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Substance Abuse ServicesSubstance Abuse ServicesIntegration of Care CommitteeIntegration of Care Committee

June 22, 2010June 22, 2010

Nina Rothschild, DrPHNina Rothschild, DrPHTerri Wilder, MSWTerri Wilder, MSW

Marybec Griffin-Tomas, MAMarybec Griffin-Tomas, MA

HIV Planning Council of New YorkHIV Planning Council of New YorkCare, Treatment, and Housing ProgramCare, Treatment, and Housing Program

Bureau of HIV/AIDS Prevention and ControlBureau of HIV/AIDS Prevention and ControlNew York City Department of Health and Mental HygieneNew York City Department of Health and Mental Hygiene

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OverviewOverview

► BackgroundBackground► Definition of US Health Resources and Services Definition of US Health Resources and Services

Administration (HRSA) Service CategoriesAdministration (HRSA) Service Categories► Definition of the NY EMA Service CategoryDefinition of the NY EMA Service Category► Strengths and Challenges of the NY EMA ModelStrengths and Challenges of the NY EMA Model► HRR Contracts and Clients ServedHRR Contracts and Clients Served► Literature ReviewLiterature Review► Best PracticesBest Practices► Service Model Recommendations from Needs Service Model Recommendations from Needs

Assessment CommitteeAssessment Committee► DOHMH RecommendationsDOHMH Recommendations

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BackgroundBackground

► In preparation for the re-bid process, In preparation for the re-bid process, CTHP has reviewed:CTHP has reviewed: Epidemiologic dataEpidemiologic data Data from existing substance abuse Data from existing substance abuse

treatment contractstreatment contracts Evidence-based practices for provision of Evidence-based practices for provision of

substance abuse services substance abuse services Current HRSA guidance on substance Current HRSA guidance on substance

abuse servicesabuse services

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Epidemiologic DataEpidemiologic Data

► Of newly diagnosed cases of HIV in 2006 (N=4,030), Of newly diagnosed cases of HIV in 2006 (N=4,030), reported to NYC HARS as of September 30, 2009:reported to NYC HARS as of September 30, 2009: Total substance users=1,109 (27.5%)Total substance users=1,109 (27.5%) Substance use includes:Substance use includes:

► Heroin, crack/cocaine, methadone, methamphetamine, or Heroin, crack/cocaine, methadone, methamphetamine, or other/unspecified substance abuse; and persons with a history other/unspecified substance abuse; and persons with a history of injection drug useof injection drug use

► Alcohol use (any)Alcohol use (any)► Marijuana use (any)Marijuana use (any)

► *Alcohol and marijuana use do not have measures for *Alcohol and marijuana use do not have measures for frequency or intensity of use. ANY use of these substances frequency or intensity of use. ANY use of these substances results in this classification.results in this classification.

► Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented to Integration of Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented to Integration of Care Committee meeting, January 28, 2010Care Committee meeting, January 28, 2010

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Non-Substance Users Non-Substance Users Compared with OthersCompared with Others

► Compared with non-substance users…Compared with non-substance users… Substance users overall: more likely to be male Substance users overall: more likely to be male

and Hispanicand Hispanic Hard substance users: more likely to be male, Hard substance users: more likely to be male,

Hispanic, in their 40s or 50s, and Bronx Hispanic, in their 40s or 50s, and Bronx residents, and less likely to start care within residents, and less likely to start care within three months of diagnosisthree months of diagnosis

Alcohol users: more likely to be male, Hispanic, Alcohol users: more likely to be male, Hispanic, and in their 50s, and less likely to be Brooklyn and in their 50s, and less likely to be Brooklyn residentsresidents

► Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented Source: E. Weiss Wiewel, YT Grant, HIV/AIDS in Substance-Using New Yorkers, presented to Integration of Care Committee meeting, January 28, 2010to Integration of Care Committee meeting, January 28, 2010

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HRSA Definition:HRSA Definition:Outpatient Substance Abuse TreatmentOutpatient Substance Abuse Treatment

►Core serviceCore service►Provision of medical or other treatment Provision of medical or other treatment

and/or counseling to address substance and/or counseling to address substance abuse problems (i.e., alcohol and/or abuse problems (i.e., alcohol and/or legal and illegal drugs) legal and illegal drugs)

►Outpatient setting by a physician or Outpatient setting by a physician or under the supervision of a physician, or under the supervision of a physician, or by other qualified personnel.by other qualified personnel.

