Making Successful Referrals for Substance Use Disorders

1. Making Successful Referrals for Substance Use Disorders UCSF Collaborative Education Project Elinore McCance-Katz, MD, PhD

2. Learning Objectives • Compare and contrast the different levels of care available for substance use disorders. • Determine the appropriate level of care required based on severity of use, availability of resources, and patient willingness. • Understand the process of making referrals to specialty care for substance use disorders. • Be able to successfully refer patients to Bay Area treatment facilities and programs.

3. Outline • Levels of care for substance use disorders (SUD) • How to assess appropriate level of care • How to make a referral • Local resources • Best practices, clinical tips

4. Acute Care Continuum • Inpatient medical withdrawal: For use with alcohol, benzodiazepines, complicated opioid withdrawal (i.e.: with other co-occurring illnesses such as polysubstance dependence, HIV, or other significant medical illness) • Outpatient medical withdrawal: For use with opioids (uncomplicated), stimulants (cocaine/ amphetamines) • Residential treatment: Often can undertake medical withdrawal and other medical needs while providing ongoing substance abuse treatment after initial withdrawal is completed • Intensive outpatient treatment: Usually takes those without acute medical needs, but with the need for intensive treatment of substance use disorder (any of the abuse disorders (i.e.: abuse of any substance that does not rise to level of substance dependence)) or non-physiological substance dependence

5. Chronic Care Continuum (After any medical withdrawal needs have been attended to)

6. Overview: Continuum of Care for Substance Use Disorders Substance abuse treatment modalities may be mixed; i.e.: include multiple types of treatment interventions in each setting Inpatient short term (days to a few weeks); Residential (30-90 days); IOP (approx. 12 wks) Will include multiple modalities: Medical management Medical withdrawal Psychiatric assessment/treatment if needed Psychological testing Individual assessment and therapy Group therapy Family therapy 12 Step groups Vocational assessment Once inpatient, residential or IOP program is completed; a patient will be referred for a less intensive, but ongoing treatment: “Aftercare” – usually low intensity 1/wk individual or group therapy Those without a sober living environment to return to may need long-term residential: Half-way house: a group residential facility where recovering people can get support for sobriety from each other. Not staffed by addiction professionals. Not a treatment program. 6

7. But Does Treatment Even Work? • Providers sometimes feel discouraged about referring pts for SUD treatment. Sometimes it seems like it just isn’t worth the effort. But relapse rates are really no different than other chronic diseases: http://www.nida.nih.gov/PODAT/faqs.html#Comparison

8. Referral Algorithm/Guidelines • So how do you maximize the likelihood of success? You must first know what level of care you should be referring to. • Determine if patient is drug or alcohol dependent (and needs medical withdrawal) (inpatient) or is a substance abuser (outpatient unless has other risk factors) • Determine if patient has other risk factors that would make them better candidates for inpatient treatment than outpatient treatment: • Co-occurring mental illness (may need a psych consult) • Polysubstance use and dependence on multiple substances • Serious medical illnesses that may be exacerbated when substance use changes (i.e.: when the patient stops abusing); e.g.: HIV/AIDS, active HCV, cirrhosis, other serious illnesses)

9. Other Factors to Consider • Insurance coverage • Private: must check with insurer to determine what kind of treatment and what facilities they will pay for • Public: Medi-CAL/City/County: Refer to public treatment facilities in city or county where the patient resides • Language ability/cultural competence • Treatment history (have they failed outpatient treatment in past?) • Location/transportation: can the patient and their family easily access the treatment facility • Family support • Can the facility treat both substance use disorders and mental illness? • Can the facility treat both substance use disorders and medical illness? • Does the facility offer/support pharmacotherapy for maintenance of abstinence? • Does the facility have a good record of keeping referring medical staff informed of patient progress and ongoing needs?

