Relapse Sensitive Care: Changing

Systems of Addiction Treatment

Stacey C. Conroy LICSW, MPH

Richmond VA Medical Center - Supervisory Social

Worker Mental Health & Substance Abuse

1

Stacey C. Conroy LICSW, MPH,

Disclosures

2

• Stacey C. Conroy LICSW, MPH, has no financial

relationships to disclose.

The contents of this activity may include discussion of off label or investigative drug uses. The

faculty is aware that is their responsibility to disclose this information.

Planning Committee, Disclosures

3

AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on

evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone

in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This

disclosure information is listed below:

The following developers and planning committee members have reported that they have no commercial relationships

relevant to the content of this module to disclose: PCSSMAT lead contributors Frances Levin, MD and Adam Bisaga,

MD; AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten,

MD, Joji Suzuki, MD; AMERSA staff and faculty Colleen LaBelle, BSN, RN-BC, CARN, Doreen Baeder and AAAP

Staff Kathryn Cates-Wessel, Miriam Giles and Blair Dutra.

All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is

accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of

patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted

standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the

committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers will inform the

learners if their presentation will include discussion of unlabeled/investigational use of commercial products.

Accreditation Statement

4

• American Academy of Addiction Psychiatry (AAAP)

is accredited by the Accreditation Council for

Continuing Medical Education to provide continuing

medical education for physicians.

Designation Statement

5

• American Academy of Addiction Psychiatry

designates this enduring material

educational activity for a maximum of one

(1)AMA PRA Category 1 Credit™.

Physicians should only claim credit

commensurate with the extent of their

participation in the activity.

Date of Release: March 15, 2016

Date of Expiration: March 15, 2019

System Requirements

6

• In order to complete this online module you will need

Adobe Reader. To install for free click the link below:

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Target Audience

7

• The overarching goal of PCSS-MAT is to make

available the most effective medication-assisted

treatments to serve patients in a variety of settings,

including primary care, psychiatric care, and pain

management settings.

Educational Objectives

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• At the conclusion of this activity participants should be able to:

• Identify 2 factors that contribute to supporting a Relapse Sensitive Care model of addiction treatment

• Assess current practice for relapse sensitive care concepts

• Develop an action plan to implement relapse sensitive care in current practice

• Discuss Quality of Life as a potential Outcome Measure for addiction treatment

Treatment Completion Matters to

Outcomes

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• Patients who completed the treatment program used significantly fewer psychiatric inpatient bed days of care the year after they completed the program, both in comparison to their own prior use and in comparison to program dropouts.

• Graduates were more likely to be abstinent and less likely to fully relapse or be incarcerated at 6- month follow-up.

Wallace, A.E. & Weeks, W.B. (2004). Substance abuse intensive

outpatient treatment: Does program graduation matter?

Journal of Substance Abuse Treatment, 27-30.

Seeking But Not Completing Treatment

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56% of those who seek treatment do not complete treatment:

• Treatment completed: 44 percent

• Dropped out: 26 percent

• Transferred for further treatment: 15 percent

• Terminated by facility: 7 percent

• Other: 5 percent – failed to complete for other reasons

• Incarcerated: 2 percent

Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2011. Discharges from Substance Abuse Treatment Services. BHSIS Series S-70, HHS Publication No. (SMA) 14-4846. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

• We would hope that the days are numbered in which the addictions field can argue that addiction is a primary health care problem while its clinicians continue to treat the primary symptoms of addiction as bad behavior subject to “disciplinary discharge.”

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White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)

“It’s time to stop kicking people out of treatment.” Counselor.

Changing how Addiction is viewed…

A Few Common Administrative

Discharge Reasons

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• Failing to participate in service activities, e.g.,

missing counseling sessions.

• Possessing contraband in the treatment facility

(e.g., illicit drugs, cigarettes, prohibited food

items).

• Using alcohol or non-prescribed drugs.

• Failing to secure medication for a psychiatric

condition.

White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)

“It’s time to stop kicking people out of treatment.” Counselor.

• What has OR does honesty about relapse lead to?

• Who created the “liars” in addiction

treatment? Hint: It was “Us” the providers

• What incentive do patients have to be

honest if discharge is the outcome?

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Honesty

Relapse Sensitive Care (RSC)

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• A systemic philosophy of care with the goal of

maintaining an individual in addiction treatment to

enhance the potential for sustained recovery.

In certain settings this systemic philosophy of

care can be expanded to encompass an

individuals definition of recovery with outcomes

based on quality of life and not solely on

abstinence.

