Rx16 treat tues_330_1_mcneely_2d_onofrio_3macdonald

Closing Treatment Gaps in the Health Care and Criminal Justice Systems

Presenters:• Jennifer McNeely, MD, MS, Assistant Professor, New York University

School of Medicine• Gail D’Onofrio, MD, MS, Chair, Department of Emergency Medicine,

Yale School of Medicine• Ross MacDonald, MD, Chief of Medicine, Division of Correctional

Health Services, New York City Health and Hospitals

Treatment Track

Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of Science Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and Member, Rx and Heroin Summit National Advisory Board

Disclosures

Gail D’Onofrio, MD, MS; Ross MacDonald, MD; Jennifer McNeely, MD, MS; and Christopher M. Jones, PharmD, MPH, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Describe gaps in the identification and treatment of opioid use disorders (OUDs) in health care systems.

2. Identify approaches for improving identification of OUDs and engagement in treatment.

3. Distinguish the characteristics of persons most frequently admitted to the New York City jail system.

4. Outline strategies to improve outcomes for frequently incarcerated individuals.

Gail D’Onofrio MD, MSProfessor & ChairYale School of Medicine

Jennifer McNeely MD, MSAssistant Professor NYU School of Medicine

March 29, 2016

Treatment Track: Closing Treatment Gaps in the Health Care and Criminal Justice Systems

Learning Objectives

• Describe screening tools in the identification of opioid use disorders (OUDs) in health care systems.

• Identify approaches for improving identification of OUDs and engagement in treatment.

Disclosure Statement

Gail D’Onofrio MD, MS

Jennifer McNeely MD, MS

Has disclosed no relevant, real or apparent personal or professional relationships with propriety entities that produce health care good or services

Has disclosed no relevant, real or apparent personal or professional relationships with propriety entities that produce health care good or services

&Screening & Treatment of Opioid Use Disorders: Closing the Gap

The substance use disorder treatment gap

Substance use leads to more death and disability than any other preventable condition

In 2014,• 21.5 million people w/ SUD• 2.3 million received

treatment

Robert Wood Johnson Foundation, 2010Mokdad et al., JAMA 2004National Survey on Drug Use and Health, 2014

21.5 million Americans

11%

Health care contacts offer an opportunity for intervention

• 2/3 of people with substance use disorders (SUD) see a health care provider at least twice a year.

• People with SUD have high rates of ED and hospital admission

• But… most MDs are unaware of their patients’ substance use

ASAM Policy Statement on Screening for Addiction in Primary Care Settings, 2005Walley AY, et al., J Addict Med 2012D’Amico EJ, et al., Medical Care 2005Friedmann PD, et al., Arch Intern Med 2001Saitz R, et al., Am J Drug Alc Abuse 1997

What are the goals of identifying drug use in medical settings?

1. Patient safety• Drug interactions• Withdrawal

2. Accurate diagnosis3. Prevention

• Overdose • Infectious disease• Comorbid conditions

4. Prescriptions and monitoring5. Reduce substance use

Opening the door to treatment

Medical settings can provide:• Pharmacotherapy • Integrated behavioral health care• Referral to addictions treatment• Brief intervention for risky use

Intensity of Treatment Provided

Proportion of Population Reached

Addiction & Mental Healthsettings

Non-specialty settings

Barriers to screening for drug use

• Time• Workflow• Knowledge/Training• Discomfort• Attitudes

Sterling S, et al., Addict Med Clin Pract 2012Friedmann PD, et al., J Gen Int Med 2000Friedmann PD, et al., Arch Int Med 2001Anderson P, et al., Alcohol Alcoholism 2004McCormick KA, et al., J Gen Int Med 2006

Having the right tools can help

Choice of a screening tool depends on the context

Screenin

g

Assess

ment

Diagnosi

s

Characterizing drug screening tools

Screening vs Assessment , Diagnosis

Single substance vs Comprehensive

Self-administered vs Interview

General population vs Specific groups

Low resources High resources

Suggested brief screening tools

Low resources High resources

1. Single-item screening question for drugs2. Substance Use Brief Screen (SUBS)3. Screen of Drug Use (SoDU)

SISQ-DrugHow many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? • Identifies unhealthy use (any response >0)

Sensitivity Specificity AUC

Interviewer 85% 96% 0.89

Self-administered 71% 94% 0.83

Smith PC, et al., Arch Int Med 2010McNeely J, et al., J Gen Int Med 2015

Substance Use Brief Screen (SUBS)

