Medicare patients with 2,619 opioid prescriptions.
It will be up to Medicare to follow up with patients whose opioid use suggests addiction, recreational use, or resale. In one case, a Pennsylvania woman received 10,728 oxycodone pills and 570 fentanyl patches from a single physician during 2018. A Medicare member in Alabama acquired 56 opioid prescriptions from 25 different prescribers within 1 year.
In a statement, the Centers for Medicare & Medicaid Services said: “Fighting the opioid epidemic has been a top priority for the Trump administration. We are encouraged by the OIG’s conclusion which finds significant progress has been made in our efforts to decrease opioid misuse while simultaneously increasing medication-assisted treatment in the Medicare Part D program.”
The agency points to recent efforts to curb opioid misuse including a 7-day limit on first-time opioid prescriptions, pharmacy alerts about Medicare beneficiaries who receive high doses of pain medication, and drug management programs that may restrict a patient’s supply. CMS says it does not use a “one-size-fits-all” approach. Medicare patients in long-term care facilities or hospice care and those in cancer treatment are exempt from the opioid-prescribing restrictions.
The opioid-prescribing limits are raising alarms among some Medicare recipients, especially those who qualify based on a long-term disability and deal with severe, chronic pain.
Jae Kennedy, PhD, a disability policy expert at Washington State University, Spokane, said cutting back on opioid prescriptions is generally a good development.
“But we hear from people in the disability community who feel like they’re being victimized by this new, very stringent set of dispensing limits,” said Dr. Kennedy. “People have been managing their pain, in some cases for many years without a problem, and now they’re being kind of criminalized by this new bureaucratic backlash.”
Ms. Anderson said the OIG agrees that “some patients need opioids and they should receive those needed for their condition. This report raises concerns that some patients may be receiving opioids above and beyond those needs.”
While most Medicare beneficiaries are 65 years or older, the 15% who are under 65 and disabled may be the key piece of this report. Dr. Kennedy’s research shows they are up to three times more likely to describe persistent pain than are other adults and 50% more likely to report opioid misuse. A 2017 OIG report found that 74% of Medicare beneficiaries at serious risk for addiction and overdose deaths were under age 65 years.
Dr. Kennedy said it’s good to see Medicare expanding access to medication-assisted treatment, known as MAT, for addiction, but the agency needs to make sure that more buprenorphine prescribers accept all patients, not just the ones who are easiest to manage. Patients with disabilities often need many different medications for multiple physical and mental health conditions.
“Saying, ‘Well, because you’ve got schizophrenia or manic depressive disorder, we can’t treat you,’ I think is discriminatory,” Dr. Kennedy said. “It’s happening with private buprenorphine prescribers in this country because there are so few.”
Americans 65 years or older have the lowest rates of opioid overdose deaths. Even so, the Centers for Disease Control and Prevention says the number of deaths among seniors increased by 279% from 1999 to 2017.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. WBUR, a public radio station owned by Boston University, is a member station of NPR.
About 174,000 Medicare beneficiaries received such a medication – either buprenorphine or naltrexone – to help them with recovery in 2018, according to the Office of Inspector General in the Department of Health & Human Services.
In addition, prescriptions for naloxone – the drug that can reverse an opioid overdose – spiked since 2016, rising 501% – and that is likely an underestimate because it doesn’t include doses of the nasal spray Medicare members might have received through local programs, the OIG said.
“For now, the numbers are going in the right direction,” said Miriam Anderson, lead investigator on the report. “But this is a national crisis and we must remain vigilant and continue to fight this epidemic and ensure that opioids are prescribed and used appropriately.”
During the 2 years studied, the threat of new addictions appeared to slow. Prescriptions for an opioid through Medicare Part D decreased by 11%. The numbers of the beneficiaries considered at serious risk for misuse or overdose ― either because they received extreme amounts of opioids or appeared to be “doctor shopping” – dropped 46%. And there were 51% fewer doctors or other providers flagged for prescribing opioids to patients at serious risk from 2016 to 2018.
The report says the OIG and other law enforcement agencies will investigate the highest-level prescribers for possible fraud and signs that some providers operate pill mills. The report mentions a physician in Florida who provided 104 high-risk Medicare patients with 2,619 opioid prescriptions.
It will be up to Medicare to follow up with patients whose opioid use suggests addiction, recreational use, or resale. In one case, a Pennsylvania woman received 10,728 oxycodone pills and 570 fentanyl patches from a single physician during 2018. A Medicare member in Alabama acquired 56 opioid prescriptions from 25 different prescribers within 1 year.
In a statement, the Centers for Medicare & Medicaid Services said: “Fighting the opioid epidemic has been a top priority for the Trump administration. We are encouraged by the OIG’s conclusion which finds significant progress has been made in our efforts to decrease opioid misuse while simultaneously increasing medication-assisted treatment in the Medicare Part D program.”
The agency points to recent efforts to curb opioid misuse including a 7-day limit on first-time opioid prescriptions, pharmacy alerts about Medicare beneficiaries who receive high doses of pain medication, and drug management programs that may restrict a patient’s supply. CMS says it does not use a “one-size-fits-all” approach. Medicare patients in long-term care facilities or hospice care and those in cancer treatment are exempt from the opioid-prescribing restrictions.
The opioid-prescribing limits are raising alarms among some Medicare recipients, especially those who qualify based on a long-term disability and deal with severe, chronic pain.
Jae Kennedy, PhD, a disability policy expert at Washington State University, Spokane, said cutting back on opioid prescriptions is generally a good development.
“But we hear from people in the disability community who feel like they’re being victimized by this new, very stringent set of dispensing limits,” said Dr. Kennedy. “People have been managing their pain, in some cases for many years without a problem, and now they’re being kind of criminalized by this new bureaucratic backlash.”
Ms. Anderson said the OIG agrees that “some patients need opioids and they should receive those needed for their condition. This report raises concerns that some patients may be receiving opioids above and beyond those needs.”
While most Medicare beneficiaries are 65 years or older, the 15% who are under 65 and disabled may be the key piece of this report. Dr. Kennedy’s research shows they are up to three times more likely to describe persistent pain than are other adults and 50% more likely to report opioid misuse. A 2017 OIG report found that 74% of Medicare beneficiaries at serious risk for addiction and overdose deaths were under age 65 years.
Dr. Kennedy said it’s good to see Medicare expanding access to medication-assisted treatment, known as MAT, for addiction, but the agency needs to make sure that more buprenorphine prescribers accept all patients, not just the ones who are easiest to manage. Patients with disabilities often need many different medications for multiple physical and mental health conditions.
“Saying, ‘Well, because you’ve got schizophrenia or manic depressive disorder, we can’t treat you,’ I think is discriminatory,” Dr. Kennedy said. “It’s happening with private buprenorphine prescribers in this country because there are so few.”
Americans 65 years or older have the lowest rates of opioid overdose deaths. Even so, the Centers for Disease Control and Prevention says the number of deaths among seniors increased by 279% from 1999 to 2017.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. WBUR, a public radio station owned by Boston University, is a member station of NPR.
Opioid exposure leads to poor perinatal and postnatal outcomes
according to data from more than 8,000 children.
Previous studies have shown the increased risk of a range of health problems associated with maternal opioid use, including neonatal abstinence syndrome (NAS), but data on the long-term consequences of in utero opioid exposure are limited, wrote Romuladus E. Azuine, DrPH, MPH, of the U.S. Department of Health and Human Services, Rockville, Md., and colleagues.
In a study published in JAMA Network Open, the researchers reviewed data from 8,509 mother/newborn pairs in the Boston Birth Cohort, a database that included a large urban, low-income, multiethnic population of women who had singleton births at the Boston Medical Center starting in 1998.
A total of 454 infants (5%) experienced prenatal opioid exposure. Mothers were interviewed 48-72 hours after delivery about sociodemographic factors, drug use, smoking, and alcohol use.
The risk of small for gestational age and preterm birth were significantly higher in babies exposed to opioids (OR 1.87 and OR 1.49, respectively), compared with unexposed newborns.
Children’s developmental outcomes were collected starting in 2003 based on electronic medical records. A total of 3,153 mother-newborn pairs were enrolled in a postnatal follow-up study. For preschoolers, prenatal opioid exposure was associated with increased risk of lack of expected physiological development and conduct disorder/emotional disturbance (OR 1.80 and OR 2.13, respectively), compared with unexposed children. School-aged children with prenatal opioid exposure had an increased risk of ADHD (OR 2.55).
The incidence of NAS in the study population was at least 24 per 1,000 hospital births starting in 2004, and peaked at 61 per 1,000 hospital births in 2008, but remained higher than 32 per 1,000 through 2016.
The study findings were limited by several factors including potential misclassification of opioid exposure, confounding from other pregnancy exposures, loss of many participants to follow-up, and a lack of generalizability, but the results support the need for additional research, and show that the prevalence of NAS was approximately 10 times the national average in a subset of low-income, urban, minority women, the researchers said.
“However, the effect of opioids is still difficult to disentangle from effects of other childhood exposures. Policy and programmatic efforts to prevent NAS and mitigate its health consequences require more comprehensive longitudinal and intergenerational research,” they concluded.
The study findings contribute to and support the evidence of poor neurodevelopmental and emotional/behavioral outcomes for children with prenatal exposure to opioids or a history of NAS, Susan Brogly, PhD, MSc, noted in an accompanying editorial. Other studies have shown increased risks for visual impairments including strabismus, reduced visual acuity, and delayed visual maturation.
Dr. Brogly, of Queen’s University, Kingston Health Science Center, Ontario, nonetheless noted that a child’s home environment may modify the impact of prenatal opioid exposure or NAS, as evidence has shown that children with in utero heroin exposure have improved outcomes in healthy home environments.
Although the mechanism for how opioid exposure affects development remains uncertain, she suggested that future research should address “interventions to improve health outcomes in this rapidly growing population of children, regardless of the causal mechanism of impairment.”
Dr. Brogly noted that most of the opioid-using mothers in the study by Azuine et al. were unmarried, non-Hispanic white, and multiparous, and had histories of other substance abuse. She emphasized the need for supportive communities for women at risk of opioid use, who also are more likely to have unstable housing situations and histories of sexual and physical abuse.
“The risks of poor pregnancy and child outcomes in cases of maternal opioid exposure are not because of prenatal opioid exposure alone; ongoing difficult social and environmental circumstances have an important role,” and future interventions should address these circumstances to improve long-term health of high-risk women and their children, she emphasized.
The Boston Birth Cohort study is supported in part by grants from the National Institutes of Health and the U.S. Department of Health and Human Services. None of the authors had financial conflicts to disclose.
Dr. Brogly disclosed grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development outside the submitted work.
SOURCE: Azuine RE et al. JAMA Network Open. 2019 Jun 28. doi: 10.1001/jamanetworkopen.2019.6405; Brogly S. JAMA Network Open. 2019 Jun 28. doi:10.1001/jamanetworkopen.2019.6428.
according to data from more than 8,000 children.
Previous studies have shown the increased risk of a range of health problems associated with maternal opioid use, including neonatal abstinence syndrome (NAS), but data on the long-term consequences of in utero opioid exposure are limited, wrote Romuladus E. Azuine, DrPH, MPH, of the U.S. Department of Health and Human Services, Rockville, Md., and colleagues.
In a study published in JAMA Network Open, the researchers reviewed data from 8,509 mother/newborn pairs in the Boston Birth Cohort, a database that included a large urban, low-income, multiethnic population of women who had singleton births at the Boston Medical Center starting in 1998.
A total of 454 infants (5%) experienced prenatal opioid exposure. Mothers were interviewed 48-72 hours after delivery about sociodemographic factors, drug use, smoking, and alcohol use.
The risk of small for gestational age and preterm birth were significantly higher in babies exposed to opioids (OR 1.87 and OR 1.49, respectively), compared with unexposed newborns.
Children’s developmental outcomes were collected starting in 2003 based on electronic medical records. A total of 3,153 mother-newborn pairs were enrolled in a postnatal follow-up study. For preschoolers, prenatal opioid exposure was associated with increased risk of lack of expected physiological development and conduct disorder/emotional disturbance (OR 1.80 and OR 2.13, respectively), compared with unexposed children. School-aged children with prenatal opioid exposure had an increased risk of ADHD (OR 2.55).
The incidence of NAS in the study population was at least 24 per 1,000 hospital births starting in 2004, and peaked at 61 per 1,000 hospital births in 2008, but remained higher than 32 per 1,000 through 2016.
The study findings were limited by several factors including potential misclassification of opioid exposure, confounding from other pregnancy exposures, loss of many participants to follow-up, and a lack of generalizability, but the results support the need for additional research, and show that the prevalence of NAS was approximately 10 times the national average in a subset of low-income, urban, minority women, the researchers said.
“However, the effect of opioids is still difficult to disentangle from effects of other childhood exposures. Policy and programmatic efforts to prevent NAS and mitigate its health consequences require more comprehensive longitudinal and intergenerational research,” they concluded.
The study findings contribute to and support the evidence of poor neurodevelopmental and emotional/behavioral outcomes for children with prenatal exposure to opioids or a history of NAS, Susan Brogly, PhD, MSc, noted in an accompanying editorial. Other studies have shown increased risks for visual impairments including strabismus, reduced visual acuity, and delayed visual maturation.
Dr. Brogly, of Queen’s University, Kingston Health Science Center, Ontario, nonetheless noted that a child’s home environment may modify the impact of prenatal opioid exposure or NAS, as evidence has shown that children with in utero heroin exposure have improved outcomes in healthy home environments.
Although the mechanism for how opioid exposure affects development remains uncertain, she suggested that future research should address “interventions to improve health outcomes in this rapidly growing population of children, regardless of the causal mechanism of impairment.”
Dr. Brogly noted that most of the opioid-using mothers in the study by Azuine et al. were unmarried, non-Hispanic white, and multiparous, and had histories of other substance abuse. She emphasized the need for supportive communities for women at risk of opioid use, who also are more likely to have unstable housing situations and histories of sexual and physical abuse.
“The risks of poor pregnancy and child outcomes in cases of maternal opioid exposure are not because of prenatal opioid exposure alone; ongoing difficult social and environmental circumstances have an important role,” and future interventions should address these circumstances to improve long-term health of high-risk women and their children, she emphasized.
The Boston Birth Cohort study is supported in part by grants from the National Institutes of Health and the U.S. Department of Health and Human Services. None of the authors had financial conflicts to disclose.
Dr. Brogly disclosed grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development outside the submitted work.
SOURCE: Azuine RE et al. JAMA Network Open. 2019 Jun 28. doi: 10.1001/jamanetworkopen.2019.6405; Brogly S. JAMA Network Open. 2019 Jun 28. doi:10.1001/jamanetworkopen.2019.6428.
according to data from more than 8,000 children.
Previous studies have shown the increased risk of a range of health problems associated with maternal opioid use, including neonatal abstinence syndrome (NAS), but data on the long-term consequences of in utero opioid exposure are limited, wrote Romuladus E. Azuine, DrPH, MPH, of the U.S. Department of Health and Human Services, Rockville, Md., and colleagues.
In a study published in JAMA Network Open, the researchers reviewed data from 8,509 mother/newborn pairs in the Boston Birth Cohort, a database that included a large urban, low-income, multiethnic population of women who had singleton births at the Boston Medical Center starting in 1998.
A total of 454 infants (5%) experienced prenatal opioid exposure. Mothers were interviewed 48-72 hours after delivery about sociodemographic factors, drug use, smoking, and alcohol use.
The risk of small for gestational age and preterm birth were significantly higher in babies exposed to opioids (OR 1.87 and OR 1.49, respectively), compared with unexposed newborns.
Children’s developmental outcomes were collected starting in 2003 based on electronic medical records. A total of 3,153 mother-newborn pairs were enrolled in a postnatal follow-up study. For preschoolers, prenatal opioid exposure was associated with increased risk of lack of expected physiological development and conduct disorder/emotional disturbance (OR 1.80 and OR 2.13, respectively), compared with unexposed children. School-aged children with prenatal opioid exposure had an increased risk of ADHD (OR 2.55).
The incidence of NAS in the study population was at least 24 per 1,000 hospital births starting in 2004, and peaked at 61 per 1,000 hospital births in 2008, but remained higher than 32 per 1,000 through 2016.
The study findings were limited by several factors including potential misclassification of opioid exposure, confounding from other pregnancy exposures, loss of many participants to follow-up, and a lack of generalizability, but the results support the need for additional research, and show that the prevalence of NAS was approximately 10 times the national average in a subset of low-income, urban, minority women, the researchers said.
“However, the effect of opioids is still difficult to disentangle from effects of other childhood exposures. Policy and programmatic efforts to prevent NAS and mitigate its health consequences require more comprehensive longitudinal and intergenerational research,” they concluded.
The study findings contribute to and support the evidence of poor neurodevelopmental and emotional/behavioral outcomes for children with prenatal exposure to opioids or a history of NAS, Susan Brogly, PhD, MSc, noted in an accompanying editorial. Other studies have shown increased risks for visual impairments including strabismus, reduced visual acuity, and delayed visual maturation.
