Connecticut Medicine The Journal Journal of the Connecticut State Medical Society VOLUME 78
SEPTEMBER 2014
NUMBER 8
Owned, Published, and Copyrighted, ©2014 by the Connecticut State Medical Society CONNECTICUT MEDICINE (ISSN 0010-6178), published monthly except June / July and November/December at 127 Washington Washington Ave., East Building, 3rd Floor, Floor, North Haven, CT 06473. 06473. Subscription rate incl uded in membership dues. Nonmembers: $60.00 per year. Periodicals postage paid at New Haven, Connecticut and at additional mailing offices. POSTMASTER: Send address changes to Connecticut Medicine, 127 Washington Washington Ave., East Building, 3rd F loor, North Haven, CT 06473.
Pilot Results of a New Model of Addiction reatment: Managing Addiction as a Chronic C hronic Disease ELLEN LOCKARD EDENS, MD, MPE, CHRISINE A. DONAHUE, BS, AND CHARLES CHA RLES E. RIORDAN, R IORDAN, MD
A BSR ABS R AC � Backg Background round:: Addic Addiction tion is increasinc reasingly conceptualized as a chronic disease, yet the current addiction treatment system is largely based upon an acute illness model, with weeks of residential care followed by intensive day progra ms. o o address this mismatch between best practices and current standards of care, we initiated a new model of highly intensive, rigorously monitored, year-long outpatient addiction treatment in Connecticut between December 2012 and June 2013. Method s: We conduct conducted ed a proof-of-conc proof-of-concept ept pilot study, accepting everyone who was willing to participate and able to pay for the care. Results: Resu lts: A total of five par participa ticipants nts were enrol enrolled led during this period, all with DSM-5 substance use disorder (SUD), severe. Tese participants, who comprised the entire pool of pilot participants and each completed completed 12 months of treatment, all achieved sustained abstinence (defined as more than si x months of continuous sobriety), as confirmed by frequent, random alcohol and drug tests. Conclusions: Tese pilot results demonstrate demonstr ate the feasibility and potential effectiveness of an innovative model of addiction treatment.
Introduction �������� �� the 2012 National Survey of Drug Dr ug Use and Health (NSDUH), 20.7 million mil lion adults and 1.5 million youth aged 12-17 met criteria for DSM-4 substance use disorder (SUD),1 not including tobacco use disorder, and 20 2009 09 cost estimates indicate the U.S. spent $24 billion on SUD treatment.2 SUD is now conceptualized conceptuali zed as a chronic disease, often involving cycles of relapse and remission.3 Best practices for managing this chronic disease include continuity of care, care , monitoring during periods of abstinence, early reintervention upon relapse, self-management, and recovery support.4 Te current system of addiction treatment remains based, however, on an acute illness model of disease management — commonly providing a period of shortterm residential rehabilitation, followed by an intensive day program of three to five sessions a week for six to eight weeks, and requiring requiri ng patients to leave their homes, families, jobs, or schools for weeks at a time to begin care, at a cost to the patient of $10,000 to $35,000 $35,00 0 or more. Tis standard of SUD care has remained largely unchanged for decades and tools long proven to aid in abstinence are seldom fully deployed. Fewer than 25% of rehabilitation programs prescribe any craving-reduction drugs, for instance, despite several studies that have proven that these drugs offer patients significant help in sustaining abstinence.5 Following treatment, patients typically find themselves in the same communities where they abused alcohol and/or drugs, left largely to their own devices to obtain the on-going support they need to learn to maintain abstinence. As a result, more than half hal f relapse.6 Wee developed a model of addiction treatmen W t reatmentt that provides highly intensive, rigorously monitored outpatient care for a full year, because research shows that maintaining abstinence for a year dramatically dra matically improves a person’s chance of sustained recovery.7,8 Te model manages addiction as a chronic illness il lness using a multidis-
A
ELLEN LOCKARD LOCKA RD EDENS, MD, MPE, VA VA Connecticut Healthcare System, West West Haven, Assistant Professor of Psychiatry, Yale Y ale University School of Medicine,West Haven; CHRISINE A. DONAHUE, DO NAHUE, BS, Cofounder Cofounder,, Aware Recovery Care, Inc., Madison; CHARLES E. RIORDAN, MD, Clinical Professor of Psychiatry, Yale University School of Medicine, West Haven, Medical Director, Aware Recovery Care, Inc., Madison; Corresponding author: CHRIS author: CHRISINE INE A. DONAHUE, BS,
[email protected].
