Transforming Treatment: - PowerPoint Presentation

Slide1

Transforming Treatment: Treating Substance Use Disorders as Health Conditions

South Carolina Department of Alcohol and Other Drug Abuse ServicesUniversity of South CarolinaRecovery Program Transformation & Innovation Fund ConferenceSeptember 10, 2015

Howard

Padwa

, Ph.D.

University of California, Los Angeles

Integrated Substance Abuse Programs

1Slide2

Recovery Program Transformation & Innovation FundFour priority areas for Planning and Implementation Grants:Medication Assisted TreatmentIntegration of Behavioral Health Services (mental health, medical)Adolescent/family services – forming and strengthening partnershipsInfrastructure for accessible, integrated services

Reflect national and historic trend toward treating substance use disorders (SUD) like we treat other health conditions 2Slide3

Transformation:Seeing SUDs as Health ConditionsHistorically, problematic alcohol/drug use seen as a vice, moral failing, weakness, or choiceAssociation of substances with racial, political “enemies”

Major policy responses:Control supplyPunitive approach to users3Slide4

4Transformation:Seeing SUDs as Health Conditions 1940s-2000s: Recognition of SUD as a medical problem

McLellan et al., “Drug Dependence, A Chronic Medical Illness” published in JAMA (2000) Compared SUD to diabetes, hypertension, asthma Similar roles of genetics, personal choice, environment

Comparable outcomes if managed with behavior modification, ongoing monitoring, medications

Clinical argument for increased insurance/primary care involvement, on par with other medical conditionsSlide5

Transformation: Bringing Treatment Out Of IsolationSUD Treatment Has Been IsolatedInebriate Asylums, Narcotic FarmsCriminal Justice SettingsMethadone Clinics

Peer support emphasis12-Step focusTherapeutic CommunitiesMost SUD treatment occurred in places that only focused on SUD

5Slide6

2008 Wellstone-Domenici Mental Health and Addiction Equity Parity Act2010 Affordable Care ActAssure coverage of SUD in parity with other health benefitsEncouraging integration of SUD services into other health settings, service systemsHolding SUD services up to same standards as other areas of medicine

6Transformation: Bringing Treatment Out Of IsolationSlide7

Transformation of SUD Services7 Two interrelated changes Treating SUD like other medical conditions

Bringing SUD services in to the health care systemSlide8

The Isolation of SUD TreatmentMEDICAL SYSTEM

MENTAL HEALTH(MH) SYSTEM

SUD

SYSTEM

8Slide9

The burden of coordinating care and meeting population needs “should rest on the system, not the families or consumers who are already struggling because of a serious illness.”President’s New Freedom Commission, 2003Making Services More Patient-Centered

9Slide10

One of the major goals of health care reform is to move from services that are system-centered to ones that are patient-centered. Integration can make services more patient-centered. For SUD clientsFor people who would benefit from SU services but do not receive them

Making Services More Patient-Centered10Slide11

What Integration Can DoMEDICAL SYSTEM

MENTAL HEALTH(MH) SYSTEM

SUD

SYSTEM

11Slide12

What Integration Can DoHelp create a “no wrong door” system that includes SUD services12Slide13

Why Integrate?Different Reasons for Different Populations

Humphreys & McLellan, 201013Slide14

Integration for clients in treatment14

SUDTreat people, not disordersSubstance use is rarely the only problem

SUD clients have unmet MH needs

SUD clients have unmet medical needsSlide15

Why Integrate MH Services with SUD Treatment?MH disorders are more prevalent among individuals with SUDs.SAMHSA 2014, NSDUH Mental Health Findings

15Slide16

Co-Occurring MH Disorders Are Associated With Worse OutcomesIncreased risk for:Suicidal IdeationAggression/InjuryHIVHepatitisChronic health problems (cardiovascular, liver, GI)Hospitalization

Social ExclusionHomelessnessCSAT 2005; Horsfall

et al., 2009

16Slide17

MH Disorders are particularly common among people in SUD treatmentMore likely to seek treatment if there is a co-occurring MH disorderApprox. 50-70% with lifetime history of MH disordersEstimated 40-50% with current MH disordersCo-occurring MH disorders should be considered the rule, not the exception

Why Integrate MH Services with

SUD Treatment?