Dr. Brogly, of Queen’s University, Kingston Health Science Center, Ontario, nonetheless noted that a child’s home environment may modify the impact of prenatal opioid exposure or NAS, as evidence has shown that children with in utero heroin exposure have improved outcomes in healthy home environments.
Although the mechanism for how opioid exposure affects development remains uncertain, she suggested that future research should address “interventions to improve health outcomes in this rapidly growing population of children, regardless of the causal mechanism of impairment.”
Dr. Brogly noted that most of the opioid-using mothers in the study by Azuine et al. were unmarried, non-Hispanic white, and multiparous, and had histories of other substance abuse. She emphasized the need for supportive communities for women at risk of opioid use, who also are more likely to have unstable housing situations and histories of sexual and physical abuse.
“The risks of poor pregnancy and child outcomes in cases of maternal opioid exposure are not because of prenatal opioid exposure alone; ongoing difficult social and environmental circumstances have an important role,” and future interventions should address these circumstances to improve long-term health of high-risk women and their children, she emphasized.
The Boston Birth Cohort study is supported in part by grants from the National Institutes of Health and the U.S. Department of Health and Human Services. None of the authors had financial conflicts to disclose.
Dr. Brogly disclosed grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development outside the submitted work.
SOURCE: Azuine RE et al. JAMA Network Open. 2019 Jun 28. doi: 10.1001/jamanetworkopen.2019.6405; Brogly S. JAMA Network Open. 2019 Jun 28. doi:10.1001/jamanetworkopen.2019.6428.
FROM JAMA NETWORK OPEN
CBT intervention tied to Internet addiction remission in men
A manualized cognitive-behavioral therapy (CBT) program that combines group and individual interventions might effectively treat Internet and computer game addiction in men, results of a multicenter randomized trial suggest.
In the study, Klaus Wölfling, PhD, and colleagues randomized 143 men (mean age, 26.2 years) with Internet addiction (IA), which was defined as a score greater than 13 on the Assessment of Internet and Computer Game Addiction Self-Report (AICA-S). The men were recruited at four outpatient clinics in Germany and Austria from Jan. 24, 2012, to June 14, 2017. The primary endpoint of remission, defined as a score of less than 7 on the AICA-S, was achieved by 50 patients (69.4%) in the treatment arm, compared with 17 patients (23.9%) of the wait-list control arm. The greatest declines in AICA-S scores were seen by midtreatment, but mean scores continued at similar levels through follow-up. The study was published in JAMA Psychiatry (2019 Jul 10. doi: 10.1001/jamapsychiatry.2019.1676).
Dr. Wölfling and colleagues chose to limit the scope of the study to male participants because they represent most of those affected by IA; however, the authors admitted this limits the results’ generalizability. They also noted that many of the patients were ambivalent toward treatment, which is a core characteristic of patients affected by IA. Recruitment was slow, so the investigators had to evaluate a smaller number of participants than planned, although they felt their analyses were still statistically powerful enough to detect difference in endpoints. The authors also noted that, although they tried to control for comorbidities, which are often associated with IA, they had to define exclusion criteria for certain conditions such as major depression and some personality disorders.
IA was included in the DSM-5 in 2013 as a condition warranting further research, the authors of this study noted. More recently, it was “introduced as a new diagnosis in the International Classification of Diseases, 11th Revision, in the section Disorders Due to Substance Use or Addictive Behaviors.”
A manualized cognitive-behavioral therapy (CBT) program that combines group and individual interventions might effectively treat Internet and computer game addiction in men, results of a multicenter randomized trial suggest.
In the study, Klaus Wölfling, PhD, and colleagues randomized 143 men (mean age, 26.2 years) with Internet addiction (IA), which was defined as a score greater than 13 on the Assessment of Internet and Computer Game Addiction Self-Report (AICA-S). The men were recruited at four outpatient clinics in Germany and Austria from Jan. 24, 2012, to June 14, 2017. The primary endpoint of remission, defined as a score of less than 7 on the AICA-S, was achieved by 50 patients (69.4%) in the treatment arm, compared with 17 patients (23.9%) of the wait-list control arm. The greatest declines in AICA-S scores were seen by midtreatment, but mean scores continued at similar levels through follow-up. The study was published in JAMA Psychiatry (2019 Jul 10. doi: 10.1001/jamapsychiatry.2019.1676).
Dr. Wölfling and colleagues chose to limit the scope of the study to male participants because they represent most of those affected by IA; however, the authors admitted this limits the results’ generalizability. They also noted that many of the patients were ambivalent toward treatment, which is a core characteristic of patients affected by IA. Recruitment was slow, so the investigators had to evaluate a smaller number of participants than planned, although they felt their analyses were still statistically powerful enough to detect difference in endpoints. The authors also noted that, although they tried to control for comorbidities, which are often associated with IA, they had to define exclusion criteria for certain conditions such as major depression and some personality disorders.
IA was included in the DSM-5 in 2013 as a condition warranting further research, the authors of this study noted. More recently, it was “introduced as a new diagnosis in the International Classification of Diseases, 11th Revision, in the section Disorders Due to Substance Use or Addictive Behaviors.”
A manualized cognitive-behavioral therapy (CBT) program that combines group and individual interventions might effectively treat Internet and computer game addiction in men, results of a multicenter randomized trial suggest.
In the study, Klaus Wölfling, PhD, and colleagues randomized 143 men (mean age, 26.2 years) with Internet addiction (IA), which was defined as a score greater than 13 on the Assessment of Internet and Computer Game Addiction Self-Report (AICA-S). The men were recruited at four outpatient clinics in Germany and Austria from Jan. 24, 2012, to June 14, 2017. The primary endpoint of remission, defined as a score of less than 7 on the AICA-S, was achieved by 50 patients (69.4%) in the treatment arm, compared with 17 patients (23.9%) of the wait-list control arm. The greatest declines in AICA-S scores were seen by midtreatment, but mean scores continued at similar levels through follow-up. The study was published in JAMA Psychiatry (2019 Jul 10. doi: 10.1001/jamapsychiatry.2019.1676).
Dr. Wölfling and colleagues chose to limit the scope of the study to male participants because they represent most of those affected by IA; however, the authors admitted this limits the results’ generalizability. They also noted that many of the patients were ambivalent toward treatment, which is a core characteristic of patients affected by IA. Recruitment was slow, so the investigators had to evaluate a smaller number of participants than planned, although they felt their analyses were still statistically powerful enough to detect difference in endpoints. The authors also noted that, although they tried to control for comorbidities, which are often associated with IA, they had to define exclusion criteria for certain conditions such as major depression and some personality disorders.
IA was included in the DSM-5 in 2013 as a condition warranting further research, the authors of this study noted. More recently, it was “introduced as a new diagnosis in the International Classification of Diseases, 11th Revision, in the section Disorders Due to Substance Use or Addictive Behaviors.”
FROM JAMA PSYCHIATRY
Mindfulness-based relapse prevention tied to lower anxiety, depression
SAN ANTONIO – A mindfulness-based relapse prevention program resulted in significantly greater declines in anxiety and depressive symptoms among participants in an opioid addiction treatment program than those seen in patients who received treatment as usual, suggest results of a small nonrandomized controlled trial. Relapse rates trended downward with mindfulness but were not significantly different from the treatment-as-usual (TAU) group.
“Mindfulness-based relapse prevention (MBRP) can be successfully implemented in an outpatient setting with as good as or better results as treatment as usual,” Keith J. Zullig, PhD, MSPH, chair and professor in the department of social and behavioral sciences at the West Virginia University School of Public Health in Morgantown, said at the annual meeting of the College on Problems of Drug Dependence.
Though relapse rates did not show a statistically significant drop with mindfulness treatment compared with treatment as usual, the downward trend suggests that it is worthwhile to conduct a larger scale study, Dr. Zullig said.
, he added.
The researchers recruited 60 participants from a Comprehensive Opioid Addiction Treatment program who had been substance free for at least 90 consecutive days. Participants chose whether to enter the MBRP group or the treatment-as-usual group.
The treatment-as-usual group attended biweekly 60-minute sessions with a cognitive-based therapy process group led by a licensed therapist for 36 weeks. The MBRP group involved 24 weeks of biweekly attendance at 60-minute sessions, also led by a licensed therapist, followed by 12 weeks in the treatment-as-usual group.
The MBRP instruction involved the following:
- Mindful skill building
- Breathing
- Meditation
- Mindful movement (“gentle yoga practiced with mindful awareness of the body”)
- Using all the senses
- Increasing awareness of breath, body sensations, thoughts, and emotional energy
- Mindfulness in everyday life
- Daily home practice of formal mindfulness meditation for 30 minutes per day, 5-6 days a week
- Discussing practice/exercises both in and outside class
Researchers tracked retention rates, any prohibited substance relapse, and four self-reported measures at 12, 24, and 36 weeks’ follow-up. The self-reported measures looked at craving, with the Desire for Drug Questionnaire; anxiety, with the Overall Anxiety Severity and Impairment Scale, range 0-20); depression, with the Overall Depression Severity and Impairment Scale, range 0-20; and mindfulness, with the Five Facet Mindfulness Questionnaire.
Participants in both groups were statistically similar in gender, employment, education, insurance, and marital status at baseline.
Of the 24 patients who entered the MBRP program, 14 completed the full 24 weeks of intervention and 12 subsequent weeks. Among the 36 participants who entered the treatment-as-usual group, 20 completed the 36 weeks.
Retention was 75% in both groups at 24 weeks, but retention from 24 to 36 weeks was nonsignificantly greater in the mindfulness group (93% vs. 91% treatment as usual).
Relapse at both 24 and 36 weeks was lower among those using mindfulness but without a statistically significant difference. At 24 weeks, 44% of the treatment-as-usual participants had relapsed at least once, compared with 33% of the MBRP participants (intent to treat).
At 36 weeks (n = 37), 45% of the 22 remaining in the treatment-as-usual group had relapsed, compared with 40% of the 15 in the MBRP group. However, 20% of those in MBRP (3 of 15) relapsed between the 24 and 36 week follow-ups, compared with 5% (1 of 22) in the treatment-as-usual group, still a nonsignificant difference.
Anxiety scores were higher at baseline in the MBRP group (11 MBRP vs. 7.25 TAU) but were similar in both groups at 36 weeks (5.79 MBRP vs. 5.6 TAU). Depression scores also were higher at baseline in the MBRP (8 vs. 6.3) but ended slightly lower than the treatment-as-usual group at 36 weeks (3.71 MBRP vs. 4.35 TAU). The reductions in depression and anxiety scores for the MBRP group were significantly greater than in the treatment-as-usual group.
Mindfulness scores were not significantly different at baseline between the groups but were significantly higher at 36 weeks in the mindfulness groups (3.47 vs. 3.3, range 1-5).
“Relapse rates were trending lower in the MBRP group although not statistically significant,” Dr. Zullig said. “Significant decreases occurred in craving in both MBRP and treatment-as-usual groups.”
The Centers for Disease Control and Prevention funded the research. The authors had no disclosures.
SAN ANTONIO – A mindfulness-based relapse prevention program resulted in significantly greater declines in anxiety and depressive symptoms among participants in an opioid addiction treatment program than those seen in patients who received treatment as usual, suggest results of a small nonrandomized controlled trial. Relapse rates trended downward with mindfulness but were not significantly different from the treatment-as-usual (TAU) group.
“Mindfulness-based relapse prevention (MBRP) can be successfully implemented in an outpatient setting with as good as or better results as treatment as usual,” Keith J. Zullig, PhD, MSPH, chair and professor in the department of social and behavioral sciences at the West Virginia University School of Public Health in Morgantown, said at the annual meeting of the College on Problems of Drug Dependence.
Though relapse rates did not show a statistically significant drop with mindfulness treatment compared with treatment as usual, the downward trend suggests that it is worthwhile to conduct a larger scale study, Dr. Zullig said.
, he added.
The researchers recruited 60 participants from a Comprehensive Opioid Addiction Treatment program who had been substance free for at least 90 consecutive days. Participants chose whether to enter the MBRP group or the treatment-as-usual group.
The treatment-as-usual group attended biweekly 60-minute sessions with a cognitive-based therapy process group led by a licensed therapist for 36 weeks. The MBRP group involved 24 weeks of biweekly attendance at 60-minute sessions, also led by a licensed therapist, followed by 12 weeks in the treatment-as-usual group.
The MBRP instruction involved the following:
- Mindful skill building
- Breathing
- Meditation
- Mindful movement (“gentle yoga practiced with mindful awareness of the body”)
- Using all the senses
- Increasing awareness of breath, body sensations, thoughts, and emotional energy
- Mindfulness in everyday life
- Daily home practice of formal mindfulness meditation for 30 minutes per day, 5-6 days a week
- Discussing practice/exercises both in and outside class
Researchers tracked retention rates, any prohibited substance relapse, and four self-reported measures at 12, 24, and 36 weeks’ follow-up. The self-reported measures looked at craving, with the Desire for Drug Questionnaire; anxiety, with the Overall Anxiety Severity and Impairment Scale, range 0-20); depression, with the Overall Depression Severity and Impairment Scale, range 0-20; and mindfulness, with the Five Facet Mindfulness Questionnaire.
Participants in both groups were statistically similar in gender, employment, education, insurance, and marital status at baseline.
Of the 24 patients who entered the MBRP program, 14 completed the full 24 weeks of intervention and 12 subsequent weeks. Among the 36 participants who entered the treatment-as-usual group, 20 completed the 36 weeks.
Retention was 75% in both groups at 24 weeks, but retention from 24 to 36 weeks was nonsignificantly greater in the mindfulness group (93% vs. 91% treatment as usual).
Relapse at both 24 and 36 weeks was lower among those using mindfulness but without a statistically significant difference. At 24 weeks, 44% of the treatment-as-usual participants had relapsed at least once, compared with 33% of the MBRP participants (intent to treat).
At 36 weeks (n = 37), 45% of the 22 remaining in the treatment-as-usual group had relapsed, compared with 40% of the 15 in the MBRP group. However, 20% of those in MBRP (3 of 15) relapsed between the 24 and 36 week follow-ups, compared with 5% (1 of 22) in the treatment-as-usual group, still a nonsignificant difference.
Anxiety scores were higher at baseline in the MBRP group (11 MBRP vs. 7.25 TAU) but were similar in both groups at 36 weeks (5.79 MBRP vs. 5.6 TAU). Depression scores also were higher at baseline in the MBRP (8 vs. 6.3) but ended slightly lower than the treatment-as-usual group at 36 weeks (3.71 MBRP vs. 4.35 TAU). The reductions in depression and anxiety scores for the MBRP group were significantly greater than in the treatment-as-usual group.
Mindfulness scores were not significantly different at baseline between the groups but were significantly higher at 36 weeks in the mindfulness groups (3.47 vs. 3.3, range 1-5).
“Relapse rates were trending lower in the MBRP group although not statistically significant,” Dr. Zullig said. “Significant decreases occurred in craving in both MBRP and treatment-as-usual groups.”
The Centers for Disease Control and Prevention funded the research. The authors had no disclosures.
SAN ANTONIO – A mindfulness-based relapse prevention program resulted in significantly greater declines in anxiety and depressive symptoms among participants in an opioid addiction treatment program than those seen in patients who received treatment as usual, suggest results of a small nonrandomized controlled trial. Relapse rates trended downward with mindfulness but were not significantly different from the treatment-as-usual (TAU) group.
“Mindfulness-based relapse prevention (MBRP) can be successfully implemented in an outpatient setting with as good as or better results as treatment as usual,” Keith J. Zullig, PhD, MSPH, chair and professor in the department of social and behavioral sciences at the West Virginia University School of Public Health in Morgantown, said at the annual meeting of the College on Problems of Drug Dependence.
Though relapse rates did not show a statistically significant drop with mindfulness treatment compared with treatment as usual, the downward trend suggests that it is worthwhile to conduct a larger scale study, Dr. Zullig said.
, he added.
The researchers recruited 60 participants from a Comprehensive Opioid Addiction Treatment program who had been substance free for at least 90 consecutive days. Participants chose whether to enter the MBRP group or the treatment-as-usual group.
The treatment-as-usual group attended biweekly 60-minute sessions with a cognitive-based therapy process group led by a licensed therapist for 36 weeks. The MBRP group involved 24 weeks of biweekly attendance at 60-minute sessions, also led by a licensed therapist, followed by 12 weeks in the treatment-as-usual group.
The MBRP instruction involved the following:
- Mindful skill building
- Breathing
- Meditation
- Mindful movement (“gentle yoga practiced with mindful awareness of the body”)
- Using all the senses
- Increasing awareness of breath, body sensations, thoughts, and emotional energy
- Mindfulness in everyday life
- Daily home practice of formal mindfulness meditation for 30 minutes per day, 5-6 days a week
- Discussing practice/exercises both in and outside class
Researchers tracked retention rates, any prohibited substance relapse, and four self-reported measures at 12, 24, and 36 weeks’ follow-up. The self-reported measures looked at craving, with the Desire for Drug Questionnaire; anxiety, with the Overall Anxiety Severity and Impairment Scale, range 0-20); depression, with the Overall Depression Severity and Impairment Scale, range 0-20; and mindfulness, with the Five Facet Mindfulness Questionnaire.
Participants in both groups were statistically similar in gender, employment, education, insurance, and marital status at baseline.
