©Treatment Research Institute, 201204/19/23

Why Integrate Addiction Care into Mainstream Medicine?

©Treatment Research Institute, 2013

A. Thomas McLellanTreatment Research Institute

Part I

Closing Thoughts

Substance use disorders” will soon be a regular part of mainstream healthcare:1.SUDs are too omnipresent, dangerous & expensive in healthcare to be ignored

2.Market forces will accelerate integrationo Insurance benefits will bring new meds,

continuing care protocols & other tools

3.Mainstream healthcare can do this!o Several protocols already fit into the system

Substance Use Among US Adults

Addiction ~ 23,000,000

Harmful – 40,000,000 Use

Little or No UseLittle/NoUse

VerySeriousUse

In Treatment ~ 2,300,000

1

1. Because it will improve general medical care

2. Because it will save money

3. Because it’s the law.

Alcohol and drug use below “addiction” lead to:misdiagnoses,poor adherence to care,interference with prescribed meds, more physician time, unnecessary medical testing, poor outcomesincreased costs Particularly in chronic illness.

Substance Use Impact on Healthcare

Vinson D, Ann Fam Med, 2004. Brown RL, J Amer Board Fam Prac, 2001. Humeniuk R, WHO, 2006. Manwell LB, J Addict Dis, 1998. Longabaugh R. Alcohol Res Health, 1999. Healthiest Wisconsin 2010, WI DHFS, 2000. USPSTF, Screening for Alcohol Misuse, 2004. National Quality Forum, National Voluntary Consensus Standards, 2006. Bernstein J, Drug Alcohol Depend, 2005. Saunders B, Addiction, 1995. Stephens RS, J Consult Clin Psychol, 2000. Copeland J, J Subst Abuse Treat 2001. Fleming MF, Med Care, 2000. Fleming MF, Alcohol Clin Exp Res, 2002. Gentilello LM, Ann Surg, 1999. Estee S, Medicaid Cost Outcomes, Interim Report 4.61.1.2007.2, Washington State Department of Social and Health Services. Yarnall KSH, Am J Public Health, 2003. Solberg LI, Am J Prev Med, 2008. National Committee on Prevention Priorities, http://www.prevent.org/content/view/43/71/.

5

1

Alcohol Use and Breast CancerBefore Diagnosis – heavy drinkers

1.5 times chance of contracting

2.3 times chance w/BRCa2 gene

After Diagnosis – ANY Drinking

Increases risk of relapse

Interferes radio & chemo therapy

1

Phillips, D. P. et al. 2008;168:1561-1566.

Alc/Drg RelatedFatal Errors

FME Death Rate1983 - 2004

Potential impact on Safety: Fatal Medical Errors

• BU study of 87 patients with undisclosed opioid use receiving primary care at BU Medical Center.

• 100% received at least one medication with a significant drug-drug interaction

• Average number of significant interactions = 5• 15 of 87 patients (17%) were treated by ED for

their interaction ($$$)

Drug-Drug Interactions – Safety Issues

Walley et al., J. Gen Internal Medicine, 24(9): 1007-11, 2009

1

Causes of Accidental Death

#1 Medication Overdose

#2 Car Accidents

#3 Accidental Shooting

Source: CDC, 2013

Pain Society and State Guidelines for Pain Management

Model policy for the use of opioids in the treatment of pain.http://www.fsmb.org/pdf/

2004_grpol_Controlled_Substances.pdf

Gilson AM, Joranson DE, Maurer MA. Improving state pain policies: recent progress and continuing opportunities.