► Source: HRSA Guidance 8/14/09Source: HRSA Guidance 8/14/09

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HRSA Definition:HRSA Definition: Residential Substance Abuse TreatmentResidential Substance Abuse Treatment

►Non-coreNon-core► Provision of treatment to address substance Provision of treatment to address substance

abuse problems (including alcohol and/or abuse problems (including alcohol and/or legal and illegal drugs) in a residential legal and illegal drugs) in a residential health service setting (short term)health service setting (short term)

►May not be used for inpatient detoxification May not be used for inpatient detoxification in a hospital setting UNLESS detoxification is in a hospital setting UNLESS detoxification is offered in a separate licensed residential offered in a separate licensed residential setting within the walls of a hospital.setting within the walls of a hospital.

► HRSA Guidance 8/14/09HRSA Guidance 8/14/09

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HRSA 2010 Clarification of HRSA 2010 Clarification of Outpatient Substance Abuse TreatmentOutpatient Substance Abuse Treatment

► Services should be limited to:Services should be limited to: Pre-treatment/recovery readiness programsPre-treatment/recovery readiness programs Harm reductionHarm reduction Mental health counseling to reduce depression, anxiety Mental health counseling to reduce depression, anxiety

and other disorders associated with substance abuseand other disorders associated with substance abuse Outpatient drug-free treatment and counselingOutpatient drug-free treatment and counseling Opiate assisted therapyOpiate assisted therapy Neuro-psychiatric pharmaceuticalsNeuro-psychiatric pharmaceuticals Relapse preventionRelapse prevention Acupuncture therapy provided by a certified or licensed Acupuncture therapy provided by a certified or licensed

practitioner and/or program is allowed in substance abuse practitioner and/or program is allowed in substance abuse programsprograms

► Source: HRSA Guidance 4/8/10Source: HRSA Guidance 4/8/10

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NY EMA DefinitionNY EMA Definition Harm Reduction, Recovery Readiness, and Harm Reduction, Recovery Readiness, and Relapse Prevention Services (HR/RR/RP)Relapse Prevention Services (HR/RR/RP)

►Easily accessible harm reduction, Easily accessible harm reduction, recovery readiness, and relapse recovery readiness, and relapse prevention services to individuals who prevention services to individuals who are HIV-positive and actively using are HIV-positive and actively using drugs, relapsing, or in recovery.drugs, relapsing, or in recovery.

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NY EMA Definition NY EMA Definition Harm Reduction, Recovery Readiness, and Harm Reduction, Recovery Readiness, and Relapse Prevention Services (HR/RR/RP)Relapse Prevention Services (HR/RR/RP)

► Service elements include:Service elements include: Rapid HIV testingRapid HIV testing Linkage to HIV primary care*Linkage to HIV primary care* Outreach in SRO hotelsOutreach in SRO hotels Individual, family or group harm reduction counselingIndividual, family or group harm reduction counseling Assessment and referral for diagnosis and treatment of Assessment and referral for diagnosis and treatment of

sexually transmitted infectionssexually transmitted infections Screening and referral for substance use treatmentScreening and referral for substance use treatment Training and provision for overdose prevention with NarcanTraining and provision for overdose prevention with Narcan Individual, family, or group low threshold AOD servicesIndividual, family, or group low threshold AOD services Buprenorphine treatmentBuprenorphine treatment

*Encouraged but not reimbursed. All other services are reimbursed. The EMA is working to *Encouraged but not reimbursed. All other services are reimbursed. The EMA is working to add confirmatory testing and linkage to care for the newly diagnosed to the model of reimbursed add confirmatory testing and linkage to care for the newly diagnosed to the model of reimbursed services in August/September 2010.services in August/September 2010.

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NY EMA: Service FamiliesNY EMA: Service Families

► The NY EMA HRR service category The NY EMA HRR service category has four service families:has four service families:

1.1. Rapid HIV TestingRapid HIV Testing

2.2. Medical ServicesMedical Services

3.3. AOD ServicesAOD Services

4.4. Low Threshold AOD ServicesLow Threshold AOD Services

► Each service family has one or more Each service family has one or more service typesservice types

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Service Family: Rapid TestingService Family: Rapid Testing

►Service Type and Description: Service Type and Description: Rapid HIV testing includes the provision of Rapid HIV testing includes the provision of

pre- and post-test counseling, completion pre- and post-test counseling, completion of consent and Provider Report Forms of consent and Provider Report Forms (PRF), provision of or referrals to (PRF), provision of or referrals to confirmatory testing, in accordance with confirmatory testing, in accordance with state regulations.state regulations.

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Service Family: Medical ServicesService Family: Medical Services

► Service Type and Description:Service Type and Description: Medical Outreach in SROsMedical Outreach in SROs

►Making contact with SRO residents to encourage, Making contact with SRO residents to encourage, promote and support utilization of and decrease promote and support utilization of and decrease barriers to medical care, substance use treatment barriers to medical care, substance use treatment options and harm reduction services.options and harm reduction services.