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ciplinary team that is led by an addiction psychiatrist who is also the medical director, includes a registered nurse (RN), and provides day-to-day support over the course of the year from a trained peer in recovery, a certified recovery advisor (CRA), who meets frequently with the client in his or her home. home. Tis model provides provides pharmacotherapy for alcohol and opioid use disorders and robust compliance management through frequent, random alcohol and drug tests and voluntary, continuous GPS monitoring of the client’s location. Te model also includes weekly sessio sessions ns with a licensed therapist, family therapy as indicated, and guided assimilation assimilat ion into 12-step and other recovery support support programs, as well as psychosocial education and suppo support. rt. In short, the model has as its mission to help people learn the new skills skil ls and daily habits required to resume their lives in their own communities without using alcohol or drugs. We began conducting a feasibility study upon the acceptance of our first client in December, 2012. Because the majority of people people with an SUD also a lso smoke cigarettes, the program began offering a smokingcessation program in September 2013. Here, we present present pilot results on specific health and quality of life outcomes outcomes for our first five participants, par ticipants, one of whom opted into into the smoking-cessation smokingcessation program. While the t he number treated is low, their outcomes suggest the feasibility of this model for SUD treatment. We are therefore reporting these preliminary results.
provider (PCP), meeting as needed with the client c lient at his or her home over over the course of the year. If the participant par ticipant does not have a PCP, the program helps the client find one to arrange a full physical examination. If medical specialists are required, such as for care for liver disease, the program helps the client cl ient arrange arrang e the appointment(s). appointment(s). Te certified recovery advisor is a new role designed to provide daily support and care coordination from a peer in recovery. Each CRA is in sustained recovery and has completed training with the Connecticut Community for Addiction Recovery, and with the program. Each CRA is trained in motivational motivational interviewing (MI) ( MI)9 and is familiar with Prochaska’s transtheoretical model of behavior change.10 An initial goal goa l of the CRA is to build a trust-based relationship with each participant, using MI to foster the client’s intrinsic motivation to change. Te CRA CRA meets with the participant for four hours hours the first and second days, then at least: • Four times a week for the rst two t wo weeks. • ree times a week in weeks three through th rough eight. eight. • Twice a week in weeks eight through 23. • Weekly for the next six months. Te CRA CRA is also available to the client client via phone phone and text at other times as required. Te CRA works under the guidance of the medical director and uses the program’s detailed 52-week psychosocial educational curriculum curr iculum to help the client learn to manage the disease of addiction by mastering new skills skill s and daily habits, including how best to prevent relapse and how to use local 12-step 1 2-step programs to full advantage. Te CRA selects 12-step meetings appropriate for each client and accompanies the client to the initial 12-step 1 2-step meetings. meetings. Te CRA also coordinates random alcohol (EtG (EtG urine testing and a nd breathalyzer) and urine drug screening of each client and GPS tracking to monitor and encourage compliance. GPS track tracking ing is implemented via either an app on the client’s cell phone or a tracking device in the client’s car. Additionally Additi onally,, each client is enco encouraged uraged to meet weekly with a licensed therap therapist. ist. If the client already has a thera thera-pist, he or she is encouraged to continue working with that provider. If the client does not have a therapist, the program helps the client cl ient find one. Te CRA actively facilitates these appointments. Te program also facilitates facil itates family therapy as needed and a nd helps the client access wellness resources, such as aids for meditation, therapeutic massage, and coaching on physical fitness. Te data for this report is prese presented nted as five case studies studies..