Of the 24 patients who entered the MBRP program, 14 completed the full 24 weeks of intervention and 12 subsequent weeks. Among the 36 participants who entered the treatment-as-usual group, 20 completed the 36 weeks.
Retention was 75% in both groups at 24 weeks, but retention from 24 to 36 weeks was nonsignificantly greater in the mindfulness group (93% vs. 91% treatment as usual).
Relapse at both 24 and 36 weeks was lower among those using mindfulness but without a statistically significant difference. At 24 weeks, 44% of the treatment-as-usual participants had relapsed at least once, compared with 33% of the MBRP participants (intent to treat).
At 36 weeks (n = 37), 45% of the 22 remaining in the treatment-as-usual group had relapsed, compared with 40% of the 15 in the MBRP group. However, 20% of those in MBRP (3 of 15) relapsed between the 24 and 36 week follow-ups, compared with 5% (1 of 22) in the treatment-as-usual group, still a nonsignificant difference.
Anxiety scores were higher at baseline in the MBRP group (11 MBRP vs. 7.25 TAU) but were similar in both groups at 36 weeks (5.79 MBRP vs. 5.6 TAU). Depression scores also were higher at baseline in the MBRP (8 vs. 6.3) but ended slightly lower than the treatment-as-usual group at 36 weeks (3.71 MBRP vs. 4.35 TAU). The reductions in depression and anxiety scores for the MBRP group were significantly greater than in the treatment-as-usual group.
Mindfulness scores were not significantly different at baseline between the groups but were significantly higher at 36 weeks in the mindfulness groups (3.47 vs. 3.3, range 1-5).
“Relapse rates were trending lower in the MBRP group although not statistically significant,” Dr. Zullig said. “Significant decreases occurred in craving in both MBRP and treatment-as-usual groups.”
The Centers for Disease Control and Prevention funded the research. The authors had no disclosures.
REPORTING FROM CPDD 2019
Treatment in prison systems might lead to drop in overdose deaths
Incarceration versus treatment takes center stage in a new analysis of U.S. data from researchers in the United Kingdom.
The researchers performed an observational study looking at rates of incarceration, income, and drug-related deaths from 1983 to 2014 in the United States. They found a strong association between incarceration rates and drug-related deaths. Also, a very strong association was found between lower household income and drug-related deaths. Strikingly, in the counties with the highest incarceration rates, there was a 50% higher rate of drug deaths, reported Elias Nosrati, PhD, and associates (Lancet Public Health. 2019 Jul 3;4:e326-33). It is clearer every day that our opioid epidemic was in part wrought by a zealous push to change protocols on treating chronic pain. The epidemic also appears tied to well-meaning but overprescribing doctors and allegedly unscrupulous pharmaceutical companies and distributors. What we are learning through this most recent study is that another factor tied to the opioid and overdose epidemic could be incarceration.
According to the study, an increase in crime rates combined with sentencing reforms led the number of people incarcerated in state and federal prisons to soar from less than 200,000 in 1970 to almost 1 million in 1995. Furthermore, Dr. Nosrati and associates wrote, “Incarceration is directly associated with stigma, discrimination, poor mental health, and chronic economic hardship, all of which are linked to drug use disorders.”
Treatment for drug addiction in prison systems is rare, as is adequate mental health treatment. However, treatment for this population would likely help reduce drug overdose deaths and improve the quality of life for people who are incarcerated and their families. In the Philadelphia prison system, for example, treatment for inmates is available for opioid addiction, both with methadone and now more recently with buprenorphine (Suboxone). The Philadelphia Department of Prisons also provides cognitive-behavioral therapy. In Florida, Chapter 397 of the Florida statutes – known as the Marchman Act – provides for the involuntary (and voluntary) treatment of individuals with substance abuse problems.
The court systems in South Florida have a robust drug-diversion program, aimed at directing people facing incarceration for drug offenses into treatment instead. North Carolina has studied this issue specifically and found through a model simulation that diverting 10% of drug-abusing offenders out of incarceration into treatment would save $4.8 billion in legal costs for North Carolina counties and state legal systems. Diverting 40% of individuals would close to triple that savings.
There are striking data from programs treating individuals who are leveraged into treatment in order to maintain professional licenses. These such individuals, many of whom are physicians, airline pilots, and nurses, have a rate of sobriety of 90% or greater after 5 years. This data show that
In addition to the potential reduction in morbidity and mortality as well as the financial savings, why is treatment important? Because of societal costs. When parents or family members are put in jail for a drug charge or other charge, they leave behind a community, family, and very often children who are affected economically, emotionally, and socially. Those children in particular have higher risks of depression and PTSD. Diverting an offender into treatment or treating an incarcerated person for drug and mental health problems can change the life of a child or family member, and ultimately can change society.
Dr. Jorandby is chief medical officer of Lakeview Health in Jacksonville, Fla. She trained in addiction psychiatry at Yale University, New Haven, Conn.
Incarceration versus treatment takes center stage in a new analysis of U.S. data from researchers in the United Kingdom.
The researchers performed an observational study looking at rates of incarceration, income, and drug-related deaths from 1983 to 2014 in the United States. They found a strong association between incarceration rates and drug-related deaths. Also, a very strong association was found between lower household income and drug-related deaths. Strikingly, in the counties with the highest incarceration rates, there was a 50% higher rate of drug deaths, reported Elias Nosrati, PhD, and associates (Lancet Public Health. 2019 Jul 3;4:e326-33). It is clearer every day that our opioid epidemic was in part wrought by a zealous push to change protocols on treating chronic pain. The epidemic also appears tied to well-meaning but overprescribing doctors and allegedly unscrupulous pharmaceutical companies and distributors. What we are learning through this most recent study is that another factor tied to the opioid and overdose epidemic could be incarceration.
According to the study, an increase in crime rates combined with sentencing reforms led the number of people incarcerated in state and federal prisons to soar from less than 200,000 in 1970 to almost 1 million in 1995. Furthermore, Dr. Nosrati and associates wrote, “Incarceration is directly associated with stigma, discrimination, poor mental health, and chronic economic hardship, all of which are linked to drug use disorders.”
Treatment for drug addiction in prison systems is rare, as is adequate mental health treatment. However, treatment for this population would likely help reduce drug overdose deaths and improve the quality of life for people who are incarcerated and their families. In the Philadelphia prison system, for example, treatment for inmates is available for opioid addiction, both with methadone and now more recently with buprenorphine (Suboxone). The Philadelphia Department of Prisons also provides cognitive-behavioral therapy. In Florida, Chapter 397 of the Florida statutes – known as the Marchman Act – provides for the involuntary (and voluntary) treatment of individuals with substance abuse problems.
The court systems in South Florida have a robust drug-diversion program, aimed at directing people facing incarceration for drug offenses into treatment instead. North Carolina has studied this issue specifically and found through a model simulation that diverting 10% of drug-abusing offenders out of incarceration into treatment would save $4.8 billion in legal costs for North Carolina counties and state legal systems. Diverting 40% of individuals would close to triple that savings.
There are striking data from programs treating individuals who are leveraged into treatment in order to maintain professional licenses. These such individuals, many of whom are physicians, airline pilots, and nurses, have a rate of sobriety of 90% or greater after 5 years. This data show that
In addition to the potential reduction in morbidity and mortality as well as the financial savings, why is treatment important? Because of societal costs. When parents or family members are put in jail for a drug charge or other charge, they leave behind a community, family, and very often children who are affected economically, emotionally, and socially. Those children in particular have higher risks of depression and PTSD. Diverting an offender into treatment or treating an incarcerated person for drug and mental health problems can change the life of a child or family member, and ultimately can change society.
Dr. Jorandby is chief medical officer of Lakeview Health in Jacksonville, Fla. She trained in addiction psychiatry at Yale University, New Haven, Conn.
Incarceration versus treatment takes center stage in a new analysis of U.S. data from researchers in the United Kingdom.
The researchers performed an observational study looking at rates of incarceration, income, and drug-related deaths from 1983 to 2014 in the United States. They found a strong association between incarceration rates and drug-related deaths. Also, a very strong association was found between lower household income and drug-related deaths. Strikingly, in the counties with the highest incarceration rates, there was a 50% higher rate of drug deaths, reported Elias Nosrati, PhD, and associates (Lancet Public Health. 2019 Jul 3;4:e326-33). It is clearer every day that our opioid epidemic was in part wrought by a zealous push to change protocols on treating chronic pain. The epidemic also appears tied to well-meaning but overprescribing doctors and allegedly unscrupulous pharmaceutical companies and distributors. What we are learning through this most recent study is that another factor tied to the opioid and overdose epidemic could be incarceration.
According to the study, an increase in crime rates combined with sentencing reforms led the number of people incarcerated in state and federal prisons to soar from less than 200,000 in 1970 to almost 1 million in 1995. Furthermore, Dr. Nosrati and associates wrote, “Incarceration is directly associated with stigma, discrimination, poor mental health, and chronic economic hardship, all of which are linked to drug use disorders.”
Treatment for drug addiction in prison systems is rare, as is adequate mental health treatment. However, treatment for this population would likely help reduce drug overdose deaths and improve the quality of life for people who are incarcerated and their families. In the Philadelphia prison system, for example, treatment for inmates is available for opioid addiction, both with methadone and now more recently with buprenorphine (Suboxone). The Philadelphia Department of Prisons also provides cognitive-behavioral therapy. In Florida, Chapter 397 of the Florida statutes – known as the Marchman Act – provides for the involuntary (and voluntary) treatment of individuals with substance abuse problems.
The court systems in South Florida have a robust drug-diversion program, aimed at directing people facing incarceration for drug offenses into treatment instead. North Carolina has studied this issue specifically and found through a model simulation that diverting 10% of drug-abusing offenders out of incarceration into treatment would save $4.8 billion in legal costs for North Carolina counties and state legal systems. Diverting 40% of individuals would close to triple that savings.
There are striking data from programs treating individuals who are leveraged into treatment in order to maintain professional licenses. These such individuals, many of whom are physicians, airline pilots, and nurses, have a rate of sobriety of 90% or greater after 5 years. This data show that
In addition to the potential reduction in morbidity and mortality as well as the financial savings, why is treatment important? Because of societal costs. When parents or family members are put in jail for a drug charge or other charge, they leave behind a community, family, and very often children who are affected economically, emotionally, and socially. Those children in particular have higher risks of depression and PTSD. Diverting an offender into treatment or treating an incarcerated person for drug and mental health problems can change the life of a child or family member, and ultimately can change society.
Dr. Jorandby is chief medical officer of Lakeview Health in Jacksonville, Fla. She trained in addiction psychiatry at Yale University, New Haven, Conn.
Poverty, incarceration may drive deaths from drug use
High rates of both incarceration and reduced household income are significantly associated with drug-related deaths in the United States, based a regression analysis of several decades of data.
“More than half a million drug-related deaths have occurred in the USA in the past three and half decades, however, no studies have investigated the association between these deaths and the expansion of the incarcerated population,” wrote Elias Nosrati, PhD, of the University of Oxford (England) and colleagues.
The researchers reviewed previously unavailable data on jail and prison incarceration at the county level from the nonprofit Vera Institute of Justice in New York, as well as mortality data from the U.S. National Vital Statistics System. The analysis was published in the Lancet Public Health.
After adjustment for multiple confounding variables, each standard deviation in admission rates to local jails (an average of 7,018 per 100,000 population) was associated with a significant 1.5% increase in drug-related deaths, and each standard deviation in admission rates to state prisons (an average of 254.6 per 100,000 population) was associated with a significant 2.6% increase in drug-related deaths, reported Dr. Nosrati and colleagues.
“On average, the researchers wrote. In addition, each standard-deviation decrease in median household income was associated with a 12.8% increase in drug-related deaths within counties.
The findings were limited by several factors, including the observational nature of the study, the potential skewing of results because of missing data from some counties, and the inability to examine support for individuals released from jail or prison, the researchers noted.
However, the results suggest that, “when coupled with economic hardship, the operations of the prison and jail systems constitute an upstream determinant of despair, whereby regular exposures to neighborhood violence, unstable social and family relationships, and psychosocial stress trigger destructive behaviours,” they wrote.
In an accompanying comment, James LePage, PhD, wrote that current laws regarding trespassing, loitering, and vagrancy “unfairly criminalize individuals of low economic status and homeless individuals” by increasing their likelihood of interaction with the legal system and thus increasing the incarceration rate in this population.
“Future studies should focus on racial and ethnic biases in arrests and sentencing, and the subsequent effect on drug-related mortality,” wrote Dr. LePage of the VA North Texas Health Care System in Dallas.
Neither the researchers in the main study nor Dr. LePage had financial conflicts to disclose.
SOURCE: Nosrati E et al. Lancet Public Health. 2019 Jul 3;4:e326-33.
High rates of both incarceration and reduced household income are significantly associated with drug-related deaths in the United States, based a regression analysis of several decades of data.
“More than half a million drug-related deaths have occurred in the USA in the past three and half decades, however, no studies have investigated the association between these deaths and the expansion of the incarcerated population,” wrote Elias Nosrati, PhD, of the University of Oxford (England) and colleagues.
The researchers reviewed previously unavailable data on jail and prison incarceration at the county level from the nonprofit Vera Institute of Justice in New York, as well as mortality data from the U.S. National Vital Statistics System. The analysis was published in the Lancet Public Health.
After adjustment for multiple confounding variables, each standard deviation in admission rates to local jails (an average of 7,018 per 100,000 population) was associated with a significant 1.5% increase in drug-related deaths, and each standard deviation in admission rates to state prisons (an average of 254.6 per 100,000 population) was associated with a significant 2.6% increase in drug-related deaths, reported Dr. Nosrati and colleagues.
“On average, the researchers wrote. In addition, each standard-deviation decrease in median household income was associated with a 12.8% increase in drug-related deaths within counties.
The findings were limited by several factors, including the observational nature of the study, the potential skewing of results because of missing data from some counties, and the inability to examine support for individuals released from jail or prison, the researchers noted.
However, the results suggest that, “when coupled with economic hardship, the operations of the prison and jail systems constitute an upstream determinant of despair, whereby regular exposures to neighborhood violence, unstable social and family relationships, and psychosocial stress trigger destructive behaviours,” they wrote.
In an accompanying comment, James LePage, PhD, wrote that current laws regarding trespassing, loitering, and vagrancy “unfairly criminalize individuals of low economic status and homeless individuals” by increasing their likelihood of interaction with the legal system and thus increasing the incarceration rate in this population.
“Future studies should focus on racial and ethnic biases in arrests and sentencing, and the subsequent effect on drug-related mortality,” wrote Dr. LePage of the VA North Texas Health Care System in Dallas.
Neither the researchers in the main study nor Dr. LePage had financial conflicts to disclose.
SOURCE: Nosrati E et al. Lancet Public Health. 2019 Jul 3;4:e326-33.
High rates of both incarceration and reduced household income are significantly associated with drug-related deaths in the United States, based a regression analysis of several decades of data.
“More than half a million drug-related deaths have occurred in the USA in the past three and half decades, however, no studies have investigated the association between these deaths and the expansion of the incarcerated population,” wrote Elias Nosrati, PhD, of the University of Oxford (England) and colleagues.
The researchers reviewed previously unavailable data on jail and prison incarceration at the county level from the nonprofit Vera Institute of Justice in New York, as well as mortality data from the U.S. National Vital Statistics System. The analysis was published in the Lancet Public Health.
After adjustment for multiple confounding variables, each standard deviation in admission rates to local jails (an average of 7,018 per 100,000 population) was associated with a significant 1.5% increase in drug-related deaths, and each standard deviation in admission rates to state prisons (an average of 254.6 per 100,000 population) was associated with a significant 2.6% increase in drug-related deaths, reported Dr. Nosrati and colleagues.
“On average, the researchers wrote. In addition, each standard-deviation decrease in median household income was associated with a 12.8% increase in drug-related deaths within counties.
The findings were limited by several factors, including the observational nature of the study, the potential skewing of results because of missing data from some counties, and the inability to examine support for individuals released from jail or prison, the researchers noted.
However, the results suggest that, “when coupled with economic hardship, the operations of the prison and jail systems constitute an upstream determinant of despair, whereby regular exposures to neighborhood violence, unstable social and family relationships, and psychosocial stress trigger destructive behaviours,” they wrote.
In an accompanying comment, James LePage, PhD, wrote that current laws regarding trespassing, loitering, and vagrancy “unfairly criminalize individuals of low economic status and homeless individuals” by increasing their likelihood of interaction with the legal system and thus increasing the incarceration rate in this population.
“Future studies should focus on racial and ethnic biases in arrests and sentencing, and the subsequent effect on drug-related mortality,” wrote Dr. LePage of the VA North Texas Health Care System in Dallas.
Neither the researchers in the main study nor Dr. LePage had financial conflicts to disclose.
SOURCE: Nosrati E et al. Lancet Public Health. 2019 Jul 3;4:e326-33.
FROM THE LANCET PUBLIC HEALTH
Key clinical point: Reduced household income and increased incarceration are significantly associated with drug-related deaths in the U.S. population.
Major finding: High incarceration rates are associated with an increase in drug-related deaths of more than 50% at the county level.
