Engaging Individuals with an Opioid Use Disorder (OUD) David Loveland, Ph.D. - PowerPoint Presentation

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Engaging Individuals with an Opioid Use Disorder (OUD) David Loveland, Ph.D. - PPT Presentation

Engaging Individuals with an Opioid Use Disorder OUD David Loveland PhD Community Care 2017 Community Care Behavioral Health Organization Questions to Consider 1 2 Could you effectively engage individuals with an OUD in treatment soon after they had recovered from an overdose and could ID: 762638

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Questions to Consider 1 2 Could you effectively engage individuals with an OUD in treatment soon after they had recovered from an overdose and could you do it for as low as $5.00 a day? © 2017 Community Care Behavioral Health Organization

Questions to Consider 2 3 Your clients have two options for an opioid treatment program (OTP with methadone): one option is the standard 2.5 hours of counseling a month, regardless of substance use patterns; the other one requires a systematic increase or decrease in counseling load based on substance use behaviors (the load could be 10 times higher than the standard OTP). Which version would have better retention & better outcomes? © 2017 Community Care Behavioral Health Organization

Questions to Consider 3 4 Teenagers who are starting to drink alcohol are provided with one of two educational options to help them stop drinking: One option is a 2-hour, comprehensive training covering a wide range of topics on risks & reasons to stop drinking; the other is a 5-minute behavioral exercise with no suggestion to stop drinking Which method is more likely to lead to a reduction in drinking over time? © 2017 Community Care Behavioral Health Organization

Questions to Consider 3 5 One client is leaving your program because he or she continues to struggle with relapse and is disengaging from treatment, another client is being tapered off of an agonist medication & will be discharged from your OTP or OBOT for the same reasons (e.g., ongoing substance use.) Will you try and re-engage these two individuals and, if so, what can you do to re-engage them? © 2017 Community Care Behavioral Health Organization

Questions to Consider 4 6 Two individuals who are similar in demographics are distressed and anxious; one of them is on a diet and the other one is not If both individuals have access to the same wide range of food at the same time, what will likely occur? In other words, how much will each person eat and will it be the same, more or less, than what they would have eaten when they were not anxious? © 2017 Community Care Behavioral Health Organization

Questions to Consider 5 7 © 2017 Community Care Behavioral Health Organization What does the trey of freshly baked chocolate chip cookies on the left have in common with the bowl of radishes on the right?

Challenges of Changing Behavior The cookies and radishes displayed in the prior slide have been used repeatedly in an experiment to examine the powerful impact of ego depletion , Ego depletion is the loss of mental energy and a subsequent reduction in capacity to avoid urges or persevere on challenging tasks The research is summarized in Baumeister , R.R. & Tierney, J. (2011). Willpower . New York: Penquin Press 8 © 2015 Community Care Behavioral Health Organization

Challenges of Changing Behavior Participants are separated in to two groups & asked to sit at a table for 10 minutes before the experiment begins the participants are unaware that waiting in the room is the experiment At the table is a trey of freshly baked chocolate chip cookies that were pulled out of the oven as the participants sit down The table also has a bowl of radishes Participants in one group are told to help themselves to the cookies or radishes while those in the other group are asked to avoid the cookies, but they can eat the radishes if they get hungry while waiting 9 © 2015 Community Care Behavioral Health Organization

Challenges of Changing Behavior Participants are combined again after 10 minutes of waiting in separate rooms and asked to complete one of two tests of endurance that is timed Place one hand and lower arm in a tank of ice water or Work on a puzzle that cannot be solved the participants don’t know that it can’t be solved, so they are timed on how long they try before giving up One of the groups always outperforms the other group; in other words, one group, on average, can last 30% longer in the ice water or work on the puzzle – which group does better and why? 10 © 2015 Community Care Behavioral Health Organization

Countering Ego Depletion - Example Both groups were set up so that all participants had to resist the cookies for 5 minutes (half the time of the first study) The difference between the groups was in how the participants were treated with the knowledge that they only had to wait 5 minutes, instead of 10 minutes 12 © 2015 Community Care Behavioral Health Organization