5/20/2014

SUBS

• Identifies unhealthy use• Self-administered (computer or paper)

Substance Sensitivity Specificity AUC

Illicit Drugs 81% 97% .89

Rx Drugs 56% 92% .74

Any Drugs 83% 91% 0.87

McNeely J, et al., Am J Med 2015

Screen of Drug Use

1. How many days in the past 12 months have you used drugs other than alcohol? [7+=positive]

2. How many days in the past 12 months have you used drugs more than you meant to? [2+=positive]

• Identifies drug use disorder

Sensitivity Specificity AUC

92% 93% .93

Tiet QQ, et al., JAMA Int Med 2015

Suggested brief assessment tools

Low resources High resources

1. DAST-102. ACASI ASSIST3. TAPS Tool

DAST-10Pros:

• 10 items• Interviewer or self-administered• Identifies moderate-risk and high-risk

Cons:• Does not identify specific substances• High face validity

Yudko E, et al., J Sub Abuse Treat 2007Smith PC, et al., Arch Int Med 2010

ACASI ASSISTAudio computer-assisted self interview (ACASI) version of the

WHO ASSISTPros:

• Identifies specific substances• Integrates tobacco, alcohol, and drugs• Identifies risk level (low-moderate-high)• Equivalent results to the interviewer version

Cons:• Requires computer• Average time to complete = 4.4 minutes (range 1-15)

McNeely J, et al., Addiction 2016McNeely J, et al., J Sub Abuse Treat 2014

Diagnostic Interview

Pros:• Facilitates treatment initiation by establishing a

diagnosis of SUD• Substance-specific

Cons:• Time to administer• Complexity• Requires trained interviewer

– Though MINI-Plus has self-administered version• Does not identify moderate-risk use

NIDA TAPS Tool

Screening (TAPS-1)

Assessment (TAPS-2)

4-item Screener• Tobacco• Alcohol• Rx drugs• Illicit drugs

Modified ASSIST-Lite• 7 items• Each has 2-3

branching questions

Self-administered (iPad)or

Interviewer-administered

TAPS Tool• Developed by team of researchers from NIDA Clinical

Trials Network• Validation study conducted in 5 sites with 2,000

primary care patients

Screening AssessmentSingle substance Comprehensive Self-administered Interview General population Specific groups

Screening & Treatment of Opioid Use Disorders: Closing the Gap

Why the ED??

That’s where the patients are

photo credit: YNHH/Yale University

Scope of the Problem

• 21.5 million Americans 12 or older had a substance use disorder in 2014;

1.9 million involved prescription pain relievers & 586,000 involved heroin.• Emergency Department (ED) visits related to opioids increased

− 145,000 to 420,000 from 2004-2012• Options for ED providers include referral and since 2002, initiation of

buprenorphine• One study evaluated the efficacy of referral with or without a Brief

Intervention vs. ED-initiated buprenorphine (JAMA 2015)– ED-initiated medication is common for other chronic medical conditions

(diabetes, hypertension, asthma)

Drug overdose is the leading cause of accidental death in the US: 47,055 deaths in 2014.

• 18,893 overdose deaths related to prescription pain relievers• 10,574 overdose deaths related to heroin

– CDC, National Vital Statistics 2015

Overdose22 year old female presents to ED in private vehicle driven by friends. On arrival patient pulled out of vehicle by ED staff, unresponsive with O2 Sat of 53%. Patient responded well to IV naloxone. Just 2 weeks before, she switched from prescription drugs to IV heroin.

Why is this different than any other acute emergency???

Innovative Interventions

Why not initiatetreatment immediately ?

Intervention for Substance Use Disorders

Project ASSERT Alcohol and Substance Abuse Services, Education and Referral to TreatmentHealth Promotion Advocates (HPAs) provide SBIRT in ED setting D’Onofrio G, Degutis C. Integrating Project ASSERT: a screening, intervention, and referral

to treatment program for unhealthy alcohol and drug use into an urban emergency department. Acad Emerg Med 2010;17:903-911.

Project ASSERT 2015

A Randomized Trial of ED-InitiatedInterventions for Opioid Dependence

Yale School of Medicine Emergency Medicine

Gail D’Onofrio MD, MS, Patrick G. O’Connor MD, MPHSteven L. Bernstein MD, Marek C. Chawarski PhD,

Michael V. Pantalon PhD, Patricia H. Owens MS, Susan H. Busch PhD, and David A. Fiellin MD

Departments of Emergency Medicine, General Medicine, Psychiatry and School of Public Health, Yale University, New Haven CT

Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial JAMA. 2015;313(16):1636-1644. 