Study details: The data come from a regression analysis of data from multiple institutions, including the U.S. National Vital Statistics System and the Institute for Health Metrics and Evaluation, as well as incarceration data from the Vera Institute of Justice for 2,640 U.S. counties from 1983 to 2014.
Disclosures: The researchers had no financial conflicts to disclose.
Source: Nosrati E et al. Lancet Public Health. 2019 Jul 3;4:e326-33.
Improved Patient Outcomes and Reduced Wait Times: Transforming a VA Outpatient Substance Use Disorder Program
Substance use disorders (SUDs) are an increasing public health concern in the US. The 2015 National Survey on Drug Use and Health indicated that 27 million people (8% of the US population) reported current use of recreational drugs or misuse of alcohol or prescription medications.1 The 2013 National Survey on Drug Use and Health indicated that 1.5 million veterans (roughly 6.6%) met the criteria for a SUD.2 More than 50% of patients awaiting entry into a SUD treatment program will never achieve admission due, in part, to long wait times.3-5
National attention has been focused on increasing veteran access to quality treatment based on evidence-based practices (EBPs). Several national legislative measures and treatment protocols have been implemented: the Uniform Mental Health Services in US Department of Veterans Affairs (VA) medical centers and clinics; Veterans Access, Choice, and Accountability Act (2014); Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) Training Program; and the Psychotropic Drug Safety Initiative (PDSI).6-8 Consistent with these directives and in line with American Society of Addiction Medicine (ASAM) and Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for medication-assisted therapies (MAT),the James A. Haley Veterans’ Hospital (JAHVH) Mental Health and Behavioral Sciences Service (MH&BSS) Substance Use Disorders Service (SUDS) in Tampa, Florida, implemented an evidence-based, treatment-on-demand model of care.9-11
Meeting SUD Treatment Needs
What does the new supervisor of a clinical program do when a 24-employee outpatient VA Alcohol and Drug Addiction Treatment Program (ADATP) has an average 33-day wait time for treatment with 54% of patients lost to care between initial evaluation and admission?12 Patients lacked consistent access to SUD pharmacotherapy. The national VA clinical performance indicators were substandard and there are no additional resources available to apply to the program.
At JAHVH the program supervisor enlisted hospital leadership to support program redesign. The redesign sought to improve operational efficiency and eliminate patient wait time; adopt national standards for assessment and treatment developed by ASAM; implement strictly evidence-based psychotherapeutic treatments; educate program psychiatrists about evidence-based psychopharmacologic treatments and hold them accountable for patient adherence; streamline documentation templates; free clinical providers from nonclinical tasks; create an inpatient addiction consult team to diagnose and treat chronic hospitalized patients with SUDs; ensure continuity of care; and, standardize consistent, objective measures of patient response to treatment to track the program’s effectiveness.
In this article, the authors provide an explanation of the clinical, theoretical foundation and the practical steps taken to design and implement this transformation. They then describe the lessons learned, hoping that their process will serve as a model for those in similar situations.
Program Redesign
July 1, 2015, a new program supervisor was hired and began a 2-month evaluation and analysis of the program with input from leadership, staff, and hospital/community stakeholders. September 1, the monthlong process of developing the redesign began. On September 30 the plan was presented to, and approved by, MH&BSS leadership. October was spent preparing for change with an implementation date of November 2 selected. On November 2, 2015, the complete redesign was implemented.
Needs Assessment
A needs assessment yielded improvement opportunities in program structure (levels of care); clinical content; staff and resource allocation, including clinical workflow and management systems. Staff identified philosophical and practical variance in the program, often leading to confusion for patients and clinicians and potentially resulting in disparate quality care and patient outcomes. Recommendations for addressing these needs included incorporating ASAM guidelines for assignment to clinically appropriate levels of care, implementation of consistent EBPs for SUD and comorbid conditions,9 and emphasis on staff training and development to champion evidence-based program philosophy and service delivery.
The assessment determined that the average waitlist time was 33 days, and patients were required to abstain from substance or alcohol use prior to admission to the Intensive Outpatient Program. If a waitlisted patient relapsed, she or he was removed from the waitlist and denied admission. A study conducted at JAHVH reported that 54% of waitlisted patients in this clinic (prior to November 2, 2015) never were admitted to the program.12 Access to care was considered a significant issue.
Program Implementation
September was spent developing a comprehensive redesign of the SUD clinic. The vision included incorporating all ASAM levels of care; creating an evidence-based, treatment-on-demand model of care; and, securing the support of MH&BSS leadership team, staff, and patients for the redesign. The supervisory clinician interviewed staff both individually and as a group. Clinicians were provided extensive training on EBP for SUDs, including psychotherapies, psychosocial treatments, and psychopharmacologic interventions. A journal club was started with staff-generated topics that offered articles sharing current research, EBPs, and psychotherapeutic techniques, continuing education on substances, and management of coexisting diagnoses. Clinicians increased the frequency of SUD in-service trainings. Psychiatrists provided several Grand Rounds to the MH&BSS service. All counselors were assigned to 1 of the program’s 3 clinical psychologists for individual weekly clinical supervision.
By providing all staff with current, evidence-based, clinically relevant treatment information and emphasizing its relationship to successful patient outcomes, program leadership energized staff support. Staff were encouraged to perform at the top of their scope of practice and engage in training and consultation. Each staff member was delegated a role in the process to inspire buy-in.
Preparation for the Shift
October was spent preparing for a seamless, one-day implementation of proposed changes, including implementation of updated clinical policies, procedures, and document templates (rewritten to include only clinically appropriate information required by VA policy or the Joint Commission); streamlined staff schedules; and utilization of staff-developed and research/policy-driven EBP handbook. Finally, the Brief Addiction Monitor (BAM) was selected as objective criteria to consistently assess patient progress in treatment, and staff were instructed to use this measure at regular intervals and for all levels of care.
Emphasis was placed on ongoing fortification of staff and patient support for the reorganization. For example, the Addiction Severity Index, though not required by policy, was historically used, adding 90 minutes to the evaluation and admission session. Staff agreed to remove this measure to improve clinician availability. Staff were also empowered to rename the redesigned program, and chose Substance Use Disorders Service (SUDS).
Process Changes
To achieve same-day access to clinical care, program leadership created a daily morning orientation group. Patients are scheduled or may attend as a walk-in. The orientation’s purpose is to explain what services are available and to offer each patient an opportunity for immediate evaluation and treatment. Staff schedules were modified to provide patient evaluation appointment slots immediately following orientation. The number of immediate evaluation slots was initially assessed by analyzing the demand for treatment over the previous 6 months, determining the daily mean, and setting the number of slots to accommodate 3 standard deviations above the daily mean. If a patient in a daily orientation group expresses a willingness to engage in treatment, he or she is immediately evaluated by a counselor during a 90-minute session and seen by a psychiatrist to determine whether pharmacologic treatment would be appropriate. If needed, the medication is prescribed that day. The primary purpose of the patient’s initial clinical evaluation is to determine the most appropriate level of care based on ASAM criteria. Also available were 90-minute afternoon evaluation appointments with psychiatrists for patients who walk into the clinic after the morning orientation group had ended.
Prior to the redesign, clinic psychiatrists were minimally prescribing evidence-based pharmacotherapy for sobriety support. At the time of redesign, only 8% of patients diagnosed with opioid use disorders (OUDs) were prescribed buprenorphine/naloxone or naltrexone. Just 1.9% of patients diagnosed with alcohol use disorder (AUD) were prescribed naltrexone or acamprosate. With the redesign, access to these medications has significantly expanded.
All templates were redesigned to ensure consistent documentation. This change decreased the overall provider task burden, and explicitly supported the use of ASAM multidimensional criteria and the Brief Addiction Monitor (BAM) to identify a pretreatment baseline score and track each patient’s clinical progress.13 Evidence-based written curricula were standardized for individual and group psychotherapies to reduce provider and programmatic variation.
The redesign creates distinct levels of care based on ASAM criteria, including harm reduction, ambulatory detoxification, outpatient group and individual psychotherapy, an evidence-based Intensive Outpatient Program (IOP), and aftercare. Application of the ASAM standards has allowed clinicians to make accurate placement decisions that best meet individual patient needs and to serve as effective stewards even with limited treatment and financial resources. Although JAHVH does not have a residential SUD program, procedures were developed to refer veterans to community-based residential treatment programs when appropriate.
Group Therapies
With the redesign, SUDS was no longer exclusively a 12-step program; however, it still supported and recognized the value of this approach for some patients. A psychologist periodically audits group sessions to prevent drift from that group’s curriculum. Counselors are assigned to weekly hour-long clinical supervision sessions with a psychologist to review patient care and reinforce the application of evidence-based individualized treatment.
After reviewing empirical literature and VA directives, CBT-SUD was adopted. It encompasses individual and group interventions, such as motivational interviewing (MI), contingency management (CM), and medication-assisted therapies as primary therapeutic treatment modalities, all of which have demonstrated efficacy as measured by length of sobriety postintervention.9,14,15
Clinical Staff Improvements
Staff were reorganized into 3 interdisciplinary treatment teams. A weekly team meeting is scheduled to coordinate care and discuss the treatment of complex patients. Clinical staff focus has shifted from case-management to diagnosis and treatment; now patients are referred to their primary care team’s social worker for case management services. Allowing clinical staff to focus solely on the diagnosis and clinical treatment of SUDs has significantly enhanced productivity and morale.
Staff receive training in the newly adopted interventions during brief monthly refresher courses provided by inhouse psychologists. Additional training includes participation in local and national SUD teleconferences and onsite meetings with experts in harm reduction and motivational interventions. During the transition, clinicians were encouraged to attend staff resiliency training. Continuing education was available to the SUDS psychiatrists and all inpatient and outpatient psychiatrists at JAHVH. Recently, this educational initiative was expanded to include all primary care and inpatient internal medicine physicians.
Implementation
On November 2, 2015, all planned programmatic changes were simultaneously implemented. On that day, clinician and patient schedules changed, the new EBP curriculum was administered, the use of streamlined documentation procedures began, and daily orientation groups followed by same-day evaluations were initiated.
The pretreatment sobriety requirement was eliminated as a barrier to care, and the program began to use a harm-reduction treatment track as recommended by ASAM guidelines. Patients with urgent or emergent medical or psychiatric problems were immediately assessed by SUDS health care providers and treated in the clinic or transported to the emergency department. Previously unavailable, patient access to ambulatory detoxification was initiated. The prescription of buprenorphine/naloxone for the treatment of OUD treatments increased from 1 prescriber to all 3.
Three months after program reorganization, the leadership reviewed overall workflow, conducted patient satisfaction surveys, and evaluated facility use and productivity. To address patient needs and facilitate optimal use of space, the number of same-day evaluation slots was reduced while the number of individual therapy slots was increased.
Staff meet in workgroups to discuss EBPs and further refine content with feedback from the supervisory clinician and team psychologists who routinely audit group therapy sessions. Staff report ongoing benefit from weekly supervision with a clinical psychologist. An inpatient addiction consultation team that uses existing manpower and resources has been developed.
Program Goals and Outcomes
The SUDS program serves more patients at multiple levels of standardized care with 2 fewer full-time positions. One counselor and one advanced practice registered nurse were reallocated to different programs within the JAHVH VA mental health clinic. Following a review of all program clinic profiles in the VA’s Computerized Patient Record System (CPRS) for utilization, accuracy, and necessity, and allowing for accurate program data capture, the transition resulted in a reduction of distinct clinics from 114 to 67 (-58.7%). In fiscal year 2018, review of CPRS yielded 19,786 total visits (3,645 unique visits).
Eliminate Patient Wait Tme
Patient wait time, as measured in CPRS from date of initial evaluation to date of treatment was reduced from an average of 33 days to 0 within 2 weeks of program implementation. A review of CPRS data also indicated that preadmission attrition dropped from 54% to < 1%; all patients desiring treatment are assigned a counselor and treatment is initiated the same day.
Adopt ASAM Criteria
After the redesign, patients have received more appropriate care based on individualized treatment plans. Due to the implementation of a fluid and supportive model, patients can move through levels of care as clinical need dictates rather than failing treatment and having to reengage. Staff receive ongoing education on the use of ASAM. Evaluation and treatment plan templates now reflect assignment to level of care rationale using ASAM guidelines.
Use of Evidence-Based Psychotherapeutic Treatments
More consistent, coordinated, and effective psychotherapies have improved patient care. The program’s previous issues with patients receiving conflicting treatment guidance from different providers has been resolved. Duplicate and ineffective treatments, including multiple readmissions to the IOP level of care, overemphasis of abstinence-based modalities for patients in active use, and referrals to inpatient SUD care under the assumption that “higher level of care is better” have ceased through staff education, leadership support, and appropriate staffing and communication. Review of patient advocate complaints tracked by and resolved by the service demonstrated an 80% decrease in patient advocate complaints regarding SUD clinic services.
Implement Evidence-Based Psychopharmacologic Treatments
The pharmacotherapy education initiative yielded tangible benefits and is likely a significant contributor to the program’s improved clinical outcomes. Prescription of pharmacotherapy for patients with OUD has risen from 8% to 25.1% in eligible patients. Appropriate medication prescription for the treatment of AUD has risen from 1.9% to 9.8% in eligible patients. These data are reflected in the VA Pharmaceutical Drug Safety Initiative (PDSI) dashboard.
Streamline Documentation
Significantly reducing the charting burden was likely a significant contributor to increased provider productivity and improved patient outcomes. Regular meetings between SUDS leadership and clinical informatics ensure that standardized note templates meet hospital policy and gather all necessary accreditation information.
Improve Employee Morale
Increased staff morale is indicated by a noticeable reduction in employee sick days; a decrease of > 20% (over the same time period the previous year), per the VA electronic timekeeping system, during the first 6 months following the November 2 program implementation.
SUDS Inpatient Addiction Consult Team
In January of 2017, SUDS began an inpatient medicine consultation service to offer evaluation, pharmacotherapy, and supportive counseling to patients diagnosed with SUDs who had been admitted to inpatient medical and surgical services. This team includes existing SUDS staff members reallocated to the inpatient service, is led by a SUDS psychiatrist, and includes 3 multidisciplinary clinicians with extensive training in assessment, diagnosis, and treatment planning of SUDs and comorbid conditions. Prior to implementation, the SUDS inpatient addiction consult team met with hospital leadership and attending physicians for inpatient medicine and psychiatry physicians.
To access the SUDS inpatient addiction consult team, physicians request a consult. Patients are offered an evaluation and are assigned to a level of care with orders for outpatient appointments with a counselor and psychiatrist within 7 days of hospital discharge. Medication-assisted treatment for chronic SUDs is implemented while patients remain admitted to the inpatient medical service. In fiscal year 2018, the SUDS inpatient addiction consult team performed 1,428 inpatient evaluations.
Consistent Treatment Outcome Measures
The BAM is a clinical tool designed to measure patient outcomes in substance use disorders.13 Its 17-item scale measures substance use risk factors that may lead to relapse, and protective factors that are recovery-oriented behaviors that help prevent relapse. It demonstrates sensitivity to change and has excellent test-retest reliability. The BAM has been in use in the addictions treatment program since 2011 but was previously administered only after admission to the IOP and again after a 30- to 90-day follow-up period. Since the program redesign, all SUDS patients are administered the BAM at their initial evaluation and at each individual appointment thereafter. The initial BAM assessment encompasses the previous 30 days; this 30-day version is also used for monthly follow-ups. For BAM assessments that occur within 30 days from the time of the last evaluation, a 7-day version is used. Prior to the redesign, about 24% of patients received a follow-up 30-day BAM assessment.12 Per CPRS review of veterans participating in continued treatment, the rate rose to 100% 3 months after the redesign.
When program staff compared preredesign and postredesign BAM data, they detected significant clinical differences. Data demonstrate a 22.2% improvement in protective factors, including patient confidence in their ability to remain abstinent; engaging in self-help activities, such as attending Alcoholics Anonymous meetings; engaging in organized spiritual activities; going to school, working, or volunteering; securing a regular income; and time spent with friends or family who are supportive of recovery.
The data also show a marked reduction in substance use at follow-up points in treatment and a corresponding decrease in risk factors. One item of the BAM assesses patient level of satisfaction with their treatment. Since the redesign, patients report that they are “considerably” satisfied with their SUD treatment.
Currently, program staff are conducting a review of BAM scores by level of care to further parse the impact of various treatments and best target patient need using measurement-based care and EBP, such as contingency management, which provides small monetary incentives when patients maintain clean urine drug screens.16 In addition, the program plans to achieve more uniformity in BAM assessment intervals at all levels of care, and possibly also integrate BAM data into SUD group therapies. Correlation of the BAM scores to other metrics, such as readmission to inpatient medicine, relapse, urine drug screen, or critical laboratory values, will provide additional insight into impact of programmatic changes.
Discussion
Feedback from other clinics and services within the hospital has been very positive. Some providers have reported that they appreciate the ease and availability of access to SUDS. Additionally, patients engaged in treatment prior to the redesign have been contacted for an updated evaluation and assignment to a counselor and appropriate level of care. From the staff’s perspective, the shift to immediate access to care has allowed a more streamlined process with fewer hurdles for patient admission. Staff report that they now feel empowered to meet the needs of veterans in a comprehensive, same-day fashion.
