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Deaths due to substance use disorder are skyrocketing. Eric Strain, a substance use disorder expert at Johns Hopkins, says although it is tempting to think everyone with substance use disorder should be hospitalized, other forms of care may be more appropriate.

Strain: Hospitalization should be the peak of the triangle, so very small, and then we should be thinking about devoting more resources to thinks like residential services, which are lower cost on a per day basis, can treat a larger number of people and there’s probably more people with things like mental health substance abuse and general medical care that don’t need to be in a hospital but need to be in some supervised environment to get them stabilized.  :28

Strain says that staff shortages are impacting hospital-based care in all specialty areas, including mental health and substance use disorder, and notes that residential treatment centers may also enable more coordinated services. At Johns Hopkins, I’m Elizabeth Tracey.

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Managing the full breadth of health issues in someone with substance use disorder could help reduce the likelihood of a bad outcome, especially in the 40% of people who have both mental health issues and substance abuse. Eric Strain, a substance use disorders expert at Johns Hopkins, says beginning with full primary care integration would be a good start.

Strain: The fact of the matter is we’ve got a substantial number of kids with ADHD who are getting treatment from their pediatrician, we have a substantial proportion of adults with garden variety major depression who get antidepressants from their primary care physician, we need to look at a system where the relatively straightforward conditions that can be treated by primary care physicians, nurse practitioners, providers like that, can be cared for in those settings so our specialty services can care for the more complicated people.  :31

Strain says such integration needs to begin with education of providers and patients. At Johns Hopkins, I’m Elizabeth Tracey.

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Substance use, mental health problems, and physical ailments are currently treated separately, but need to be integrated. That’s according to Eric Strain, a substance use disorder expert at Johns Hopkins.

Strain: You’ve got these complicated patients and we’ve got patients with substance abuse disorders and significant medical problems and we’ve got people with mental health problems and substance abuse problems and we’ve got all those combinations. We need to get away from thinking that each of those three areas is separate and needs to be defended by their own little fiefdoms.  :23

Electronic medical records can help.

Strain: Things like integrated health records make a lot of sense to better coordinate care. We also need to look at the funding streams for mental health, substance abuse and general medical care, and see better integration of those funding streams.  :16

At Johns Hopkins, I’m Elizabeth Tracey.

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If you’re receiving treatment for a substance use disorder, it’s likely that your other medical issues are being addressed elsewhere, including mental health issues. With a recent study showing that 40% of the time mental health issues and substance abuse occur together, that’s a problem. Eric Strain, a substance use disorder expert at Johns Hopkins, explains.

Strain: We have a fragmented healthcare system and which actually in some states such as New York has three bins to it. so there’s the mental health bin, there’s the substance use bin, and there’s what you might call the somatic therapy or the general medical care bin. Those bins or siloes need to be better integrated. It’s very tragic that way given the high comorbidity between substance abuse and other mental health conditions, that you’ve got this fragmented system.  :29

Strain says the likelihood of bad outcomes, including death, is much higher when care isn’t coordinated. At Johns Hopkins, I’m Elizabeth Tracey.

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Convalescent plasma, which is donated by someone who’s had Covid-19 and survived, is a much more reliable treatment for infection today than it was early in the pandemic. Arturo Casadevall, a convalescent plasma expert at Johns Hopkins, explains why.

Casadevall: We lucked out in that now we can get extremely high titer plasma, something that did not exist in 2020. Why? Because people like myself, who’ve been vaccinated and then get Covid mount enormous antibody responses. So the quality of the plasma today is significantly better than anything that we ever used in the past. So you have better plasma, and you have need, and convalescent plasma is back. It’s also been documented that if you use monoclonals, which bind only to a single piece, that you select for monoclonal resistant variants.  :33 

Casadevall says people who are immunocompromised are the best candidates for convalescent plasma treatment. At Johns Hopkins, I’m Elizabeth Tracey.

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Early on in the pandemic plasma collected from people who’d had Covid-19 and survived, so called convalescent plasma, was used to treat others, with mixed success. Now that new variants have emerged that can escape antibodies stimulated by vaccines and most monoclonals aren’t useful, Arturo Casadevall, a convalescent plasma expert at Johns Hopkins, says the treatment is being used again.

Casadevall: it’s now very clear that immunosuppressed individuals are not clearing this. it becomes chronic. It interferes with the rest of their therapy, and then the monoclonals are not there, Paxlovid has a lot of drug drug interactions, so then plasma finds a role. Plasma is being used today at Hopkins and Mayo largely as replacement therapy. Because people with B cell defects don’t make antibody and they are being treated with this, and the results are good, I mean people clear the infection when they are given plasma.  :31

Casadevall says the plasma requires intravenous administration. At Johns Hopkins, I’m Elizabeth Tracey.

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Apps to help people manage health conditions are getting more and more sophisticated, with some studies showing they reduce hospitalizations and slow down disease progression. Cardiologist Seth Martin at Johns Hopkins and developer of one such app says use of these apps compares favorably with clinically focused approaches.

Martin: Even if it’s as good but we can increase access to care to people who can’t currently access existing clinical care because of various barriers like cost, or transportation, that’s still a big win. But I think we have the potential to both increase access to care and also take current care to another level because we’re able to use algorithms and send coaching messages through the app. I think we can both scale up existing care and improve it in the long term.  :30

Martin notes that as smart phones become more ubiquitous and privacy concerns are put to rest, more and more of us will be using such apps to manage our health. At Johns Hopkins, I’m Elizabeth Tracey.