CSAT 2005: Flynn & Brown, 2009

17Slide18

Similar SUD outcomes, worse MH outcomesLess satisfied with treatmentBelieve treatment is less clear, less supportiveMore likely to drop outLess change in beliefs/relapse prevention skillsSee fewer benefits to quittingLess confident they can stay abstinentLess likely to develop problem-solving skills

How Do Clients With MH DisordersDo In SUD Treatment?

Boden

& Moos 2009;

Horsfall

et al., 2009

18Slide19

Why Do COD Clients Struggle with “Traditional” SUD Treatment?Client LevelLess motivation to changeFailure to recognize psychiatric symptoms Self-medicationCognitive challengesProgram Level

Perceived necessity of sequential treatmentConfrontational approaches Opposition to psychotropic medicationSuspicion of medical expertise vs lived experience

19Slide20

Integration Can Help Address SUD Clients’ MH NeedsMEDICAL SYSTEM

MENTAL HEALTH SYSTEM

SUD

SYSTEM

20Slide21

What are the ways that MH and SUD services are integrated?21

MH/SUD Consultation

MH/SUD

Coordination

Integration of services

Full

IntegrationSlide22

What are the ways that MH and SUD services are integrated? 22

MH/SUD

Consultation

Informal relationships between SUD and MH providers.

Referrals/linkages to providers of other specialty when necessary.

Consultation on client needs, engagement, prevention, and early intervention.Slide23

What are the ways that MH and SUD services are integrated? 23

MH/SUD

Coordination

Formalized relationships between SUD and MH providers

Specialty MH and SUD providers will discuss specific clients.

More clinically integrated, with providers working as a team.Slide24

What are the ways that MH and SUD services are integrated? 24

Full

Integration

Services to address both mental health and substance use disorders are provided in the same program.

Services provided by one integrated team that has professionals with expertise in providing services for MH, SUD, and COD.Slide25

What Integrating MH and SUD Services Can DoBenefits of integrationImprove access to MH servicesMake interventions more focused on client needsTransfer burden of care coordination from the client to the systemTreatment that addresses both MH and SUD at the same time associated with less crises (arrests, hospitalization)

There is not clear evidence of which integration model leads to the best outcomes Mangrum 2006; Drake et al., 2008; Sterling et al., 2011

25Slide26

Where should integrated services be provided?26

Severity of SU Disorder

Severity of MH Disorder

Mauer, 2006Slide27

What Is the Goal? Co-Occurring CapabilityNot all programs need to offer fully integrated careThe key is to be co-occurring capableDetect MH needsEither link to MH services or treat them Provide services that are sensitive

to needs of clients with mental illnessDual Diagnosis Capability in Addiction Treatment (DDCAT) Index See SAMHSA’s DDCAT Version 4.0 for more details

27Slide28

Diagnostic ServicesMedicationsPsychoeducationMotivational InterviewingContingency Management

Cognitive Behavioral Therapy TechniquesRelapse Prevention Strategies28Co-Occurring Capable

Treatment Tools

See the Center for Substance Abuse Treatment’s TIP 42 for more details. Slide29

Integration Can Help Address SUD Clients’ Medical NeedsMEDICAL SYSTEM

MENTAL HEALTH SYSTEM

SUD

SYSTEM

29Slide30

Why Integrate Medical Care with SUD Treatment?Behavioral risksMore tobacco use: breathing problems/cancerInjections: collapsed veins, infections Intoxication leads to more risky sex behaviors

Violence (pharmacological, systemic)PovertyUnderutilization of healthcare servicesBoles 2003, McCoy 2001, NIDA 2012

30Slide31

Why Integrate Medical Care with SUD Treatment?Direct medical consequences of substancesEffects on heart rate/heart attacksDecreases lung functioningStomach inflammationLiver damage

Kidney damage/failureIncreased blood pressure/strokeSubstance use and SUD contribute to over 70 conditions that require medical care1/3 of people with SUD have a chronic physical condition or disease

31

NIDA 2012, Reif 2011; NCASA 2012Slide32

Substance use shortens life…32Substance Use DisorderPremature Death

Premature Death from Natural CausesPercentage of Premature Deaths Not Accident/ODAlcohol Dependence

1.97 times the risk

1.7 times

the risk

66%

Opioid Dependence6 times the risk

4 times the risk

47%

Harris 1998Slide33

…especially in the public SUD systemPeople who receive public SUD services:Live 26.1 years less than the general populationIf they have co-occurring MH disorders, they live 34.5 years lessNearly two-thirds of deaths are due to medical causes