Methods Te model model delivers highhigh-touch touch care through a multidisciplinary team that meets with the client over the course of a year in i n his or her home. Tis model encourages clients to manage their SUD as a s a chronic disease — just like diabetes or hypertension — and provides intensive care coordination to prevent acute care episodes. Te first step in each client’s program of care is an evaluation by an addiction psychiatrist assessing any cooccurring occurr ing disorders and the need for medication-assisted treatment, as indicated. Te evaluation includes meeting with the participants’ significant family membe members rs to assess the home situation. If a participant requires detox, he/she he/s he is referred to an accredited facility. Upon discharge from the facility, the program picks the client up and drives him or her home to begin care. Te program then begins working face-to-face face-to-face with the client in his or her home, addressing the physical, mental, and emotional health issues required to prevent relapse. On the first day, the RN meets with each client at home for one to two hours to conduct a full nursing Results assessment, which includes any medications the partici10-year history histor y Participant 1, male nonsmoker, had a 10-year pant is tak taking. ing. Te RN then works in collaborat collaboration ion with of daily binge drinking drink ing and, as a result, had lost his job the addiction psychiatrist and the client’s primary care three years yea rs prior. He had completed completed two 28-day 2 8-day inpatient 488
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stays at local and regional treatment centers in 2011 and 2012, respectively. Each stay was followed by quick or immediate relapse. His wife started star ted divorce proceedings and contacted the program. An addiction psychiatrist evaluated the participant and prescribed disulfiram to be taken in the t he presence of his wife. Te couple reported an immediate reduction of tension in their home. He abstained from alcohol for several weeks, as confirmed by frequent, random alcohol alcohol tests, then experienced three brief periods of intoxication. Te CRA was meeting frequently with the participant par ticipant and so was immediately aware of each slip and able to help the part participant icipant resume abstinence. Te participant consistently attended weekly sessions with a licensed alcohol and drug counselor (LADC) for individual therapy and with a licensed clinical social worker (LCSW) for couples therapy, as confirmed by the therapists. He participated in an average of five Alcoholics Anonymous (AA) meetings each week, as confirmed by by GPS GPS tracking. His wife reported reported participating in one or two Al-Anon meetings each week. At the end of his year of care with the program, Participant 1 had been abstinent for seven months, as confirmed by frequent random urine screens for EtG and by breathalyzer tests, his h is longest period of sobriety as an adult. He is employed for the first time in three years and has reconciled with his spouse. spouse. Participant 2, male smoker, had a 30-year-history of progressively severe alcohol addiction and had been drinking drinki ng in excess of a fifth of vodka daily for the previous five years. He suffered from elevated liver enzymes enzy mes and severe neuropathy in his legs and feet and his employment was at risk. He smoked a pack of cigarettes a day. Upon initial evaluation, he was referred for alcohol detoxification at a local hospital, which required six days. During his stay, he was prescribed oral naltrexone. Following discharge, he consistently reported medication adherence to the program’s program’s RN and CRA. He attended weekly sessions with an LCSW/LADC, as confirmed by the counselor, and participated in an average of six AA meetings meetings each week, as confirmed by GPS tracking, regularly regula rly chairing meetings. After nine months of of care by the program, this participant began the program’s Smok Smok-ing Cessation program. At the end of his year of care with the t he program, this participant par ticipant had been abstinen abstinentt from alcohol for for the full f ull year, as confirmed by frequent random urine screens for EtG, his longest period of sobriety as an adult, and had been abstinent from tobacco for 11 weeks. His blood tests showed normalization of his liver enzyme levels and his h is blood pressure pressure returned to normal without medication. Te participant also reported significant improvement in the numbness and tingling tingli ng in his legs and feet and in his overall balance. He proactively scheduled his yearly preven preventative tative healthcare,
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which he had had previously previously neglected, including an annual physical examination. Participant 2 continued working for his employer and achieved his best-ever yearly performance results. His siblings reported significantly better relations with him. Participant 3, male smoker, had a 12-year history of prescription opioid addiction that began after being prescribed oxycodone ox ycodone for management of knee and back pain. At program admission, he was taking up to 360 mg oxycodone daily, daily, as well as a s 30 mg of diazepam. He was drinking drink ing a fifth fi fth of bourbon daily dai ly,, meeting criteria for alcohol use disorder as well. A smoker, he had been diagnosed with hypertensio hypertension, n, depression, depression, and anxiet anxiety. y. He had been charged with w ith Driving Under the Influence several days before starting treatmen t reatmentt with the t he program, resulting in the threat of termination of employment. He was assessed and referred for opioid and alcohol detoxification at a local hospital, which required eight days. o o address the t he participant’s part icipant’s opioid use disorder, he was refe referred rred to a psychia psychiatrist trist to prescri prescribe be bup bupreno renorphine rphine-naloxone. Te participant was maintained on 16 mg buprenorphine-naloxone daily and consistently reported medication adherence throughout his involvement with the program, as confirmed by urine testing. He was also prescribed escitalopram for