Bertha K Madras, PhD(the Honorable)

Professor of PsychobiologyDept of Psychiatry

Harvard Medical School

Experiences as the Experiences as the White House Deputy Drug Czar White House Deputy Drug Czar

For Prevention, Treatment: For Prevention, Treatment: Identifying Needs on a National ScaleIdentifying Needs on a National Scale

Experiences as the Experiences as the White House Deputy Drug Czar White House Deputy Drug Czar

For Prevention, Treatment: For Prevention, Treatment: Identifying Needs on a National ScaleIdentifying Needs on a National Scale

Introduction…

Research and Teaching

Government Service

Public Outreach

Madras BK. Office of National Drug Control Policy: a scientist in drug policy in Washington, DC. Ann N Y Acad Sci. 2010 Feb;1187:370-402. Review.

ConsequencesChildren, Families

Health Education

Employment Safety: crime, home, workplace, highway

CostsHealthcare,

Criminal Justice Productivity

Populations Children

AdolescentsYoung adults

Gender Elderly

Prison populationsMilitary

Employment statusPsychiatric status

Race, ethnicity

Old and Emerging Drugs Alcohol, inhalants

NicotineMarijuana

CocaineMethamphetamine

Opioids, Prescription opioidsHallucinogens

Anabolic steroidsDesigner drugs

Research voidsControversies

Resource AllocationPolicies

Other Nations

• 20.6 million people need do not receive treatment

• 94.%: no need for treatment• 3.7%: need treatment, don’t try

• 1.7%: Need treatment, try

3.7% 1.7%

94.6%

0

5

10

15

Age at first use vs abuse/dependence

% a

buse

/add

ictio

n

14y

18y+18y+

14y

Alcohol Marijuana

Source: SAMHSA, 2012 National Survey on Drug Use and Health (September 2013)

Age of users

%

Prevention: At risk adolescents, youth populations

Unidentified: ~ 70 million with risky, problematic use

Unidentified: > 22 million people with Substance Use Disorders

Scalability: 200+ evidence-based programs !?!

Resistance to change: Analysis of factors

Poor Treatment programs: Evidence based, seamless entry, records, poor medical resources, recovery support services, no chronic care model

Focus on a strategy, SBIRT, in response to some challenges of Demand Reduction.

Effective and Cost-effective?

Analysis of Resistance to Change?

Incentives to address resistance?

SBIRT

Source: Madras et al. Drug and Alcohol Dependence 99: 280-295, 2009

Social change

0

20

40

60

80

100Intake6 month follow-up

***

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% r

ep

ort

ing

du

nc

tion

al d

om

ain

sa

t in

tak

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6 m

on

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ollo

w-u

p

% Change in Functional Domains

-80

-60

-40

-20

0

20

40

60

80

-80

-60

-40

-20

0

20

40

60

80

p < 0.001(3622)

(889)

(1000)

(397)

(459)

(n)

% C

han

ge

fro

m in

take

an

d6

mo

nth

fo

llow

-up

Negative Screen Positive screen77.3 % 22.7 %

Screening

Positive Reinforcement

Brief Intervention Brief Treatment Referral to Treatment

Moderate Use Moderate/High Use Abuse/Dependence

70 % 16 %14 %

Total screened (n) = 459,599

Screened positive (n) + 104,505

Source: Madras et al. Drug and Alcohol Dependence 99: 280-295, 2009

Analysis of Incentives for Translation to Scale

Population: aged, blind, disabledN: 1,000 screened in 9 hospitalsSavings: $157 – $202 / member / month Reductions: due to decline in inpatient hospital costs

Overall estimated savings:1,000 Medicaid patients savings ~ $1.9 - $2.4 million/year

Targeted meetingsTargeted meetingsAHA, AHIP, ACS-AHA, AHIP, ACS-

COTCOTBully pulpit

FEHB, HHS: NIDA. NIAA, CMS, SAMHSA, HRSA, Surgeon General, etc)Dept of Justice Dept of Labor Dept of Education Veteran’s Administration Indian Health Services, Dept of CommerceDept of DefenseDept of TransportationIndian Health Services

Invite to White House Conferences Fund Programs

Scientific data, cost-benefitPartnerships Public and private sector

Reductions in Substance Use from intake to 6 month follow-up

0

20

40

60

80Intake6 Month follow-up

***

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***

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% R

epor

ting

spec

ific

subs

tanc

esat

inta

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nd a

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onth

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National National LeadershipLeadership

Conference onConference onMedical Education Medical Education

in in Substance AbuseSubstance Abuse

Nov 30-Dec 1 2006Nov 30-Dec 1 2006Jan 15 2008Jan 15 2008Sept 5 2008Sept 5 2008

During Office• New CPT®, Medicare (“G”) and Medicaid (“H”) billing codes for SBIRT• State Medicaid Directors: > 10 states adopt SBIRT codes. • Office of Personnel and Management: new codes in “call” letter • CMS: sets aside $265,000 million, SBIRT Codes reimbursement• VA: mandates SBI for alcohol in health care systems, June 2008. • SAMHSA: Expands SBIRT to 14 locations • SAMHSA: Expands Rx abuse screening • SAMHSA: Medical residency training program in SBIRT• SAMHSA and DoJ: SBIRT pilot in juvenile court program • ACS, Committee on Trauma: Expand SBIRT for Rx abuse • Federation of State Medical Boards: adopt policy on SBIRT medical

education .• Accreditation Council for Continuing Medical Education (ACCME):

features screening, brief interventions as representative CME course and video of SBI

• Health Resources Services Administration (HRSA): Incorporates SBIRT into routine screening

• NIDA: Generate new RFA’s for screening, brief interventions; • (2) Develop a web training site for screening, brief interventions

(NIDAMED went live April 2009); (3) Develop a prescription drug screening strategy; (4) Implement SBIRT in NIDA treatment programs.

• United Nations: Issues proclamation in support of SBIRT.• Criteria for improving quality and effectiveness of treatment: in

documents• SAMHSA- Access to recovery: (1) Promoted research and reporting of a

new treatment program, Access to Recovery (ATR); (2) develop an ATR manual, to enable program replication in multiple sites and nations.

Subsequent Legacy2009-2013: National Drug Control

Strategy highlights SBIRT as key component of strategy

January 2012: Medicare will cover an annual alcohol misuse screening by a beneficiary’s primary care provider and include four behavioral counseling sessions/year if a beneficiary screens positive for alcohol misuse.

Present: SBIRT research, training, support is rapidly gaining momentum in healthcare programs nation-wide.

Treatment Needs will Expand – a few reasons Treatment Needs will Expand – a few reasons • SBIRT: will identify millions of people in need of

treatment (federal programs, private sector).• Increasing drug use: increased use (and daily use) of

marijuana, designer drugs, [prescription opioids].• Policy decisions: legalization movement, reduced

criminal penalties, increased focus on drug courts, treatment.

• Medical care costs: higher in patients with SUDs.• Insurance expanded for children to age 26: this

population at highest risk for substance abuse. • Workplace inefficiency: Industry aware of relationship .

Effective Principles of Treatment are Critical!