10. Assessment Domains for Treatment Planning Determining the appropriate level of care, requires a multilevel assessment of many factors. These factors include: Severity: substance type amount, frequency, duration Alcohol “at risk” or “hazardous”= drinking Men: >5 drinks/day; >14 drinks/wk Women: >4 drinks/day; >7 drinks/wk Route of administration Consequences of use Comorbidity: Medical Psychiatric Social support/environment/triggers for relapse (i.e.: will they need a sober living facility after finishing treatment?) Motivation External obstacles: insurance, location of treatment program 10

11. Case Study • Paul is a 35 y.o. man with two children aged 12 and 15. He has been your patient for the past 2 years and has seen you for regular healthcare/physical examinations. He has no ongoing medical problems noted. He drinks nightly after work, as has been his habit for many years and has reported drinking 1-3 drinks per sitting. He presents today asking if there is a medication he can take for his nerves as he has noticed that he is losing his temper with his children more often. He recently got into a physical fight with his 15 y.o. after several drinks that resulted in a neighbor calling police. Other complaints include problems with sleep—he notes that he often falls asleep after 4-5 beers in the evening, but wakes up at 2 or 3 AM and has problems returning to sleep. He sometimes feels anxious and at times has sweats in the mornings and wonders if he is “going crazy”. Physical examination is normal except for increased blood pressure at 150/92 and heart rate of 95 bpm. His last drink was at 10 PM the night before and you are seeing him at 3 PM. He admits that his drinking has increased “some” since you saw him last and he thinks he now drinks about 5 beers daily.

12. Case Study • What is the likely diagnosis and where should he be sent for treatment? • Diagnosis: Alcohol dependence. Physical examination shows only mild hypertension which could occur as a result of alcohol withdrawal (it has been 17 hours since his last drink). Although he could also have a mental disorder and this should be evaluated further as should the hypertension once medical withdrawal is completed, his current symptoms are most consistent with alcohol dependence. Based on his history of withdrawal symptoms, he is a good candidate for care at a substance abuse treatment program that can offer inpatient medical withdrawal or this can be accomplished at a local inpatient hospital (psychiatry may take such a patient given the question of depression and anxiety with consequences (i.e.:police involvement, social work involvement needed)). His symptoms indicate that he is likely to need medication to assist with withdrawal symptoms. After medical withdrawal he will need ongoing substance abuse treatment, most likely in an IOP setting.

13. After the Assessment: Nuts and Bolts • Who do you call? see Provider Listing in attached excel file for this module. • What form do you fill out? May use a standard UCSF specialist referral form or you may be able to give a verbal report to the receiving institution • Need to get authorization? You will likely not do this; but if you do the actual referral you may be asked what insurance the patient has—the facility will know immediately if they can take the patient or not; if they can’t they may be able to direct you to another facility that will take the patient’s insurance. • What support staff can help? Clinic nursing or administrative staff may be able to help with determination of insurance and whether a facility would be able to take the patient. Medical information will need to come from the clinician.

14. The Referral “Package” (1) • A strong referral to appropriate specialty care is key but that’s not all… • How will you interact/communicate with the specialist? Have the patient sign a release of information form before they go to substance abuse treatment. • What is your follow-up plan with the patient? Arrange follow-up contacts and appointments with you since there may be a waitlist for specialty care. • What ongoing management strategies will you use? Monitor labs? Look for medical symptoms of ongoing use? (Look for physical/psychological symptoms and use POS urine drug screens) Medication to reduce cravings ? (speak with treatment facility to determine need and type of pharmacotherapy) Make plan for harm reduction? (Determine patient’s goals (do they intend to stay abstinent? “controlled” use? Be prepared to counsel regarding whether “controlled” use is possible given extent of their disease; realize SUDs are chronic, relapsing diseases and the patient may need more than a single treatment—so you may, at some point, have to reassess and refer to treatment again)

