Substance Abuse Treatment by Lc7NC17

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									Substance Abuse Services
 Integration of Care Committee
         June 22, 2010

                Nina Rothschild, DrPH
                  Terri Wilder, MSW
              Marybec Griffin-Tomas, MA

            HIV Planning Council of New York
         Care, Treatment, and Housing Program
       Bureau of HIV/AIDS Prevention and Control
  New York City Department of Health and Mental Hygiene


                                                          1
                     Overview
► Background
► Definition of US Health Resources and Services
  Administration (HRSA) Service Categories
► Definition of the NY EMA Service Category
► Strengths and Challenges of the NY EMA Model
► HRR Contracts and Clients Served
► Literature Review
► Best Practices
► Service Model Recommendations from Needs Assessment
  Committee
► DOHMH Recommendations



                                                        2
                 Background

   preparation for the re-bid process, CTHP
► In
 has reviewed:
   Epidemiologic data
   Data from existing substance abuse treatment
    contracts
   Evidence-based practices for provision of
    substance abuse services
   Current HRSA guidance on substance abuse
    services
                                                   3
                               Epidemiologic Data
►   Of newly diagnosed cases of HIV in 2006 (N=4,030),
    reported to NYC HARS as of September 30, 2009:
      Total substance users=1,109 (27.5%)
      Substance use includes:
            ► Heroin,  crack/cocaine, methadone, methamphetamine, or
              other/unspecified substance abuse; and persons with a history of
              injection drug use
            ► Alcohol use (any)
            ► Marijuana use (any)

            ► *Alcohol   and marijuana use do not have measures for frequency or
               intensity of use. ANY use of these substances results in this
               classification.
►   Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented to Integration of Care
    Committee meeting, January 28, 2010




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                      Non-Substance Users
                      Compared with Others
► Compared              with non-substance users…
      Substance users overall: more likely to be male and
       Hispanic
      Hard substance users: more likely to be male, Hispanic,
       in their 40s or 50s, and Bronx residents, and less likely
       to start care within three months of diagnosis
      Alcohol users: more likely to be male, Hispanic, and in
       their 50s, and less likely to be Brooklyn residents

►   Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented to
    Integration of Care Committee meeting, January 28, 2010




                                                                                               5
                                HRSA Definition:
       Outpatient Substance Abuse Treatment
► Core  service
► Provision of medical or other treatment
  and/or counseling to address substance
  abuse problems (i.e., alcohol and/or legal
  and illegal drugs)
► Outpatient setting by a physician or under
  the supervision of a physician, or by other
  qualified personnel.
►   Source: HRSA Guidance 8/14/09



                                                   6
                            HRSA Definition:
       Residential Substance Abuse Treatment
► Non-core
► Provision of treatment to address substance abuse
  problems (including alcohol and/or legal and illegal
  drugs) in a residential health service setting (short
  term)
► May not be used for inpatient detoxification in a
  hospital setting UNLESS detoxification is offered in
  a separate licensed residential setting within the
  walls of a hospital.
►   HRSA Guidance 8/14/09



                                                      7
             HRSA 2010 Clarification of
       Outpatient Substance Abuse Treatment
►   Services should be limited to:
      Pre-treatment/recovery readiness programs
      Harm reduction
      Mental health counseling to reduce depression, anxiety and other
       disorders associated with substance abuse
      Outpatient drug-free treatment and counseling
      Opiate assisted therapy
      Neuro-psychiatric pharmaceuticals
      Relapse prevention
      Acupuncture therapy provided by a certified or licensed practitioner
       and/or program is allowed in substance abuse programs
►   Source: HRSA Guidance 4/8/10




                                                                          8
             NY EMA Definition
 Harm Reduction, Recovery Readiness, and Relapse
         Prevention Services (HR/RR/RP)


► Easily accessible harm reduction, recovery
  readiness, and relapse prevention services
  to individuals who are HIV-positive and
  actively using drugs, relapsing, or in
  recovery.