33ODHS 2008Slide34

Common Medical Conditions in the SUD Population: HIVTransmitted through sexual contact or bloodDestroys CD4 cells leading to Acquired Immunodeficiency Syndrome (AIDS), leaving body vulnerable to infections and cancersInjection drug users account for 30% of new cases outside of sub-Saharan Africa

30-40% of injection drug users in US are HIV positive34Des Jarlais & Semaan

2008, Harris 1998, Clark 2010

http://www.niaid.nih.gov/topics/hivaids/understanding/howhivcausesaids/pages/howhiv.aspxSlide35

Common Medical Conditions in the SUD Population: Hepatitis CVirus that leads to liver inflammation

60%-85% of cases lead to chronic infection, leading to increased risk of cirrhosis.High risk of transmission through injection drug use or needle sharing

Most common infectious disease among injection drug users (60-90%)

Injection drug users are largest group infected with Hepatitis C in the US

https://nccih.nih.gov/health/hepatitisc/hepatitiscfacts.htm

Edlin

2002, Clark 2010

35Slide36

Inflammation of lining inside heart valves and chambersUsually caused by infection or fungusIncreased risk from injection drug use:Particulates in drugsPoor injection hygieneUnsterile equipmentContaminantsRisk is higher with cocaine injection

Common Medical Conditions in the SUD Population: Endocarditishttp://www.nlm.nih.gov/medlineplus/ency/imagepages/18142.htm

Schwartz 2010

36Slide37

Damaged airways and sacs in lungs, causing breathing difficultyInhalation of stimulants can cause buildups in lungsEmphysema associated with IV drug useAssociation with tobacco useAsthma twice as prevalent among individuals with SUD

Common Medical Conditions in the SUD Population: Lung Disease

http://nihseniorhealth.gov/copd/whatiscopd/01.html

Wesselius

1997,

Mertens

2003

37Slide38

Common Medical Conditions in the SUD Population: HypertensionHigh blood pressure increases risk of stroke, heart attack, brain damage, vision lossThree drinks per day increases riskCaused by stimulantsTwice as prevalent in SUD population

https://www.nlm.nih.gov/medlineplus/highbloodpressure.htmlSesso 2008, MacMahon 2010, Mertens

200338Slide39

Prevents cells from receiving sugar, leading to buildup in bloodCan lead to blindness, heart disease, stroke, kidney failure, amputationBinge drinking increases riskSubstance use associated with earlier age of onsetAlcohol worsens diabetes health outcomes

Common Medical Conditions in the SUD Population: Type 2 DiabetesPietraszek 2010, Johnson 2001, Emanuele

1998

39Slide40

Inflammation of tissue lining joints, leading to breakdown of cartilageCauses pain, stiffness, swelling, reduced mobilitySeptic arthritis caused by infection, associated with injection drug useArthritis almost three times as prevalent among people with SUDCommon Medical Conditions in the SUD Population: Arthritis

Mertens 2003https://www.nlm.nih.gov/medlineplus/ency/imagepages/17128.htm

40Slide41

Over One-Half of SUD Clients Do Not Receive Regular Medical CareAmong them:12% have liver disease16% have hypertension20% have asthma or COPD6% have hepatitis3% have HIV/AIDS

47% have sexually transmitted infectionsDe Alba 200441Slide42

Integration with medical services improves clients’ health…Decreases hospitalization ratesDecreases number of inpatient daysDecreases ED visitsIncreases adherence to HIV antiretroviral therapy Can cut total medical costs in half

42Parthasarathy 2003, Weisner 2001, Parry 2007Slide43

…and it makes treatment more effective!!!!Primary care reduces drinking and drug use by people with SUD 2-10 primary care visits/year triples chances of SUD remission after five years Integrated SUD/medical services reduces SUD severity after 12 months; off-site referral does not

43Saitz et al 2005, Friedmann 2003, Mertens 2008Slide44

Changes Bringing Greater Integration with Medical CareMEDICATIONUSE

FDA APPROVALBuprenorphineOpioid Use Disorder

2002

Acamprosate

Alcohol Use

Disorder2004Naltrexone

(Ext. Release)

Alcohol Use Disorder

Opioid

Use Disorder

2006

2010

Safe and highly effective when used with other services

Less than half of SUD programs have a physician who can prescribe these medications

Integrating with medical care can improve access to medications

SAMHSA 2012

44Slide45

Newly insured population expected to have high levels of SUD needSUD services among essential benefits under the ACAInsurance reimbursement will lead to greater links with primary care (like other specialties)Changes Bringing Greater Integration with Medical Care