Countering Ego Depletion - Example Group 1: the participants were asked in a kind voice “we ask that you don’t eat the cookies; is that okay” The researcher went on to explain the experiment which was to resist temptation (no deception was used), thanked the students for their time, and closed with the following statement: “ if you have any suggestions or thoughts about how we can improve this experiment, please let me know. We want you to help us make this experience as good as possible ” 13 © 2015 Community Care Behavioral Health Organization

Countering Ego Depletion - Example Group 2: the participants were told in a stern voice “you must not eat the cookies” The researcher did not explain the purpose of the study, compliment them or show any interest in their questions. She closed her statement with: “ the experiment will begin shortly ” 14 © 2015 Community Care Behavioral Health Organization

Countering Ego Depletion - Example Participants are combined again after 5 minutes of waiting in separate rooms and asked to complete work on a puzzle that cannot be solved the participants don’t know that it can’t be solved, so they are timed on how long they try before giving up One of the two groups performed 60% better than the other group 15 © 2015 Community Care Behavioral Health Organization

Countering Ego Depletion - Example Participants in group 1 had significantly more mental energy; i.e., ability to persist on the task, then group 2 Researchers found out later that students in group 1 felt like they had more self control over the experiment and were involved in a value-driven task; i.e., promoting kn0wledge and science A combination of 5 minutes of ego depletion and rudeness dramatically undermined group 2 participant’s ability to persevere Some of the students in group 2 showed signs of frustration and anger with the experimenters 16 © 2015 Community Care Behavioral Health Organization

Barriers to Change Motivation may not be a barrier to change, but a person’s life stressors, existing demands, and established habits are likely barriers to change Point A Point B © 2017 Community Care Behavioral Health Organization Ego Depletion Limited time Decision fatigue Established habits Unrealistic plans

Behavioral Principles for Engagement Rule 1 : Powerful habits dominate human behavior during states of mental exhaustion People binge eat when mentally exhausted, such as at night or while attempting to diet, Relapses to tobacco, alcohol & other drugs occur more in negative mental states that create exhaustion, such as anxiety or pain, Couples have more arguments when distressed or feeling overwhelmed Step 1 : Increase ego strength to avoid habits by providing active listening, simple steps, and inspiration Individuals can be inspired to avoid powerful habits if given simple options that can occur quickly and based on their values and goals, not their deficits or diagnoses © 2017 Community Care Behavioral Health Organization

Factors Undermining Tx for OUD Individuals with an OUD diagnosis experience rapid returns to using opioids after tx Nearly all individuals will use alcohol or other drugs after tx ; however, those with an OUD experience a greater risk of overdose (OD) when they do return to using due to the lethality of illicit opioids, alone or mixed with other powerful medications, such as benzodiazepines OD rates increase after tx because tolerance levels for opioids drops rapidly within 3 to 5 days of abstaining; so a single detoxification episode can lead to a significant reduction in tolerance for opioids © 2016 Community Care Behavioral Health Organization 21

OUD & Mortality Rates Clients with an OUD who leave treatment have a 2- to 6-fold increase in mortality immediately after treatment compared to individuals who remain in treatment (Albert et al., 2011; Evans et al., 2015; Degenhardt et al., 2010; Martins et al., 2015; The mortality rate is similar for people leaving residential or MAT programs & for those who graduate or leave AMA Incarcerated individuals with an OUD have a 3- to 10-fold increase in mortality within the first 4 weeks of being released compared to the individuals in the community (Albert et al., 2011; Binswanger et al., 2013; Martins et al., 2015;; Merrall et al., 2010; Wakeman et al., 2009) 22 © 2016 Community Care Behavioral Health Organization

OUD & Mortality Rates Data from Allegheny County highlights the increased risk of OD within 30 days after discharge from jail, residential or outpatient services (the full report can be downloaded at https://assets.documentcloud.org/documents/3010144/Opiate-Related-Overdose-Deaths-in-Allegheny-County.pdf ) The county tracked 1,355 opiate related OD deaths between 2008 and 2014, 38% (531) were individuals who had been released from jail in the past year, 25% (350) were individuals who had left a D&A program in the past year, and 45% (616) were individuals who had received mental health services in the past year (most within 2 to 4 weeks) 24 © 2016 Community Care Behavioral Health Organization