                                                   9
                                  NY EMA Definition
Harm Reduction, Recovery Readiness, and Relapse
        Prevention Services (HR/RR/RP)
►   Service elements include:
       Rapid HIV testing
       Linkage to HIV primary care*
       Outreach in SRO hotels
       Individual, family or group harm reduction counseling
       Assessment and referral for diagnosis and treatment of sexually
        transmitted infections
       Screening and referral for substance use treatment
       Training and provision for overdose prevention with Narcan
       Individual, family, or group low threshold AOD services
       Buprenorphine treatment
    *Encouraged but not reimbursed. All other services are reimbursed. The EMA is working to
    add confirmatory testing and linkage to care for the newly diagnosed to the model of reimbursed
    services in August/September 2010.




                                                                                                      10
           NY EMA: Service Families

►   The NY EMA HRR service category has
    four service families:
     1.   Rapid HIV Testing
     2.   Medical Services
     3.   AOD Services
     4.   Low Threshold AOD Services
►   Each service family has one or more
    service types

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      Service Family: Rapid Testing

► Service   Type and Description:
   Rapid HIV testing includes the provision of pre-
    and post-test counseling, completion of consent
    and Provider Report Forms (PRF), provision of
    or referrals to confirmatory testing, in
    accordance with state regulations.




                                                   12
     Service Family: Medical Services

► Service    Type and Description:
   Medical Outreach in SROs
     ► Making contact with SRO residents to encourage, promote and
       support utilization of and decrease barriers to medical care,
       substance use treatment options and harm reduction services.
   Buprenorphine Initial Visit
     ► The  induction phase of buprenorphine treatment, including
       prescribing and administering dose as well as conducting in-
       office observation for up to two hours.
   Buprenorphine Routine Visit
     ► Follow-up   visits to assess clients and adjust dosage through the
       stabilization and maintenance phases of buprenorphine
       treatment.

                                                                        13
     Service Family: AOD Services (1)

► Service   Type and Description:
   Family Counseling
     ► Counseling  and education provided to a family unit regarding
       substance use, abuse and harm reduction. Includes sexual risk
       reduction, IDU risk reduction, HIV and/or Hepatitis C secondary
       prevention, medical treatment plan adherence.
   Group Counseling
     ► Group counseling and education session conducted with a
       group of at least three Ryan White clients on the same range of
       subjects as in Family Counseling - AOD
   Individual Counseling
     ► Individual counseling and education conducted with an
       individual client on same range of subjects as in Family
       Counseling - AOD

                                                                     14
    Service Family: AOD Services (2)

► Service   Type and Description:
   Assessment for STI
     ►Assessment  of client’s risk for STIs and (if
      appropriate) referral to screening and treatment
      programs




                                                         15
     Service Family: AOD Services (3)

► Service   Type and Description:
   Overdose Prevention Training – Group
     ► Overdose  prevention education and training, including risk
       reduction, assessment, response, and reversal, and prescribing
       and dispensing Narcan conducted with a group of at least three
       Ryan White clients
   Overdose Prevention Training – Individual
     ► One-on-one  overdose prevention education, otherwise identical
       to Overdose Prevention Training - Group
   Substance Use Assessment
     ► Screening and (if appropriate) referral for substance use
       treatment for syringe exchange, ESAP, buprenorphine,
       methadone, detox, peer community support

                                                                    16
               Service Family:
        Low Threshold AOD Services (1)
►   Service Type and Description:
     Low Threshold AOD Services – Family
        ► Services   provided to a family unit (the client plus at least one other
          family member or significant other) to encourage testing and
          enrollment into primary care. Some examples are stress reduction,
          supportive counseling, activities of daily living kits, and drop-in
          activities
     Low Threshold AOD Services – Group
        ► Conducted  with a group of at least three Ryan White participants.
          Otherwise identical to Low Threshold AOD Services - Family
     Low Threshold AOD Services – Individual
        ► Conducted  with an individual client (or a family member within the first
          90 days of the family member’s enrollment). Otherwise identical to
          Low Threshold AOD Services - Family


                                                                                     17
            Service Family:
     Low Threshold AOD Services (2)
► Service   Type and Description
   Low Threshold Assessment and Referral for STI
     ►Assessment  of client’s risk for STIs and (if
      appropriate) referral to screening and treatment
      programs
   Low-Threshold Screening and Referral for
    Substance Use Treatment
     ►Screening and (if appropriate) referral for substance
      use treatment for syringe exchange, ESAP,
      buprenorphine, methadone, detox, peer community
      support

                                                              18
               Service Family:
        Low Threshold AOD Services (3)
►   Low threshold services are the AOD/HR services available
    to individuals who may not know their HIV status to
    encourage testing and enrollment into primary care.
►   These services “meet the clients where they’re at” and
    include counseling and education related to HR, stress
    reduction, ADL counseling, provision of hygiene kits, etc.
►   Although low threshold services are primarily accessed by
    HIV status unknown clients, some programs allow HIV+
    clients to access them.