45Slide46

Why Integrate?Different Reasons for Different Populations

Humphreys & McLellan, 201046Slide47

Integration for people who need SUD treatment but don’t get it47

SUDSAMHSA 2014Slide48

Integration Can Improve Access to SUD ServicesMEDICAL SYSTEMMENTAL

HEALTH SYSTEM

SUD

SYSTEM

48Slide49

SUD in Mental Health Settings49

SUDSelf medication to alleviate stress, anxiety, depression

Mental health disorders increase likelihood of substance use, dependence

SUDs over three times as common in individuals with mental illness

25-50% of people in MH treatment have SUD

Weiss 1992, Robinson 2011, SAMHSA 2010; CSAT 2005Slide50

50 Almost 38% of older problem drinkers use alcohol to manage pain 9%-41% of chronic pain patients abuse opioids

Approx. 22% of healthcare patients misuse substanceOver 7.5 million ED visits annually due to alcoholBrennan 2005, Machikanti

2006, , McDonnald

III 2004; TRI 2010

SUD in Medical Settings

SUDSlide51

Integration for people who don’t need treatment…yetExcessive drinking and drug use cause changes in brain that can lead to SUDUse mental health and medical visits as a “teachable moment” to facilitate behavior change Educate about risks associated with substance use, including SUD

Briefly use motivational interviewing and cognitive behavior techniques 51

At Risk

Problematic Use

McLellan

2000, Madras 2009Slide52

Integration for people who don’t need treatment…yetScreeningBriefIntervention

Referral toTreatment52

At Risk

Problematic Use

Pre-post studies have shown reductions in alcohol/drug use

More rigorous trials showed effect for risky drinking, but not heavy drinking or drug use

Major Challenges:

How “brief” can “brief interventions” be?

How to make the “RT” work

Madras 2009;

Saitz

2015Slide53

Integration for people who don’t need treatment…yetScreeningBriefIntervention

Referral toTreatment53

At Risk

Problematic Use

SBIRT is feasible and potentially beneficial in places outside of the medical system

Largest potential benefit in places where there are at-risk populations or high levels of substance use

Schools and Universities

Juvenile Justice

Jails

Social Services Slide54

How Can Integration Happen?54Mauer 2006

Severity of MH/SU Disorder

Severity of

Physical DisorderSlide55

What Does High MH/SUD, High Primary Care Look Like?There have been early adopters across the countryBeen developing integrated care for a long timeHave a lot of resourcesFor details see:

Treatment Research Institute “Forum on Integration” (2010)SAMHSA “Innovations in Addiction Treatment: Addiction Treatment Providers Working With Integrated Primary Care Services (2012)55Slide56

SUD/Medical IntegrationCalifornia (2011-2012)43 of 44 California counties surveyed reported SUD/PC integrationTwo most common models:

Behavioral health in primary carePrimary care in SUD settingsThere is no clear evidence of which integration model is “best”56Slide57

How Does Integration Happen?Behavioral Health in Primary CareBH staff trained in SUD treatment conducts SBIRTBH staff works as member of primary care team in coordination with medical doctorBH staff provides counseling, other services for 3-5 sessionsExperience shows this can lead to more focus on MH than SUD

57PRIMARYCARE

Behavioral HealthSlide58

How Does Integration Happen?Primary Care in SUD TreatmentMedical staff provide services onsite in SUD treatment facilities.Give physicals, screen for chronic diseases, refer to medical specialists SUD treatment staff screen for physical problems, refer as necessary58

SUD Treatment

Medical CareSlide59

Integrating Isn’t Always Easy“Integrated…care is like a pomegranate: overwhelmingly people say they like it, but few buy it.” Cummings, 200959Slide60

Common Barriers to IntegrationDOCUMENTATION Incompatible Systems Confidentiality/Privacy Concerns

FUNDING Silos Poor Reimbursement Sustainability

ORGANIZATIONAL CHARACTERISTICS

Reluctance

to Change

Lack of implementation resources (space, time)

Poor role clarityPROVIDER CHARACTERISTICS Reluctance to deliver new services

Divergent service philosophies

Different work paces/styles

60Slide61

Common Facilitators of Integration61FUNDING Flexible or dedicated funding

DOCUMENTATION Develop/utilize EHRs that facilitate integration Client consents to share information

LEADERSHIP (SYSTEM

AND CLINIC LEVEL)

