Managing Benzodiazepines with MAT: The Philadelphia Story

April 14, 2014

Maureen Fitzgerald

Editor, ATTC Network Coordinating Office and NIATx

With this month’s Third Thursday iTraining (2:00pm EST, April 17, 2014) coming up, “Management of Benzodiazepines in Medication-Assisted Treatment,” I took a few minutes to chat with Roland Lamb, Director of the Office of Addiction Services at Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS).

Lamb and colleagues at DBHIDS got the ball rolling to create a set of practice guidelines for benzodiazepines back in 2011, in response to what they saw as a very confusing environment for Philadelphia providers and their constituents. 

“We were seeing a lot of different approaches to benzodiazepines and MAT for opioid dependence,” says Lamb. “Some providers were medicating patients with benzodiazepines and others refused to treat anyone who was using them. There were also providers who just didn’t know what to do with patients who continually tested positive for benzodiazepines while receiving MAT. And then there were patients who were getting prescriptions for benzodiazepines but not testing positive—so they must have been dealing. It was a very confusing environment for providers and for patients, but our main concern at DBHIDS was that we did not want to see people discharged from treatment for the very reason they needed treatment.”

A suggestion from Dr. Trusandra Taylor led Lamb to consider creating a resource similar to the ATTC buprenorphine treatment blending product. He then reached out to Dr. Arthur Evans, Commissioner of DBHIDs, Dr. Matthew Hurford, Chief Medical Officer at DBHIDS, Dr. James Schuster, Chief Medical Officer at Community Care Behavioral Health Organization, and Mike Flaherty, then director of IRETA, to get the project going.  Drs. Hurford and Schuster, along with Dr. Dawn Lindsay of IRETA, will present the April 17 iTraining.

“We saw this as not just a Philadelphia problem, but a statewide and national problem,” says Lamb. “The end result we hoped would be a set of guidelines that would focus on treating the person rather than managing the medications.”

The resulting guidelines, developed by IRETA, join the of Practice Guidelines for Recovery Oriented Treatment that DBHIDS has created as part of its Tools for Transformation initiative. Jessica Williams provides a great overview of the guidelines in her article in this month’s ATTC Messenger. For more about the Transformation Initiative, see Jon Korczykowski’s recent story in Behavioral Healthcare, "Transformation in Philadelphia". 

“Philadelphia providers have welcomed the benzodiazepine guidelines, but at the same time they’ve given some providers reasons to question use of benzodiazepines. We still need to figure out how to fit this all together in terms of risk management,” says Lamb. “We’re hoping that providers will begin to tell us which guidelines are useful, and we also want to hear from those they’re treating.”

Overall, says Lamb, creating the guidelines demonstrates how payers like DHBIDS can enhance quality of care. “Partnering with providers serves our constituents better, and creating guidelines like these allows us to extend the partnership with greater continuity.” 

Alcohol Awareness Month and Technology

April 2, 2014

Dave Gustafson, Ph.D.

Director, Center for Health Enhancement Systems Studies (CHESS) and NIATx

This April marks the National Council on Alcoholism and Drug Dependence’s 28^th Alcohol Awareness Month, “Help for Today. Hope for Tomorrow.” NCADD devotes this month every year to reducing stigma and increasing awareness about alcohol addiction. NCADD’s message is that alcoholism is a serious illness and not a choice. This year’s theme on preventing underage drinking is a reminder about starting early in educating our children on the dangers of alcohol abuse.

What’s interesting to me is that probably a lot more people are hearing about Alcohol Awareness Month today than back in 1987, when NCADD started the campaign. In 1987, radio, TV, and print media were the main ways to build awareness.

Today, the Internet and social media are spreading NCADD’s message faster and farther. Through Facebook, Twitter, and email, more people in more places can participate easily in alcohol awareness discussions and activities. My guess is that this translates into an exponential increase in awareness and activities and that more schools, parents, churches and communities will be getting the word out.

The Internet is an incredible tool for sharing information, and with technology changing at breakneck speed we may be at just the start of huge technological innovations. I’ve heard that we are in the first minute of the first day of the digital revolution. It’s hard to even imagine what might be in store for us just a year from today.

Public information campaigns like Alcohol Awareness Month use the Internet to increase awareness. But increasing awareness doesn’t solve the problem. We need to equip people with effective tools to manage their chronic conditions. How do we do something about the problem once we’ve raised awareness?

And here again, Internet technology offers an answer. 

Back in 2003 when we started to look at ways to improve the treatment system—with the Robert Wood Johnson Foundation grant that created NIATx—I talked to a lot of researchers and policy makers who said that the problem was “not enough people.” There also seemed to be a general feeling that having more counselors would give more people access to treatment. 

But as an engineer (stay with me now), my first thought was that addiction treatment is incredibly labor-intensive, and that almost any industry that builds things (I was thinking of treatment as a product) doesn’t ask, “How can we get more people?” They ask instead—“How can we do more with what we already have?”

 

I never thought that “more people” was the answer to improving the addiction treatment system. I thought we needed to ask different questions: “How can we supplement the work that people are already doing? How can we reduce repetitive tasks? How can we use other existing resources to meet our goals?”

Don’t get me wrong—people are great. (I’m even married to one and she’s pretty wonderful.) But they have limited memory and have to deal with competing demands like eating and sleeping and even taking a vacation now and then. And in the treatment field (as in other fields) counselor skill and the quality of care they provide varies.

Enter the Internet. While some have raised concerns about new mobile health systems reducing or eliminating the human factor, the Internet actually supplements the human factor.  People suffering from alcoholism and other SUDs need emotional and social support to recover. A counselor can provide some of that support once a week or so—but an Internet-based social support group makes it available 24/7. Now it’s possible for a teen in small Iowa farming community to connect at any time of day or night with someone in his support network of people of different ages and backgrounds from across the country, all united in their goal to embrace a life in recovery.

That’s just one example of how technology is really a facilitator, an extension of the human support that a counselor and groups such as AA provide. With unlimited time and energy, technology is an addition, not a replacement.

NCADD’s Alcohol Awareness Month reminds us that alcoholism is a chronic disease; like other chronic conditions it requires using various resources to make a difference. Technology-based tools increase the resources available to help people manage their conditions. These rapidly evolving innovations offer great potential to combat the devastating consequences of alcohol and other drugs on individuals, families, and communities.   

David H. Gustafson, Ph.D., is Research Professor of Industrial and Systems Engineering at the University of Wisconsin-Madison and director of the Center for Health Enhancement Systems Studies, which includes NIATx. His interests in decision, change, and information theory come together in the design of systems and tools to help individuals and organizations make effective changes. Dr. Gustafson leads a research team that has developed A-CHESS, a smartphone-based health system for recovery support and relapse prevention.