Research Science on Substance Use Disorders:Integrated Collaborative Care,

Improved Treatment, Better Outcomes, Increased

Client Experience of Care

Mark Stanford, Ph.D. Division Director, Addiction Medicine & Therapy Services

SCVMC Dept of Alcohol & Drug Services

In just the last 15 years,

advances in science

have revolutionized our

fundamental views of

substance use disorders

and allowed for the

development of

improved treatments!

control Methamphetamine use

control methamphetamine addicted brain

Research shows that . . .

Prolonged Drug Use Changes

the Brain

in Fundamental and Lasting

Ways

And there is scientific evidence that these changes can be

both structural and functional.

Diagnosing Addiction

• Diagnosing Addiction: The 4 “C’s”

– C = Control

– C = Compulsion

– C = Continued use despite consequences

– C = Craving

Koob, G. Scripps. 2014

Risk Factors for SUD

• Biological: Genetics account for 50-75%

• Psychological: Mental illness, temperament

• Ecological: Social networks, employment

status, access

Lembke A, et al. Stanford. 2014. Ling W, et al. UCLA 2012.

Biology/genes

Environment

Biology/

Environment

Interactions

IFH + high tolerance = 60%

IFH + low tolerance = 15%Schuckit M. UCSD. 2002.

We know there’s a genetic contribution to addiction…

overlapping with environmental influences that help

make addiction a complex disease.

Control Addicted

Cocaine

Alcohol

DA

DA

DA DADA

DA

Reward Circuits

DADA DA

DA

DA

Reward Circuits

DA

DA

DA

DA DA

DA

Drug Abuser

Non-Drug Abuser

Heroin

Meth

Dopamine D2 Receptors are Lower in Addiction

DA

The typical drug addict/alcoholic?

Rethinking the “drug abuser”

Persons with SUDs are not a homogenous group of people who use/drink in excess

• More accurately called Substance Use Disorders (SUD),

it describes use along a continuum of severity from mild

misuse, to problem use, to chronic relapsing conditions.

• The most severe form of SUD is a chronic and relapsing

condition much like diabetes, hypertension and asthma.

Treatment success and relapse rates for SUD mirror those

other chronic disorders

• The most severe form of SUD is a primary disease and

not the result of other emotional or psychiatric problems.

How is “addiction” defined after 30 years

of robust scientific study?

American Society of Addiction Medicine,

2011.

The National Institute of Drug Abuse (NIDA), National Institute of

Alcohol Abuse and Addiction (NIAAA), and the Institute of Medicine

(IOM) have each articulated explicit evidence-based standards for

effective SUD treatment services.

The cornerstones of these guidelines are:

Addiction is a chronic disease

Addiction is treatable

Addiction treatment must be on-going and continuous

No single treatment is effective for all individuals

Co-occurring medical and psychiatric conditions must

be addressed

California Society of Addiction Medicine. 2011

The National Quality Forum

The National Quality Forum (NQF), dedicated to

improving the quality of health care in the United States,

has identified and endorsed 8 evidence-based standards of

care for the treatment of substance use disorders:

1. Screening & case finding 5. Withdrawal management

2. Diagnosis & assessment 6. Psychosocial interventions

3. Brief intervention 7. Pharmacotherapy

(methadone, buprenorphine,

naltrexone, acamprosate, etc.)

4. Promoting engagement in 8. Continuing care management

treatment

What Are Evidence-Based Practices?

Institute of Medicine (2001):

Evidence-based practices

“. . . Evidence is comprised of research findings

derived from the systematic collection of data

through observation and experiment and the

formulation of questions and testing of

hypotheses" (www.ebbp.org).

Criteria for EBP Designation for SUD Practices

• The results of the research have been published in a peer-

reviewed journal or documented in a comprehensive evaluation

report

• Sufficient documentation exists in the form of manuals, training

materials, etc. to facilitate dissemination of the approach

• Meets a minimum statistical parameter that determines efficacy

over placebo, treatment as usual, or no treatment at all

• The approach has demonstrated positive outcomes (p < 0.05) in

>1 studies

National Registry of Evidence Based Programs and Practices (NREPP). 2014.

What are the most important evidence-based practices?

Behavioral

• Motivational Interviewing/Brief Intervention

• Contingency Management

• Cognitive-Behavioral Coping Skills Training

• Couples and Family Counseling

• 12 Step Facilitation Therapy (12 step meetings can be important

peer recovery support but themselves are not tx)

• Screening, Brief Intervention and Referral to Treatment (SBIRT )

Addiction Medicines (coupled with behavioral treatment)

• Methadone

• Buprenorphine (Subutex and Suboxone)

• Naltrexone (oral and extended release, i.e. Vivitrol)

• Naloxone (for overdose prevention)

• Campral (acamprosate)

• Antabuse (disulfiram)

40-60%

Compulsive

illicit drug useCriminal

activity

Unemployment

From decades of

outcomes data, we know

that

SUD treatment works!

40-60% 60%

NIDA. 2006.