Objective

To compare the efficacy of 3 interventions for opioid dependent ED patients

Referral to Treatment

Brief Intervention& Facilitated Referral

Brief Intervention with ED-initiated Buprenorphine

Primary Care follow-up for 10 weeks treatment

329 Patients were enrolled from April 2009 - June 2013

Interventions

ReferralHandout of all drug treatment providers/services in the area relevant to insurance status and access to a phone

Brief Intervention

The BNI, discussion of treatment options, and a facilitated referral to treatment [BNI, mean time 10.6 (SD) 4.3]

BuprenorphineThe BNI + ED-initiated buprenorphine and referral to Primary Care in 24-72 hours for ongoing buprenorphine medical management (10 weeks), followed by transfer or detoxification

Brief Negotiation Interview (BNI)Raise The Subject

– Establish rapport – Raise the subject of drug use– Assess comfort

Provide Feedback– Review patient’s drug use and patterns– Make connection between drug use and negative

consequences; risk of HIV/AIDS (e.g. impaired judgment leading to unprotect sex/sharing needles); MINI feedback

– Make a connection between drug use and ED visit– Discuss issues related to physical dependence, such as

tolerance and withdrawal

• Manual Driven• Performed by RAs • Recorded

Enhance MotivationAssess readiness to change: One a scale 1 to 10 how ready are you to enroll in program / start buprenorphine/naloxone (Suboxone)?(Why didn’t you pick a lower number?)

Negotiate And Advise- Negotiate goal - Give advice- Summarize and complete referral / Initiate buprenorphine/naloxone

BNI (continued)

Consort Diagram

Engaged in Treatment at 30-Days

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Prop

ortio

n in

Tre

atm

ent a

t 30

Day

s

30 days No. (%, 95% CI)

Treatment Effect

30 day Treatment Engagement(Referral)

(Brief Intervention) (Buprenorphine)

38/102 (37, 0.3-0.5)50/111 (45, 0.4-0.5)

89/114 (78, 0.7-0.9) p<0.001

P<0.001

Referral Brief Intervention Buprenorphine

7-Day Illicit Opioid Use

Baseline 30 Day FU0

1

2

3

4

5

6

SRTSBIRTSBIRT+BupPC

Day

s

BaselineMean(95% CI)

30 daysMean(95% CI)

Treatment Effect

Interaction Effect

Mean # days of use (Referral)

(Brief Intervention)(Buprenorphine)

5.4 (5.1-5.7)5.6 (5.3-5.9)5.4 (5.1-5.7)

2.3 (1.7-3.0)2.4 (1.8-3.0)0.9 (0.5-1.3)

P<0.001 P=0.02

Treatment Effect: P<0.001Time effect: P<0.001Interaction Effect: P=0.02

ReferralBrief InterventionBuprenorphine

Inpatient and ED-Based Addiction Treatment in the Past 30-Days

   Baseline 30 Days

  N No (%) p-value N No (%) p-value

% Inpatient Addiction Treatment 

Referral 104 10 (9.6)   84 31 (36.9)  

Brief Intervention 111 7 (6.3)   91 32 (35.2)  

Buprenorphine 114 7 (6.1) p=0.55 100 11 (11.0) p<.001

% ED-based Addiction Treatment  

Referral 104 8 (7.7)   69 15 (21.7)  

Brief Intervention 111 6 (5.4)   82 12 (14.6)  

Buprenorphine 114 5 (4.4) p=0.57 93 18 (19.4) p=0.51

Primary Care Treatment

• Physician visits (Primary Care Management)– Week 1 (30-40 minute)– Weeks 2, 3, 5, 7, 9 (15 minute)

• Nurse visits (Medical Management) CTN 030 (POATS)

– Day 1 (30 minute)– Days 3, 5 (15 minute)– Weeks 2, 3 (20 minute)– Weeks 4-10, weekly or q 2 weeks based on stability

(20 minute)

Conclusion

• Screening must be integrated in clinical settings • Interventions need to initiated at the time of entry into the healthcare system• Follow up care must be facilitated

The latest research shows that we really should do something

with all this research

Research SupportGail D’Onofrio MD, MS

Jennifer McNeely MD, MS

NIH/NIDA K12 DA033312SAMHSA U79 T1025362NIDA U10DA013038NIAAA 5R01AA022083NIDA 5R01DA035775NHLBI 5R18HL108788

NIH/NIDA K23 DA030395NIH/NCATS UL1 TR000038NIDA cooperative grant award UG1DA013035