Buprenorphine Initial VisitBuprenorphine Initial Visit►The induction phase of buprenorphine treatment, The induction phase of buprenorphine treatment,

including prescribing and administering dose as well as including prescribing and administering dose as well as conducting in-office observation for up to two hours.conducting in-office observation for up to two hours.

Buprenorphine Routine VisitBuprenorphine Routine Visit►Follow-up visits to assess clients and adjust dosage Follow-up visits to assess clients and adjust dosage

through the stabilization and maintenance phases of through the stabilization and maintenance phases of buprenorphine treatment.buprenorphine treatment.

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Service Family: AOD Services (1)Service Family: AOD Services (1)

► Service Type and Description:Service Type and Description: Family CounselingFamily Counseling

►Counseling and education provided to a family unit Counseling and education provided to a family unit regarding substance use, abuse and harm reduction. regarding substance use, abuse and harm reduction. Includes sexual risk reduction, IDU risk reduction, HIV Includes sexual risk reduction, IDU risk reduction, HIV and/or Hepatitis C secondary prevention, medical and/or Hepatitis C secondary prevention, medical treatment plan adherence.treatment plan adherence.

Group CounselingGroup Counseling►Group counseling and education session conducted with Group counseling and education session conducted with

a group of at least three Ryan White clients on the a group of at least three Ryan White clients on the same range of subjects as in Family Counseling - AODsame range of subjects as in Family Counseling - AOD

Individual CounselingIndividual Counseling► Individual counseling and education conducted with an Individual counseling and education conducted with an

individual client on same range of subjects as in Family individual client on same range of subjects as in Family Counseling - AODCounseling - AOD

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Service Family: AOD Services (2)Service Family: AOD Services (2)

►Service Type and Description:Service Type and Description: Assessment for STIAssessment for STI

►Assessment of client’s risk for STIs and (if Assessment of client’s risk for STIs and (if appropriate) referral to screening and appropriate) referral to screening and treatment programstreatment programs

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Service Family: AOD Services (3)Service Family: AOD Services (3)

► Service Type and Description:Service Type and Description: Overdose Prevention Training – GroupOverdose Prevention Training – Group

►Overdose prevention education and training, including Overdose prevention education and training, including risk reduction, assessment, response, and reversal, and risk reduction, assessment, response, and reversal, and prescribing and dispensing Narcan conducted with a prescribing and dispensing Narcan conducted with a group of at least three Ryan White clientsgroup of at least three Ryan White clients

Overdose Prevention Training – IndividualOverdose Prevention Training – Individual►One-on-one overdose prevention education, otherwise One-on-one overdose prevention education, otherwise

identical to Overdose Prevention Training - Groupidentical to Overdose Prevention Training - Group Substance Use AssessmentSubstance Use Assessment

►Screening and (if appropriate) referral for substance use Screening and (if appropriate) referral for substance use treatment for syringe exchange, ESAP, buprenorphine, treatment for syringe exchange, ESAP, buprenorphine, methadone, detox, peer community supportmethadone, detox, peer community support

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Service Family:Service Family:Low Threshold AOD Services (1)Low Threshold AOD Services (1)

► Service Type and Description:Service Type and Description: Low Threshold AOD Services – FamilyLow Threshold AOD Services – Family

► Services provided to a family unit (the client plus at least one Services provided to a family unit (the client plus at least one other family member or significant other) to encourage testing other family member or significant other) to encourage testing and enrollment into primary care. Some examples are stress and enrollment into primary care. Some examples are stress reduction, supportive counseling, activities of daily living kits, reduction, supportive counseling, activities of daily living kits, and drop-in activitiesand drop-in activities

Low Threshold AOD Services – GroupLow Threshold AOD Services – Group► Conducted with a group of at least three Ryan White Conducted with a group of at least three Ryan White

participants. Otherwise identical to Low Threshold AOD participants. Otherwise identical to Low Threshold AOD Services - FamilyServices - Family

Low Threshold AOD Services – IndividualLow Threshold AOD Services – Individual► Conducted with an individual client (or a family member Conducted with an individual client (or a family member

within the first 90 days of the family member’s enrollment). within the first 90 days of the family member’s enrollment). Otherwise identical to Low Threshold AOD Services - FamilyOtherwise identical to Low Threshold AOD Services - Family

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Service Family:Service Family:Low Threshold AOD Services (2)Low Threshold AOD Services (2)

►Service Type and DescriptionService Type and Description Low Threshold Assessment and Referral for Low Threshold Assessment and Referral for