The success of our redesign was contingent on internal and external sta
The successful implementation of these changes has revealed several important elements regarding patient care. The first lesson was that improving access and integrating best practices is possible without additional resources, outside monies, or disruption to patient services. With the support of MH&BSS leadership, the program streamlined existing processes and used both staff and clinic resources more efficiently.
The second lesson involved the importance of continually reviewing and revising standard operating procedures to match the needs of the current patient population. Policies and procedures that once were viewed as potential barriers to change have been replaced with a more flexible approach and willingness to evolve.
As a result, far fewer patients have been lost to treatment. The time and resources that staff historically dedicated to nonclinical patient care are now redirected to immediate service provision. This increase in operational efficiency and treatment efficacy has resulted in a boost to staff morale, even during a time of immense change and increased productivity. Program staff are now able to personally witness the significant changes in their patients’ lives and feel a sense of pride at being a member of a hard-working team that provides the highest quality of substance use treatment. This is critical to job satisfaction and meets the VA mission to provide timely, effective, and evidence-based treatments to patients.
Conclusion
JAHVH strives to continue to provide the highest quality of SUD treatment available. Future directions aim to streamline clinic operations by constantly monitoring and reviewing workloads, while also considering patient feedback. A continuous review of EBP is part of our clinic’s culture. Program leadership endeavors to promote an open environment where providers can share their triumphs and frustrations and foster a team approach to problem solving. Further plans include expanding the range of treatment levels offered by developing a residential SUD treatment facility.
1. Substance Abuse and Mental Health Services Administration. 2015 National Survey on Drug Use and Health: Summary of the Effects of the 2015 NSDUH Questionnaire Redesign: Implications for Data Users. https://www.samhsa.gov/data/sites/default/files/NSDUH-TrendBreak-2015.pdf. Published June 2016. Accessed June 12, 2019.
2. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
3. Donovan DM, Rosengren DB, Downey L, Cox GB, Sloan PDSKL. Attrition prevention with individuals awaiting publicly funded drug treatment. Addiction. 2001;96(8):1149-1160.
4. Hser Y, Maglione M, Polinsky ML, Anglin MD. Predicting treatment entry among treatment-seeking drug abusers. J Subst Abuse Treatment. 1997;15(3):213-220.
5. Stark MJ, Campbell BK, Brinkerhoff CV. “Hello, may we help you?” A study of attrition prevention at the time of the first phone contact with substance-abusing clients. Am J Drug Alcohol Abuse. 1990;16:67-76.
6. US Department of Veterans Affairs. Uniform Mental Health Services in VA Medical Centers and Clinics. VHA Handbook 1160.01. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762. Updated November 2015. Accessed December 12, 2017.
7. Veterans Access, Choice and Accountability Act of 2014, 2 USC § 933.
8. DeMarce JM, Gnys M, Raffa SD, Karlin, BE. Cognitive Behavioral Therapy for Substance Use Disorders Among Veterans: Therapist Manual. Washington, DC: US Department of Veterans Affairs; 2014.
9. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013.
10. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the Treatment of Alcohol Use Disorder: A Brief Guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.
11. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for Opioid Use Disorder – Full Document. HHS Publication No. (SMA) 18-5063FULLDOC. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018.
12. Winn JL, Shealy SE, Kropp GJ, Felkins-Dohm D, Gonzales-Nolas C, Francis E. Housing assistance and case management: Improving access to substance use disorder treatment for homeless veterans. Psychological Serv. 2013;10(2):233-240.
13. Cacciola JS, Alterman AI, DePhilippis D, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treatment. 2013;44(3):256-263.
14. McHugh RK, Hearon BA, Otto MW. Cognitive-behavioral therapy for substance use disorders, Psychiatr Clinics North Am. 2010;33:511–525.
15. Karlin, BE, Cross, G. From the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs health care system. Am Psychol. 2014;69:19-33.
16. DePhilippis D, Petry NM, Bonn-Miller MO, Rosenbach SB, McKay JR. The national implementation of contingency management (CM) in the Department of Veterans Affairs: attendance at CM sessions and substance use outcomes, Drug Alcohol Dependence. 2018;185:367-373.
Substance use disorders (SUDs) are an increasing public health concern in the US. The 2015 National Survey on Drug Use and Health indicated that 27 million people (8% of the US population) reported current use of recreational drugs or misuse of alcohol or prescription medications.1 The 2013 National Survey on Drug Use and Health indicated that 1.5 million veterans (roughly 6.6%) met the criteria for a SUD.2 More than 50% of patients awaiting entry into a SUD treatment program will never achieve admission due, in part, to long wait times.3-5
National attention has been focused on increasing veteran access to quality treatment based on evidence-based practices (EBPs). Several national legislative measures and treatment protocols have been implemented: the Uniform Mental Health Services in US Department of Veterans Affairs (VA) medical centers and clinics; Veterans Access, Choice, and Accountability Act (2014); Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) Training Program; and the Psychotropic Drug Safety Initiative (PDSI).6-8 Consistent with these directives and in line with American Society of Addiction Medicine (ASAM) and Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for medication-assisted therapies (MAT),the James A. Haley Veterans’ Hospital (JAHVH) Mental Health and Behavioral Sciences Service (MH&BSS) Substance Use Disorders Service (SUDS) in Tampa, Florida, implemented an evidence-based, treatment-on-demand model of care.9-11
Meeting SUD Treatment Needs
What does the new supervisor of a clinical program do when a 24-employee outpatient VA Alcohol and Drug Addiction Treatment Program (ADATP) has an average 33-day wait time for treatment with 54% of patients lost to care between initial evaluation and admission?12 Patients lacked consistent access to SUD pharmacotherapy. The national VA clinical performance indicators were substandard and there are no additional resources available to apply to the program.
At JAHVH the program supervisor enlisted hospital leadership to support program redesign. The redesign sought to improve operational efficiency and eliminate patient wait time; adopt national standards for assessment and treatment developed by ASAM; implement strictly evidence-based psychotherapeutic treatments; educate program psychiatrists about evidence-based psychopharmacologic treatments and hold them accountable for patient adherence; streamline documentation templates; free clinical providers from nonclinical tasks; create an inpatient addiction consult team to diagnose and treat chronic hospitalized patients with SUDs; ensure continuity of care; and, standardize consistent, objective measures of patient response to treatment to track the program’s effectiveness.
In this article, the authors provide an explanation of the clinical, theoretical foundation and the practical steps taken to design and implement this transformation. They then describe the lessons learned, hoping that their process will serve as a model for those in similar situations.
Program Redesign
July 1, 2015, a new program supervisor was hired and began a 2-month evaluation and analysis of the program with input from leadership, staff, and hospital/community stakeholders. September 1, the monthlong process of developing the redesign began. On September 30 the plan was presented to, and approved by, MH&BSS leadership. October was spent preparing for change with an implementation date of November 2 selected. On November 2, 2015, the complete redesign was implemented.
Needs Assessment
A needs assessment yielded improvement opportunities in program structure (levels of care); clinical content; staff and resource allocation, including clinical workflow and management systems. Staff identified philosophical and practical variance in the program, often leading to confusion for patients and clinicians and potentially resulting in disparate quality care and patient outcomes. Recommendations for addressing these needs included incorporating ASAM guidelines for assignment to clinically appropriate levels of care, implementation of consistent EBPs for SUD and comorbid conditions,9 and emphasis on staff training and development to champion evidence-based program philosophy and service delivery.
The assessment determined that the average waitlist time was 33 days, and patients were required to abstain from substance or alcohol use prior to admission to the Intensive Outpatient Program. If a waitlisted patient relapsed, she or he was removed from the waitlist and denied admission. A study conducted at JAHVH reported that 54% of waitlisted patients in this clinic (prior to November 2, 2015) never were admitted to the program.12 Access to care was considered a significant issue.
Program Implementation
September was spent developing a comprehensive redesign of the SUD clinic. The vision included incorporating all ASAM levels of care; creating an evidence-based, treatment-on-demand model of care; and, securing the support of MH&BSS leadership team, staff, and patients for the redesign. The supervisory clinician interviewed staff both individually and as a group. Clinicians were provided extensive training on EBP for SUDs, including psychotherapies, psychosocial treatments, and psychopharmacologic interventions. A journal club was started with staff-generated topics that offered articles sharing current research, EBPs, and psychotherapeutic techniques, continuing education on substances, and management of coexisting diagnoses. Clinicians increased the frequency of SUD in-service trainings. Psychiatrists provided several Grand Rounds to the MH&BSS service. All counselors were assigned to 1 of the program’s 3 clinical psychologists for individual weekly clinical supervision.
By providing all staff with current, evidence-based, clinically relevant treatment information and emphasizing its relationship to successful patient outcomes, program leadership energized staff support. Staff were encouraged to perform at the top of their scope of practice and engage in training and consultation. Each staff member was delegated a role in the process to inspire buy-in.
Preparation for the Shift
October was spent preparing for a seamless, one-day implementation of proposed changes, including implementation of updated clinical policies, procedures, and document templates (rewritten to include only clinically appropriate information required by VA policy or the Joint Commission); streamlined staff schedules; and utilization of staff-developed and research/policy-driven EBP handbook. Finally, the Brief Addiction Monitor (BAM) was selected as objective criteria to consistently assess patient progress in treatment, and staff were instructed to use this measure at regular intervals and for all levels of care.
Emphasis was placed on ongoing fortification of staff and patient support for the reorganization. For example, the Addiction Severity Index, though not required by policy, was historically used, adding 90 minutes to the evaluation and admission session. Staff agreed to remove this measure to improve clinician availability. Staff were also empowered to rename the redesigned program, and chose Substance Use Disorders Service (SUDS).
Process Changes
To achieve same-day access to clinical care, program leadership created a daily morning orientation group. Patients are scheduled or may attend as a walk-in. The orientation’s purpose is to explain what services are available and to offer each patient an opportunity for immediate evaluation and treatment. Staff schedules were modified to provide patient evaluation appointment slots immediately following orientation. The number of immediate evaluation slots was initially assessed by analyzing the demand for treatment over the previous 6 months, determining the daily mean, and setting the number of slots to accommodate 3 standard deviations above the daily mean. If a patient in a daily orientation group expresses a willingness to engage in treatment, he or she is immediately evaluated by a counselor during a 90-minute session and seen by a psychiatrist to determine whether pharmacologic treatment would be appropriate. If needed, the medication is prescribed that day. The primary purpose of the patient’s initial clinical evaluation is to determine the most appropriate level of care based on ASAM criteria. Also available were 90-minute afternoon evaluation appointments with psychiatrists for patients who walk into the clinic after the morning orientation group had ended.
Prior to the redesign, clinic psychiatrists were minimally prescribing evidence-based pharmacotherapy for sobriety support. At the time of redesign, only 8% of patients diagnosed with opioid use disorders (OUDs) were prescribed buprenorphine/naloxone or naltrexone. Just 1.9% of patients diagnosed with alcohol use disorder (AUD) were prescribed naltrexone or acamprosate. With the redesign, access to these medications has significantly expanded.
All templates were redesigned to ensure consistent documentation. This change decreased the overall provider task burden, and explicitly supported the use of ASAM multidimensional criteria and the Brief Addiction Monitor (BAM) to identify a pretreatment baseline score and track each patient’s clinical progress.13 Evidence-based written curricula were standardized for individual and group psychotherapies to reduce provider and programmatic variation.
The redesign creates distinct levels of care based on ASAM criteria, including harm reduction, ambulatory detoxification, outpatient group and individual psychotherapy, an evidence-based Intensive Outpatient Program (IOP), and aftercare. Application of the ASAM standards has allowed clinicians to make accurate placement decisions that best meet individual patient needs and to serve as effective stewards even with limited treatment and financial resources. Although JAHVH does not have a residential SUD program, procedures were developed to refer veterans to community-based residential treatment programs when appropriate.
Group Therapies
With the redesign, SUDS was no longer exclusively a 12-step program; however, it still supported and recognized the value of this approach for some patients. A psychologist periodically audits group sessions to prevent drift from that group’s curriculum. Counselors are assigned to weekly hour-long clinical supervision sessions with a psychologist to review patient care and reinforce the application of evidence-based individualized treatment.
After reviewing empirical literature and VA directives, CBT-SUD was adopted. It encompasses individual and group interventions, such as motivational interviewing (MI), contingency management (CM), and medication-assisted therapies as primary therapeutic treatment modalities, all of which have demonstrated efficacy as measured by length of sobriety postintervention.9,14,15
Clinical Staff Improvements
Staff were reorganized into 3 interdisciplinary treatment teams. A weekly team meeting is scheduled to coordinate care and discuss the treatment of complex patients. Clinical staff focus has shifted from case-management to diagnosis and treatment; now patients are referred to their primary care team’s social worker for case management services. Allowing clinical staff to focus solely on the diagnosis and clinical treatment of SUDs has significantly enhanced productivity and morale.
Staff receive training in the newly adopted interventions during brief monthly refresher courses provided by inhouse psychologists. Additional training includes participation in local and national SUD teleconferences and onsite meetings with experts in harm reduction and motivational interventions. During the transition, clinicians were encouraged to attend staff resiliency training. Continuing education was available to the SUDS psychiatrists and all inpatient and outpatient psychiatrists at JAHVH. Recently, this educational initiative was expanded to include all primary care and inpatient internal medicine physicians.
Implementation
On November 2, 2015, all planned programmatic changes were simultaneously implemented. On that day, clinician and patient schedules changed, the new EBP curriculum was administered, the use of streamlined documentation procedures began, and daily orientation groups followed by same-day evaluations were initiated.
The pretreatment sobriety requirement was eliminated as a barrier to care, and the program began to use a harm-reduction treatment track as recommended by ASAM guidelines. Patients with urgent or emergent medical or psychiatric problems were immediately assessed by SUDS health care providers and treated in the clinic or transported to the emergency department. Previously unavailable, patient access to ambulatory detoxification was initiated. The prescription of buprenorphine/naloxone for the treatment of OUD treatments increased from 1 prescriber to all 3.
Three months after program reorganization, the leadership reviewed overall workflow, conducted patient satisfaction surveys, and evaluated facility use and productivity. To address patient needs and facilitate optimal use of space, the number of same-day evaluation slots was reduced while the number of individual therapy slots was increased.
Staff meet in workgroups to discuss EBPs and further refine content with feedback from the supervisory clinician and team psychologists who routinely audit group therapy sessions. Staff report ongoing benefit from weekly supervision with a clinical psychologist. An inpatient addiction consultation team that uses existing manpower and resources has been developed.
Program Goals and Outcomes
The SUDS program serves more patients at multiple levels of standardized care with 2 fewer full-time positions. One counselor and one advanced practice registered nurse were reallocated to different programs within the JAHVH VA mental health clinic. Following a review of all program clinic profiles in the VA’s Computerized Patient Record System (CPRS) for utilization, accuracy, and necessity, and allowing for accurate program data capture, the transition resulted in a reduction of distinct clinics from 114 to 67 (-58.7%). In fiscal year 2018, review of CPRS yielded 19,786 total visits (3,645 unique visits).
Eliminate Patient Wait Tme
Patient wait time, as measured in CPRS from date of initial evaluation to date of treatment was reduced from an average of 33 days to 0 within 2 weeks of program implementation. A review of CPRS data also indicated that preadmission attrition dropped from 54% to < 1%; all patients desiring treatment are assigned a counselor and treatment is initiated the same day.
Adopt ASAM Criteria
After the redesign, patients have received more appropriate care based on individualized treatment plans. Due to the implementation of a fluid and supportive model, patients can move through levels of care as clinical need dictates rather than failing treatment and having to reengage. Staff receive ongoing education on the use of ASAM. Evaluation and treatment plan templates now reflect assignment to level of care rationale using ASAM guidelines.
Use of Evidence-Based Psychotherapeutic Treatments
More consistent, coordinated, and effective psychotherapies have improved patient care. The program’s previous issues with patients receiving conflicting treatment guidance from different providers has been resolved. Duplicate and ineffective treatments, including multiple readmissions to the IOP level of care, overemphasis of abstinence-based modalities for patients in active use, and referrals to inpatient SUD care under the assumption that “higher level of care is better” have ceased through staff education, leadership support, and appropriate staffing and communication. Review of patient advocate complaints tracked by and resolved by the service demonstrated an 80% decrease in patient advocate complaints regarding SUD clinic services.
Implement Evidence-Based Psychopharmacologic Treatments
The pharmacotherapy education initiative yielded tangible benefits and is likely a significant contributor to the program’s improved clinical outcomes. Prescription of pharmacotherapy for patients with OUD has risen from 8% to 25.1% in eligible patients. Appropriate medication prescription for the treatment of AUD has risen from 1.9% to 9.8% in eligible patients. These data are reflected in the VA Pharmaceutical Drug Safety Initiative (PDSI) dashboard.
Streamline Documentation
Significantly reducing the charting burden was likely a significant contributor to increased provider productivity and improved patient outcomes. Regular meetings between SUDS leadership and clinical informatics ensure that standardized note templates meet hospital policy and gather all necessary accreditation information.