Tx Completion Rates – TEDS CY2013SAMHSA’s Treatment Episode Data Set (TEDS) provides an annual summary of tx admissions & discharges in the US 2016 report for CY2013 includes 1,594,906 discharges CY2013 is the most recent year of discharge data available Individuals with an AUD (first) or OUD (second) accounted for two thirds of all discharges Individuals with an OUD were less likely to complete any level of care, which has been the trend for many years (see the next slide) © 2016 Community Care Behavioral Health Organization 26

MAT vs non-MAT Tx Abstinence-based treatment (ABT) tends to be more effective for people with AUD and less effective for those with an OUD Because of the poor response to ABT combined with the elevated risk of OD after tx, individuals with an OUD need tx interventions that will retain them longer Individuals with an OUD stay significantly longer in tx for methadone & buprenorphine, and slightly longer in treatment on XR-naltrexone compared to ABT only (see the next slides) © 2016 Community Care Behavioral Health Organization 28

Behavioral Principles for Engagement Rule 2: Fighting urges without an alternative option will lead to ego depletion & an increase in the urge People who try to ignore urges by using “will power” will usually give into the urge & experience a stronger relapse People tend to fail at other goals when they deplete their mental energy through white-knuckling their urges People give in to about 50% of all urges within a few minutes Step 2 : Plan for urges & create alternative plans to counter the urge instead of ignoring the sensation Create new habits to replace existing habits © 2015 Community Care Behavioral Health Organization

Immediate MAT Reduces OD Rates Researchers at Yale tested a rapid tx model for people entering an ED who were identified as having an OUD Individuals were randomized to one of three methods for referring them to addiction treatment after they left the ED, including: Immediate initiation of buprenorphine in the ED with a warm handoff to an OBOT for ongoing tx, A Screening, Brief-Intervention and Referral to Tx (SBIRT) protocol – an evidenced-based engagement protocol based on motivation interviewing, or A referral only group – individuals were provided with a referral to an addiction treatment program upon discharge © 2016 Community Care Behavioral Health Organization 31

Immediate MAT Reduces OD Rates Researchers have tested a rapid access model of MAT for individuals seeking methadone or buprenorphine treatment who were placed on a waiting list for tx Interim MAT has been tested on wait list clients trying to access either OTP or OBOT programs Clients are randomly assigned to either interim MAT or to remain on the waiting list that they were already assigned Clients assigned to the interim MAT receive the medication, following OTP or OBT guidelines, but none to minimal counseling services while they wait for an opening in the MAT © 2016 Community Care Behavioral Health Organization 33

Immediate MAT Reduces OD Rates Clients assigned to the interim MAT, compared to the wait list group, also had significant reductions: criminal activity, overall healthcare costs, and HIV/HCV risk behaviors The overall costs of the interim methadone tx was approximately $5.00/day © 2016 Community Care Behavioral Health Organization 35

Immediate MAT Reduces OD Rates Clients assigned to the interim MAT, compared to the regular OTP or enhance counseling OTP had: Slightly lower costs than the other two groups, Similar significant reductions in criminal activity and risky behaviors © 2016 Community Care Behavioral Health Organization 37

Techniques: Improving the Path Teenagers were asked to voluntarily participate in a high school health education study if they were actively drinking alcohol (Armitage et al., 2014) The teenagers were not asked to stop drinking nor were they screened for alcohol abuse issues They were assigned randomly to one of two “educational sessions about alcohol” with both groups receiving a health risk message about alcohol use from AUDIT manual The experimental group received a 5 minute intervention that required minimal instruction from the researchers 40 © 2015 Community Care Behavioral Health Organization

Behavioral Principles for Engagement Rule 3: the more decisions, options or goals that you have to select or set, the less likely you are to make the right choice or achieve your goal People are often frozen by ego depletion or decision fatigue Referring people to treatment can increase ego depletion because most of the steps will be new, unknown, and difficult to achieve Step 3 : Provide treatment immediately, by offering medications, peer support, & counseling People recovering from an overdose are in an extreme state of mental and physical exhaustion & have limited capacity to make difficult decisions © 2015 Community Care Behavioral Health Organization

Provide Peers in ED Settings Dr. Charles Barbera and his team at Reading Hospital provide CRS staff (peers) to all individuals with an OUD who enter the ED The peers are housed on the ED and are engaged upon an automatic flag in the electronic health record (e.g., the “order” for a peer occurs automatically & without asking patients), The automated system of peers led to significant increases in engagement in treatment after patients left the ED © 2016 Community Care Behavioral Health Organization 44

