According to the National Survey of Substance Abuse Treatment Services (2016), facilities were asked how many patients in treatment on 03/21/16 received MAT for detoxification and maintenance purposes. Within this survey, MAT includes the use of methadone and buprenorphine for the treatment of opioid addiction or dependence, and the use of extended-release injectable naltrexone (Vivitrol) for relapse prevention in opioid addiction. Of the total 1,150,423 patients in treatment, 365,064 (32 percent) received MAT in OTP facilities.
The goal of using medications as part of comprehensive treatment plan is to assist an individual with leading a healthy, productive life in recovery. In recognizing the integral role that medication plays within the recovery process along with the connection between rapid linkage and engagement; Horizon Health Services initiated the Boulevard Outpatient Stabilization program where patients seeking treatment are triaged and given either same day or next day admission appointment to the Boulevard Outpatient Stabilization program, which consists of an abbreviated assessment process with the intention of rapid admission and linkage to a medication consult and treatment services. Within this assessment, core areas of lethality, substance use, and medical concerns are explored. This ensures understanding of risk management and appropriate triaging to trained high risk clinicians with various sub-specialties. These subspecialties include strong understanding of treatment modalities to assist clients with complex histories, strong understanding of family interventions, and strong understanding of MAT. The goals of this program are to assist patients with stabilization of current substance use symptoms, address foundational skill work to decrease cravings (monitored through weekly Urges and Cravings Measurement, Figure 1), and provide continued medication.
The goals of stabilizing current symptoms and exploring foundational skill work have been implemented via group and individual sessions. Within the Stabilization program, patients are recommended to engage in family group and “Mindful Recovery” group. Through DBT and relapse prevention modalities; “Mindful Recovery” has an overarching goal of decreasing high risk substance use. This is accomplished by means of working to increase mindfulness skills to directly manage cravings. While also providing information on and challenging application of wise mind/value-based decisions. With the understanding that substance use in a family dictates social adaptation that impairs the system’s thinking, feeling, and behavior; recovery is enhanced when therapy occurs in a family group setting. Within this systems theory, the goal of family group is to provide education and support to family members. Family members engaged in this group have reported a greater understanding of methods to support their loved ones within the recovery process and healthy management of relapse.
The role of the stabilization team, through the lens of individual sessions, is to reinforce foundational skill work to allow patients to better participate in rehabilitative therapies. Foundational skill work includes the evidenced based practices of DBT, CBT, and Motivational Interviewing. In conjunction with Family Group, high risk clinicians further encourage collateral involvement during individual sessions. Within this framework, expectations for treatment are established along with more person-centered family interventions. These interventions can include: substance use education, healthy communication skills, appropriate boundary setting, increasing awareness of signs/symptoms of relapse, and healthy management of family conflict. At times, the severity of family dynamics warrants referrals to codependency counseling with our family support specialist. The high-risk clinicians are further expected to monitor medication adherence, which is accomplished via patient self-report, toxicology reports, film/pill counts, and the Urges and Cravings Measurement Survey.
Upon initial admission into the stabilization program, patients meet with providers on a weekly basis. Routine coordination occurs between high risk clinician and provider to ensure medication effectiveness and adherence. As patients indicate reduction in cravings and appropriate implementation of behavioral skills, provider appointments are extended to a bi-weekly then monthly basis.
Once stabilization goals are achieved, the patient will be referred to a rehabilitative clinician who will focus on developing chronic care management. The rehabilitative clinician will conduct follow up assessment, exploring further psychosocial factors and mental health related concerns. Based on this assessment, patients will be encouraged to elaborate on their goal setting, participate in targeted group therapies, address medication management, and continue family work.
Since initiating the program in August 2017, we have seen a remarkable decrease in days wait time between initial assessment and admission and also days wait to medications consult. The data includes: Admissions (55); Average days between admission and medication consult (3.75); Average days between admission and follow up appointment with high risk clinician (4.48).
Additionally, in restructuring to accommodate rapid linkage, we have found a direct correlation to increased engagement rates. This data includes: Total untoward discharges (13); Discharge reasons: Lost to contact (7); Non-compliance (3); Services refused (1); Incarceration (1).
From an anecdotal perspective, participating patients have endorsed a positive therapeutic experience and ability to effectively work towards personal goals. More specifically, a patient shared; “I was a wreck and I didn’t really know if I wanted to stop. Going through this process, there couldn’t be a better thing for me. Vivitrol was a great added insurance. Family Group and Mindfulness were helpful not only in my relationships with my mother, but a change in my attitude and how I react with other people on a day to day basis.”
In conclusion, the Boulevard Outpatient Stabilization program, has shown to be effective in offering patients rapid medication and treatment services. Furthermore, this model of treatment presents a promising opportunity to bridge the gap between inpatient and hospital-based settings with outpatient providers.
All questions or concerns regarding this article can be directed to: Elliot Zimpfer, LMHC, CASAC, Horizon Health Services, (716) 833-3708, and at EZimpfer@horizon-health.org.