Extra slide: For Q & A

The Rikers Island Hot Spotters:Caring for the most Frequently Incarcerated

Ross MacDonald, MDChief of Service, Medicine

NYC Health + HospitalsCorrectional Health Services

New York City Jail System

NYC Jails

• 12 Jails– Each with 24/7 Clinic with at least one physician at

all times• 60,000 admissions per year

– Each gets full history and physical exam• 10,000 average daily population

– Median Length of stay 13 days, Average 49 days

NYC Jails Care Delivery• Medical

– Sick call– Chronic care– Emergency care– Transtional Health Care Coordiantion

• Mental Health– Routine referrals within 72 hours– Stat referrals 24/7– Specialized units modeled after inpatient– Mental Health Discharge Planning

• Substance Use Treatment– Rikers island KEEP program (Opioid Treatment Program)– CBT-based programming units

CHS Clinical Agenda: Incorporating Human Rights

Patient Safety

Human RightsPopulation Health

High Risk Population, Dangerous Place

• Risks have generally been ascribed to individual characteristics of those incarcerated– Mental illness – Substance abuse– Chronic disease

• New Frame:– Environmental components of the jail confer risk– Structural components of the process of

incarceration confer risk

Health Risks of Jail• Injury, including Traumatic Brain Injury• Withdrawal• Communicable disease• Medication interruption• Self-Harm• Post-release mortality

– Mortality is increased in the immediate post-release period (2-4 weeks)

• True for Prison – SMR of 12.71

• True for jail (NYC data)- SMR of 8.02

• Driven largely by overdose death

1.Binswanger et al 2007 2. Lim et al 2012

Zach Gross, The New Yorker

Hot Spotters Methodology

Total Data Collection Period ~6 years

2009 2010 2011 2012 2013 201408

Jail Electronic Health RecordImplemented

Incarceration Frequency Period

• 78,618 Admissions.

• 57,194 Individuals

• All Patients admitted to NYC Jails in 2013• 800 most frequently incarcerated since 11/2008• Compared to 800 randomly selected

Hot Spotters , Over ~6 YearsFrequently Jailed Pts. n=800

Rikers Control Pts. n=800

Number of Incarcerations 18,713 3,108Mean Number of Incarcerations per Person 23.4* 3.9Sum of Years Incarcerated 1,423 yrs 415 yrsEstimated Costs of Incarceration $129,105,794 $37,679,178Length of stay, days

Mean 28* 49 Median 11 13

*p<.0001

Control

Hot SpottersHispanic

Non-Hispanic Black

Non-Hispanic White

Other/unknown

73%*

58%

<10%

Mean Age 42*

Mean Age 35*p<.0001

Hot Spotters CharacteristicsFrequently Jailed Pts. n=800

Rikers Control Pts. n=800

Mental Health

Serious Mental Illness 19.0%** 8.5% Anti-psychotic Prescribed 37.0%** 15.6%Substance Use

Significant Drug/Alcohol Use 96.9%** 55.6% Alcohol Withdrawal in Jail 22.1%** 4.4%Services

Evidence of Homelessness in Chart 51.5%** 14.7% Ever with a Medicaid Number 95.9%** 78%

*p<.0001

Hot Spotters Chronic DiseaseFrequently Jailed Pts. n=800

Rikers Control Pts. n=800

HIV + 10.9%* 4.3%

Hepatitis C 18.3%* 7.4%Diabetes 8.9%* 4.1%Epilepsy 8.8%* 5.4%

Hot Spotters Charges

Hot-spotters Control0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

88.70%

54.90%

10.30%

42.30%

Charge Type

Misdemeanor Felonies

Hot Spotters Charges

Petit larceny Criminal possession of substance to the

7th

Criminal Trespass in the second degree

Theft of services Assault of any type0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

29.9%

23.8%

5.7% 5.5%2.80%

Charges

Hot-spotters Control

Institutional Circuit

• A revolving set of institutions that also serve the role of temporary housing

• “…these and allied systems have the perverse institutional effect of perpetuating rather than arresting the ‘residential instability’ that is the underlying dynamic of recurring literal homelessness.”1

1. Hopper K et al., Psychiatric Services, May 1997

Institutional Circuit• Where?