CA Cancer J Clin. 2007;57(6):341–353

1. Screening for & discussing substance use

2. Patient contract – Single doc & pharmacy

3. Patient & family education on safe storage of medications

4. Urine Screening pre and during prescribing (expanded test panel)

1

1. Because it will improve general medical care

2. Because it will save money3. Because it’s the law.

Substance Use Cost in Healthcare

Addiction ~ 23,000,000

“Harmful – 40,000,000 Use”

Little or No UseLittle/NoUse

VerySeriousUse

In Treatment ~ 2,300,000

$80 BYr

$40BYr

1

1. Because it will improve general medical care

2. Because it will save money3. Because it’s the law.

2009 Parity Act“MHPAEA”

“If” a health plan covers MH/SA benefits should be comparable to those of similar physical illnesses”

2010 Affordable Care Act

• Funds full continuum of care• Prevent, BI, Meds, Spec Care

• Significant change in benefit • The nature/number of benefits• The types of eligible providers

• SUD care is an “Essential Service”

SUD Benefits Today

Addiction ~ 23,000,000

“Harmful – 40,000,000 Use”

Little or No UseLittle/NoUse

VerySeriousUse

In Treatment ~ 2,300,000

Addiction

• Detoxification – 100%

– Ambulatory – 80%

• Opioid Substitution Therapy – 50%

• Urine Drug Screen – 100%– 7 per year

1

Medicaid Diabetes benefit

• Physician Visits – 100%

• Clinic Visits – 100%

• Home Health Visits – 100%

• Glucose Tests, Monitors, Supplies – 100%

• Insulin and 4 other Meds – 100%

• HgA1C, eye, foot exams 4x/yr – 100%

• Smoking Cessation – 100%

• Personal Care Visits – 100%

• Language Interpreter - Negotiated

SUD Insurance Under ACA

Addiction ~ 23,000,000

“Harmful – 40,000,000 Use”

Little or No UseLittle/NoUse

VerySeriousUse

In Treatment ~ 2,300,000

Insurancefor

“SubstanceUse

Disorders”

• Physician Visits – 100%– Screening, Brief Intervention, Assessment

– Evaluation and medication – Tele monitoring

• Clinic Visits – 100%

• Home Health Visits – 100%– Family Counseling

• Alcohol and Drug Testing – 100%

• 4 Maintenance and Anti-Craving Meds – 100%

• Monitoring Tests (urine, saliva, other)

• Smoking Cessation – 100%

Substance Use Among US Adults

Addiction ~ 23,000,000

“Harmful – 40,000,000 Use”

Little or No UseLittle/NoUse

VerySeriousUse

In Treatment ~ 2,300,000

Prevention

Early Intervention

Chronic CareModel

Closing Thoughts

Substance use disorders” will soon be a regular part of mainstream healthcare:1.Too common, dangerous & expensive in healthcare to be ignored

2.Public understanding that addiction is an illness not a sinSUDs are too commo

3.Mainstream healthcare can do this!o Chronic Care Management protocols are appropriate

1

How Can State Government Improve Quality?

~12,000 specialty programs in US

• 31% treat less than 200 patients per year

• 77% primarily government funded

Private insurance <12%

1

1. Require state schools to teachsubstance use disorders

2. Stop buying sub-standard care3. Educate consumers to

demand quality

1

1. Require state schools to teachsubstance use disorders

2. Stop buying sub-standard care3. Educate consumers to

demand quality

Delaware’s Performance Based Contracting

• 2002 Budget – 90% of 2001 Budget

• Opportunity to Make 106%• Two Criteria for Outpatient Providers

– Full Utilization

– Active Participation

• Audit for accuracy and access

Delaware’s ResultsYears 1 & 2

• One program lost contract

• Two new providers entered, did well– Mental Health and Employment Programs

• Programs worked together– First, common sense business practices

– Second, incentives for teams or counselors

• 5 programs learned MI and MET

Utilization

3000

3500

4000

4500

5000

5500

6000

6500

Ave

rage

Dai

ly C

ensu

s

2001 2002 2003 2004 2005 2006 2007

% Attending

20

30

40

50

60

70

80

2001 2002 2003 2004 2005 2006 2007

>30 days >60 days

Buy the Continuum of Care:Not the Pieces

The Current Continuum of CareContinuing Care

2x per mo.Outpatient Care

1 – 2 x per wk.

Intensive OP

3x per wk.Residential Care

7 – 30 days

Purchaser

Functional Continuum of Care

Continuing Care

2x per mo.Outpatient Care

1 – 2 x per wk.Intensive OP

3x per wk.Residential Care

7 – 30 days

Purchaser

Sober H

ousing

Why continue the segregation?