Improve Employee Morale
Increased staff morale is indicated by a noticeable reduction in employee sick days; a decrease of > 20% (over the same time period the previous year), per the VA electronic timekeeping system, during the first 6 months following the November 2 program implementation.
SUDS Inpatient Addiction Consult Team
In January of 2017, SUDS began an inpatient medicine consultation service to offer evaluation, pharmacotherapy, and supportive counseling to patients diagnosed with SUDs who had been admitted to inpatient medical and surgical services. This team includes existing SUDS staff members reallocated to the inpatient service, is led by a SUDS psychiatrist, and includes 3 multidisciplinary clinicians with extensive training in assessment, diagnosis, and treatment planning of SUDs and comorbid conditions. Prior to implementation, the SUDS inpatient addiction consult team met with hospital leadership and attending physicians for inpatient medicine and psychiatry physicians.
To access the SUDS inpatient addiction consult team, physicians request a consult. Patients are offered an evaluation and are assigned to a level of care with orders for outpatient appointments with a counselor and psychiatrist within 7 days of hospital discharge. Medication-assisted treatment for chronic SUDs is implemented while patients remain admitted to the inpatient medical service. In fiscal year 2018, the SUDS inpatient addiction consult team performed 1,428 inpatient evaluations.
Consistent Treatment Outcome Measures
The BAM is a clinical tool designed to measure patient outcomes in substance use disorders.13 Its 17-item scale measures substance use risk factors that may lead to relapse, and protective factors that are recovery-oriented behaviors that help prevent relapse. It demonstrates sensitivity to change and has excellent test-retest reliability. The BAM has been in use in the addictions treatment program since 2011 but was previously administered only after admission to the IOP and again after a 30- to 90-day follow-up period. Since the program redesign, all SUDS patients are administered the BAM at their initial evaluation and at each individual appointment thereafter. The initial BAM assessment encompasses the previous 30 days; this 30-day version is also used for monthly follow-ups. For BAM assessments that occur within 30 days from the time of the last evaluation, a 7-day version is used. Prior to the redesign, about 24% of patients received a follow-up 30-day BAM assessment.12 Per CPRS review of veterans participating in continued treatment, the rate rose to 100% 3 months after the redesign.
When program staff compared preredesign and postredesign BAM data, they detected significant clinical differences. Data demonstrate a 22.2% improvement in protective factors, including patient confidence in their ability to remain abstinent; engaging in self-help activities, such as attending Alcoholics Anonymous meetings; engaging in organized spiritual activities; going to school, working, or volunteering; securing a regular income; and time spent with friends or family who are supportive of recovery.
The data also show a marked reduction in substance use at follow-up points in treatment and a corresponding decrease in risk factors. One item of the BAM assesses patient level of satisfaction with their treatment. Since the redesign, patients report that they are “considerably” satisfied with their SUD treatment.
Currently, program staff are conducting a review of BAM scores by level of care to further parse the impact of various treatments and best target patient need using measurement-based care and EBP, such as contingency management, which provides small monetary incentives when patients maintain clean urine drug screens.16 In addition, the program plans to achieve more uniformity in BAM assessment intervals at all levels of care, and possibly also integrate BAM data into SUD group therapies. Correlation of the BAM scores to other metrics, such as readmission to inpatient medicine, relapse, urine drug screen, or critical laboratory values, will provide additional insight into impact of programmatic changes.
Discussion
Feedback from other clinics and services within the hospital has been very positive. Some providers have reported that they appreciate the ease and availability of access to SUDS. Additionally, patients engaged in treatment prior to the redesign have been contacted for an updated evaluation and assignment to a counselor and appropriate level of care. From the staff’s perspective, the shift to immediate access to care has allowed a more streamlined process with fewer hurdles for patient admission. Staff report that they now feel empowered to meet the needs of veterans in a comprehensive, same-day fashion.
The success of our redesign was contingent on internal and external sta
The successful implementation of these changes has revealed several important elements regarding patient care. The first lesson was that improving access and integrating best practices is possible without additional resources, outside monies, or disruption to patient services. With the support of MH&BSS leadership, the program streamlined existing processes and used both staff and clinic resources more efficiently.
The second lesson involved the importance of continually reviewing and revising standard operating procedures to match the needs of the current patient population. Policies and procedures that once were viewed as potential barriers to change have been replaced with a more flexible approach and willingness to evolve.
As a result, far fewer patients have been lost to treatment. The time and resources that staff historically dedicated to nonclinical patient care are now redirected to immediate service provision. This increase in operational efficiency and treatment efficacy has resulted in a boost to staff morale, even during a time of immense change and increased productivity. Program staff are now able to personally witness the significant changes in their patients’ lives and feel a sense of pride at being a member of a hard-working team that provides the highest quality of substance use treatment. This is critical to job satisfaction and meets the VA mission to provide timely, effective, and evidence-based treatments to patients.
Conclusion
JAHVH strives to continue to provide the highest quality of SUD treatment available. Future directions aim to streamline clinic operations by constantly monitoring and reviewing workloads, while also considering patient feedback. A continuous review of EBP is part of our clinic’s culture. Program leadership endeavors to promote an open environment where providers can share their triumphs and frustrations and foster a team approach to problem solving. Further plans include expanding the range of treatment levels offered by developing a residential SUD treatment facility.
Substance use disorders (SUDs) are an increasing public health concern in the US. The 2015 National Survey on Drug Use and Health indicated that 27 million people (8% of the US population) reported current use of recreational drugs or misuse of alcohol or prescription medications.1 The 2013 National Survey on Drug Use and Health indicated that 1.5 million veterans (roughly 6.6%) met the criteria for a SUD.2 More than 50% of patients awaiting entry into a SUD treatment program will never achieve admission due, in part, to long wait times.3-5
National attention has been focused on increasing veteran access to quality treatment based on evidence-based practices (EBPs). Several national legislative measures and treatment protocols have been implemented: the Uniform Mental Health Services in US Department of Veterans Affairs (VA) medical centers and clinics; Veterans Access, Choice, and Accountability Act (2014); Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) Training Program; and the Psychotropic Drug Safety Initiative (PDSI).6-8 Consistent with these directives and in line with American Society of Addiction Medicine (ASAM) and Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines for medication-assisted therapies (MAT),the James A. Haley Veterans’ Hospital (JAHVH) Mental Health and Behavioral Sciences Service (MH&BSS) Substance Use Disorders Service (SUDS) in Tampa, Florida, implemented an evidence-based, treatment-on-demand model of care.9-11
Meeting SUD Treatment Needs
What does the new supervisor of a clinical program do when a 24-employee outpatient VA Alcohol and Drug Addiction Treatment Program (ADATP) has an average 33-day wait time for treatment with 54% of patients lost to care between initial evaluation and admission?12 Patients lacked consistent access to SUD pharmacotherapy. The national VA clinical performance indicators were substandard and there are no additional resources available to apply to the program.
At JAHVH the program supervisor enlisted hospital leadership to support program redesign. The redesign sought to improve operational efficiency and eliminate patient wait time; adopt national standards for assessment and treatment developed by ASAM; implement strictly evidence-based psychotherapeutic treatments; educate program psychiatrists about evidence-based psychopharmacologic treatments and hold them accountable for patient adherence; streamline documentation templates; free clinical providers from nonclinical tasks; create an inpatient addiction consult team to diagnose and treat chronic hospitalized patients with SUDs; ensure continuity of care; and, standardize consistent, objective measures of patient response to treatment to track the program’s effectiveness.
In this article, the authors provide an explanation of the clinical, theoretical foundation and the practical steps taken to design and implement this transformation. They then describe the lessons learned, hoping that their process will serve as a model for those in similar situations.
Program Redesign
July 1, 2015, a new program supervisor was hired and began a 2-month evaluation and analysis of the program with input from leadership, staff, and hospital/community stakeholders. September 1, the monthlong process of developing the redesign began. On September 30 the plan was presented to, and approved by, MH&BSS leadership. October was spent preparing for change with an implementation date of November 2 selected. On November 2, 2015, the complete redesign was implemented.
Needs Assessment
A needs assessment yielded improvement opportunities in program structure (levels of care); clinical content; staff and resource allocation, including clinical workflow and management systems. Staff identified philosophical and practical variance in the program, often leading to confusion for patients and clinicians and potentially resulting in disparate quality care and patient outcomes. Recommendations for addressing these needs included incorporating ASAM guidelines for assignment to clinically appropriate levels of care, implementation of consistent EBPs for SUD and comorbid conditions,9 and emphasis on staff training and development to champion evidence-based program philosophy and service delivery.
The assessment determined that the average waitlist time was 33 days, and patients were required to abstain from substance or alcohol use prior to admission to the Intensive Outpatient Program. If a waitlisted patient relapsed, she or he was removed from the waitlist and denied admission. A study conducted at JAHVH reported that 54% of waitlisted patients in this clinic (prior to November 2, 2015) never were admitted to the program.12 Access to care was considered a significant issue.
Program Implementation
September was spent developing a comprehensive redesign of the SUD clinic. The vision included incorporating all ASAM levels of care; creating an evidence-based, treatment-on-demand model of care; and, securing the support of MH&BSS leadership team, staff, and patients for the redesign. The supervisory clinician interviewed staff both individually and as a group. Clinicians were provided extensive training on EBP for SUDs, including psychotherapies, psychosocial treatments, and psychopharmacologic interventions. A journal club was started with staff-generated topics that offered articles sharing current research, EBPs, and psychotherapeutic techniques, continuing education on substances, and management of coexisting diagnoses. Clinicians increased the frequency of SUD in-service trainings. Psychiatrists provided several Grand Rounds to the MH&BSS service. All counselors were assigned to 1 of the program’s 3 clinical psychologists for individual weekly clinical supervision.
By providing all staff with current, evidence-based, clinically relevant treatment information and emphasizing its relationship to successful patient outcomes, program leadership energized staff support. Staff were encouraged to perform at the top of their scope of practice and engage in training and consultation. Each staff member was delegated a role in the process to inspire buy-in.
Preparation for the Shift
October was spent preparing for a seamless, one-day implementation of proposed changes, including implementation of updated clinical policies, procedures, and document templates (rewritten to include only clinically appropriate information required by VA policy or the Joint Commission); streamlined staff schedules; and utilization of staff-developed and research/policy-driven EBP handbook. Finally, the Brief Addiction Monitor (BAM) was selected as objective criteria to consistently assess patient progress in treatment, and staff were instructed to use this measure at regular intervals and for all levels of care.
Emphasis was placed on ongoing fortification of staff and patient support for the reorganization. For example, the Addiction Severity Index, though not required by policy, was historically used, adding 90 minutes to the evaluation and admission session. Staff agreed to remove this measure to improve clinician availability. Staff were also empowered to rename the redesigned program, and chose Substance Use Disorders Service (SUDS).
Process Changes
To achieve same-day access to clinical care, program leadership created a daily morning orientation group. Patients are scheduled or may attend as a walk-in. The orientation’s purpose is to explain what services are available and to offer each patient an opportunity for immediate evaluation and treatment. Staff schedules were modified to provide patient evaluation appointment slots immediately following orientation. The number of immediate evaluation slots was initially assessed by analyzing the demand for treatment over the previous 6 months, determining the daily mean, and setting the number of slots to accommodate 3 standard deviations above the daily mean. If a patient in a daily orientation group expresses a willingness to engage in treatment, he or she is immediately evaluated by a counselor during a 90-minute session and seen by a psychiatrist to determine whether pharmacologic treatment would be appropriate. If needed, the medication is prescribed that day. The primary purpose of the patient’s initial clinical evaluation is to determine the most appropriate level of care based on ASAM criteria. Also available were 90-minute afternoon evaluation appointments with psychiatrists for patients who walk into the clinic after the morning orientation group had ended.
Prior to the redesign, clinic psychiatrists were minimally prescribing evidence-based pharmacotherapy for sobriety support. At the time of redesign, only 8% of patients diagnosed with opioid use disorders (OUDs) were prescribed buprenorphine/naloxone or naltrexone. Just 1.9% of patients diagnosed with alcohol use disorder (AUD) were prescribed naltrexone or acamprosate. With the redesign, access to these medications has significantly expanded.
All templates were redesigned to ensure consistent documentation. This change decreased the overall provider task burden, and explicitly supported the use of ASAM multidimensional criteria and the Brief Addiction Monitor (BAM) to identify a pretreatment baseline score and track each patient’s clinical progress.13 Evidence-based written curricula were standardized for individual and group psychotherapies to reduce provider and programmatic variation.
The redesign creates distinct levels of care based on ASAM criteria, including harm reduction, ambulatory detoxification, outpatient group and individual psychotherapy, an evidence-based Intensive Outpatient Program (IOP), and aftercare. Application of the ASAM standards has allowed clinicians to make accurate placement decisions that best meet individual patient needs and to serve as effective stewards even with limited treatment and financial resources. Although JAHVH does not have a residential SUD program, procedures were developed to refer veterans to community-based residential treatment programs when appropriate.
Group Therapies
With the redesign, SUDS was no longer exclusively a 12-step program; however, it still supported and recognized the value of this approach for some patients. A psychologist periodically audits group sessions to prevent drift from that group’s curriculum. Counselors are assigned to weekly hour-long clinical supervision sessions with a psychologist to review patient care and reinforce the application of evidence-based individualized treatment.
After reviewing empirical literature and VA directives, CBT-SUD was adopted. It encompasses individual and group interventions, such as motivational interviewing (MI), contingency management (CM), and medication-assisted therapies as primary therapeutic treatment modalities, all of which have demonstrated efficacy as measured by length of sobriety postintervention.9,14,15
Clinical Staff Improvements
Staff were reorganized into 3 interdisciplinary treatment teams. A weekly team meeting is scheduled to coordinate care and discuss the treatment of complex patients. Clinical staff focus has shifted from case-management to diagnosis and treatment; now patients are referred to their primary care team’s social worker for case management services. Allowing clinical staff to focus solely on the diagnosis and clinical treatment of SUDs has significantly enhanced productivity and morale.
Staff receive training in the newly adopted interventions during brief monthly refresher courses provided by inhouse psychologists. Additional training includes participation in local and national SUD teleconferences and onsite meetings with experts in harm reduction and motivational interventions. During the transition, clinicians were encouraged to attend staff resiliency training. Continuing education was available to the SUDS psychiatrists and all inpatient and outpatient psychiatrists at JAHVH. Recently, this educational initiative was expanded to include all primary care and inpatient internal medicine physicians.
Implementation
On November 2, 2015, all planned programmatic changes were simultaneously implemented. On that day, clinician and patient schedules changed, the new EBP curriculum was administered, the use of streamlined documentation procedures began, and daily orientation groups followed by same-day evaluations were initiated.
The pretreatment sobriety requirement was eliminated as a barrier to care, and the program began to use a harm-reduction treatment track as recommended by ASAM guidelines. Patients with urgent or emergent medical or psychiatric problems were immediately assessed by SUDS health care providers and treated in the clinic or transported to the emergency department. Previously unavailable, patient access to ambulatory detoxification was initiated. The prescription of buprenorphine/naloxone for the treatment of OUD treatments increased from 1 prescriber to all 3.
Three months after program reorganization, the leadership reviewed overall workflow, conducted patient satisfaction surveys, and evaluated facility use and productivity. To address patient needs and facilitate optimal use of space, the number of same-day evaluation slots was reduced while the number of individual therapy slots was increased.
Staff meet in workgroups to discuss EBPs and further refine content with feedback from the supervisory clinician and team psychologists who routinely audit group therapy sessions. Staff report ongoing benefit from weekly supervision with a clinical psychologist. An inpatient addiction consultation team that uses existing manpower and resources has been developed.
Program Goals and Outcomes
The SUDS program serves more patients at multiple levels of standardized care with 2 fewer full-time positions. One counselor and one advanced practice registered nurse were reallocated to different programs within the JAHVH VA mental health clinic. Following a review of all program clinic profiles in the VA’s Computerized Patient Record System (CPRS) for utilization, accuracy, and necessity, and allowing for accurate program data capture, the transition resulted in a reduction of distinct clinics from 114 to 67 (-58.7%). In fiscal year 2018, review of CPRS yielded 19,786 total visits (3,645 unique visits).
Eliminate Patient Wait Tme
Patient wait time, as measured in CPRS from date of initial evaluation to date of treatment was reduced from an average of 33 days to 0 within 2 weeks of program implementation. A review of CPRS data also indicated that preadmission attrition dropped from 54% to < 1%; all patients desiring treatment are assigned a counselor and treatment is initiated the same day.
Adopt ASAM Criteria
After the redesign, patients have received more appropriate care based on individualized treatment plans. Due to the implementation of a fluid and supportive model, patients can move through levels of care as clinical need dictates rather than failing treatment and having to reengage. Staff receive ongoing education on the use of ASAM. Evaluation and treatment plan templates now reflect assignment to level of care rationale using ASAM guidelines.
Use of Evidence-Based Psychotherapeutic Treatments
More consistent, coordinated, and effective psychotherapies have improved patient care. The program’s previous issues with patients receiving conflicting treatment guidance from different providers has been resolved. Duplicate and ineffective treatments, including multiple readmissions to the IOP level of care, overemphasis of abstinence-based modalities for patients in active use, and referrals to inpatient SUD care under the assumption that “higher level of care is better” have ceased through staff education, leadership support, and appropriate staffing and communication. Review of patient advocate complaints tracked by and resolved by the service demonstrated an 80% decrease in patient advocate complaints regarding SUD clinic services.