depression depression and anxiet anxiety, y, lisinopril for hypertension, and trazodone for sleep. He attended weekly sessions with a licensed therapist for four months, then ceased therapy, citing financial concerns. He participated in an average of six AA A A meetings each week, as confirmed by by GPS tracking. At At the end of of his year of care with w ith the program, Participant 3 had been continuously abstinent from illicit opioids, alcohol, and benzodiazepines, as confirmed by frequent random alcohol and drug tests, including urine screens for EtG and breathalyzer tests, his longest period of sobriety as an adult. He has experienced exper ienced weight loss of more more than 40 pounds and marked improvement in his blood pressure. He has successfully completed his court-mandated DUI classes. classe s. He has continued continued his employment and dramatically improved his work performance, as confirmed by his employer. His family members report significantly better relations with him and he reports an intention to resume therapy in the near-term. Participant 4 , female nonsmoker, had a 20-year history of progressively severe alcohol addiction and for the previous four years had been drinking in excess of a pint of vodka daily. She had been hospitalized twice for jaundice and had been diagnosed with hepatic cirrhosis, but continued to drink. In the two years prior to program admission, she had received no medical care, was unemp unemployed, loyed, and a nd had become alienated al ienated from her husband. She and her husband were separated but were postponing divorce until they could sell their house,
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which was in disrepair disrepair and had been on the market for for cluded that his continued participation in the program four years. On admission ad mission to the program she was assessed was an effective alternative to incarceration incarceration.. He received and diagnosed with w ith alcohol use disorder, severe, alcoholic a significantly reduced sentence sentence of community service. serv ice. liver damage, and dependent personality disorder. She Conclusions/Future Directions was referred to a gastroenter gastroenterologist ologist to assess her liver In the first year of operation, four of the five pilot status. In addition to working with the program’s RN participants icipants showed continuous continuous abstinence from alcohol and CRA, she was referred to a clinical cli nical psychologist. Te part and/orr illicit ill icit drugs since beginning care and all a ll showed participant part icipant consistently attends weekly sessions with the and/o clinical psychol psychologist. ogist. She attends an average of 10 to 12 continuous abstinence for at least seven months. Tree AA meetings each week, as confirmed by GPS track- of the five had co-occurring psychiatric illnesses that a nd addressed. None experienced ex perienced any a ny ing, and has taken ta ken on leadership roles roles in AA, A A, including were identified and sequelae typical of SUDs during the period of par participa ticipachairing chair ing meetings. At the end of her her year of care with the hospitalizat ion for liver program, Participant Part icipant 4 had been continuously abstinent, tion. For example, none required hospitalization overdose, e, suicidality, suicidal ity, cognitive problems, problems, as confirmed by frequent random urine uri ne screens for EtG. EtG. disease, trauma, overdos She reported successfully managing renovations to her or exacerbation of comorbidities. Rather, participants home in preparat preparation ion for for selling it. She had also applied reengaged in their medical care and demonstrated imfor employment for the first time in four years. yea rs. Her adult provements in general health. One stopped smoking. In addition, the fee for this model of highly intensive, children report significantly better relations with her. rigorously monitored, year-long outpatient addiction Participant 5, male smoker, had a 15-year history of treatment is comparable to that for a typical private 28heroin addiction for which he had received treatment day residential rehabilitation program. from more than a dozen residential treatment programs, Despite the low number treated, these pilot results relapsing following discharge discharg e each time. He was referred to the program by his LADC. He was assessed and demonstrate the feasibility and potential effectiveness referred to a PCP who prescribed 24 2 4 mg buprenorphine- of an innovative model of addiction treatment. Clients naloxone daily, dai ly, which was subsequently reduced to 6 mg. admitted subsequent to the pilot study have shown similarr results in the first months of care. Te program is Te part participant icipant consistently reports adherence to his simila medication, as monitored and confirmed by the CRA. currently not participating with any health insurers and, w ith the means to pay were admitIn the first weeks of care, the CRA had the participant par ticipant therefore, only those with feasibility ility study study,, limiting generalizabiltake his medication in front of the CRA on the days ted to the initial feasib they met. On the days when they did d id not have a meeting ity. Further study is imperative to determine whether this scheduled, the CRA required the participant to use his innovative model employing evidence-based practices w ith greater Smartphone to video himself taking tak ing his medication and in addiction treatment is indeed associated with send the video to the CRA via text. tex t. Te CRA has since effectiveness. As a next step, the program is exploring confirmed medication adherence using urine testing. multiple funding strategies to increase accessibility to Te participant attends weekly sessi sessions ons with his LADC, this model of care. as confirmed by GPS tracking and the therapist, and REFERENCES participates in an average of five AA and/or Narcotics 1. Substance Abuse and Mental Health Serv Services ices Administra Anonymous (NA) meetings each week, as confirmed tion, Results from the 2012 National Survey on Drug Use and Health: Summar y of National Findings, NSDUH Series by GPS tracking. 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