Enhance buy-in

Use a provider “champion” to lead change

Foster strong collaborative relationships (individuals, agencies) Training, technical assistance Quality improvement Flexibility, freedom to experimentSlide62

Take Away PointsSUD services are being integrated into the mainstream of the US health care systemIntegration with mental health and medical services can help: Better address whole-person needs of clients in treatmentFacilitate access to most modern, evidence-based approaches to SUD careClose the SUD treatment gap

62Slide63

SUD integration can/should be not only with medical services, but other places where there are likely to be high levels of risk or needThe benefits of integration are clear, but some questions remain:How can integrated services be enhanced to have maximum benefit ?Funding and leadership that support service integration can help overcome barriers to implementation Take Away Points

63Slide64

QUESTIONS?64Slide65

WORKS CITEDBoden, M. T., & Moos, R. (2009). Dually diagnosed patients' responses to substance use disorder treatment. Journal of Substance Abuse Treatment,37(4), 335-345.Boles SM,

Miotto K. 2003. Substance abuse and violence: a review of the literature. Aggression and Violent Behavior. 8(2):155-174Brennan PL, Schutte KK, Moos RH. 2005. Pain and use of alcohol to manage pain: prevalence and 3-year outcmes among older problem and non-problem drinkers. Addiction. 100(6):777-786.Center for Substance Abuse Treatment,

Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3922. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.

Clark RE, O’Connell E,

Samnaliev M. 2010.

Substacne Abuse and Healthcare Costs. Knowledge Asset web site created by the Robert Wood Johnson Foundation’s Substance Abuse Policy Research Program; March 2010.

http://saprp.org/knowledgeassets/knowledge_detail.cfm?KAID=21Cummings NA, O’Donohue WT, Cummings JL. 2009. The Financial Dimension of Integrated Behavioral/Primary Care. Journal of Clinical Psychology in Medical Settings16:31-34.

De Alba I,

Samet

JH,

Saitz

R. Burden of Medical Illness in Drug- and Alcohol –dependent Persons Without Primary Care. American Journal on Addictions. 13:33-45.

Des

Jarlais

DC,

Semaan

S. HIV Prevention for Injecting Drug Users: The First 25 Years and Counting. Psychosomatic Medicine. 70(5):606-6111

Drake RE, O’Neal EL, Wallach MA. 2008. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment 34(1):123-138

Edlin

BR. 2002. Prevention and treatment of hepatitis C in injection drug users.

Hepatology

36(S1):S210-S219.

Emanuele

NV,

Swade

TF,

Emanuele

MA. 1998. Consequences of Alcohol Use in Diabetics. Alcohol Health and Research World. 22(3):211-219.

65Slide66

WORKS CITEDFlynn PM & Brown BS. 2009. Co-Occurring Disorders in Substance Abuse Treatment: Issues and Prospects. Journal of Substance Abuse Treatment. 34(1):36-47 Friedmann PD, Zhang Z, Hendrickson J, et al. 2003. Effect of Primary Medical Care on Addiction and Medical Severity in Substance Abuse Treatment Programs. Journal of General Internal Medicine. 18(1):1-8.Harris EC, Barraclough

B. 1998, Excess mortality of mental disorder. British Journal of Psychiatry 173:11-53Horsfall, J., Cleary, M., Hunt, G. E., & Walter, G. (2009). Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): A review of empirical evidence. Harvard review of psychiatry, 17(1), 24-34.Humphreys K,

McLellan AT. Brief intervention, treatment and recovery support services for Americans who have substance use disorders: An overview of policy in the Obama Administration.

Psychological Services

. 2010;7(4):275-284.John son KH,

Bazargan M, Cherpitel

CJ. 2001. Alcohol, tobacco, and drug use and the onset of type 2 diabetes among inner-city minority patients. Journal of the American Board of Family Medicine. 14(6):430-436Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites. Drug and Alcohol Dependence.

2009;99(1-3):280-295.

Manchikanti

L, Cash KA,

Damron

KS. 2006. Controlled substance abuse and illicit drug use in chronic pain patients: an evaluation of multiple variables. Pain Physician. 9:215-226.

MacMahon

MJ,

Tallentire

VR. 2010. Stimulating stuff: the pathological effects of cocaine and amphetamines on the cardiovascular system. British Journal of Diabetes & Vascular Disease. 10:251-255

Mangrum

, L. F., Spence, R. T., & Lopez, M. (2006). Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders. 