Implement Evidence-Based Psychopharmacologic Treatments
The pharmacotherapy education initiative yielded tangible benefits and is likely a significant contributor to the program’s improved clinical outcomes. Prescription of pharmacotherapy for patients with OUD has risen from 8% to 25.1% in eligible patients. Appropriate medication prescription for the treatment of AUD has risen from 1.9% to 9.8% in eligible patients. These data are reflected in the VA Pharmaceutical Drug Safety Initiative (PDSI) dashboard.
Streamline Documentation
Significantly reducing the charting burden was likely a significant contributor to increased provider productivity and improved patient outcomes. Regular meetings between SUDS leadership and clinical informatics ensure that standardized note templates meet hospital policy and gather all necessary accreditation information.
Improve Employee Morale
Increased staff morale is indicated by a noticeable reduction in employee sick days; a decrease of > 20% (over the same time period the previous year), per the VA electronic timekeeping system, during the first 6 months following the November 2 program implementation.
SUDS Inpatient Addiction Consult Team
In January of 2017, SUDS began an inpatient medicine consultation service to offer evaluation, pharmacotherapy, and supportive counseling to patients diagnosed with SUDs who had been admitted to inpatient medical and surgical services. This team includes existing SUDS staff members reallocated to the inpatient service, is led by a SUDS psychiatrist, and includes 3 multidisciplinary clinicians with extensive training in assessment, diagnosis, and treatment planning of SUDs and comorbid conditions. Prior to implementation, the SUDS inpatient addiction consult team met with hospital leadership and attending physicians for inpatient medicine and psychiatry physicians.
To access the SUDS inpatient addiction consult team, physicians request a consult. Patients are offered an evaluation and are assigned to a level of care with orders for outpatient appointments with a counselor and psychiatrist within 7 days of hospital discharge. Medication-assisted treatment for chronic SUDs is implemented while patients remain admitted to the inpatient medical service. In fiscal year 2018, the SUDS inpatient addiction consult team performed 1,428 inpatient evaluations.
Consistent Treatment Outcome Measures
The BAM is a clinical tool designed to measure patient outcomes in substance use disorders.13 Its 17-item scale measures substance use risk factors that may lead to relapse, and protective factors that are recovery-oriented behaviors that help prevent relapse. It demonstrates sensitivity to change and has excellent test-retest reliability. The BAM has been in use in the addictions treatment program since 2011 but was previously administered only after admission to the IOP and again after a 30- to 90-day follow-up period. Since the program redesign, all SUDS patients are administered the BAM at their initial evaluation and at each individual appointment thereafter. The initial BAM assessment encompasses the previous 30 days; this 30-day version is also used for monthly follow-ups. For BAM assessments that occur within 30 days from the time of the last evaluation, a 7-day version is used. Prior to the redesign, about 24% of patients received a follow-up 30-day BAM assessment.12 Per CPRS review of veterans participating in continued treatment, the rate rose to 100% 3 months after the redesign.
When program staff compared preredesign and postredesign BAM data, they detected significant clinical differences. Data demonstrate a 22.2% improvement in protective factors, including patient confidence in their ability to remain abstinent; engaging in self-help activities, such as attending Alcoholics Anonymous meetings; engaging in organized spiritual activities; going to school, working, or volunteering; securing a regular income; and time spent with friends or family who are supportive of recovery.
The data also show a marked reduction in substance use at follow-up points in treatment and a corresponding decrease in risk factors. One item of the BAM assesses patient level of satisfaction with their treatment. Since the redesign, patients report that they are “considerably” satisfied with their SUD treatment.
Currently, program staff are conducting a review of BAM scores by level of care to further parse the impact of various treatments and best target patient need using measurement-based care and EBP, such as contingency management, which provides small monetary incentives when patients maintain clean urine drug screens.16 In addition, the program plans to achieve more uniformity in BAM assessment intervals at all levels of care, and possibly also integrate BAM data into SUD group therapies. Correlation of the BAM scores to other metrics, such as readmission to inpatient medicine, relapse, urine drug screen, or critical laboratory values, will provide additional insight into impact of programmatic changes.
Discussion
Feedback from other clinics and services within the hospital has been very positive. Some providers have reported that they appreciate the ease and availability of access to SUDS. Additionally, patients engaged in treatment prior to the redesign have been contacted for an updated evaluation and assignment to a counselor and appropriate level of care. From the staff’s perspective, the shift to immediate access to care has allowed a more streamlined process with fewer hurdles for patient admission. Staff report that they now feel empowered to meet the needs of veterans in a comprehensive, same-day fashion.
The success of our redesign was contingent on internal and external sta
The successful implementation of these changes has revealed several important elements regarding patient care. The first lesson was that improving access and integrating best practices is possible without additional resources, outside monies, or disruption to patient services. With the support of MH&BSS leadership, the program streamlined existing processes and used both staff and clinic resources more efficiently.
The second lesson involved the importance of continually reviewing and revising standard operating procedures to match the needs of the current patient population. Policies and procedures that once were viewed as potential barriers to change have been replaced with a more flexible approach and willingness to evolve.
As a result, far fewer patients have been lost to treatment. The time and resources that staff historically dedicated to nonclinical patient care are now redirected to immediate service provision. This increase in operational efficiency and treatment efficacy has resulted in a boost to staff morale, even during a time of immense change and increased productivity. Program staff are now able to personally witness the significant changes in their patients’ lives and feel a sense of pride at being a member of a hard-working team that provides the highest quality of substance use treatment. This is critical to job satisfaction and meets the VA mission to provide timely, effective, and evidence-based treatments to patients.
Conclusion
JAHVH strives to continue to provide the highest quality of SUD treatment available. Future directions aim to streamline clinic operations by constantly monitoring and reviewing workloads, while also considering patient feedback. A continuous review of EBP is part of our clinic’s culture. Program leadership endeavors to promote an open environment where providers can share their triumphs and frustrations and foster a team approach to problem solving. Further plans include expanding the range of treatment levels offered by developing a residential SUD treatment facility.
1. Substance Abuse and Mental Health Services Administration. 2015 National Survey on Drug Use and Health: Summary of the Effects of the 2015 NSDUH Questionnaire Redesign: Implications for Data Users. https://www.samhsa.gov/data/sites/default/files/NSDUH-TrendBreak-2015.pdf. Published June 2016. Accessed June 12, 2019.
2. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
3. Donovan DM, Rosengren DB, Downey L, Cox GB, Sloan PDSKL. Attrition prevention with individuals awaiting publicly funded drug treatment. Addiction. 2001;96(8):1149-1160.
4. Hser Y, Maglione M, Polinsky ML, Anglin MD. Predicting treatment entry among treatment-seeking drug abusers. J Subst Abuse Treatment. 1997;15(3):213-220.
5. Stark MJ, Campbell BK, Brinkerhoff CV. “Hello, may we help you?” A study of attrition prevention at the time of the first phone contact with substance-abusing clients. Am J Drug Alcohol Abuse. 1990;16:67-76.
6. US Department of Veterans Affairs. Uniform Mental Health Services in VA Medical Centers and Clinics. VHA Handbook 1160.01. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762. Updated November 2015. Accessed December 12, 2017.
7. Veterans Access, Choice and Accountability Act of 2014, 2 USC § 933.
8. DeMarce JM, Gnys M, Raffa SD, Karlin, BE. Cognitive Behavioral Therapy for Substance Use Disorders Among Veterans: Therapist Manual. Washington, DC: US Department of Veterans Affairs; 2014.
9. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013.
10. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the Treatment of Alcohol Use Disorder: A Brief Guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.
11. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for Opioid Use Disorder – Full Document. HHS Publication No. (SMA) 18-5063FULLDOC. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018.
12. Winn JL, Shealy SE, Kropp GJ, Felkins-Dohm D, Gonzales-Nolas C, Francis E. Housing assistance and case management: Improving access to substance use disorder treatment for homeless veterans. Psychological Serv. 2013;10(2):233-240.
13. Cacciola JS, Alterman AI, DePhilippis D, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treatment. 2013;44(3):256-263.
14. McHugh RK, Hearon BA, Otto MW. Cognitive-behavioral therapy for substance use disorders, Psychiatr Clinics North Am. 2010;33:511–525.
15. Karlin, BE, Cross, G. From the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs health care system. Am Psychol. 2014;69:19-33.
16. DePhilippis D, Petry NM, Bonn-Miller MO, Rosenbach SB, McKay JR. The national implementation of contingency management (CM) in the Department of Veterans Affairs: attendance at CM sessions and substance use outcomes, Drug Alcohol Dependence. 2018;185:367-373.
1. Substance Abuse and Mental Health Services Administration. 2015 National Survey on Drug Use and Health: Summary of the Effects of the 2015 NSDUH Questionnaire Redesign: Implications for Data Users. https://www.samhsa.gov/data/sites/default/files/NSDUH-TrendBreak-2015.pdf. Published June 2016. Accessed June 12, 2019.
2. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
3. Donovan DM, Rosengren DB, Downey L, Cox GB, Sloan PDSKL. Attrition prevention with individuals awaiting publicly funded drug treatment. Addiction. 2001;96(8):1149-1160.
4. Hser Y, Maglione M, Polinsky ML, Anglin MD. Predicting treatment entry among treatment-seeking drug abusers. J Subst Abuse Treatment. 1997;15(3):213-220.
5. Stark MJ, Campbell BK, Brinkerhoff CV. “Hello, may we help you?” A study of attrition prevention at the time of the first phone contact with substance-abusing clients. Am J Drug Alcohol Abuse. 1990;16:67-76.
6. US Department of Veterans Affairs. Uniform Mental Health Services in VA Medical Centers and Clinics. VHA Handbook 1160.01. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762. Updated November 2015. Accessed December 12, 2017.
7. Veterans Access, Choice and Accountability Act of 2014, 2 USC § 933.
8. DeMarce JM, Gnys M, Raffa SD, Karlin, BE. Cognitive Behavioral Therapy for Substance Use Disorders Among Veterans: Therapist Manual. Washington, DC: US Department of Veterans Affairs; 2014.
9. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013.
10. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the Treatment of Alcohol Use Disorder: A Brief Guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.
11. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for Opioid Use Disorder – Full Document. HHS Publication No. (SMA) 18-5063FULLDOC. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018.
12. Winn JL, Shealy SE, Kropp GJ, Felkins-Dohm D, Gonzales-Nolas C, Francis E. Housing assistance and case management: Improving access to substance use disorder treatment for homeless veterans. Psychological Serv. 2013;10(2):233-240.
13. Cacciola JS, Alterman AI, DePhilippis D, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J Subst Abuse Treatment. 2013;44(3):256-263.
14. McHugh RK, Hearon BA, Otto MW. Cognitive-behavioral therapy for substance use disorders, Psychiatr Clinics North Am. 2010;33:511–525.
15. Karlin, BE, Cross, G. From the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs health care system. Am Psychol. 2014;69:19-33.
16. DePhilippis D, Petry NM, Bonn-Miller MO, Rosenbach SB, McKay JR. The national implementation of contingency management (CM) in the Department of Veterans Affairs: attendance at CM sessions and substance use outcomes, Drug Alcohol Dependence. 2018;185:367-373.
Data sharing to third parties prevalent in depression, smoking cessation apps
“Mechanisms that potentially enable a small number of dominant online service providers to link information about the use of mental health apps, without either user consent or awareness, appear to be prevalent,” Kit Huckvale, MB ChB, MSc, PhD, of Black Dog Institute at the University of New South Wales Sydney in Randwick, New South Wales, Australia, and colleagues wrote in their study. “Mismatches between declared privacy policies and observed behavior highlight the continuing need for innovation around trust and transparency for health apps.” The study was published in JAMA Network Open.
Dr. Huckvale and colleagues examined the top 36 depression and smoking cessation apps for Android and iOS in the United States accessed in January 2018; Of the apps downloaded, 15 apps were Android-only, 14 apps were iOS-only, and 7 apps were available on both platforms. The apps were assessed over a series of two sessions while network traffic was captured during use, which allowed researchers to determine what personal information was in each data transmission and where the information was going.
There were 25 apps with a privacy policy (69%), 22 of 25 apps (88%) described how that app primarily collected data, and only 16 of 25 apps (64%) provided information on secondary uses of data. Despite 23 of 25 apps (92%) addressing “the possibility of transmission of data to any third party,” 33 of 36 apps overall (92%) transmitted data to third parties. The two most common entities that received third-party data for marketing, advertising, or analytic purposes were Google and Facebook (29 of 36 apps; 81%). However, 12 of 28 apps (43%) that sent data to Google and 6 of 12 apps (50%) that sent data to Facebook disclosed that they would share data with those companies.
The type of data sent to Google and Facebook consisted of a strong identifier to the device or a username (9 of 33 apps; 27%), or a weak identifier in the form of an advertising identifier or a pseudonymous profile that can link users to their behavior on the app and on other products and platforms (26 of 33 apps; 79%).
“As smartphones continue to gain capabilities to collect new forms of personal, biometric, and health information, it is imperative for the health care community to respond with new methods and processes to review apps and ensure they remain safe and protect personal health information,” the researchers concluded.
One of the investigators, Mark E. Larsen, DPhil, reported receiving grants from National Health and Medical Research Council. The other authors reported no relevant conflicts of interest.
SOURCE: Huckvale K et al. JAMA Netw Open. 2019. doi: 10.1001/jamanetworkopen.2019.2542.
“Mechanisms that potentially enable a small number of dominant online service providers to link information about the use of mental health apps, without either user consent or awareness, appear to be prevalent,” Kit Huckvale, MB ChB, MSc, PhD, of Black Dog Institute at the University of New South Wales Sydney in Randwick, New South Wales, Australia, and colleagues wrote in their study. “Mismatches between declared privacy policies and observed behavior highlight the continuing need for innovation around trust and transparency for health apps.” The study was published in JAMA Network Open.
Dr. Huckvale and colleagues examined the top 36 depression and smoking cessation apps for Android and iOS in the United States accessed in January 2018; Of the apps downloaded, 15 apps were Android-only, 14 apps were iOS-only, and 7 apps were available on both platforms. The apps were assessed over a series of two sessions while network traffic was captured during use, which allowed researchers to determine what personal information was in each data transmission and where the information was going.
There were 25 apps with a privacy policy (69%), 22 of 25 apps (88%) described how that app primarily collected data, and only 16 of 25 apps (64%) provided information on secondary uses of data. Despite 23 of 25 apps (92%) addressing “the possibility of transmission of data to any third party,” 33 of 36 apps overall (92%) transmitted data to third parties. The two most common entities that received third-party data for marketing, advertising, or analytic purposes were Google and Facebook (29 of 36 apps; 81%). However, 12 of 28 apps (43%) that sent data to Google and 6 of 12 apps (50%) that sent data to Facebook disclosed that they would share data with those companies.
The type of data sent to Google and Facebook consisted of a strong identifier to the device or a username (9 of 33 apps; 27%), or a weak identifier in the form of an advertising identifier or a pseudonymous profile that can link users to their behavior on the app and on other products and platforms (26 of 33 apps; 79%).
“As smartphones continue to gain capabilities to collect new forms of personal, biometric, and health information, it is imperative for the health care community to respond with new methods and processes to review apps and ensure they remain safe and protect personal health information,” the researchers concluded.
One of the investigators, Mark E. Larsen, DPhil, reported receiving grants from National Health and Medical Research Council. The other authors reported no relevant conflicts of interest.
SOURCE: Huckvale K et al. JAMA Netw Open. 2019. doi: 10.1001/jamanetworkopen.2019.2542.
“Mechanisms that potentially enable a small number of dominant online service providers to link information about the use of mental health apps, without either user consent or awareness, appear to be prevalent,” Kit Huckvale, MB ChB, MSc, PhD, of Black Dog Institute at the University of New South Wales Sydney in Randwick, New South Wales, Australia, and colleagues wrote in their study. “Mismatches between declared privacy policies and observed behavior highlight the continuing need for innovation around trust and transparency for health apps.” The study was published in JAMA Network Open.
Dr. Huckvale and colleagues examined the top 36 depression and smoking cessation apps for Android and iOS in the United States accessed in January 2018; Of the apps downloaded, 15 apps were Android-only, 14 apps were iOS-only, and 7 apps were available on both platforms. The apps were assessed over a series of two sessions while network traffic was captured during use, which allowed researchers to determine what personal information was in each data transmission and where the information was going.
There were 25 apps with a privacy policy (69%), 22 of 25 apps (88%) described how that app primarily collected data, and only 16 of 25 apps (64%) provided information on secondary uses of data. Despite 23 of 25 apps (92%) addressing “the possibility of transmission of data to any third party,” 33 of 36 apps overall (92%) transmitted data to third parties. The two most common entities that received third-party data for marketing, advertising, or analytic purposes were Google and Facebook (29 of 36 apps; 81%). However, 12 of 28 apps (43%) that sent data to Google and 6 of 12 apps (50%) that sent data to Facebook disclosed that they would share data with those companies.
