Innovative Approaches to Substance Use Disorder Treatment at the VA

Dr. Geppert. Incredible. That leads to my next question: One of the most challenging issues facing primary care practitioners is how to manage patients who are on chronic opiate therapy but also use medical marijuana in the increasing number of states where it’s legal. Do you have some advice on how to approach these situations?

Dr. Drexler. It’s a great question, and it’s one I’m sure more and more VA practitioners are grappling with. By our policy, we do not exclude veterans who are taking medical marijuana from any VA services, and we encourage the veterans to speak up about it so that it can be considered as part of their treatment plan.

By policy, however, VA practitioners do not fill out forms for state-approved marijuana. Marijuana is still a Schedule I controlled substance by federal law, so it’s a very interesting legal situation where it’s illegal federally; but some states have passed laws making it legal by state law. It will be interesting to see how this plays out over the next few years.

But in that situation—and really, this is our policy, in general for substance use disorders—a patient having a substance use disorder should not be precluded or excluded from getting treatment for other medical conditions. Similarly, other medical conditions shouldn’t exclude patients from getting treatment for their substance use disorder. However, the best treatment comes when we look at the whole person and try to take both things into account.

In the same way that patients can become addicted to their opioid pain medicines, patients can become addicted to medical marijuana. So the marijuana use needs to be evaluated objectively; and whether or not they have a form, just like whether or not someone has a prescription for their opioid that may be causing them problems, that needs to be taken into account in the treatment plan; and the treatment needs to be individualized.

Dr. Geppert. What in VA substance use disorder programs and treatment do you think is especially innovative when compared to the community?

Dr. Drexler. One of the places where I think the VA is well ahead of our colleagues elsewhere in health care is…from SAIL [Strategic Analytics for Improvement and Learning] metrics. About 34% or 35% of veterans who are diagnosed clinically within our system with opioid use disorders are receiving medication-assisted therapy either with buprenorphine, methadone, or extended-release injectable naltrexone. When you look at the SAMHSA survey, the National Survey on Drug Use and Health, the percentage of patients in the community who meet criteria for a substance use disorder [who] actually receive treatment is more like 12%. We have no numbers from SAMHSA about what percentage are receiving medication-assisted treatment. They don’t ask. In that way, even though we have a long ways to go, we’re ahead of the curve when it comes to medication-assisted treatment. But the demand is growing, we’re going to have to keep working hard to keep up and to get ahead at this. When I think about it compared to other chronic illnesses, only 35% of our patients are getting the first-line recommended treatment. We still have a long ways to go.

Another place where we’re innovative is with contingency management. I mentioned psychosocial treatments. Behavioral treatment is very effective and yet is not often used in treatment of substance use disorders; but it works. And even better than that, it is fun.

Let me try to explain what this means. It’s based on the idea that the benefits of using drugs are immediate, and the benefits of staying sober take a long time to realize. And it is that difference that makes early recovery so challenging because, if someone has a craving for alcohol or another drug, they can satisfy that craving immediately and then have to pay the price, though, of health consequences or financial consequences or legal consequences from that alcohol or drug use.

On the other hand, staying sober is tough. But it takes a long time to put one’s life back together, to get one’s chronic health conditions that have been caused or made worse by the drug use back together. And the idea behind contingency management is to give immediate rewards early in recovery to keep folks engaged long enough to start realizing some of the longer-term benefits of recovery.

So the way this works, we use what we call the fishbowl model of contingency management. And we started with stimulant use disorders, which is one of the substance use disorders for which there’s no strong evidence for a medication that works; but this particular psychosocial intervention works very well. So patients come to the clinic twice a week, give a urine specimen for drug screen; and, based on those test results, if their test is negative and they haven’t used any stimulants, then they get a draw from the fishbowl, which is filled with slips of paper. Half of the slips of paper say, “Good job! Keep up the good work,” or something encouraging like that. And half of the slips of paper have a prize associated with them, and it could be a small prize like $1 or $5 for exchange at the VA Canteen store, or it could be a larger prize like $100 or $200. Of course, the less expensive prizes are more common than the more expensive prizes; but just that immediate reward can make such a difference.

With the first negative urine drug screen, you get 1 draw from the fishbowl. The second one in a row, you get 2; and so it goes that the longer you stay sober, the more chances you have for winning a prize. And this treatment can go on for as long as the veteran wants to continue for up to 12 weeks. Usually by 12 weeks, folks’ health and their lives are coming back together; and so there’s many more rewards for staying sober than just the draws from the fishbowl. And what we find is folks who get a good start with contingency management tend to stay on that trajectory towards recovery.

And this has been a wonderful partnership between the Center of Excellence for Substance Abuse Treatment and Education in Philadelphia and the VA Canteen Service, who has generously donated canteen coupons. So it doesn’t cost the medical center anything to offer these prizes, and we’ve had just some amazing results.

To listen to the unedited interview here