Something New

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Recovery Orientated

Systems of Care

Relapse Sensitive Care Harm Reduction

Development of Network of

Community Base Services

Development of Internal and

External Recovery Supports

– Single Agency

Often one component of

larger agency

Fully implemented in a few

places

Can be implemented in any

size agency or practice

Restrictions on

implementation due to

public opinion

May be abstinence based

with standard rate of

administrative d/c due to

substance use

Motivational/Values/

Quality-of-Life Based

Does not require that the

behavior with the negative

outcome stops, simply finds

a safer way to engage in

behavior while motivation

for change develops

Traditionally Abstinence

Based

Chronic Disease

Management

Public Health / Safety

Consider

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Relapse Sensitive Care

• Multiple opportunities to engage in treatment, stopping the revolving door of multiple treatment episodes

• Increase in recovery supports following a relapse while remaining in treatment (not a discharge and referral model)

• Explores additional measure of treatment success i.e. Quality of Life (QoL) Measures

Traditional Care

• One strike on substance use often leads to discharge

• Decreases recovery supports through discharge – often when a patient relapses they leave treatment which may include loss of housing, emotional supports, freedom due to legal issues

• Urine Drug Screen is most common measure of treatment success

Disease Model of Addiction

Not as New as People

Think

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Addiction Behavior or Biology…

Patients to be Treated

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• 1784 - Dr. Benjamin Rush’s Inquire into the effects of

Aberrant Sprits on the Human Mind and Body – argued

that this condition is a disease that physicians should be

treating

• 1810 - Dr. Rush calls for the establishment of a “Sober

House” to care for the confirmed “drunkard”

• 1891-1892 - Keeley League “Laws must realize a

leading fact: Medical not penal treatment reforms the

drunkard.”

White, W. (1998) Slaying the Dragon: The History of Addiction Treatment

and Recovery in America. Bloomington IL: Chestnut Health Systems

Public Health Issue

White, W. (1998) Slaying the Dragon: The History of Addiction Treatment

and Recovery in America. Bloomington IL: Chestnut Health Systems.

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• 1944 - Marty Mann founds the National Committee for Education on Alcoholism (today the National Council on Alcoholism and Drug Dependence) around the following propositions:

1. Alcoholism is a disease.

2. The alcoholic, therefore, is a sick person.

3. The alcoholic can be helped.

4. The alcoholic is worth helping.

5. Alcoholism is our No. 4 public health problem, and our public responsibility.

Specialty Medicine

White, W. (1998) Slaying the Dragon: The History of Addiction Treatment

and Recovery in America. Bloomington IL: Chestnut Health Systems.

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• 1954 - Ruth Fox, MD establishes the New York City

Medical Society on Alcoholism, today known as the

American Society of Addiction Medicine (ASAM).

• 1967 - The American Medical Association passes

resolution identifying alcoholism as a "complex" disease

and a "disease that merits the serious concern of all

members of the health professions."

• 1967 - The New York Medical Society alters its mission

to become the American Society on Addiction Medicine.

Development of Medications

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Diseases are treated with medications:

• Methadone – 1947 in powder form for compounding; 1973 tablet for suspension; 2010 solution oral

• Disulfiram (Antabuse) 1951

• Buprenorphine,(Suboxone, Subutex) 2002

• Acamprosate (Campral) 2004

• XR-Naltexone (Vivtrol) 2006

FDA/Center for Drug Evaluation and Research Office of Communications Division of Online Communications Update Frequency: Daily www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Search_Drug_Name

Neuroscience Of Cue Induced

Relapse

AND

Reinstatement in Animal

Studies

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Drug Related Cue

Literature Review

These drug-related cues may be:

• Visual (seeing words, pictures or silent videos)

• Auditory (e.g., listening to imagery scripts)

• Audiovisual (combination of sights and sounds)

• Tactile or haptic (handling the corresponding paraphernalia)

• Olfactory or gustatory (smelling or tasting the substance)

• Increasingly often, multi-sensory drug cues are also employed (e.g., holding a cigarette while watching audio- videos of smoking)

• Induced Neuroadaptations in the Nac cAMP second messenger system in relapse

Jasinska A.J., Stein E.A., ,Kaiser J., ,Naumer M.J., Yalachkov Y. (2014).

Factors modulating neural reactivity to drug cues in addiction: A survey of

human neuroimaging studies. NeurosciBiobehavRev 38:1–16.