15. The Referral Package (2) • Encourage continued use of 12 step programs or support groups as well as ongoing group and/or individual therapy. • Remember that giving the patient a list of local 12 step meetings is far more effective that just vaguely suggesting they go. You can find updated SF meeting lists at www.aasf.org. Ask for commitment to attend a specific meeting on a specific day. • Impress on receiving facility that you want regular updates starting with their assessment of the patient’s needs and the treatment they provide as well as their plan for ongoing care after the patient leaves their facility. Note: Most substance abuse treatment programs and providers are eager to provide ongoing input about your patient. They realize that you are looking to them to effectively treat the substance use disorder and to make a comprehensive discharge plan. They are also aware that you can refer to a number of facilities (and they usually are appreciative of your referral), so they will try to give you the updates and information you need to so that you can make sure that the patient’s ongoing treatment needs are met. If you refer to a facility that does not provide you updates; don’t refer to them again.

16. So What’s Available Locally? • See the Attached Listing for SF Bay Area Treatment Facilities (excel file in the folder for this module) • Provides type of facility • Services offered • Medicare/Medi-Cal acceptance • Languages/special populations served • Differentiates public and private facilities • Websites for many 12 step and self-help groups

17. Preparing the Pt for the Referral • Assess the appropriate level of care needed and finding the right facility is really just half the battle. All that work will be lost if the pt is unable or unwilling to follow through. • What would you do to help prepare the pt for treatment? • Would this differ depending on the level of care?

18. Preparing the Pt for the Referral: Our Suggestions • Motivation – recall the discussion of motivation (and how to build it) in Module 6. Be sure the pt is motivated and willing to attend before making the referral. • Ask the pt to “look ahead” and identify any potential obstacles or roadblocks. Do some advance problem-solving on how to address these issues. • Ask the pt to share his/her worries or what they imagine treatment will be like. Provide corrective information. • Use testimonials from other pts, use the weight of your professional opinion and your relationship with the pt. • Normalize anxiety and ambivalence. • Remind pt that he/she has choice. If one program doesn’t fit, try another. There are many options. • Reassure pt you won’t abandon them regardless of how tx turns out. • Enlist the support of family members to help get the patient to treatment (obtain releases of information to be able to speak with family members the patient identifies as important in their lives).

19. Common Mistakes • PCP rushes into “action” and makes a tx referral when the pt isn’t interested. • PCP refers to an overfull program or to a program that doesn’t take the pt’s insurance. Pt feels unheard and frustrated. • PCP doesn’t create a referral “package” – i.e. other strategies/programs or homework the pt can try while they are on a tx program waitlist. • PCP doesn’t consider pharmacotherapy to reduce cravings and/or reduce suffering. • PCP gets frustrated and sees the pt as “resistant” or “self-sabotaging” instead of having a difficult chronic disease. What could you do to avoid each of these mistakes? How will you assess your success?

20. Take Home Points • Substance abuse treatment works and there are ways to maximize the likelihood of a successful referral. • Substance abuse treatment occurs on a continuum with several modalities overlapping in multiple treatment settings • Level of care is determined by severity of illness: is patient dependent or do they have substance abuse. Comorbidities? • Inpatient treatment reserved for those with more serious illness (dependence, more than one substance, medical/psychiatric illness co-occurring)

21. Take Home Points • Substance abuse treatment facilities should provide you ongoing updates with a valid release of information; if they do not; don’t refer to them again • Substance abuse treatment facilities should provide you with a structured discharge plan discussing the patient’s ongoing treatment needs and making specific recommendations as to what and where the patient might access those interventions • Addiction is a chronic relapsing illness; continued monitoring after substance abuse treatment is needed and you may have to refer to substance abuse treatment more than one time for any particular patient

22. Related Tools and Resources • See Excel Spreadsheet Listing for Local Alcohol and Drug Treatment Facilities and Programs • SF Bay Area • SF County Treatment Access Program 1-800-750-2727 • CA ADP resource website listings: • http://www.adp.ca.gov/Treatment/index.shtml • SAMHSA Treatment Facility Locator Tool • http://findtreatment.samhsa.gov/