STISTI►Assessment of client’s risk for STIs and (if Assessment of client’s risk for STIs and (if

appropriate) referral to screening and appropriate) referral to screening and treatment programstreatment programs

Low-Threshold Screening and Referral for Low-Threshold Screening and Referral for Substance Use TreatmentSubstance Use Treatment►Screening and (if appropriate) referral for Screening and (if appropriate) referral for

substance use treatment for syringe exchange, substance use treatment for syringe exchange, ESAP, buprenorphine, methadone, detox, peer ESAP, buprenorphine, methadone, detox, peer community support community support

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Service Family: Service Family: Low Threshold AOD Services (3)Low Threshold AOD Services (3)

► Low threshold services are the AOD/HR services Low threshold services are the AOD/HR services available to individuals who may not know their HIV available to individuals who may not know their HIV status to encourage testing and enrollment into status to encourage testing and enrollment into primary care. primary care.

► These services “meet the clients where they’re at” These services “meet the clients where they’re at” and include counseling and education related to and include counseling and education related to HR, stress reduction, ADL counseling, provision of HR, stress reduction, ADL counseling, provision of hygiene kits, etc. hygiene kits, etc.

► Although low threshold services are primarily Although low threshold services are primarily accessed by HIV status unknown clients, some accessed by HIV status unknown clients, some programs allow HIV+ clients to access them. programs allow HIV+ clients to access them.

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Service Family: Service Family: Low Threshold AOD Services (4)Low Threshold AOD Services (4)

► HIV status unknown clients may only access low HIV status unknown clients may only access low threshold AOD services for a maximum of 90 threshold AOD services for a maximum of 90 days. days.

► Low threshold AOD services for HIV status Low threshold AOD services for HIV status unknown clients are primarily used to help with unknown clients are primarily used to help with substance use issues, promote safer sex substance use issues, promote safer sex practices, and engage the client in HIV testing practices, and engage the client in HIV testing services. services.

► After 90 days, if a client still has not been tested After 90 days, if a client still has not been tested or has tested negative, he or she must be or has tested negative, he or she must be referred to another program as he/she is no referred to another program as he/she is no longer eligible to receive RW funded services. longer eligible to receive RW funded services.

► Clients who test HIV positive are then eligible for Clients who test HIV positive are then eligible for the entire spectrum of RW services.the entire spectrum of RW services.

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Service Family: Service Family: Low Threshold AOD Services (5)Low Threshold AOD Services (5)

► HIV positive clients may access any service offered HIV positive clients may access any service offered by the HRR agency (both low threshold AOD and by the HRR agency (both low threshold AOD and AOD services). AOD services).

► Low threshold services are sometimes designed to Low threshold services are sometimes designed to engage new HIV positive clients in services (i.e., engage new HIV positive clients in services (i.e., talking about risk reduction, decision making skills, talking about risk reduction, decision making skills, etc.) or to support HIV positive clients who have etc.) or to support HIV positive clients who have been enrolled in HRR services for a longer time and been enrolled in HRR services for a longer time and are stabilized and in the process of transitioning out are stabilized and in the process of transitioning out of HRR services (i.e., they have ‘graduated’ or no of HRR services (i.e., they have ‘graduated’ or no longer need the services). longer need the services).

► AOD services are designed to help HIV positive AOD services are designed to help HIV positive clients manage their HIV diagnosis, reduce their clients manage their HIV diagnosis, reduce their substance use, and/or reduce risk behaviors.substance use, and/or reduce risk behaviors.

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Strengths of the HRR ModelStrengths of the HRR Model

►Provides counseling in a variety of Provides counseling in a variety of settings and methods (individual, settings and methods (individual, group, family)group, family)

►Flexibility of the ‘sobriety requirement’Flexibility of the ‘sobriety requirement’ Clients do not have to be completely Clients do not have to be completely

abstinentabstinent

►Few payer of last resort issuesFew payer of last resort issues

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Challenges of the HRR ModelChallenges of the HRR Model

► Counseling services are misunderstood and Counseling services are misunderstood and underutilized underutilized Almost no agencies serve eligible entities such as client Almost no agencies serve eligible entities such as client

familiesfamilies► Retaining clients is challenging due to transient and Retaining clients is challenging due to transient and

often chaotic nature of the populationoften chaotic nature of the population► Focus is on services for opiate usersFocus is on services for opiate users

Does not include similar interventions for more prevalent Does not include similar interventions for more prevalent crack, cocaine, crystal meth, and alcohol userscrack, cocaine, crystal meth, and alcohol users

► Maintaining staff with prescribing privileges (MDs, Maintaining staff with prescribing privileges (MDs, NPs, PAs) is expensiveNPs, PAs) is expensive