Relapse is Biological

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Each of these reinstatement relapse concepts has been reproduced in animal studies – absent of human psychosocial stressors

• Discrete cue-induced reinstatement

• Context-induced reinstatement

• Discriminative cue-induced reinstatement

• Reinstatement model

Bossert et al, (2013) The reinstatement model of drug relapse: recent

neurobiological findings, emerging research topics transitional research.

Pharmacology 229: 453-476.

History, Medicine, and Neuroscience

Are Telling Us…

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The messages outward are that:

• The client is not in control of their alcohol and/or drug

intake or its consequences.

• The client needs professional treatment to reacquire

such control.

• Reacquisition of control over [Alcohol & Other Drugs]

AOD use/nonuse decisions takes time and may be

preceded by one or more episodes of relapse.

• Long-term recovery is best supported by patience and

support rather than punishment and abandonment.

White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)

“It’s time to stop kicking people out of treatment. Counselor.

Relapse Sensitive Care

• What would it be like if a patient were honest and remained in treatment following a relapse?

• How could we support them in their recovery process? Do we know our internal and external sources of recovery supports?

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Back to Honesty

How to Start Changing a System:

Change Can Be Challenging

For Patients AND Staff

Relapse Sensitive Care

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Begin with Assessment of Current

Policies and Procedures

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What happens in our system, facility, or practice if a patient

has a positive urine drug screen?

• d/c?

• d/c with referral – often a requirement for state funded

treatment programs?

• Maintained in treatment with a consequence and

support for ongoing treatment?

• Maintained in treatment with increase in recovery

supports?

What research supports our current policies and

procedures?

Recovery Supports

29

• Addiction treatment and recovery support services have

repeatedly been shown to be effective with many

people achieving recovery. As with any chronic disease,

however, discrete treatment episodes, supported by

continuing recovery support services, are often needed

to help people achieve and maintain recovery.

Treatment for addictive disorders is not typically a “one-

shot” type of intervention.

Kaplan, L., The Role of Recovery Support Services in Recovery-Oriented Systems of Care. DHHS Publication No. (SMA) 08-

4315. Rockville, MD: Center for Substance Abuse Services, Substance Abuse and Mental Health Services Administration,

2008.

Identify Internal Recovery Supports

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• Do you have groups? Individual counseling?

• Do you have on site 12 step meetings?

• Do you have peer mentors?

What is your time frame for the additional

supports to assist the recovery process? 14

days, 30 days?

Recovery supports will not resolve a relapse

over night – what is the time frame in which

change is anticipated?

Identify External Recovery Supports

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• Do you have the ability to refer to other providers of group

or individual counseling?

Will you maintain treatment until referral provider

establishes and begins to implement a treatment plan?

• Can you provide 12 step meeting list?

Do you have the ability to explain types of meetings,

benefits of meetings, how to utilize meetings, along with

explaining the role of sponsors?

It is one thing to give a referral or send to meetings, it is

another to facilitate the referral with warm handoff

Educational Needs

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What education will be needed to

implement Recovery Sensitive Care

philosophy within our System of care?

First Level of Education

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Easy to implement (example):

• Pleasure Unwoven: inexpensive DVD outlining historical and modern concepts of calling addiction a disease – staff and patients

Increases discussion on the realities why relapse happens despite honest desire for recovery

Increases understanding of the biological aspect of addiction and why someone may relapse while in treatment

Increase understanding that RSC is part of a disease model of care for a chronic condition

McCauley, Kevin (producer) (2009). Pleasure Unwoven: a personal

journey about addiction. (DVD) Institute for Addiction Study.

Longer implementation process:

• Basic facts on neuroscience and relapse - reinforce the need for behavioral and social recovery supports to achieve desired recovery

• Why do I need 12 step meetings

Behavioral supports will assist when cravings come from a cue induced response you may not be aware of

• Why is MAT a good option for my recovery

While developing the behavioral and social supports for recovery MAT can assist in reducing neurological triggers for relapse which are a biological occurrence.

o Behavioral support will remain important if addiction has been to multiple substances

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Second Level Education

12 step concepts are well established connecting traditional

learning to newer neuroscience concepts may enhance the

buy-in for having RSC in place

• People

Cue induced drug-seeking and or craving

o Visual, audio, multisensory

• Places

Cue induced drug-seeking and or craving

o Visual, audio, olfactory multisensory

• Things

Stress induced drug-seeking and or craving

o Visual, audio, olfactory, multisensory

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Connecting Old and New Concepts for

Staff and Patients

Provider Role

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We often know if a patient is a “frequent flyer” -what do we offer this patient? How do we as providers adjust treatment for the at-risk patient?