                                                                 19
            Service Family:
     Low Threshold AOD Services (4)
► HIV  status unknown clients may only access low
  threshold AOD services for a maximum of 90 days.
► Low threshold AOD services for HIV status
  unknown clients are primarily used to help with
  substance use issues, promote safer sex practices,
  and engage the client in HIV testing services.
► After 90 days, if a client still has not been tested
  or has tested negative, he or she must be referred
  to another program as he/she is no longer eligible
  to receive RW funded services.
► Clients who test HIV positive are then eligible for
  the entire spectrum of RW services.
                                                     20
              Service Family:
       Low Threshold AOD Services (5)
► HIV positive clients may access any service offered by the
  HRR agency (both low threshold AOD and AOD services).
► Low threshold services are sometimes designed to engage
  new HIV positive clients in services (i.e., talking about risk
  reduction, decision making skills, etc.) or to support HIV
  positive clients who have been enrolled in HRR services for
  a longer time and are stabilized and in the process of
  transitioning out of HRR services (i.e., they have
  ‘graduated’ or no longer need the services).
► AOD services are designed to help HIV positive clients
  manage their HIV diagnosis, reduce their substance use,
  and/or reduce risk behaviors.


                                                               21
         Strengths of the HRR Model

► Provides   counseling in a variety of settings
  and methods (individual, group, family)
► Flexibility of the ‘sobriety requirement’
   Clients do not have to be completely abstinent
► Few   payer of last resort issues




                                                     22
           Challenges of the HRR Model

►   Counseling services are misunderstood and underutilized
     Almost no agencies serve eligible entities such as client families
►   Retaining clients is challenging due to transient and often
    chaotic nature of the population
►   Focus is on services for opiate users
     Does not include similar interventions for more prevalent crack,
      cocaine, crystal meth, and alcohol users
►   Maintaining staff with prescribing privileges (MDs, NPs,
    PAs) is expensive
►   Low threshold AOD services for clients with unknown HIV
    status


                                                                           23
        HRR Service Contracts in FY 2009

►   Planning Council ranked HRR as Priority #4
►   HRSA Service Category: Core
►   Approximately 11% of the total RW budget is allocated to
    HRR
     Service category allocation: $11,232,026
     Modified spending plan: $10,993,517
►   The HRR program funds 26 programs in NYC
     Projected units of service: 93,059
     Actual units of service: 94,105
►   The portfolio was newly re-bid in 2007
     The HRR service category has been part of the NYC EMA RW Part A
      portfolio since at least 1994
    Source: Service Category Scorecards 6/15/10

                                                                    24
              HRR Clients Served in FY 2009
                20,409 Clients Received Services in FY 2009
►   HIV Status
      18% HIV+ (non-AIDS), 8% CDC-defined AIDS, 54% HIV-, 18% Unknown
       Status/Pending, 11% Family Member/Significant Other
►   Gender
      43% Female, 59% Male, 1% Transgender
►   Race and Ethnicity
      52% Black, 35% Hispanic, 7% White, 1% Asian/Pacific Islander, 3%
       Other/Unknown
►   Age
      3% 0-19 Years of Age, 19% are 20-29 Years of Age, 19% are 30-39 Years of Age,
       31% are 40-49 Years of Age, 28% Ages 50+
►   Special Populations
      1% Young MSM of Color, 12% LGBT, 37% Women of Color, 2% Immigrants

      Source: Service Category Scorecards 6/15/19
    *=Among the total clients served in FY 2009, 54% were HIV-negative. However, these clients cycle through every 90
    days and often leave care. HIV+ clients, by contrast, remain in care. Although the number of HIV-clients is high,
    they filter through the programs more rapidly.




                                                                                                                   25
  2009 Consumer Focus Group Results

          to the report from the 2009
► According
 consumer focus groups in the New York
 EMA:
   Substance use is an important issue.
   Substance abuse treatment assisted entry into
    and engagement in HIV treatment.
   Services are useful and easily accessible.