► Low threshold AOD services for clients with Low threshold AOD services for clients with unknown HIV statusunknown HIV status

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HRR Service Contracts in FY 2009HRR Service Contracts in FY 2009

► Planning Council ranked HRR as Priority #4 Planning Council ranked HRR as Priority #4 ► HRSA Service Category: CoreHRSA Service Category: Core► Approximately 11% of the total RW budget is Approximately 11% of the total RW budget is

allocated to HRRallocated to HRR Service category allocation: $11,232,026Service category allocation: $11,232,026 Modified spending plan: $10,993,517Modified spending plan: $10,993,517

► The HRR program funds 26 programs in NYCThe HRR program funds 26 programs in NYC Projected units of service: 93,059Projected units of service: 93,059 Actual units of service: 94,105Actual units of service: 94,105

► The portfolio was newly re-bid in 2007The portfolio was newly re-bid in 2007 The HRR service category has been part of the NYC EMA The HRR service category has been part of the NYC EMA

RW Part A portfolio since at least 1994RW Part A portfolio since at least 1994Source: Service Category Scorecards 6/15/10Source: Service Category Scorecards 6/15/10

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HRR Clients Served in FY 2009HRR Clients Served in FY 200920,409 Clients Received Services in FY 200920,409 Clients Received Services in FY 2009

► HIV StatusHIV Status 18% HIV+ (non-AIDS), 8% CDC-defined AIDS, 54% HIV-, 18% Unknown 18% HIV+ (non-AIDS), 8% CDC-defined AIDS, 54% HIV-, 18% Unknown

Status/Pending, 11% Family Member/Significant OtherStatus/Pending, 11% Family Member/Significant Other► GenderGender

43% Female, 59% Male, 1% Transgender43% Female, 59% Male, 1% Transgender► Race and EthnicityRace and Ethnicity

52% Black, 35% Hispanic, 7% White, 1% Asian/Pacific Islander, 3% 52% Black, 35% Hispanic, 7% White, 1% Asian/Pacific Islander, 3% Other/UnknownOther/Unknown

► AgeAge 3% 0-19 Years of Age, 19% are 20-29 Years of Age, 19% are 30-39 Years 3% 0-19 Years of Age, 19% are 20-29 Years of Age, 19% are 30-39 Years

of Age, 31% are 40-49 Years of Age, 28% Ages 50+ of Age, 31% are 40-49 Years of Age, 28% Ages 50+ ► Special PopulationsSpecial Populations

1% Young MSM of Color, 12% LGBT, 37% Women of Color, 2% Immigrants1% Young MSM of Color, 12% LGBT, 37% Women of Color, 2% Immigrants

Source: Service Category Scorecards 6/15/19Source: Service Category Scorecards 6/15/19*=Among the total clients served in FY 2009, 54% were HIV-negative. However, these clients cycle *=Among the total clients served in FY 2009, 54% were HIV-negative. However, these clients cycle through every 90 days and often leave care. HIV+ clients, by contrast, remain in care. Although the through every 90 days and often leave care. HIV+ clients, by contrast, remain in care. Although the number of HIV-clients is high, they filter through the programs more rapidly.number of HIV-clients is high, they filter through the programs more rapidly.

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2009 Consumer Focus Group 2009 Consumer Focus Group ResultsResults

►According to the report from the 2009 According to the report from the 2009 consumer focus groups in the New consumer focus groups in the New York EMA:York EMA: Substance use is an important issue.Substance use is an important issue. Substance abuse treatment assisted entry Substance abuse treatment assisted entry

into and engagement in HIV treatment.into and engagement in HIV treatment. Services are useful and easily accessible.Services are useful and easily accessible.

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Literature ReviewLiterature Review

► Harm reduction psychotherapy (HRP) is based on Harm reduction psychotherapy (HRP) is based on the principle that individuals can become healthier the principle that individuals can become healthier even when they are still consuming drugs. even when they are still consuming drugs.

► HRP does not penalize individuals for their choices HRP does not penalize individuals for their choices about drug use but instead supports them in an about drug use but instead supports them in an open discussion.open discussion.

► HRP employs Stages of Change and Motivational HRP employs Stages of Change and Motivational Interviewing and focuses on diminishing resistance Interviewing and focuses on diminishing resistance and traversing stumbling blocks. and traversing stumbling blocks.

Source: P. Denning, “Harm Reduction Psychotherapy: An Innovative Alternative to Classical Addictions Source: P. Denning, “Harm Reduction Psychotherapy: An Innovative Alternative to Classical Addictions Theory” Theory”

American Clinical LaboratoryAmerican Clinical Laboratory May 2002: 16-18. May 2002: 16-18.