• Bill Wilson, co-founder of Alcoholics Anonymous, and

Marty Mann, founder of the National Council on Alcoholism and Drug Dependence, were both treatment recidivists (ten prior treatments between them before finding sobriety).

White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006)

“It’s time to stop kicking people out of treatment. Counselor.

Change is a Process

for Treatment Providers

37

• MAT treatment was once considered to be outside of the

mainstream of addiction treatment- though in recent years

it has gained wider acceptance as Evidence Based

Practice.

• Relapse Sensitive Care may be the Next Change –

keeping those who seek treatment engaged to improve

outcomes.

• BUT what constitutes a desired “Outcome”?

If Negative Urine Drug Screens is

Not the Outcome Measure

then What Is?

Quality of Life

QoL

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Outcomes?

Quality of Life as a Recovery Outcome

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• SAMHSA has established a working definition of recovery that

defines recovery as a process of change through which

individuals improve their health and wellness, live self-

directed lives, and strive to reach their full potential.

Recovery is built on access to evidence-based clinical

treatment and recovery support services for all populations.

SAMHSA's Working Definition of Recovery Pub id: PEP12-RECDEF,

Publication Date: 2/2012, Format: Brochure

SAMHSA’s Working Definition of Recovery — 2012.

Quality of Life as Treatment Outcome

Measures

Psychoactive Drugs, 47:2, 149-157. 40

Mitchell et al (2015)

• Findings were statistically significant (all ps < .001).

Continued treatment enrollment was significantly associated

with improved psychological, environmental and social

aspects 6 months into treatment

Quality of Life

measure (QoL)

Change at six month follow up

during treatment

Overall improvement 10.8% increase

Psychological 7.6% increase

Environmental 8.5% increase

Social 11.2% increase

Mitchell, S.G., Gryczynski, J., Robert P. Schwartz, R.P., Myers, C.P., O’Grady, K.E., Olsen, Y.K.,

& Jaffe, J.H. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with

Treatment Retention and Illicit Opioid Use, Journal of

QoL as treatment outcome measure

41

Dhawan, A., & Chopra, A. (2013)

• Examined QoL scores: Continued treatment enrollment

was associated with significant increases in four Quality of

Life measures at 9 months, including the physical, social,

psychological and environmental QoL domains. (p<.001)

QoL measure Baseline data 9 month follow up

during treatment

Physical 50.3 61.3

Social 45.8 56.2

Psychological 43.6 57.9

Environmental 42.3 54.3

Dhawan, A., & Chopra, A. (2013). Does buprenorphine maintenance improve the quality of life of opioid

users? The Indian Journal of Medical Research, 137(1), 130–135.

QoL and Evidenced Based Practices

42

Outcome data from a Quality of Life measure can be

incorporated into SAMHSA Evidence Based Practices:

• Motivational Interviewing: Reviewing readiness and confidence scales with patients

in context of QoL measures during treatment

• Acceptance and Commitment Therapy:

Focusing on valued direction in life, psychological flexibility –

energies/tasks moving you towards QoL, towards your valued

outcomes

Miller, W. R., and Rollnick, S. (2013) Motivational Interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.

Wilson, K.G. and DuFrene, T. (2012) The wisdom to know the difference an acceptance and commitment therapy workbook for overcoming

substance abuse. Oakland, CA: New Harbinger Publications.

Safety Matters

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• Medical based safety will still need to be considered

especially in MAT. Drug interactions or potential for

accidental OD

Discharging a patient for reason other than medical

safety should be done only after several attempts to

engage them in treatment have been made

o This includes barrier identification to maintaining

recovery

o Naloxone – OD prevention recourses for every

discharge based on medical safety

Safety Matters

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Residential program may consider RSC in context of type of

relapse:

In the community vs. bring drugs/alcohol into the

program

o Returning to the program under the influence is a

symptom and not the equivalent to bringing

drugs/alcohol into the program

• An assault is a legal issue and constitutes a choice to

end treatment

Summary

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Relapse Sensitive Care:

• Supported by Disease Model

• Supported by Neuroscience which provides evidence on

biological reasons for relapse

Treatment engagement, not punitive measures for

return of biological-based symptoms

• Supports the SAMHSA definition of recovery which

includes, health, wellness, and self determination

• Supports Quality of Life as an outcome rather than solely

on negative urine drug screens

Summary

46

Relapse Sensitive Care Implementation:

• Assessment of current policies and procedures

• Current recovery support resources

Internal and external

• Education

Patients and Staff

• Incorporating Quality of Life as on outcome measure

• QoL patient data incorporated into EBPs

References

47

Bossert et al, (2013) The reinstatement model of drug relapse: recent recent neurobiological findings,

emerging research topics transitional research. Pharmacology 229: 453-476.