Crossing the Quality Chasm

a new HEALTH system for the 21st century (IOM, 2001)

CONCLUSION

“It is not possible to deliver safe or adequate healthcare without simultaneous consideration of general health, mental health and substance use issues.”

QUESTION?Sooo….why do states license

addiction programs that do NOT:

1.Offer ALL approved types of care (medications, therapies, etc.)?

2.Treat physical AND psychiatric illnesses that occur in >40% of their patients?

1

1. Require state schools to teachsubstance use disorders

2. Stop buying antiquated care3. Educate Consumers – help

them understand & buy quality

All Programs Are Not Created Equal:

Kathleen Meyers, PhD & John Cacciola, PhDSupported by NIDA P50DA027841

Using a Comparative Consumer Guide to measure the availability of effective treatment for teens

©Treatment Research Institute, 201244

©Treatment Research Institute, 201304/19/23

Why a Consumer Guide Approach toMeasuring (and Improving) Quality?

Simple Premise – Higher quality programs have more quality elements than lower quality programs

Builds Upon Work of Mathea Falco & Drug Strategies’ “Treating Teens – A Guide to Adolescent Drug Programs”

First comparative study of EBPs in 144 “highly regarded” adolescent treatment programs

Later studies confirm programs with more “quality elements” or “evidence based practices” have better outcomes (Knudsen et al., Duda et al.)

©Treatment Research Institute, 201304/19/23

Why a Consumer Guide Approach toMeasuring (and Improving) Quality?

Consumer Guides

Offer comparative information on features (e.g., relevance, quality, value)

Inform and direct an individual consumer’s purchase (short-term)

Improve the service marketplace (long-term)

EXAMPLE #1 – Comparative Guide to Cell Phone Service

Program:Component Score Total:

A87

B51

C81

D35

E55

F49

G30

H44

I35

Assessment 2 1 2 1 1 1 1 1 1

Attention to Mental Health

2 1 1 0 1 1 0 0 0

Comprehen-sive Integrated

Treatment

2 0 1 0 0 1 0 0 0

Family Involvement

1 0 1 0 0 0 0 0 0

Developmen-tally Informed Programming

2 1 2 0 1 1 1 1 1

Engage and Retain

1 1 1 0 1 1 0 0 0

Continuing Care

1 1 1 1 0 0 0 1 0

Culturally Informed

Programming

2 0 1 0 0 0 0 0 0

Staff Qualifications

2 1 2 1 1 1 1 1 1

Program Evaluation

0 0 0 0 0 0 0 0 0

Not Present / Inadequate

Present / Adequate

Present / Good

CO

RE

SE

RV

ICE

SE

NH

AN

CE

ME

NT

SA

DM

IN.

Actual Data - Comparative Guide to Adolescent Addiction Treatment[-----------------------PROGRAMS-----------------------]

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1

Treatment of Addicted Physicians

Physician Health Plans

• 49 PHPs • All authorized by state licensing boards• Most treat many types of health professionals

• Do NOT provide treatment• Assess, Intervene, Evaluate, Refer, Monitor, Report and Advocate• All under authority of Board

McLellan, DuPont, Skipper 2008, BMJ

Evaluation and Contracting

• Phase 1 - Evaluation (1 month)• Evaluate/diagnose referred physician• Explain PHP and Contract

• Result is signed contract• 3 – 5 years in duration• Protection from immediate adverse actions• Monitoring with report to Board – 4 yrs

Treatment and Monitoring• Phase 2 – ~1 yr

• Selected residential treatment 30 – 90 days• Referral to IOP or OP ~ 6 months

• Return to practice ~ month 3• Aftercare program ~ 3-6 months

•Phase 3 – 4 yrs• AA attendance - Caduceus Society meetings • Family Therapy

•Urine Drug Screenings - throughout• Weekly - monthly (random during weekdays)• Worksite visits

Results Through Five Years

No Positive Urine Over

5 Years

78%

Results Through Five Years

Second Positive Urine After One Slip

26%