                                                    26
                                  Literature Review
►   Harm reduction psychotherapy (HRP) is based on the
    principle that individuals can become healthier even when
    they are still consuming drugs.
►   HRP does not penalize individuals for their choices about
    drug use but instead supports them in an open discussion.
►   HRP employs Stages of Change and Motivational
    Interviewing and focuses on diminishing resistance and
    traversing stumbling blocks.


Source: P. Denning, “Harm Reduction Psychotherapy: An Innovative Alternative to Classical Addictions Theory”
American Clinical Laboratory May 2002: 16-18.




                                                                                                               27
                          Literature Review
► Benefits         of harm reduction:
      Diminish the damage of illegal drug use on families,
       neighborhoods, and society
      Decrease deaths from overdoses
      Diminish the number of new cases of infections such
       as HIV and hepatitis
      Lessen drug-connected injuries and trips to EDs
      Enhance the number of individuals who are able to
       obtain treatment
      Lower the number of disturbances to family life from
       imprisonment, child abuse and mistreatment, and
       domestic fighting
Source: “Harm Reduction” in The New York Academy of Medicine


                                                               28
                      Literature Review

►Harm           reduction techniques:
     Syringe exchange*
     Preventing death from overdose with
      Narcan provision
     Fostering access to physical and
      mental health care for drug users
Source: “Harm Reduction” in The New York Academy of Medicine

*The EMA does not currently fund syringe exchange and is waiting to hear from
   HRSA whether Ryan White dollars can be used for syringe exchange programs.

                                                                           29
                            Literature Review
►   Engaging in alcohol and illegal drug use can increase the
    likelihood of risky behaviors and HIV transmission and may
    complicate adherence.

►   Addressing drug dependency with the help of
    pharmacological treatment is key. Medications for
    addressing substance use problems include:
      Opioid dependence: methadone, buprenorphine, naltrexone
      Alcohol dependence: naltrexone, acamprosate, disulfiram
      Other drugs: the FDA has not endorsed any medications to treat
       usage of other illegal drugs, including cocaine, methamphetamine,
       cannabis, or sedative/hypnotics.

    Source: RD Bruce, TF Kresina, EF McCance-Katz, “Medication-Assisted Treatment and HIV/AIDS:
    Aspects in Treating HIV-Infected Drug Users” in AIDS 2010, Vol. 24.

                                                                                                  30
                                Literature Review

         Treatment for substance abuse, mental health, and primary care
          are best incorporated and managed together
         Client retention and engagement in treatment is crucial
         Fostering a therapeutic partnership is key for long-term mental
          health and recovery goals
         Incorporation of vocational rehabilitation and general
          enhancement of functioning support lasting sobriety
         Continuing education is key for professional staff
         Treatment should incorporate motivational interviewing, group
          and individual psychodynamic and cognitive-behavioral
          approaches



Source: R Futterman, M Lorente, SW Silverman, “Beyond Harm Reduction: A New Model of
Substance Abuse Treatment Further Integrating Psychological Techniques,” Journal of
Psychotherapy Integration, Vol. 15, No. 1, pp. 3-18.                                   31
                         Literature Review
►   Outreach approaches to HIV-infected substance users
    include:
      Use of peer advocates to engage and retain clients in care
      Actively involving recent releasees from jail/prison and linking them
       with services
      Offering services via mobile units
      Drop-in facilities
      Transitional housing for people who are using drugs but also
       participating in harm reduction focused groups
Source: C. Tobias, S. Wood, M-L Drainoni, “Ryan White Title I Survey: Services for
HIV-positive Substance Users” in AIDS Patient Care, Vol. 20, No. 1, 2006, pp. 58-67.




                                                                                       32
                        Literature Review

► Ina population of triply-diagnosed patients
  (mental illness, substance use, HIV infection):
    45% of patients taking ARVs stated that they missed
     medications in previous three days
    Issues connected with non-adherence included:
        ► Abuse  of drugs and alcohol at the present time
        ► Heightened emotional distress
        ► Poorer compliance with medical appointments
        ► Not taking psychiatric medications
        ► Lower spirituality (self-report)

  Source: CA Mellins, JF Havens, C McDonnell et al., “Adherence to Antiretroviral
  Medications and Medical Care in HIV-Infected Adults Diagnosed with Mental and
  Substance Abuse Disorders” in AIDS Care, Vol. 21, No. 2, 2009, pp. 168-177.