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Literature ReviewLiterature Review

► Benefits of harm reduction:Benefits of harm reduction: Diminish the damage of illegal drug use on Diminish the damage of illegal drug use on

families, neighborhoods, and society families, neighborhoods, and society Decrease deaths from overdoses Decrease deaths from overdoses Diminish the number of new cases of infections Diminish the number of new cases of infections

such as HIV and hepatitis such as HIV and hepatitis Lessen drug-connected injuries and trips to EDs Lessen drug-connected injuries and trips to EDs Enhance the number of individuals who are Enhance the number of individuals who are

able to obtain treatmentable to obtain treatment Lower the number of disturbances to family life Lower the number of disturbances to family life

from imprisonment, child abuse and from imprisonment, child abuse and mistreatment, and domestic fightingmistreatment, and domestic fighting

Source: “Harm Reduction” in Source: “Harm Reduction” in The New York Academy of MedicineThe New York Academy of Medicine

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Literature ReviewLiterature Review

►Harm reduction techniques:Harm reduction techniques: Syringe exchange*Syringe exchange* Preventing death from overdose Preventing death from overdose

with Narcan provisionwith Narcan provision Fostering access to physical and Fostering access to physical and

mental health care for drug usersmental health care for drug usersSource: “Harm Reduction” in Source: “Harm Reduction” in The New York Academy of MedicineThe New York Academy of Medicine

*The EMA does not currently fund syringe exchange and is waiting to hear *The EMA does not currently fund syringe exchange and is waiting to hear from HRSA whether Ryan White dollars can be used for syringe from HRSA whether Ryan White dollars can be used for syringe exchange programsexchange programs..

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Literature ReviewLiterature Review

► Engaging in alcohol and illegal drug use can Engaging in alcohol and illegal drug use can increase the likelihood of risky behaviors and HIV increase the likelihood of risky behaviors and HIV transmission and may complicate adherence. transmission and may complicate adherence.

► Addressing drug dependency with the help of Addressing drug dependency with the help of pharmacological treatment is key. Medications for pharmacological treatment is key. Medications for addressing substance use problems include:addressing substance use problems include: Opioid dependence: methadone, buprenorphine, naltrexoneOpioid dependence: methadone, buprenorphine, naltrexone Alcohol dependence: naltrexone, acamprosate, disulfiramAlcohol dependence: naltrexone, acamprosate, disulfiram Other drugs: the FDA has not endorsed any medications to Other drugs: the FDA has not endorsed any medications to

treat usage of other illegal drugs, including cocaine, treat usage of other illegal drugs, including cocaine, methamphetamine, cannabis, or sedative/hypnotics.methamphetamine, cannabis, or sedative/hypnotics.

Source: RD Bruce, TF Kresina, EF McCance-Katz, “Medication-Assisted Treatment and Source: RD Bruce, TF Kresina, EF McCance-Katz, “Medication-Assisted Treatment and HIV/AIDS: Aspects in Treating HIV-Infected Drug Users” in HIV/AIDS: Aspects in Treating HIV-Infected Drug Users” in AIDSAIDS 2010, Vol. 24. 2010, Vol. 24.

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Literature ReviewLiterature Review

Treatment for substance abuse, mental health, and Treatment for substance abuse, mental health, and primary care are best incorporated and managed primary care are best incorporated and managed togethertogether

Client retention and engagement in treatment is crucialClient retention and engagement in treatment is crucial Fostering a therapeutic partnership is key for long-term Fostering a therapeutic partnership is key for long-term

mental health and recovery goalsmental health and recovery goals Incorporation of vocational rehabilitation and general Incorporation of vocational rehabilitation and general

enhancement of functioning support lasting sobrietyenhancement of functioning support lasting sobriety Continuing education is key for professional staffContinuing education is key for professional staff Treatment should incorporate motivational interviewing, Treatment should incorporate motivational interviewing,

group and individual psychodynamic and cognitive-group and individual psychodynamic and cognitive-behavioral approachesbehavioral approaches

Source: R Futterman, M Lorente, SW Silverman, “Beyond Harm Reduction: A New Model of Substance Abuse Treatment Further Integrating Psychological Techniques,” Journal of Psychotherapy Integration, Vol. 15, No. 1, pp. 3-18.

