Systems Considerations Unique to Addiction Medicine
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The premise of the systems thinking approach
The underlying premise of the systems thinking approach is that the interaction between factors in the external environment and factors inside the health care organization can prompt the changes needed to improve patient safety. Some factors that shape the system in which Addiction Medicine functions include:
- Addiction Medicine is new as a formal discipline.
- Likewise, quality standards for Addiction Medicine, which ASAM played a large role in developing, are quite new.
- There is no broad-based mandatory reporting of errors in the Addiction Medicine subspecialty.
While some states and localities may require reporting of medication errors involving a controlled substance, or reporting of deaths during treatment, the lack of a system of broad-based mandatory reporting of errors remains a challenge.
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These factors are important to keep in mind as we start to apply systems thinking to the complex, changing domain of systems of care delivery and addiction treatment.
Systems Considerations Unique to Addiction Medicine
There are unique systems considerations regarding Addiction Medicine
- Changes regarding 42 CFR Part 2
- Embedded Bias
- Medically Managed Care and Patient Autonomy
Changes regarding 42 CFR Part 2
Recent amendments to 42 CFR Part 2 have aligned it more with modern communications, the use of EHRs, and team-based care. The revised rule helps break down information silos within systems and between providers. Many systems are working to educate their staff about what 42 CRF Part 2 permits but ensuring everyone on staff knows and integrates the new norms is a work in progress.
There are three key changes:
- There is no longer a time limit to the release.
- The release does not need to specify the information to which it applies.
- The release can encompass a whole practice or care setting.
No Time Limit
Previously, a release of information under 42 CFR Part 2 had to expire after one year.
The fact that a patient can consent to disclose their information for an unspecified time is a big change.
Many programs providing long term care have systems in place to make sure releases are updated annually. While that is no longer necessary, eliminating such systems may have untoward consequences. For example, renewing the release of information assured at least one visit with the physician per year that may no longer take place. Also, programs staff who have not fully understood these changes may decline to release information if there is not an expiration date of 1 year or less on a release of information. Confusion like this can go on undetected and impede care coordination for people with addiction.
Global Release of Record Contents
Previously, a release of information had to specifically name each type of document to which it pertained.
This change requires careful patient education because, while patients no longer have to provide a comprehensive list of each part of the record that can be released, they still have the right to limit what can be shared. For example, a patient may still prefer to only release physician or medical notes to their PCP and exclude therapy notes. Or, a patient may prefer to release only urine toxicology results to their parole or probation officer and exclude other labs, notes or records of medication administration.
Release of Information to Entities
Previously patients had to specify by name each individual provider with whom information could be shared.
Now patients can choose to release their information to clinical entities such as
- Integrated care settings,
- Health Information Exchanges, (HIEs) and
- Accountable Care Organizations (ACOs).
It is important to make sure patients understand that, as a result, their diagnosis and medication may appear in the problem list and medication list in their record across an entire health system or be accessible to providers within that system. This will hopefully be of net benefit to patients but there are also risks. For example, the urologist may see buprenorphine on a patient record and then reconsider whether to treat the patient’s secondary hypogonadism—a side effect of their opioid agonist therapy—because it will go away when they “finish treatment.” With a wider distribution of patient information, the risk that it will be either incorrectly interpreted or acted upon incorrectly, resulting in errors, may increase.
Summary: Understanding the impact of 42 CRF, Part 2
Our understanding of the ways in which implementing changes to 42 CRF Part 2 impacts patient safety is still unfolding and, due to stigma and bias, may be a mixed bag in terms of the risk and benefit it will mean to patients. There are ways in which the information silos might have protected some patients in the past. The patient may have real concerns over their primary care doctor finding out that they have a substance use disorder if it results in that person no longer treating them with respect. A holistic systemic response might be to prepare patients for more people in the health care system knowing about their substance use disorder and its treatment. A systems level response is needed to prevent errors and harm to patients as a result of this change to one part of the larger system.
Reference: “The Fundamentals of 42 CFR Part 2: What Is It? Why Is It Important?” https://lac.org/addiction-confidentiality-42-cfr-part-2-important/ Published 2020. Accessed February 27, 2020.
Another system-level threat to patient safety is embedded biases. Addressing embedded biases requires holistic thinking and system-level approaches. Individual providers planning for and responding to these issues with one patient will not reduce errors and harm to patients.
These are major sources of embedded bias with consequences for patient safety in addiction care settings.
- Embedded biases related to insurance policies.
- Embedded biases in healthcare systems.