                                                                                    33
                Best Practices for Screening

► All  infectious disease clinics/providers,
    should be screening for STDs and substance
    abuse with HIV-infected persons. Those in
    need of services should be referred to
    substance abuse programs.

►   *Seth Kalichman, June 1, 2010




                                               34
                               Screening

► Alcohol screening and treatment is largely
  forgotten but very important when treating
  HIV-infected individuals, especially
  individuals who are co-infected with HCV
► No single tool is consistently used for
  alcohol screening, but most providers use
  the AUDIT (or AUDIT-C)* or CAGE or a
  combination of them
►   *Alcohol Use Disorders Identification Test

                                                 35
                                             Screening
►   Recommended: Use the AUDIT-C followed by a brief intervention
    modeled after WHO motivational interviewing (MI) protocol. Focus of
    brief intervention is to use MI to determine client’s motivation and
    readiness for harm reduction, outpatient substance abuse treatment,
    or inpatient substance abuse treatment

►   The Drinker’s Pyramid is a good tool to translate AUDIT findings into
    clinical practice.

►   The Drug Abuse Screening Test (DAST-10) is a valid and reliable
    instrument that can be used in conjunction with the AUDIT-C.
►   Strauss SM, Rindskopf DM, “Screening Patients in Busy Hospital-based HIV Care Centers for Hazardous and Harmful
    Drinking Patterns: The Identification of an Optimal Screening Tool” in Journal of the International Association of
    Physicians in AIDS Care, Vol.8, No. 6, 2009, pp. 347-353.
►   Conversation with Seth Kalichman, PhD, June 1, 2010




                                                                                                                         36
                          Best Practices for
                         Care and Treatment
► Coordinated   systems needed for HIV care
    and treatment. “One-stop shop” model
    works best because clients who are
    dependent on drugs and/or alcohol will not
    make multiple visits to multiple providers.*

►   *Seth Kalichman, June 1, 2010




                                                   37
      Needs Assessment Committee
    Service Model Recommendations (1)

► Drug  and alcohol, mental health, and
  medical services should be co-located in
  order to provide one-stop shopping.
► Clients receiving AOD services should be
  systematically and formally screened for
  mental health needs using a standardized
  screening tool.


                                             38
     Needs Assessment Committee
    Service Model Recommendations (2)

► Programs should be required to have a
 working relationship with clients’ case
 managers to ensure the coordination of all
 medical and support services needed for the
 treatment of addiction.




                                           39
    Needs Assessment Committee Service
        Model Recommendations (3)
►   Services should include risk/harm reduction (behavior
    change) and risk/removal approaches (medication-assisted
    treatment such as Buprenorphine/Methadone for opioid
    dependence, Modafinil and Bupropion for
    methamphetamine addiction) and psychosocial therapies
    provided by mental health and/or behavioral therapists to
    address AOD behavioral change and other mental health
    issues such as depression.
►   Harm reduction programs should use low threshold models
    such as street outreach and peer workers supervised by a
    trained professional staff member.
►   Programs can fund smoking cessation but need to be
    mindful that Ryan White is the payer of last resort.

                                                            40
      Needs Assessment Committee
     Service Model Recommendations (4)
► Toolsto screen for and assess levels of
 alcohol and drug use respectively should be
 systematically employed (e.g., every six
 months) with all clients.




                                               41
        Needs Assessment Committee
      Service Model Recommendations (5)
► Programs that provide outreach to individuals at risk for
  problematic alcohol and drug use should include a focus on
  youth.
► Programs providing services to youth should be able to
  demonstrate cultural and linguistic competence,
  particularly in the area of sexual orientation, and have a
  history of successfully working with the target population.
► Programs treating homeless adolescents for substance use
  should include a drop-in center for daytime and for nights.
  The safety of places offering youth a place to stay
  overnight should be carefully investigated to ensure that
  youth will not be endangered or exploited.
► Peer-to-peer outreach is a particularly useful technique
  with youth populations.
                                                            42
     Needs Assessment Committee
     Service Model Recommendations (6)
► While the EMA awaits word from HRSA
 about funding for syringe exchange
 programs (SEPs), injection drug using
 clients can be referred to non-Ryan White-
 funded syringe exchange programs.




                                              43
Thank You!




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