What's Wrong With Addiction Treatment:

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  • This is basically the charge of the current talk 1 – I have tried to put myself and the research literature I have reviewed into the position of a legislator faced with the difficult public health and public safety problems associated with addiction – BUT with competing demands for resources and reservations about what can really be expected from addiction treatment Will the public really get its money’s worth? What should we expect? How can we tell whether we are getting the best impact for the most reasonable (not necessarily the cheapest) expense? These are the issues addressed here.
  • What's Wrong With Addiction Treatment:

    1. 1. What’s Wrong With Addiction Treatment: What Are New Opportunities?
    2. 2. <ul><li>The Specialty Care System A “Customer” Perspective </li></ul><ul><li>Patient Survey </li></ul><ul><li>Care Provided </li></ul><ul><li>Infrastructure </li></ul>Part I
    3. 3. <ul><li>13,200 specialty programs in US </li></ul><ul><li>31% treat less than 200 patients per year </li></ul><ul><li>65% private, not for profit </li></ul><ul><li>80% primarily government funded Private insurance <12% </li></ul><ul><li>Sources – NSSATS, 2002; D’Aunno, 2004 </li></ul>Addiction Specialty Care
    4. 4. Substance Use Pyramid In Spec Treatment – 2,100,000 Abuse/Dependent – 23,000,000 “ Harmful Users” – ??,000,000 ?
    5. 5. Referral Sources <ul><li>Source 1990 2004 </li></ul><ul><li>Criminal Justice 38% 59% </li></ul><ul><li>Employers/EAP 10% 6% </li></ul><ul><li>Welfare/CPS 8% 16% </li></ul><ul><li>Hosp/Phys 4% 3% </li></ul>
    6. 6. Why Don’t Patients Want Treatment? Sources: 4 Review Articles Rapp et al. JSAT 2005 Stanton JMFT 2004 Appel et al. AJDA 2004 Tsogia et al. JMH 2001
    7. 7. Top Patient Reasons <ul><li>1) No Problem/Can Handle 58% </li></ul><ul><li>2) No Confidence in Trt 51% </li></ul><ul><li>3) Bad Trt Experience 36% </li></ul><ul><li>4) Abstinence-Only Goal 31% </li></ul>
    8. 8. WHY? Won’t programs deliver quality care? CAN’T
    9. 9. Three Reasons <ul><li>a. The Infrastructure </li></ul><ul><li>b. The Acute Care Model </li></ul><ul><li>The Way it is Evaluated </li></ul>
    10. 10. <ul><li>Phone Interviews With National Sample of 175 Programs regarding personnel, management, information </li></ul><ul><li>McL, Carise & Kleber JSAT , 2003 </li></ul>Program Infrastructure
    11. 11. The Treatment System <ul><li>Modality 1975 1990 2006 </li></ul>Residential 64% 39% 8% Outpatient 27% 59% 79% Methadone 9% 10% 13%
    12. 12. <ul><li>Counselor turnover 50% per year </li></ul><ul><li>50% of directors have been there Less Than 1 year </li></ul>STAFF TURNOVER!
    13. 13. Other Staff <ul><li>54% Had no physician 34% Had P/T physician 39% Had a Nurse (part of full time) </li></ul><ul><li>< 25% Had a SW or a Psychologist </li></ul><ul><li>Major professional group – Counselors </li></ul><ul><li>(Average Age – 54) </li></ul>
    14. 14. <ul><li>Modest Computer Availability </li></ul><ul><ul><li>Mostly For Administrative Work </li></ul></ul><ul><ul><li>80% Had a Computer </li></ul></ul><ul><ul><li>50% had Web Access </li></ul></ul><ul><li>Still very little computer/software availability for CLINICAL STAFF </li></ul>Information Systems:
    15. 15. <ul><li>The Acute Care Model </li></ul><ul><li>Treatment Models for Other Illnesses </li></ul>The Acute Care Model
    16. 16. A Nice Simple Rehab Model NTOMS Sample of 250 Programs Treatment Substance Abusing Patient Non- Substance Abusing Patient Medications, Therapies, JCAHO, CARF, WC Ev. Based Prac.