Journal of substance abuse treatment

, 

30

(1), 79-84

Mauer

BJ. 2006. Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-Based Practices. National Council for Community Behavioral Healthcare

McCoy CB,

Metsch

LR,

Chitwood

DD, et al. 2001. Drug Use and Barriers to Use of Health Care Services. Substance Use & Misuse, 36(6-7):789-806

McDonald III AJ, Wang NW,

Camargo

Jr. CA. US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000.

Archives of Internal Medicine

. 2004;164(5):531-537.

66Slide67

WORKS CITEDMcLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. Journal of the American Medical Association. 2000;284(13):1689-1695.Mertens JR, Flisher

AJ, Satre DD. 2008. The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependencey treatment patients. Drug and Alcohol Dependence. 98(1-2):45-53Mertens JR, Yun

WL, Parthasarathy

S, et al. 2003. Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: comparison with matched controls. Archives of Internal Medicine 163(20):2511-2517.

National Institute on Drug Abuse. (accessed February 2012). Medical Consequences of Drug Abuse. http://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse

National Center on Addiction and Substance Abuse, 2012.

Addiction Medicine: Closing the Gap Between Science and Practice. New York: The AuthorOregon Department of Human Services. 2008. Measuring Premature Mortality Among Oregonians. Oregon Department of Human Services, Addiction and Mental Health Division. National Institute on Drug Abuse . 2011. Drug Abuse and the Link to HIV/AIDS and Other Infectious Diseases. http://www.drugabuse.gov/sites/default/files/drugaids.pdfParry CD, Blank MB,

Pithey

Al. 2007. Responding to the threat of HIV among persons with mental illness and substance abuse. Current Opinion in Psychiatry. 20(3):235-241.

Parthasarathy

S,

Mertens

JM, Moore C,

Weisner

C. Utilization and cost impact of integrating substance abuse treatment and primary care. Med Care. 2003;41(3):357-367.

Pietraszek

A,

Gregersen

S,

Hermansen

K. 2919. Alcohol and Type 2 Diabetes: A Review. Nutrition, Metabolism and Cardiovascular Diseases. 20(5):366-375

President's New Freedom Commission on Mental Health.

Achieving the Promise: Transforming Mental Health Care in America: Final Report, July 2003

.

Reif

S, Larson MJ, Cheng DM, et al. 2011. Chronic disease and recent addiction treatment utilization among alcohol and drug dependent adults. Substance Abuse Treatment, Prevention, and Policy. 6:28.

Robinson J,

Sareen

J, Cox BJ, et al. 2011. Role of

Selanxiety

and substance use disorders: a longitudinal investigation. Archives of

Genf

-medication in the development of

comorbid

eral

Psychiatry 68(8):800-807.

Saitz

, R. (2015). ‘

SBIRT’is

the answer? Probably not. 

Addiction

, 

110

(9), 1416-1417

67Slide68

WORKS CITEDSaitz R, Horton NJ, Larson MJ. 2005. Primary medical care and reductions in addiction severity: a prospective cohort study. Addiction 100(1):70-78.Schwartz, B. G., Rezkalla, S., & Kloner, R. A. (2010). Cardiovascular effects of cocaine. 

Circulation, 122(24), 2558-2569.Sesso HD, Cook NR, Buring JE. 2008. Alcohol Consumption and the Risk of Hypertension in Women and Men. Hypertension 51(4):1080-1087.

Sterling, S., Chi, F., & Hinman

, A. (2011). Integrating care for people with co-occurring alcohol and other drug, medical, and mental health conditions.

Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism

, 33

(4), 338.Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.Substance Abuse and Mental Health Services Administration (2012).

Innovations in Addictions Treatment: Addiction Treatment Providers Working With Integrated Primary Care Services

Treatment Research Institute, Inc. 2010.

Forum on Integration: A Collaborative for States.

Philadelphia (PA): Treatment Research Institute, Inc.

Weisner

C,

Mertens

J,

Parthasarathy

S, et al. Integrating primary medical care with addiction treatment: a randomized control trial.

Journal of the American Medical Association

. 2001;286(14):1715-1723.

Weiss RD, Griffin ML,

Mirin

SM. Drug abuse as self-medication for depression: an empirical study. 1992. American Journal of Drug and Alcohol Abuse 18(2):121-129.

Wesselius

LJ. 1997. Pulmonary Disorders Associated With use of Illicit Drugs. Clinical Pulmonary Medicine. 4(2)

68Slide69

Howard Padwa, Ph.D.hpadwa@ucla.edu69