Health reform and other policies around substance abuse treatment systems ondcp 4.2010

Policies that promote effective systems of care for substance use disorders Keith Humphreys Senior Policy Advisor, White House ONDCP Professor of Psychiatry, Stanford University Career Research Scientist, Department of Veterans Affairs

Substance Use Disorder Care is a major focus of NDCS, but not the only one
Prevention
Reduction of Prescription Drug Abuse
Drugged Driving
New models of law enforcement and community supervision
Merida Initiative, CBSI, Afghanistan
See www.whitehousedrugpolicy.gov for the full National Drug Control Strategy

Can Countries Achieve “Tipping Points” with Substance Use Disorder Treatment?
Some nations have treatment on demand and very high population penetrance (Australia, Switzerland, The Netherlands)
Others invest some resources, but have lower population penetrance (U.S.)
Critical question is whether there is a “tipping point” with care expansion

In U.S., about one in six persons meeting diagnostic criteria for illicit drugs received specialty treatment Total needing treatment for illicit drugs = 7.559 million . Source: SAMHSA, 2008 National Survey on Drug Use and Health (September 2009). 8/2009 13

Proportion of all heroin addicted individuals in methadone maintenance, 1993 Source: MacCoun, R. J., & Reuter, P. (2001). Drug war heresies . Cambridge, UK: Cambridge University Press.

France subsequently dramatically expanded opiate agonist treatment Emmanuelli, J., & Desenclos, J-C. (2005). Harm reduction interventions, behaviours and associated health outcomes in France, 1996-2003. Addiction, 100 , 1690-1700.

..And apparently achieved a tipping point 1996-2003
Annual heroin arrests dropped from 17,328 to 4,025
Annual overdose deaths declined from 465 to 89

Only historical U.S. example
From 10/1971 – 3/1973, federal government expanded treatment slots 352%
First national annual drop in street crime in 20 years occurred from 1972-1973
Data systems at the time too crude to conduct more fine-grained analysis
References: Musto, D., & Korsmeyer, P. (2002). The quest for drug control . New Haven: Yale University Press; Massing, M. (1998). The fix . New York: Simon and Schuster.

How will the Obama Administration Increase the Quantity of Care for Substance Use Disorder?

Patient Protection and Affordable Care Act of 2010
Specifies that screening, brief intervention and treatment for substance use disorders are essential healthcare benefits
Insures about 5M more people who have substance use disorders
Extends parity regulations to exchanges
Expands Medicaid to 133% of FPL, covers childless adults

The Spectrum of Substance Use Disorder Specialty Treatment ~ 2,300,000 Abuse/Dependent – 25,000,000 “ Harmful Users” – ??,000,000 Little or No Use

What is SBIRT?
Screening, Brief Intervention and Referral for Treatment
Targeted at less dependent patients
Strong evidence of effectiveness
Usable in primary care, emergency rooms and other

Administration SBIRT proposals
CMS continue to support billable codes
President’s budget request supports their expansion with new funding for monitoring and technical support
Expand program to train physicians in SBIRT methods

Selected Administration initiatives for treatment of addicted individuals
Mental health and substance abuse parity regulations
Expansion of funding in existing health care systems (more on this later..)
Re-entry/diversion initiative
End of ban on federal funding for NEP
Increase in NIH funding
Medicaid expansion?

Will all this increase in quantity produce a “tipping point”?

A brief but important word about expanding treatment in developing countries

International Demand Reduction
PEPFAR new focus on medication assisted treatment for IDUs
Merida Initiative includes support for electronic linkage of 300 treatment centers in Mexico
NIDA international scholars and research programs

Expanding quantity does not resolve concerns about quality

Alcohol dependence was last among 30 medical conditions in proportion of care received as evidence would recommend Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United States. New England Journal of Medicine, 348 . Senile cataract 78.7% Breast cancer 75.7% Prenatal care 73.0% Hypertension 64.7% Asthma 53.5% Diabetes Mellitus 45.4% Urinary Tract Infection 40.7% Atrial Fibrillation 24.7% Alcohol Dependence 10.5%

Common quality issues
Isolation of specialty addiction treatment and mainstream health care
Sub-optimal staff training, morale and pay
Poor continuity of care
Inadequate health information technology
Minimal use of evidence-based practices
High process regulation…with weak performance standards
References: Uchtenhagen A., Stamm R., Huber J., and Vuille R. (2008) A review of systems for continued education and training in the substance abuse field. Substance Abuse 29 , 95-102. McLellan, AT, Carise, D, Kleber, HD. (2003). Can the national information treatment infrastructure support the public’s demand for quality care? . Journal of Substance Abuse Treatment. 25, 117-21 .

What policies might improve the quality of care?

Improving quality is a challenge: Dr. Zoe D. Katze

Incentivizing particular care processes: VA example
Pool of “off the top” funding set aside at beginning of each year
Meeting standards on particular indicators is rewarding financially
Success example: Alcohol screening and identification of problem drinkers

Rates of identifying substance abuse in VA versus other systems

Administration Proposal: P4P for States
President’s Budget requests $6M for a new pay for performance program
States and Tribes would compete for the funds
Those selected would receive incentive funds to reward quality in their systems
Broad latitude allowed for the dimension of care rewarded

A market-based approach to quality: Access to Recovery
Individuals seeking care receive a voucher, value varies, average around USD1600
For public sector, provides unusual freedom to select (or switch) care options
About $100M annually in 3-year cycles, offers services to about 160,000 individuals total
Obama Administration proposes $9.9M increase for program

Embedding specialty care within medicine to improve quantity and quality at once
Makes specialty care subject to the quality and process regulations of medicine
Brings in the staff and resources to meet those standards
But allows choice because U.S. insurance system is market based

Other potential advantages to expanding substance use disorder care within mainstream healthcare systems
Better integration of care from the outset
Unified health information technology
Less stigma to accessing care

Two care systems for such expansion, proposed in President’s 2011 Budget
HRSA’s Community Health Centers
Indian Health Service

Summary
Obama Administration is emphasizing brief interventions, and, treatment for people with substance use disorder
A public health “tipping point” may be achievable through treatment/brief intervention, but required amount of expansion is unknown

Summary, continued
Administration proposing major investments in expanding the quantity of treatment
Expansion of quantity does not necessarily improve quality, hence some quality focused proposals as well
Expansion of substance use disorder treatment within mainstream healthcare systems may offer quantity AND quality benefits

- The End -

Health reform and other policies around substance abuse treatment systems ondcp 4.2010

by APHA Alcohol, Tobacco, & Other Drugs Section

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Health reform and other policies around substance abuse treatment systems ondcp 4.2010 Presentation Transcript