H-SOAP STUDY. Hospital-based Services for Opioid- and Alcohol-addicted Patients

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1 H-SOAP STUDY Hospital-based Services for Opioid- and Alcohol-addicted Patients Meldon Kahan, Anita Srivastava, Kate Hardy, Sarah Clarke Canadian Society of Addiction Medicine 2014 October 17,

2 Few hospitals have addiction services. Addiction programs are often far from the patient s home. Patients face waiting lists and complex intake procedures. Access is difficult for unstable patients with concurrent physical or mental illnesses. Programs rarely provide timely pharmacotherapy for addiction Programs rarely communicate with the patient s primary care provider. 2

3 Hospital-based addiction programs can overcome these problems with care that: Is immediately accessible and on-site. Provides both pharmacotherapy and flexible, solutionfocused counselling. Provides shared care with patient s family physician. 3

4 Oslin 2013: 26-week RCT of three primary care practices 163 alcohol-dependent veterans randomized to specialized outpatient addiction counselling or naltrexone plus counselling with their primary care clinic Primary care group: Higher treatment retention rate [OR = 5.36, 95 % CI 2.99, 9.59] Lower % heavy drinking days [OR = 2.16, 95 % CI1.27, 3.66] 4

5 Randomized controlled trial Half of participants receive rapid, facilitated substance use service appointments. Half face usual wait times (2-4 weeks) and must arrange medical appointments on their own. 5

6 124 adults with alcohol and/or opioid use disorders Recruited through three residential, non-medical withdrawal management centres in downtown Toronto: Women s Own Detox Ossington Men s Withdrawal Management Centre St. Michael s Hospital Withdrawal Management Service 6

7 Inclusion criteria Exclusion criteria AUDIT > 8 and/or opioid use with harm Cognitively intact Interested in treatment Pregnant Currently on methadone, buprenorphine, or antialcohol medication Cognitive impairment > 18 < 17 7

8 People with alcohol/ opioid addiction St. Michael s Hospital Withdrawal Management Services Women s Own Detox & Ossington Men s Withdrawal Management Centre INTERVENTION GROUP Rapid facilitated access to hospital-based addiction medicine clinic at St. Michael s Hospital or Women s College Hospital CONTROL GROUP Usual referral to hospital-based addiction medicine clinic at St. Michael s Hospital or Women s College Hospital 1-3 days 2-4 weeks Communication with PCPs Counselling Pharmacotherapy Randomized assignment 8

9 H-SOAP intervention 9

10 RA accompanies patient to appointment Physician explains diagnosis Reviews causes, treatment options, and prognosis. Withdrawal is treated, if necessary. Buprenorphine, naltrexone, or other medications are prescribed or discussed. Immediate, crisis-oriented counselling is provided by MD or social worker. Follow-up is arranged. 10

11 Medication titrated to optimal dose. Physician facilitates or encourages entry into formal addiction treatment and attendance at AA/NA. Physician makes other referrals as appropriate. Patient receives solution-focused addiction counselling. Family physician receives information letter, plus note or phone call. 11

12 Treatment retention Number of participants in each study arm (intervention & control) that attend the addiction service Mean number of visits per participant at six months 12

13 Health care utilization and cost tracked from 24 months before to 12 months after enrollment Number of hospitalizations and hospital days ED visits Primary care visits Outpatient laboratory services 13

14 Pre-post changes in prescriptions from 24 months before study entry to 12 months after (for patients eligible for drug benefits) Opioids Benzodiazepenes Buprenorphine Methadone Anti-craving medications 14

15 Self-reported substance use at 6 and 12 months All substances Quality of life measures 15

16 We are conducting individual interviews with selected patients from both groups in order to collect qualitative data. Open-ended questions about patients experiences with substance use service and other addiction treatment programs. WMS and clinic staff will also be interviewed. 16

17 Recruitment almost completed 102 participants so far Quantitative and qualitative outcome data being collected Cannot present outcome data until study completion 17

18 The importance of getting help quickly: Part of the problem with opiates is when you stop doing them you get really sick, and it s constantly at the back of your mind, so when you re doing opiates you re constantly looking for more opiates so you don t get sick. So the availability, the fact that I got on Suboxone right away was key, because then I didn t have to worry about that anymore and I could start concentrating on getting into programs and getting help. When you re struggling especially at the beginning with addiction every second counts now is of the essence with addiction. 18

19 Facilitated access: It was important for me for [researcher] to be totally by my side the whole time. I would not have come on my own to this hospital. I wouldn t have been able to find the hospital. I would be scared to go and see [clinic physician]. I was just in a fog, and the only reason that things worked out so well is because [researcher] had me by the hand. 19

