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Adolescent Early Intervention and Treatment Summit ... Adolescent Early Intervention and Treatment Summit

Jun 13, 2020

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  • Adolescent Early Intervention and Treatment Summit

    Sacramento, CA November 8-9, 2017

    Paula Riggs MD Professor and Director, Division of Substance Dependence

    Department of Psychiatry University Colorado School of Medicine

    Developmental Considerations Early Intervention and Substance Treatment in

    Adolescents

    Developmental Considerations Early Intervention and Substance Treatment in

    Adolescents

  • Disclosures Disclosures ~2~

    • Scientific Advisory Board for Smart About Marijuana (SAM)

    • Senior Scientific Consultant CDPHE/NIDA supported RCT of medical cannabis for veterans with service-related, non- treatment responsive PTSD

  • Learning Objectives Learning Objectives ~3~

    Developmental Considerations • Prevention, Early Intervention, and Adolescent Substance

    Treatment

    Systems-Level Approach • What is “integrated” care and why do we need it? • What would it look like if we had it? • Where are we now? • Where do we need to go from here? • Is there a roadmap to get from here to there?

  • Learning Objectives Learning Objectives ~4~

    Systems-Level Approach • What is “integrated” care and why do we need it? • What would it look like if we had it? • Where are we now? • Where do we go from here? • Is there a roadmap to get from here to there?

    Developmental Considerations • Prevention, Early Intervention, and Adolescent Substance

    Treatment

  • ~5~

    If we could build a behavioral healthcare system from the ground up

    …knowing what we know today…….

    What would it look like ?

    Consensus among researchers and clinicians that addiction and many other psychiatric disorders are neurobiologically- based medical illnesses similar to other chronic medical diseases such as diabetes, cardiovascular disease, hypertension, asthma

    Medical advances in the treatment of most chronic diseases involves universal screening, public education, prevention, and early identification of risk factors and interventions to reduce risk

    Early intervention at first signs /symptoms of the disease to prevent further progression

    Lifestyle and behavior often contribute to disease onset, severity, prognosis

    Medical management and treatment require changes in behavior and lifestyle

    • Medical model is the roadmap

    • Psychiatry –operate as fully functional medical subspecialty providing integrated substance/mental health treatment

  • What is integrated care and what would it look like if we had it?

    What is integrated care and what would it look like if we had it?

    6

    Will you join me

    in a brief tour of

    that parallel universe

  • ~7~

    Addiction

    Mental Health

    Medical Healthcare

    funding

    This universe is dysfunctional, non- integrated silo’d system of care

    Medical Healthcare

    Cardiology

    Endocrinology

    Pulmonary surgery

    GI Psychiatry

    Behavioral Healthcare

    (substance/mental health)

    Pediatrics

    In this parallel universe, psychiatry is fully integrated into mainstream healthcare functioning as multidisciplinary medical subspecialty addressing substance and other psychiatric disorders

    What is integrated care and what would it look like if we had it?

  • What would it look like if we had it?What would it look like if we had it?

    8

    Universal and regular repeated screening in primary care settings across development/lifespan including school-based health clinics (SBHC)

    Early identification of risk factors

    Effective prevention and risk reduction interventions

    Early detection and treatment at first signs/symptoms of illness (e.g. intervention for harmful or risky use)

    • Repeated screening in medical settings across development

    • Identify those ‘at risk’

    • Provide earlier stage treatment to prevent progression

  • What would it look like if we had it?

    Chronic Disease Model of Care provides continuity of care across the continuum of care

    What would it look like if we had it?

    Chronic Disease Model of Care provides continuity of care across the continuum of care

    • Common assessment battery –characterize patients; systematically track patient outcomes (repeated outcome measures)

    • Clinicians/practitioners trained in evidence based practice • Continuity of care across the continuum of care • Practice parameters and standards of care are clearly defined and updated to reflect

    medical /research advances • Regular and systematic program and performance evaluation; quality improvement

    measures

    Hospital Detox

    Residential Rehab

    IOP Rehab Outpatient continuity of care Tele-Monitoring

    In this universe substance /mental health treatment looks a lot like prevention, treatment and continuity of care provided for patients with diabetes, cardiovascular disease, and other chronic medical conditions Early

    relapse detection

  • 0 1 2 3 4 5 6 7 8 9

    Pre During During During Post

    Treatment Research Institute

    Outcomes In Hypertension, Diabetes, Cardiovascular Disease

    Pre During Treatment Post

  • 0 2 4 6 8

    10

    Pre During During During Post Treatment Research Institute

    Outcomes In Addiction

    Pre During Treatment Post

    We have the wrong model! We must adopt a chronic disease model of care consistent with current

    research and fully integrated within the medical healthcare system

  • Very serious use 2,300,000 million in treatment

    Little to no use

    23,000,000 With “addiction”

    40,000,000 “harmful use”

    Screening and early interventions integrated into medical healthcare

    Prevention Screening

    Where are we now?

    < 10 % of those who could benefit from substance treatment receive it

    • We’ve primarily developed treatment for the most serious end of the spectrum without a meaningful continuum of care

    • Comorbidity is the rule yet, integrated SUD/MH treatment is lacking

    Lack early interventions to reduce harmful use in primary care and other medical settings

    • School-based health clinics (SBHCs) are underappreciated and under-utilized as primary care settings

    • 95% of adolescents with SUD are in still school but universal screening and school- based substance treatment is lacking

    SBIRT won’t work until we have > integration

  • Very serious use 2,300,000 million in

    treatment

    Little to no use

    23,000,000 with “addiction”

    40,000,000 “harmful use”EARLY

    INTERVENTION

    PREVENTION • Universal screening • Early risk identification; risk

    reduction

    Our “hit rock bottom” approach approach is antithetical to medical advances in treating other chronic diseases

    • Effective screening • Brief interventions for at

    risk or those with harmful use

    Where are we now?

    • Clinical workforce shortage

    • Lack adequate training

    • Poor compensation

    • High turnover

    • Increase treatment access/availability

    • Medical basis of addiction /mental illness will reduce stigma and the need for additional layers of ‘confidentiality’ protection Mental Health Parity and

    Addiction Equity Act (2008)

    It’s the LAW but still not enforced

    Where do we go from here?

    Develop or adapt existing evidence based treatments as earlier intervention implemented in medical settings/healthcare systems*

  • ENCOMPASS

    Integrated Treatment for Adolescents and Young Adults

    Research-based approach to concurrently treating co-occurring psychiatric disorders

    Can be feasibly adapted and implementation in community-based substance, outpatient mental health, or school-based settings

  • Research Practice • MET/CBT, 16 weeks 

    • Incentives   paid $25 per visit; free tx* 

     Could not apply additional  incentives/contingencies to enhance abstinence  rates

    Psychiatric treatment   Constrained by single 

    pharmacotherapy/placebo  Could not individually tailor treatment as 

    clinically indicated

    Relapse prevention/ continuing care

     Constrained by research protocol

    • MET /CBT 16 weeks

    • CM Incentives “fishbowl”

     Compliance

     Abstinence

     Non‐drug alternative activities

    Psychiatric treatment

     Broader range of options

     Psychotherapy 

     Pharmacotherapy

    Relapse prevention/continuing care 

     Involvement in non‐drug alternative  activities sustained  drug‐free lifestyle 

    School-based adaptation

  • Developmental Considerations Early Intervention and Substance Treatment in

    Adolescents

    Developmental Considerations Early Intervention and Substance Treatment in

    Adolescents

    16

    Most substance /psych