How do treatment outcomes compare?

McLellan et al., JAMA, 2000

Chronic Illness Relapse Rates(after diagnosis, treatment and stabilization)

SCVMC

Dept of Alcohol & Drug Services

MISSION STATEMENT

To develop and operate a seamless Continuum of Care for

the prevention and treatment of substance abuse problems

in the community that is appropriate for the diverse

populations of the County and that is accountable for its

services

Director Research

& Evaluation

Children, Family &

Community Services

Fiscal &

AdministrationPrevention and

Treatment Services

Addiction Medicine Psychosocial Treatment

Quality Improvement

& Data Support

--Gateway

--Outpatient

--Residential

--Clinical Standards

--Case Management

--Justice Services

--Medication-assisted treatment

--Medical Services

--Psychiatric Services

--HIV Intervention Program

--Integrated Services Initiatives

--Medical Homes

--Women’s/Perinatal

--THU

--CoCentrix EHR

--Data Analysis

--CalOMS

--Care Coordination/UM

Medical Director

-- Budget

-- Contracts

-- Personnel

-- Administrative Support

-- Prevention Services

-- School-linked Services

-- Learning Institute

-- Adolescent Treatment

Medication-assisted

Treatment

Integrated Care

Partnerships

ADULT SYSTEM OF CARE: DADS management staff. Reviews the

operational aspects of the adult managed system of care.

INNOVATIVE PARTNERSHIP (IP): A collaborative between DADS

and the community-based agencies. Monitors the continuous quality

improvement of the managed system of care.

CLINICAL SUPERVISORS: Consists of the clinical supervisor staff

from both DADS and the community-based agencies. The focus is on reviewing

and making recommendations to EG on the clinical performance aspects of the

system of care.

COMMITTEES: There are various on-going and ad hoc committees that are

task-specific. Review specific issues related to the system of care and develop

recommendations to EG. Committees include Compliance, Forms, Contracts,

Quality Improvement, Performance Measures and others.

DADS Leadership and Management Structure

DADS has also developed and implemented several innovative

promising practices including:

1. Client-Directed Outcome-Informed therapy (CDOI)

2. Continuous Recovery Monitoring (CRM)

3. Expansion of medication-assisted recovery

4. Consult service for mental health and primary care providers in

Addiction Medicine

5. Screening, Brief Intervention and Referral to Treatment

(SBIRT) for primary and specialty care

6. Training the network of providers in Trauma Informed Care and

NiaTX.

DADS Innovative and Promising Practices

DADS manages a coordinated System of Care for the

delivery of services and ensures that the client is in the

right level of care at the right time.

Determining the Level of Care and client placement is, in part,

obtained by using the American Society of Addiction Medicine -

Patient Placement Criteria (ASAM PPC 2-R)

Adult System of Care

Managed Care without the Negatives

• One System, single entry point, levels of care

• Standardized procedures, processes, forms

• All speaking the same language: assessment

dimensions, severity ratings, level of care

• Integrated service delivery

• “Managing” care: paying attention, monitoring and

evaluating provider performance and client outcomes

• Continuous Quality Improvement

SANTA CLARA VALLEY HEALTH & HOSPITAL SYSTEM

Department of Alcohol & Drug Services (DADS)

A Managed Coordinated System of Care

INDIVIDUAL

Detoxification Residential Treatment

Outpatient Treatment:

Addiction Medicine

Psychosocial Outpatient,

Perinatal Services

Transitional Housing

Ancillary Services:

• Psych Services

• Transitional HousingGateway Services:

• Screening & Referral

• Prevention Referral

GATEWAY

1-800-488-9919

Adult System of Care Themes

• Using limited resources wisely

• Matching intensity of service to severity of illness

(one size does not fit all)

• Just the right dose, at the right time, in the right

setting, for each individual client

• Client-driven, not program-driven, treatment

• Individualized, focused treatment

• Partnering with other Systems: Criminal Justice,

Department of Corrections, Social Services, Child

Welfare, Mental Health, Primary Care and VMC

Levels of Care

– Social Model Detox

– Residential

– Psychosocial Outpatient

– Addiction Medicine & Therapy Program including Integrated Medical Services

– Perinatal Outpatient & Women’s Treatment

– Transitional Housing Units

System of Care

Treatment Services

System of Care

Ancillary Services

• Psychiatric Evaluation & Medication

Consultations

• Transitional Housing

Confidentiality and

Privacy Rights

42 CFR Compliant

Competency Training and

Continuing Education

DADS places an emphasis on training and

continuing education

1. The Learning Partnership

2. Required Trainings: Safety, Confidentiality, Compliance,

Dual Relationships, Law and Ethics, Infectious/Contagious

Diseases, Best Practices, Trauma Informed Treatment,

Medication-Assisted Recovery

Also, visit the DADS web page at:

www.sccdads.org

For more information about integrating Primary Care and

Behavioral Health, visit:

SAMHSA – HRSA: Center for Integrated Health Solutions

http://www.integration.samhsa.gov/