Behavioral Principles for Engagement Rule 4: People are more likely to disengage from tx if they have no control or power to change their future Approximately two thirds of all individuals seeking addiction tx, disengage during the enrollment process & before receiving any tx, Approximately 50% of those who enter tx, disengage before completing a single episode of care Step 4 : People will stay in tx longer if they receive the care they want & have control over their care People are motivated to change and will do more work if they have a sense of control and confidence that they can make a change © 2015 Community Care Behavioral Health Organization

Motivational Stepped Care (MSC) Clients are introduced to a stepped model of work based on their ability to abstain from alcohol, opioids and other drugs as well as attend 100% of planned counseling sessions Random UA testing is used to provide feedback to clients and staff on SUD behaviors Random tests are provided weekly, throughout the course of the MSC model during the first 6 to 12 months, but can be reduced for those who successfully maintain Level I status for three consecutive months (see the next slide) Volume of counseling sessions are noted on the next slide 48 © 2016 Community Care Behavioral Health Organization

Motivational Stepped Care (MSC) Keeping clients in Level I is the goal of the MSC model Level I is unlimited in duration, though additional reinforcement can be applied for those who continue to achieve Level I objectives, such as moving to weekly take-home privileges Levels II – IV are time limited and require clients to either achieve the measurable criteria within the Level or move up to the next level within four to six weeks Level IV is a forced, medically approved taper that clients can reverse by achieving Level III objectives for two consecutive weeks 51 © 2016 Community Care Behavioral Health Organization

Research on the MSC 52 © 2016 Community Care Behavioral Health Organization Several research trials, including a randomized clinical trial, has found the MSC model to be effective compared to standard OTP The following slide displays two models of stepped care, including the MSC and another version that did not include a taper, referred to as Standard Stepped Care (SSC) The SSC condition includes the same 3 levels & volume of counseling services as well as the same standards of UAs & attendance requirements that are included in the MSC condition 65 clients were randomly assigned to MSC and 62 were randomly assigned to the SSC condition

Research Outcomes of MSC 56 © 2016 Community Care Behavioral Health Organization Randomization had to be ended at 90 days because over 55% of the SSC clients were performing poorly and had to be moved to the MSC condition Six-month, within subject results, including the SSC clients who moved to the MSC found that: Individual session attendance was 95% , Group attendance was 77% , Attendance of family members 73%, Positive UAs, all alcohol & drugs 38%

MSC and Employment The MSC model was modified to include competitive employment for all clients who had completed the first 12 months of the MSC within the medication assisted program At 12 months, all clients, except those with a disability or retired, were required to work at least part time, volunteer 20 hours of week, or be in school for 20 hours/week to remain in treatment The same 3 levels were used with the taper, with the skills training groups focusing on employment skills in year 2 Clients were moved to higher levels of job counseling if they did acquire a job or schooling within 2 months 57 © 2016 Community Care Behavioral Health Organization

MSC and Employment A review of outcomes from the first 228 clients who were eligible (unemployed & enrolled in OTP for 12 months) found: 70% were working full time in competitive positions, 19% were in par-time paid positions, 3% were in volunteer work, 1% were in college, and 7% were in levels II or III due to unemployment, and 2 clients exposed to the MSC+employment program left the program due to the methadone taper, but were already in level III for frequent positive UAs 58 © 2016 Community Care Behavioral Health Organization

Hub & Spoke Model for Engagement & Tx Vermont launched a statewide program to expand MAT for people with an OUD through a hub and spoke model in 2013 The model created 5 regional hub-spoke programs that could triage individuals by need & type of MAT The model was highly effective at rapidly increasing enrollments to methadone & buprenorphine The model also found minor savings in overall healthcare dollars after controlling for the increased cost of MAT, The model also found a steady decline in fatal ODs © 2016 Community Care Behavioral Health Organization 59

Questions about the research noted David Loveland, Ph.D. Senior Program DirectorCommunity Care Behavioral Health lovelanddl@ccbh.com 412-402-7570 61 © 2016 Community Care Behavioral Health Organization