– Jails– Emergency Departments– Inpatient Wards

• Medical• Psych

– Skilled Nursing Facilities– Inpatient Drug Rehab

• Often Court Mandated– Short-term Detox– Shelters

• Sometimes cut out of the loop

• Enormous societal cost

Qualitative Interviews (n=20)• 5 women, 15 men• Median age, 42 years (range 25 - 55)• 16 black, 2 white, 1 Hispanic/Latino, 1

multiracial• 17 unstably housed, 8 street homeless• 12 had not completed high school

Participant characteristics (n=20)

• 17 had a prior felony conviction• 17 reported a history of problem substance use• 15 reported at least one psychiatric diagnosis• Nearly all participants had extensive contact

with a wide range of services

Criminal justice involvement• Childhood often characterized by instability

including substance use, mental illness, and homelessness

• Majority had been arrested and incarcerated as juveniles

• Early CJ contact set sustained trajectory to life-long institutionalization

• Current charges were typically for petit larceny, drug possession, and theft of services

“I've been arrested mostly for petit larceny, but I'm only stealing food to eat. . . Because there ain't nobody who give nothing to me. I don't have no family, nobody to go to, to get food. . . I [had] food stamps but I lost my ID. See, when you're homeless, it's hard to keep your stuff staying with you. I lose everything. I don't have no steady foundation. So I'm in the street. What am I supposed to do? Walk around with a briefcase, homeless? Office desks and stuff? Put my office here and trinkets down in the alleyway? You can take that, pick it up and walk. I mean, hey, it's hard.”

(Walter, age 43)

Substance use

• Crack/cocaine was typically the primary drug– Some participants initiated crack use later in life

leading to more frequent arrests• All but one who reported problem substance use

had experienced at least one episode of drug treatment

• Reduction in use of participants’ primary drug often aligned with a reduction in arrest

“I took [drug diversion] twice. I denied all the rest. They always offer me drug court, all the time. I tell them I'd rather do jail time. . . Because then the alternative, if I mess it up, which is more than likely I'm gonna mess up, I'm gonna wind up doing a whole year, a whole two years, when I could have just did 90 days . . . I know me, I know who I am. I know I can't sit in the drug program and do a whole program for a year. I know I can't do that. I tried it. It doesn't work. . . If you mess it up, they give you a year, and there's no, "I don't want to take a year," they're going to mandatory give it to you, because you already pled guilty. Now I don’t have no option no more.”(Trevor, age 25)

Housing services

• The environment in many shelters was experienced as intolerable and unsafe and often likened to jails

• In some cases, street homelessness was considered less dreadful than shelters

• Obtaining permanent housing via the shelter system required wait times of several years

“I put everything in, I’ve been waiting and waiting and waiting and waiting and waiting so long. . . So long that I went back and got back into the life of crime just sitting waiting, and got in trouble. So by that time, the thing of me sitting here waiting, hoping they’re going to give me housing, give me somewhere to live, like damn, I been here almost two, three years. How long it’s going to take me?”(Walter, age 43)

Bureaucratic competence

• A set of abilities and fluencies including vocabulary, presentation, literacy, and an understanding of the importance of tenacity, all necessary to navigate complex social services2

• Many participants lacked these skills and were therefore unable to effectively utilize the services designed to support them

2. Gordon, L.K. (1975). Bureaucratic competence and success in dealing with public bureaucracies. Social Problems, 23(2), 197-208.

“They don't help out. Once you meet a social worker or case manager they, they don't do it. . . They meet you, and they say well, they can't keep you as a person on their roster or their list because they so full, but it was nice meeting you. You have to do things by yourself, and you don't know how to get around in the neighborhood doing things.”

(Leah, age 47)

Linkage to Supportive Housing• A data-driven approach• Leveraging Correctional Health Transitional Services• “Mr. B. T. has arrived in full effect - but raring to go.

Had all ID's and paperwork we need, etc. Case file has been created. He has been given his key, we are currently going to take him to the supermarket for food and then to his apartment. He is very cooperative and a little nervous but looking forward to his next 'adventure' in life. “

New York City Jail System

Closing Treatment Gaps in the Health Care and Criminal Justice Systems

Presenters:• Jennifer McNeely, MD, MS, Assistant Professor, New York University

School of Medicine• Gail D’Onofrio, MD, MS, Chair, Department of Emergency Medicine,

Yale School of Medicine• Ross MacDonald, MD, Chief of Medicine, Division of Correctional

Health Services, New York City Health and Hospitals

Treatment Track

Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of Science Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and Member, Rx and Heroin Summit National Advisory Board