Dhawan, A., & Chopra, A. (2013). Does buprenorphine maintenance improve the quality of life of opioid

users? The Indian Journal of Medical Research, 137(1), 130–135.

FDA/Center for Drug Evaluation and Research Office of Communications Division of Online

Communications Update Frequency: Daily

www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Search_Drug_Name

Jasinska A.J., Stein E.A., ,Kaiser J., ,Naumer M.J., Yalachkov Y. (2014). Factors modulating neural

reactivity to drug cues in addiction: A survey of human neuroimaging studies. NeurosciBiobehavRev 38:1–

16.

Kaplan, L., The Role of Recovery Support Services in Recovery-Oriented Systems of Care. DHHS

Publication No. (SMA) 08-4315. Rockville, MD: Center for Substance Abuse Services, Substance Abuse

and Mental Health Services Administration, 2008.

McCauley, Kevin (producer) (2009). Pleasure Unwoven: a personal journey about addiction. (DVD) Institute

for Addiction Study.

References

48

Miller, W. R., and Rollnick, S. (2013) Motivational Interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.

Mitchell, S.G., Gryczynski, J., Robert P. Schwartz, R.P., Myers, C.P., O’Grady, K.E., Olsen, Y.K., & Jaffe, J.H. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use, Journal of Psychoactive Drugs, 47:2, 149-157.

SAMHSA's Working Definition of Recovery Pub id: PEP12-RECDEF, Publication Date: 2/2012, Format: Brochure SAMHSA’s Working Definition of Recovery — 2012.

Self, D. W.; Nestler, E. J. (1998) Relapse to drug-seeking: neural and molecular mechanisms. Drug and alcohol dependence 51: 49-60.

Shannon Gwin Mitchell Ph.D., Jan Gryczynski Ph.D., Robert P. Schwartz M.D., C. Patrick Myers M.A., Kevin E. O’Grady Ph.D., Yngvild K. Olsen M.D. & Jerome H. Jaffe M.D. (2015) Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use, Journal of Psychoactive Drugs, 47:2, 149-157.

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.

References

49

Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2011. Discharges from Substance Abuse Treatment Services. BHSIS Series S-70, HHS Publication No. (SMA) 14-4846. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Wallace, A.E. & Weeks, W.B. (2004). Substance abuse intensive outpatient treatment: Does program graduation matter? Journal of Substance Abuse Treatment, 27, 27-30.

White, W.L., Scott, C. K., Dennis, M. L., and Boyle, M. G. (April 2006) It’s time to stop kicking people out of treatment. Counselor.

White, W. (1998) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington IL: Chestnut Health Systems.

Wilson, K.G. and DuFrene, T. (2012) The wisdom to know the difference an acceptance and commitment therapy workbook for overcoming substance abuse. Oakland, CA: New Harbinger Publications.

PCSS-MAT Mentoring Program

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• PCSS-MAT Mentor Program is designed to offer general information to

clinicians about evidence-based clinical practices in prescribing

medications for opioid addiction.

• PCSS-MAT Mentors comprise a national network of trained providers with

expertise in medication-assisted treatment, addictions and clinical

education.

• Our 3-tiered mentoring approach allows every mentor/mentee relationship

to be unique and catered to the specific needs of both parties.

• The mentoring program is available, at no cost to providers.

For more information on requesting or becoming a mentor visit:

pcssmat.org/mentoring

PCSS-MAT Listserv

Have a clinical question? Please click the box below!

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Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for

Medication Assisted Treatment (5U79TI024697) from SAMHSA. The views expressed in written

conference materials or publications and by speakers and moderators do not necessarily reflect the

official policies of the Department of Health and Human Services; nor does mention of trade names,

commercial practices, or organizations imply endorsement by the U.S. Government.

PCSSMAT is a collaborative effort led by American Academy

of Addiction Psychiatry (AAAP) in partnership with: American

Osteopathic Academy of Addiction Medicine (AOAAM),

American Psychiatric Association (APA), American Society of

Addiction Medicine (ASAM) and Association for Medical

Education and Research in Substance Abuse (AMERSA).

For More Information: www.pcssmat.org

Twitter: @PCSSProjects

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