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Literature ReviewLiterature Review

► Outreach approaches to HIV-infected substance Outreach approaches to HIV-infected substance users include:users include: Use of peer advocates to engage and retain clients in careUse of peer advocates to engage and retain clients in care Actively involving recent releasees from jail/prison and Actively involving recent releasees from jail/prison and

linking them with serviceslinking them with services Offering services via mobile unitsOffering services via mobile units Drop-in facilitiesDrop-in facilities Transitional housing for people who are using drugs but Transitional housing for people who are using drugs but

also participating in harm reduction focused groups also participating in harm reduction focused groups

Source: C. Tobias, S. Wood, M-L Drainoni, “Ryan White Title I Survey: Services for Source: C. Tobias, S. Wood, M-L Drainoni, “Ryan White Title I Survey: Services for HIV-positive Substance Users” in HIV-positive Substance Users” in AIDS Patient CareAIDS Patient Care, Vol. 20, No. 1, 2006, pp. 58-67. , Vol. 20, No. 1, 2006, pp. 58-67.

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Literature ReviewLiterature Review

► In a population of triply-diagnosed patients In a population of triply-diagnosed patients (mental illness, substance use, HIV infection):(mental illness, substance use, HIV infection): 45% of patients taking ARVs stated that they 45% of patients taking ARVs stated that they

missed medications in previous three daysmissed medications in previous three days Issues connected with non-adherence included:Issues connected with non-adherence included:

►Abuse of drugs and alcohol at the present timeAbuse of drugs and alcohol at the present time►Heightened emotional distressHeightened emotional distress►Poorer compliance with medical appointmentsPoorer compliance with medical appointments►Not taking psychiatric medicationsNot taking psychiatric medications►Lower spirituality (self-report)Lower spirituality (self-report)

Source: CA Mellins, JF Havens, C McDonnell et al., “Adherence to Antiretroviral Source: CA Mellins, JF Havens, C McDonnell et al., “Adherence to Antiretroviral Medications and Medical Care in HIV-Infected Adults Diagnosed with Mental and Medications and Medical Care in HIV-Infected Adults Diagnosed with Mental and Substance Abuse Disorders” in Substance Abuse Disorders” in AIDS Care, AIDS Care, Vol. 21, No. 2, 2009, pp. 168-177.Vol. 21, No. 2, 2009, pp. 168-177.

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Best Practices for ScreeningBest Practices for Screening

►All infectious disease clinics/providers, All infectious disease clinics/providers, should be screening for STDs and should be screening for STDs and substance abuse with HIV-infected substance abuse with HIV-infected persons. Those in need of services persons. Those in need of services should be referred to substance abuse should be referred to substance abuse programs.programs.

► *Seth Kalichman, June 1, 2010*Seth Kalichman, June 1, 2010

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ScreeningScreening

►Alcohol screening and treatment is Alcohol screening and treatment is largely forgotten but very important when largely forgotten but very important when treating HIV-infected individuals, treating HIV-infected individuals, especially individuals who are co-infected especially individuals who are co-infected with HCVwith HCV

►No single tool is consistently used for No single tool is consistently used for alcohol screening, but most providers use alcohol screening, but most providers use the AUDIT (or AUDIT-C)* or CAGE or a the AUDIT (or AUDIT-C)* or CAGE or a combination of themcombination of them

► *Alcohol Use Disorders Identification Test*Alcohol Use Disorders Identification Test

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ScreeningScreening

► Recommended: Use the AUDIT-C followed by a brief Recommended: Use the AUDIT-C followed by a brief intervention modeled after WHO motivational interviewing intervention modeled after WHO motivational interviewing (MI) protocol. Focus of brief intervention is to use MI to (MI) protocol. Focus of brief intervention is to use MI to determine client’s motivation and readiness for harm determine client’s motivation and readiness for harm reduction, outpatient substance abuse treatment, or inpatient reduction, outpatient substance abuse treatment, or inpatient substance abuse treatmentsubstance abuse treatment

► The Drinker’s Pyramid is a good tool to translate AUDIT The Drinker’s Pyramid is a good tool to translate AUDIT findings into clinical practice.findings into clinical practice.

► The Drug Abuse Screening Test (DAST-10) is a valid and The Drug Abuse Screening Test (DAST-10) is a valid and reliable instrument that can be used in conjunction with the reliable instrument that can be used in conjunction with the AUDIT-C. AUDIT-C.

► Strauss SM, Rindskopf DM, “Screening Patients in Busy Hospital-based HIV Care Centers for Hazardous Strauss SM, Rindskopf DM, “Screening Patients in Busy Hospital-based HIV Care Centers for Hazardous and Harmful Drinking Patterns: The Identification of an Optimal Screening Tool” in and Harmful Drinking Patterns: The Identification of an Optimal Screening Tool” in Journal of the Journal of the International Association of Physicians in AIDS CareInternational Association of Physicians in AIDS Care, Vol.8, No. 6, 2009, pp. 347-353., Vol.8, No. 6, 2009, pp. 347-353.