- Rejection of medically managed care as an embedded bias.
Embedded Biases Related to Insurance
Embedded bias on a systems level may arise in instances where insurance-related policies and practices are at odds with the treatment planning of providers, even when the medical treatments prescribed are supported by the evidence.
Embedded bias regarding insurance may arise:
- When insurance requires prior authorization.
- When insurance limits the dose of medication.
- When insurance limits the time in treatment.
- When insurance limits treatment episodes.
- When insurance won’t pay for services.
These embedded biases harm people with addiction by fragmenting care, potentially causing a return to substance use and denying life-sustaining medication, leaving the patient at risk for overdose.
Addressing embedded biases means working to change the system, but also being aware of the system as it is and trying to prevent harm to patients. If you know an insurance company requires a prior authorization, it helps to have a system in place by which your team can anticipate the need for a prior authorization or the end of coverage for treatment so you can be prepared with a plan.
Other biases embedded in health systems that can cause harm
- Arbitrary dismissals from care.
- Punishing patients for manifesting symptoms of their disease.
- Criminal justice authorities ordering patients off treatment.
- Withholding needed medical care until treatment is completed or recovery is sustained for an arbitrary period.
Arbitrary dismissals from care
Other ways embedded biases in a system can harm patients is when they result in arbitrary dismissals from care and when patients are punished for manifesting symptoms of their disease.
An example of another kind of embedded bias may be the case where a patient who smokes marijuana turns up at the methadone clinic. The patient tells you their pain treatment provider fired them because they smoked marijuana and told them they must get addiction treatment. The patient sitting in front of you may need help, but is absolutely not appropriate for your program. What do you do?
You might be inclined to blame the pain specialist but it is more productive to see it holistically. To address it, you need to go back and see what the providers in the system that provides pain treatment are doing, what training they’ve had, and what, if any, resources they have to monitor or support a patient with chronic pain and SUD. You would also want to find out what consequences the provider has or is afraid of experiencing if he or she continues to treat the patient.
Criminal justice authorities ordering patients off treatment
In some instances, criminal justice authorities of various types may tell people that they must quit treatment or risk going to jail. Looking at this situation holistically as a systems problem may prompt you to involve someone at the executive level of your program, health system leadership or possibly even elected officials.
Punishing patients for manifesting symptoms of their disease
There are other ways embedded biases at the system level punishes patients for manifesting symptoms of their disease. There are addiction treatment programs that routinely discharge patients because they test positive for one or more substances, instead of seeing the substance use as an exacerbation or evidence of disease progression.
Embedded bias may impact the care patients with substance use disorder are offered by other providers. A patient might be told he or she cannot be considered for a liver transplant until they’re off methadone. A male patient experiencing secondary hypogonadism due to chronic opioid therapy with methadone or buprenorphine might be told he can’t get testosterone replacement because the urologist doesn’t see the opioid as a life-sustaining medication and feels that person just needs to remove the cause of the condition.
Medically Managed Care and Patient Autonomy
Another embedded bias in health care systems in addiction medicine is the rejection of the medically managed care for people with substance use disorders.
Quality medically managed addiction care will:
- Recognize the autonomy and agency of people with a substance use disorder.
- Provide the tools and resources people with substance use disorder need to protect their health.
- Value healthier choices, even if they are not “treatment.” The idea that people must have multiple treatment exposures to recover may just be an artifact of the system taking an acute care and one size fits all approach to what is a chronic illness occurring in people with agency and preferences.
Accepting the role of medication in the management of the forms of SUD for which they exist is a step towards aligning addiction medicine with the patient-centered approach that is the norm in other parts of health care. It requires recognition that a person with a substance use disorder is capable of using tools and resources to improve their health and safety even if they reject formal treatment. This opens the door to reducing morbidity and mortality related to substance use as a primary outcome and allows people to build recovery capital even before they decide they are ready for treatment.
For example, in a single program, some staff may believe that the goal of medications for addiction treatment for opioid or alcohol use disorder is to get off of medication and become “drug-free,” while other staff consider the goal to be staying alive, not getting HIV or hepatitis, and building recovery capital.
Embedded Biases and Addiction Medicine
Addiction medicine is somewhat unique in terms of the scope of the system to be considered when trying to prevent or remediate errors. Limited resources and different assessments of beneficence can make solutions complex when a patient is not well served by a system. While the needed changes take place, you will surely find yourself having to mitigate harm to a patient caused by errors in the system.
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A Survey of Substance Use Disorder
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