SUD Module C:

1. SUD Module C: Care Management

2. or……. How to not cure anyone& still accomplish something & go home happy

3. What is the problem? Big News Flash!!! • Current models of addiction treatment do not result in complete and permanent remission of symptoms 100% of the time.

4. If we already know this, then what is the problem? • Initial models of addiction treatment emphasized the need for total and permanent abstinence (i.e., permanent remission, cure) • Anything less was a failure (dichotomous outcome criteria)

5. What is the problem? • Addiction treatment developed separated from medical and psychiatric treatment • Psychiatry in particular was excluded • Any treatment outside of specialized units was considered inadequate or worse (enabling)

6. Barriers to providing care for chronic addiction • Programmatic dogmatism and idealism • Lack of understanding among policymakers, society, and MCOs • Political and regulatory climate

7. Barriers to providing care for chronic addiction • Lack of training in addiction treatment • Lack of models for care management • Goal setting and treatment planning

8. Double Double Bind Bind • Clients have severe problems • Programs don’t work, won’t accept clients, or clients won’t go • If clinicians act, they are accused of enabling, or doing too much w/o results • If clinicians do not act, they are accused of neglect, doing too little

9. So we needed a new model...

10. A model that: • Accepts chronicity • Recognizes limits of treatment methods • Is palliative (non-curative) in nature

11. A model that: • Stresses long term management (years to decades) • Treats addiction like other chronic diseases such as bipolar disorder or diabetes

12. CMCA CMCA That new model is... Care Management For Chronic Addiction

13. Application of CMCA CMCA M. Willenbring, MD

14. Does patient agree to referral or is it mandated? [I] Y Refer to specialty care with attention to engagement barriers [J] N Go to Module C Go to Module R Care Management Rehabilitation From Module A

15. Can treatment plan be implemented in primary care? [E] Y N Is rehabilitation acceptable to the patient? [E] Go to Module C N From Module R

16. Care Management Indications • Moderate to extreme severity • Unwilling to commit to change • Unable to participate in rehabilitation • Poor response to multiple attempts at rehabilitation • Willing to engage in therapeutic relationship

17. Use & Problems None Moderate Continuum of Care for Addictions Severe Extreme Care Mgmt. Rehabilitation 2º Prevention Modality 1º Prevention

18. CMCA CMCA CMCA Goals • Engagement • Coordination of care • Reduce suffering • Treat complications • Improve motivation to change

19. CMCA CMCA CMCA Goals • Induce remission when possible • Prevent/limit relapse • Slow rate of deterioration • Reduce use of expensive, ineffective services

20. Episodic care only • Crisis intervention • Case management • Continue attempts to engage • Involuntary treatment when indicated • Asset management when indicated Patient in need of care management [A] Is care management acceptable to the patient? [B] N Provide episodic attention to substance use Reassess periodically [I]

21. Is care management acceptable to the patient? [B] Y Implement/continue care management plan in specialty care or primary care [See side bar] [C]

22. CMCA CMCA CMCA Principles • Supportive, engaging approach • Document substance use systematically at each visit • Document substance use: • Drinking or using days last 30 • Typical # drinks/drinking day • Max # drinks/24 hrs last 30 • Bingeing

23. Implement/continue care management plan in specialty care or primary care [See side bar] [C] • Monitor substance use • Monitor biological indicators • Encourage reduction or abstinence • Provide motivational support • Educate about substance use and associated problems • Recommend self help groups

24. Implement/continue care management plan in specialty care or primary care [See side bar] [C] • Address social functioning needs • Address financial and housing needs • Address nicotine use as appropriate • Provide opioid agonist therapy if appropriate • Provide crisis intervention as needed • Provide care coordination

25. Is care management acceptable to the patient? [B] Y Implement/continue care management plan in specialty care or primary care [See side bar] [C]

26. Consider use of addiction focused pharmacotherapy (Use Module P) Reassess progress periodically Has stable remission been achieved? [E]

27. Has stable remission been achieved? [E] Y Follow up in primary care Monitor substance use Monitor biological indicators Encourage continued reduction or abstinence Provide motivational support [F] Educate about substance use, associated problems and prevention of relapse [G]

28. CMCA CMCA CMCA Reassessment • Reassess goals periodically • Long-term, ideal goal remains full remission and improvement in all co-existing conditions • Refer to rehab when goals change

29. Has stable remission been achieved? [E] N Is referral to specialty care rehabilitation indicated and acceptable to the patient? [See side bar] [H] Y Go to Module R N Return to Box 3

30. Implement/continue care management plan in specialty care or primary care [See side bar] [C] Reassess progress periodically Return to Box 3

31. Application of Care Management: Medically Ill Heavy Drinkers

32. Application of Care Management: Medically Ill Heavy Drinkers Kristenson et al., 1983

33. Application of Care Management:Medically Ill Heavy Drinkers Kristenson et al., 1983

34. IOT 2 Year Results Willenbring and Olson, 1999

35. IOT Results Willenbring and Olson, 1999

36. IOT for Medically Ill Alcoholics 82 68 Willenbring, et al., 1994

37. IOT for Medically Ill Alcoholics 81 70 Willenbring and Olson, 1999

38. Application of Care Management: Coexisting Mental and Addictive Disorders (COMAD)

39. Severe Dependence Improvement in COMAD Abuse Abstinence Drake et al., 1998

40. Improvement in COMAD Using days past 180 Drake et al., 1998

41. Improvement in COMAD Bartels et al., 1995

42. CMCA CMCA Summary • Care management is a pragmatic approach to treating substance use disorders as a chronic illness. • Care management can be applied by any professional in any setting • Evidence to date shows a better long-term prognosis than is commonly appreciated.