► Conversation with Seth Kalichman, PhD, June 1, 2010Conversation with Seth Kalichman, PhD, June 1, 2010

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Best Practices for Best Practices for Care and TreatmentCare and Treatment

►Coordinated systems needed for HIV Coordinated systems needed for HIV care and treatment. “One-stop shop” care and treatment. “One-stop shop” model works best because clients who model works best because clients who are dependent on drugs and/or alcohol are dependent on drugs and/or alcohol will not make multiple visits to will not make multiple visits to multiple providers.*multiple providers.*

► *Seth Kalichman, June 1, 2010*Seth Kalichman, June 1, 2010

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Needs Assessment Committee Needs Assessment Committee Service Model Recommendations (1)Service Model Recommendations (1)

►Drug and alcohol, mental health, and Drug and alcohol, mental health, and medical services should be co-located medical services should be co-located in order to provide one-stop shopping.in order to provide one-stop shopping.

►Clients receiving AOD services should Clients receiving AOD services should be systematically and formally be systematically and formally screened for mental health needs screened for mental health needs using a standardized screening tool.using a standardized screening tool.

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Needs Assessment Committee Needs Assessment Committee Service Model Recommendations (2)Service Model Recommendations (2)

►Programs should be required to have a Programs should be required to have a working relationship with clients’ case working relationship with clients’ case managers to ensure the coordination managers to ensure the coordination of all medical and support services of all medical and support services needed for the treatment of addiction.needed for the treatment of addiction.

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Needs Assessment Committee Needs Assessment Committee Service Model Recommendations Service Model Recommendations

(3)(3)► Services should include risk/harm reduction Services should include risk/harm reduction

(behavior change) and risk/removal approaches (behavior change) and risk/removal approaches (medication-assisted treatment such as (medication-assisted treatment such as Buprenorphine/Methadone for opioid dependence, Buprenorphine/Methadone for opioid dependence, Modafinil and Bupropion for methamphetamine Modafinil and Bupropion for methamphetamine addiction) and psychosocial therapies provided by addiction) and psychosocial therapies provided by mental health and/or behavioral therapists to mental health and/or behavioral therapists to address AOD behavioral change and other mental address AOD behavioral change and other mental health issues such as depression. health issues such as depression.

► Harm reduction programs should use low threshold Harm reduction programs should use low threshold models such as street outreach and peer workers models such as street outreach and peer workers supervised by a trained professional staff member. supervised by a trained professional staff member.

► Programs can fund smoking cessation but need to Programs can fund smoking cessation but need to be mindful that Ryan White is the payer of last be mindful that Ryan White is the payer of last resort.resort.

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Needs Assessment CommitteeNeeds Assessment Committee Service Model Recommendations (4)Service Model Recommendations (4)

►Tools to screen for and assess levels of Tools to screen for and assess levels of alcohol and drug use respectively alcohol and drug use respectively should be systematically employed should be systematically employed (e.g., every six months) with all (e.g., every six months) with all clients.clients.

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Needs Assessment Committee Needs Assessment Committee Service Model Recommendations (5)Service Model Recommendations (5)

► Programs that provide outreach to individuals at risk Programs that provide outreach to individuals at risk for problematic alcohol and drug use should include a for problematic alcohol and drug use should include a focus on youth. focus on youth.

► Programs providing services to youth should be able to Programs providing services to youth should be able to demonstrate cultural and linguistic competence, demonstrate cultural and linguistic competence, particularly in the area of sexual orientation, and have particularly in the area of sexual orientation, and have a history of successfully working with the target a history of successfully working with the target population. population.

► Programs treating homeless adolescents for substance Programs treating homeless adolescents for substance use should include a drop-in center for daytime and for use should include a drop-in center for daytime and for nights. The safety of places offering youth a place to nights. The safety of places offering youth a place to stay overnight should be carefully investigated to stay overnight should be carefully investigated to ensure that youth will not be endangered or exploited.ensure that youth will not be endangered or exploited.

► Peer-to-peer outreach is a particularly useful technique Peer-to-peer outreach is a particularly useful technique with youth populations.with youth populations.

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Needs Assessment CommitteeNeeds Assessment Committee Service Model Recommendations (6)Service Model Recommendations (6)

►While the EMA awaits word from HRSA While the EMA awaits word from HRSA about funding for syringe exchange about funding for syringe exchange programs (SEPs), injection drug using programs (SEPs), injection drug using clients can be referred to non-Ryan clients can be referred to non-Ryan White-funded syringe exchange White-funded syringe exchange programs.programs.

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Thank You!Thank You!