20 Changes in perspective on pharmacotherapy When [clinic physician] mentioned [Suboxone], that name, I said, No-no, I m too scared of that. I don t want to take it. I don t want to become hooked on that, and I don t want to have another opiate in my system. [I had pre-conceived ideas] that I was going to be addicted, that it was going to make me feel like an opiate would that I really wasn t clean and sober that I was still using I started on [Suboxone], and... it was not what I thought it was going to make me feel there was no feeling of high or euphoria, I just felt okay. I think if anybody else [other than clinic physician] had introduced me to [naltrexone] I may not have because I m one of those people... they had to force me to take the Valium. After he explained all the physiology to me I thought, That makes perfect sense. I ll try that. 20

21 21

22 The longer the waiting time, the worse the followup. Many patients at Women s Own Detox are not chronic street users looking for shelter and rest. They have reached a crisis in their lives and they desperately want help immediately. Long delays increase the chance of relapse and treatment drop-out. 22

23 Helps patients understand that addiction is a biopsychosocial illness. Not a weakness, moral failing, etc. Addiction similar to depression: both pharmacotherapy and counselling are necessary. Reduction in craving helps retain patient in treatment and increases participation rates in counselling. If you wait till patient relapses before starting pharmacotherapy: Patient views pharmacotherapy as a crutch for losers. Patient may be lost to follow-up. 23

24 Most of the patients I ve worked with have been referred from Women s Own Detox. The majority have a history of prolonged and severe psychological trauma. They also report experiencing intense guilt and shame about their substance use, even if they continue to fulfill their social responsibilities. 24

25 Many patients have close, long-standing relationship with their family doctor. Doctors are willing to prescribe naltrexone, buprenorphine, etc. if the addiction specialist has titrated to optimal dose. Patients are much more likely to have long-term follow-up with primary care doctor than with addiction doctor. 25

26 26

27 Psychosocial programs need to provide comprehensive treatment. Some treatment programs refuse patients on methadone, buprenorphine, naltrexone, etc. This puts patients at risk for relapse. For opioid-dependent patients, it increases their risk of death from overdose. Addiction doctors need to advocate for our patients with these programs their medical directors, CEOs, and public payers. 27

28 Time for addiction doctors to join the general health care system. The model used by hospital-based addiction services is similar to that used by internists over two centuries: Work with health care providers in primary care clinics, ED, and hospitals. Explain to patient and primary care doctor the treatment approach, prognosis, etc. Initiate both pharmacotherapy and counselling. Make appropriate referrals. Shared care with family physician. 28

29 How to set up an addiction service in a general hospital? Make a business case: Low resources, low cost Highly effective compared to other medical interventions Decreased ED visits and hospitalizations Get the big people on your side: Departmental chiefs psychiatry, internal medicine, family medicine 29

30 Make sure you ask for the resources to do the job. Medical director should have protected time. Director needs time to implement withdrawal protocols, add buprenorphine and anti-craving drugs to formulary, medical education and program planning Rapid access clinic is a must. See patients from ED, hospital, and WMS Need coverage at least two-three half-days per week Need therapist for triage, short-term counselling, and case management ED coverage and inpatient coverage is very helpful. Will help guarantee ongoing support from hospital Need nurse clinician and 5-day/week medical coverage 30

31 There are several successful addictions services in Canada: Toronto: St Joseph s, St Michael s, Women s College Edmonton: Royal Alexandra Vancouver: St. Paul s A number of physicians have expressed interest in establishing addiction programs in their local hospital. 31

32 Julianne: 68-year-old woman, retired health care professional Married & stably housed in suburb near Toronto Moderate AUD: 6-8 bourbons daily, occasional blackouts, constant guilt Has been receiving supportive counselling for addiction but continues to relapse Referred to Women s Own Detox after a relapse caused by a stressful and pressure-filled family event 32

33 Met with H-SOAP RA at Women s Own Detox, enrolled in study, and was randomized to rapid group RA accompanied Julianne to the Substance Use Service at Women s College Hospital that day Addiction physician initiated pharmacotherapy (naltrexone) 33

34 Doing better she reports that she is drinking less with each binge and less on a daily basis. She reports that HSOAP offered her something that she hadn t received in the past, despite extensive experience with addiction treatment services in the past. 34

35 Building Bridges to Integrate Care (BRIDGES) Collaborative of the University of Toronto for its funding and support that contributed to this research BRIDGES funded by the MOHLTC. 35

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