The type of data sent to Google and Facebook consisted of a strong identifier to the device or a username (9 of 33 apps; 27%), or a weak identifier in the form of an advertising identifier or a pseudonymous profile that can link users to their behavior on the app and on other products and platforms (26 of 33 apps; 79%).
“As smartphones continue to gain capabilities to collect new forms of personal, biometric, and health information, it is imperative for the health care community to respond with new methods and processes to review apps and ensure they remain safe and protect personal health information,” the researchers concluded.
One of the investigators, Mark E. Larsen, DPhil, reported receiving grants from National Health and Medical Research Council. The other authors reported no relevant conflicts of interest.
SOURCE: Huckvale K et al. JAMA Netw Open. 2019. doi: 10.1001/jamanetworkopen.2019.2542.
FROM JAMA NETWORK OPEN
IHS Announces Requirements to Increase Access to OUD Treatment
Native American communities have experienced the largest increase in drug overdose deaths of all racial/ethnic groups in the US. Between 1999 and 2015, drug overdose deaths rose > 500%. To help ensure that American Indians and Alaska Natives (AI/AN) get the treatment they need, the Indian Health Service (IHS) has released Special General Memorandum 2019-01: Assuring Access to Medication Assisted Treatment for Opioid Use Disorder. It requires all IHS federal facilities to:
- Identify opioid use disorder (OUD) treatment resources in their local areas;
- Create an action plan, no later than Dec. 11, 2019; and
- Provide or coordinate patient access to medication-assisted treatment (MAT), specifically increasing access to culturally appropriate prevention, treatment, and recovery support services.
MAT is a comprehensive evidence-based approach that combines pharmacologic interventions with substance abuse counseling and culturally sensitive social support.
The IHS has recently taken other steps to further facilitate MAT access in tribal communities. For example, it has added 3 FDA-approved medications to the National Core Formulary: buprenorphine, buprenorphine/naloxone, and injectable naltrexone, all of which relieve withdrawal symptoms and psychological cravings, supporting adherence to treatment and reducing illicit opioid use.
In addition, the IHS has published the Internet Eligible Controlled Substance Provider Designation Policy. This policy, established in 2018, is designed to increase access to treatment for AI/AN who live in rural or remote areas, where it can be difficult to access a provider with the necessary training and Drug Enforcement Administration approval to prescribe buprenorphine in an outpatient or office-based setting. Once approved, IHS, tribal, and urban Indian organization health care providers can prescribe controlled substances for MAT through telemedicine.
In 2018, the IHS also launched a new website (www.IHS.gov/opioids) to share information about opioids with patients, health care providers, tribal leaders, tribal and urban program administrators, and other community members. The site includes information on approaches to prevent opioid abuse, pain management, recovery tools, and funding opportunities.
Native American communities have experienced the largest increase in drug overdose deaths of all racial/ethnic groups in the US. Between 1999 and 2015, drug overdose deaths rose > 500%. To help ensure that American Indians and Alaska Natives (AI/AN) get the treatment they need, the Indian Health Service (IHS) has released Special General Memorandum 2019-01: Assuring Access to Medication Assisted Treatment for Opioid Use Disorder. It requires all IHS federal facilities to:
- Identify opioid use disorder (OUD) treatment resources in their local areas;
- Create an action plan, no later than Dec. 11, 2019; and
- Provide or coordinate patient access to medication-assisted treatment (MAT), specifically increasing access to culturally appropriate prevention, treatment, and recovery support services.
MAT is a comprehensive evidence-based approach that combines pharmacologic interventions with substance abuse counseling and culturally sensitive social support.
The IHS has recently taken other steps to further facilitate MAT access in tribal communities. For example, it has added 3 FDA-approved medications to the National Core Formulary: buprenorphine, buprenorphine/naloxone, and injectable naltrexone, all of which relieve withdrawal symptoms and psychological cravings, supporting adherence to treatment and reducing illicit opioid use.
In addition, the IHS has published the Internet Eligible Controlled Substance Provider Designation Policy. This policy, established in 2018, is designed to increase access to treatment for AI/AN who live in rural or remote areas, where it can be difficult to access a provider with the necessary training and Drug Enforcement Administration approval to prescribe buprenorphine in an outpatient or office-based setting. Once approved, IHS, tribal, and urban Indian organization health care providers can prescribe controlled substances for MAT through telemedicine.
In 2018, the IHS also launched a new website (www.IHS.gov/opioids) to share information about opioids with patients, health care providers, tribal leaders, tribal and urban program administrators, and other community members. The site includes information on approaches to prevent opioid abuse, pain management, recovery tools, and funding opportunities.
Native American communities have experienced the largest increase in drug overdose deaths of all racial/ethnic groups in the US. Between 1999 and 2015, drug overdose deaths rose > 500%. To help ensure that American Indians and Alaska Natives (AI/AN) get the treatment they need, the Indian Health Service (IHS) has released Special General Memorandum 2019-01: Assuring Access to Medication Assisted Treatment for Opioid Use Disorder. It requires all IHS federal facilities to:
- Identify opioid use disorder (OUD) treatment resources in their local areas;
- Create an action plan, no later than Dec. 11, 2019; and
- Provide or coordinate patient access to medication-assisted treatment (MAT), specifically increasing access to culturally appropriate prevention, treatment, and recovery support services.
MAT is a comprehensive evidence-based approach that combines pharmacologic interventions with substance abuse counseling and culturally sensitive social support.
The IHS has recently taken other steps to further facilitate MAT access in tribal communities. For example, it has added 3 FDA-approved medications to the National Core Formulary: buprenorphine, buprenorphine/naloxone, and injectable naltrexone, all of which relieve withdrawal symptoms and psychological cravings, supporting adherence to treatment and reducing illicit opioid use.
In addition, the IHS has published the Internet Eligible Controlled Substance Provider Designation Policy. This policy, established in 2018, is designed to increase access to treatment for AI/AN who live in rural or remote areas, where it can be difficult to access a provider with the necessary training and Drug Enforcement Administration approval to prescribe buprenorphine in an outpatient or office-based setting. Once approved, IHS, tribal, and urban Indian organization health care providers can prescribe controlled substances for MAT through telemedicine.
In 2018, the IHS also launched a new website (www.IHS.gov/opioids) to share information about opioids with patients, health care providers, tribal leaders, tribal and urban program administrators, and other community members. The site includes information on approaches to prevent opioid abuse, pain management, recovery tools, and funding opportunities.
Co-use of opioids, methamphetamine on rise in rural Oregon
Survey shows simultaneous use climbed from 19% to 34% between 2011 and 2017
SAN ANTONIO – A perceived low risk of using methamphetamine and a belief that methamphetamine helps with opioid addiction are both driving increasing levels of concurrent methamphetamine and opioid use in rural Oregon, according to recent qualitative research.
Use of methamphetamine by those who use opioids increased from 19% to 34% between 2011 and 2017, Gillian Leichtling, research manager at HealthInsight Oregon, said at the annual meeting of the College on Problems of Drug Dependence.
The highest prevalence of simultaneous use is in the western states, where 63% of opioid users also use methamphetamine, she said. Hospitalizations and overdoses related to methamphetamine have likewise increased, particularly in rural communities.
To better understand the motivations and implications of this trend, Ms. Leichtling and her colleagues conducted a survey from March 2018 to April 2019 of adults who had nonmedically used/injected opioids or methamphetamine in the past month. All participants lived in Lane or Douglas counties in southwestern Oregon, where half the land is controlled by the U.S. Forest Service and Bureau of Land Management, and opioid overdose rates surpass that of the state average. Additional 60-minute semistructured qualitative interviews were conducted in summer 2018.
Among the 144 surveyed, 78% had used an opioid in the past month, nearly all of whom (96%) had also used methamphetamine in the past month. The interviewees included adults fairly evenly spread across ages, but most (94%) were white.
The main themes that emerged from the interviews involved the perceived benefits and consequences of those who used both opioids and methamphetamine, and the environmental circumstances that supported methamphetamine use, Ms. Leichtling explained.
Most people interviewed had their first experience with methamphetamine early in life, typically in early or mid-adolescence, she said. Two respondents, for example, first began using at 8 and 12 years old, the former learning from a preteen neighbor.
Methamphetamine’s wide availability and low cost also increased its use. In addition, methamphetamine use carries less stigma than heroin use, participants told the researchers. One person who noted the popularity of methamphetamine added: “You get treated really badly if you’re a heroin addict.”
In addition to less stigma, many of the perceived benefits of methamphetamine use related to opioids: Participants said methamphetamine “relieves opioid withdrawal, helps reduce opioid use, enhances functioning, and combines well with opioids” for a pleasurable effect, Ms. Leichtling said. Some also perceived methamphetamine as a way to reverse opioid overdose.
“I’m getting out of [the buprenorphine] program; they’re titrating me down rapidly, and so I’ve been sick for a week,” one respondent told researchers. “I’ve been doing so much more meth just to try to deflect the pain ... they’re too hard to come down from. It’s just you can’t do it without another drug ... especially if you have a job or responsibilities or kids,” they told researchers.
Another woman said she and her mother were able to come off heroin by using methamphetamine instead, and a yet another said she and her ex-boyfriend used methamphetamine to stop using opioids.
Several respondents also mentioned using methamphetamine to help them go to work, effectively put in long days, and then care for their families when they get home.
Ms. Leichtling described three main implications of the findings for interventions in rural areas. One was the need at the community level for greater access to medication-assisted treatment (MAT) of opioid use disorder to reduce the use of methamphetamine to taper opioid use or withdrawal.
Next, clinicians need to provide tailored treatment for the co-use of opioids and methamphetamine, and educate patients on alternatives to being dropped from medication-assisted opioid use disorder treatment. Finally, individual users need education on overdose that addresses the misconceptions and risks related to methamphetamine risk, Ms. Leichtling said.
Since the survey and interviews came only from two rural Oregon counties, the findings might not be generalizable, Ms. Leichtling said, and their study did not explore social determinants of health that might be at work.
The National Institute on Drug Abuse funded the research. The authors had no conflicts of interest.
Survey shows simultaneous use climbed from 19% to 34% between 2011 and 2017
Survey shows simultaneous use climbed from 19% to 34% between 2011 and 2017
SAN ANTONIO – A perceived low risk of using methamphetamine and a belief that methamphetamine helps with opioid addiction are both driving increasing levels of concurrent methamphetamine and opioid use in rural Oregon, according to recent qualitative research.
Use of methamphetamine by those who use opioids increased from 19% to 34% between 2011 and 2017, Gillian Leichtling, research manager at HealthInsight Oregon, said at the annual meeting of the College on Problems of Drug Dependence.
The highest prevalence of simultaneous use is in the western states, where 63% of opioid users also use methamphetamine, she said. Hospitalizations and overdoses related to methamphetamine have likewise increased, particularly in rural communities.
To better understand the motivations and implications of this trend, Ms. Leichtling and her colleagues conducted a survey from March 2018 to April 2019 of adults who had nonmedically used/injected opioids or methamphetamine in the past month. All participants lived in Lane or Douglas counties in southwestern Oregon, where half the land is controlled by the U.S. Forest Service and Bureau of Land Management, and opioid overdose rates surpass that of the state average. Additional 60-minute semistructured qualitative interviews were conducted in summer 2018.
Among the 144 surveyed, 78% had used an opioid in the past month, nearly all of whom (96%) had also used methamphetamine in the past month. The interviewees included adults fairly evenly spread across ages, but most (94%) were white.
The main themes that emerged from the interviews involved the perceived benefits and consequences of those who used both opioids and methamphetamine, and the environmental circumstances that supported methamphetamine use, Ms. Leichtling explained.
Most people interviewed had their first experience with methamphetamine early in life, typically in early or mid-adolescence, she said. Two respondents, for example, first began using at 8 and 12 years old, the former learning from a preteen neighbor.
Methamphetamine’s wide availability and low cost also increased its use. In addition, methamphetamine use carries less stigma than heroin use, participants told the researchers. One person who noted the popularity of methamphetamine added: “You get treated really badly if you’re a heroin addict.”
In addition to less stigma, many of the perceived benefits of methamphetamine use related to opioids: Participants said methamphetamine “relieves opioid withdrawal, helps reduce opioid use, enhances functioning, and combines well with opioids” for a pleasurable effect, Ms. Leichtling said. Some also perceived methamphetamine as a way to reverse opioid overdose.
“I’m getting out of [the buprenorphine] program; they’re titrating me down rapidly, and so I’ve been sick for a week,” one respondent told researchers. “I’ve been doing so much more meth just to try to deflect the pain ... they’re too hard to come down from. It’s just you can’t do it without another drug ... especially if you have a job or responsibilities or kids,” they told researchers.
Another woman said she and her mother were able to come off heroin by using methamphetamine instead, and a yet another said she and her ex-boyfriend used methamphetamine to stop using opioids.
Several respondents also mentioned using methamphetamine to help them go to work, effectively put in long days, and then care for their families when they get home.
Ms. Leichtling described three main implications of the findings for interventions in rural areas. One was the need at the community level for greater access to medication-assisted treatment (MAT) of opioid use disorder to reduce the use of methamphetamine to taper opioid use or withdrawal.
Next, clinicians need to provide tailored treatment for the co-use of opioids and methamphetamine, and educate patients on alternatives to being dropped from medication-assisted opioid use disorder treatment. Finally, individual users need education on overdose that addresses the misconceptions and risks related to methamphetamine risk, Ms. Leichtling said.
Since the survey and interviews came only from two rural Oregon counties, the findings might not be generalizable, Ms. Leichtling said, and their study did not explore social determinants of health that might be at work.
The National Institute on Drug Abuse funded the research. The authors had no conflicts of interest.
SAN ANTONIO – A perceived low risk of using methamphetamine and a belief that methamphetamine helps with opioid addiction are both driving increasing levels of concurrent methamphetamine and opioid use in rural Oregon, according to recent qualitative research.
Use of methamphetamine by those who use opioids increased from 19% to 34% between 2011 and 2017, Gillian Leichtling, research manager at HealthInsight Oregon, said at the annual meeting of the College on Problems of Drug Dependence.
The highest prevalence of simultaneous use is in the western states, where 63% of opioid users also use methamphetamine, she said. Hospitalizations and overdoses related to methamphetamine have likewise increased, particularly in rural communities.
To better understand the motivations and implications of this trend, Ms. Leichtling and her colleagues conducted a survey from March 2018 to April 2019 of adults who had nonmedically used/injected opioids or methamphetamine in the past month. All participants lived in Lane or Douglas counties in southwestern Oregon, where half the land is controlled by the U.S. Forest Service and Bureau of Land Management, and opioid overdose rates surpass that of the state average. Additional 60-minute semistructured qualitative interviews were conducted in summer 2018.
Among the 144 surveyed, 78% had used an opioid in the past month, nearly all of whom (96%) had also used methamphetamine in the past month. The interviewees included adults fairly evenly spread across ages, but most (94%) were white.
The main themes that emerged from the interviews involved the perceived benefits and consequences of those who used both opioids and methamphetamine, and the environmental circumstances that supported methamphetamine use, Ms. Leichtling explained.
Most people interviewed had their first experience with methamphetamine early in life, typically in early or mid-adolescence, she said. Two respondents, for example, first began using at 8 and 12 years old, the former learning from a preteen neighbor.
Methamphetamine’s wide availability and low cost also increased its use. In addition, methamphetamine use carries less stigma than heroin use, participants told the researchers. One person who noted the popularity of methamphetamine added: “You get treated really badly if you’re a heroin addict.”
In addition to less stigma, many of the perceived benefits of methamphetamine use related to opioids: Participants said methamphetamine “relieves opioid withdrawal, helps reduce opioid use, enhances functioning, and combines well with opioids” for a pleasurable effect, Ms. Leichtling said. Some also perceived methamphetamine as a way to reverse opioid overdose.
“I’m getting out of [the buprenorphine] program; they’re titrating me down rapidly, and so I’ve been sick for a week,” one respondent told researchers. “I’ve been doing so much more meth just to try to deflect the pain ... they’re too hard to come down from. It’s just you can’t do it without another drug ... especially if you have a job or responsibilities or kids,” they told researchers.
Another woman said she and her mother were able to come off heroin by using methamphetamine instead, and a yet another said she and her ex-boyfriend used methamphetamine to stop using opioids.
Several respondents also mentioned using methamphetamine to help them go to work, effectively put in long days, and then care for their families when they get home.
Ms. Leichtling described three main implications of the findings for interventions in rural areas. One was the need at the community level for greater access to medication-assisted treatment (MAT) of opioid use disorder to reduce the use of methamphetamine to taper opioid use or withdrawal.
Next, clinicians need to provide tailored treatment for the co-use of opioids and methamphetamine, and educate patients on alternatives to being dropped from medication-assisted opioid use disorder treatment. Finally, individual users need education on overdose that addresses the misconceptions and risks related to methamphetamine risk, Ms. Leichtling said.
Since the survey and interviews came only from two rural Oregon counties, the findings might not be generalizable, Ms. Leichtling said, and their study did not explore social determinants of health that might be at work.
The National Institute on Drug Abuse funded the research. The authors had no conflicts of interest.
REPORTING FROM CPDD 2019