    17. 17. How Do Other Treatments Work? Chronic Illness & Continuing Care
    18. 18. A Continuing Care Model Primary Continuing Care Primary Care Specialty Care
    19. 19. In Chronic Illnesses…. 1 – The effects of treatment do not last very long after care stops 2 – Patients who are out of treatment/contact are at elevated risk for relapse
    20. 20. So, For Treatment…. 1 – One goal is to retain patients at an appropriate level of care and monitoring 2 – Another goal is to prepare patients to do well in the next level of care 3 - The effects of treatment are evaluated during treatment – not post-discharge
    21. 21. <ul><li>Implications of How We Evaluate </li></ul><ul><li>Differences in Outcome Expectations </li></ul>The Way it is Evaluated I
    22. 22. <ul><li>Studies show few differences between… </li></ul><ul><li>Brief and Intensive Treatments </li></ul><ul><li>Inpatient and Outpatient Treatments </li></ul><ul><li>Conceptually Different Treatments </li></ul><ul><li>“ Matched” and “Mismatched” Trt. </li></ul><ul><li>Gender or Culturally Oriented Trt. </li></ul>
    23. 23. Treatment Research Institute Outcome In Hypertension Pre - During - Post
    24. 24. Treatment Research Institute Outcome In Addiction Pre - Post
    25. 25. Maybe this is why…
    26. 26. <ul><li>Studies show few differences between… </li></ul><ul><li>Brief and Intensive Treatments </li></ul><ul><li>Inpatient and Outpatient Treatments </li></ul><ul><li>Conceptually Different Treatments </li></ul><ul><li>“ Matched” and “Mismatched” Trt. </li></ul><ul><li>Gender or Culturally Oriented Trt. </li></ul>
    27. 27. <ul><li>Are there new opportunities to show the value of treatment? </li></ul><ul><li>Primary Care </li></ul><ul><li>Different Treatment Model </li></ul><ul><li>New Purchasing Methods </li></ul>Part II
    28. 28. Why & How to Work With Primary Healthcare? 1 – New Proc/Pay Codes 2 – Medications 3 – PRISM
    29. 29. <ul><li>Effective January 2008 </li></ul><ul><li>Separate Billing Codes for </li></ul><ul><ul><li>Screening of alcohol problems </li></ul></ul><ul><ul><li>Brief Interventions (advice and counsel) </li></ul></ul><ul><li>Non-Physician Assistant Codes </li></ul><ul><ul><li>Behavioral and Lifestyle Factors </li></ul></ul>New Procedure Codes
    30. 30. <ul><li>Medications </li></ul><ul><ul><li>Alcohol ( Disulfiram, Naltrexone, Accamprosate ) </li></ul></ul><ul><ul><li>Opiates ( Naltrexone, Methadone, Buprenorphine ) </li></ul></ul><ul><ul><li>Cocaine (Disulfiram, Topiramate, Vaccine?) </li></ul></ul><ul><ul><li>Marijuana (Rimanoban) </li></ul></ul><ul><ul><li>Methamphetamine – Nothing Yet </li></ul></ul>FDA-Level Evidence
    31. 31. But…
    32. 32. Referral Sources <ul><li>Source 1990 2004 </li></ul><ul><li>Criminal Justice 38% 59% </li></ul><ul><li>Employers/EAP 10% 6% </li></ul><ul><li>Welfare/CPS 8% 16% </li></ul><ul><li>Hosp/Phys 4% 3% </li></ul>
    33. 33. WHY? Can’t physicians do SBIRT? WON’T
    34. 34. Top Physician Reasons Source 426 PCPs @ SGIM <ul><li>1) Don’t know what to do 69% </li></ul><ul><li>2) No Effective Treatment 55% </li></ul><ul><li>3) Not really a medical prob 26% </li></ul><ul><li>4) No time 19% </li></ul>
    35. 35. Disorders with Higher Prevalence Among Substance Abusers Substance abusing patients = 747 Matched controls = 3,690 Percent Weisner et al. Arch Intern Med . In press.
    36. 36. Non-compliant patient John Johnson, 61 y/o, diabetes resulting in a leg amputation: “… when doctors urged him to mind his diet, “I told them I eat what I want to eat and the hell with them.” “ I’ve been smoking for 50 years — why should I stop now?” he added for good measure. “This is supposed to be a free world.” New York Times, 12/1/2006, p.1 Online version, accessed at http://www.nytimes.com/2006/12/01/us/01medicaid.html on 12/6/06
    37. 37. Program of Research to Integrate Substance Use Information into Mainstream Healthcare PRISM Chronic Illness Care
    38. 38. Substance Use Prevalence In Spec Treatment – 2,300,000 Low Level Use Focal Group
    39. 39. <ul><li>Physicians want better information to manage chronic illnesses </li></ul><ul><ul><li>Commission systematic reviews of the role of substance use in those illnesses </li></ul></ul><ul><li>Goal: improve management of chronic illnesses , by managing substance use </li></ul>The PRISM Approach
    40. 40. Systematic Reviews <ul><li>Diabetes: </li></ul><ul><ul><li>Howard et al. Ann Intern Med . </li></ul></ul><ul><li>Hypertension: </li></ul><ul><ul><li>McFadden et al. Am J Hypertens. </li></ul></ul><ul><li>Chronic pain: </li></ul><ul><ul><li>Martell et al. Ann Intern Med . </li></ul></ul><ul><li>Breast cancer: </li></ul><ul><ul><li>Terry et al. Ann Epidemiol. </li></ul></ul><ul><li>Sleep: </li></ul><ul><ul><li>Dinges et al . JAMA </li></ul></ul>
    41. 41. Risk of Mortality & Drinks/Day 1.0 1.3 1.2 1.1 1.4 0.6 0.9 0.8 0.7 7 6 5 0 2 1 Drinks per Day Risk of Mortality 3 4 Di Castelnuovo et al. Arch. Int. Med . 2006;166(22):2437
    42. 42. Results to Date <ul><li>Working with 4 primary care societies 225,000 physicians </li></ul><ul><ul><li>American College of Physicians </li></ul></ul><ul><ul><li>American Geriatrics Society </li></ul></ul><ul><ul><li>Society of General Internal Medicine </li></ul></ul><ul><ul><li>American Academy of Family Physicians </li></ul></ul><ul><li>Practice initiatives </li></ul><ul><ul><li>New guidelines to manage chronic illnesses </li></ul></ul>
    43. 43. How Does Specialty Care Work In the Rest of Medicine?
    44. 44. A Continuing Care Model Primary Continuing Care Primary Care Specialty Care
    45. 45. Example…. <ul><li>PCP - 58 y/o male reports ringing in ears, dizziness/nausea </li></ul><ul><li>Actions - </li></ul><ul><li>Order/refer for testing – on EHR </li></ul><ul><li>Results to PCP – from EHR </li></ul><ul><li>Working Dx – discuss w/pt </li></ul><ul><li>Refer to specialist – on EHR </li></ul>
    46. 46. Example Cont’d…. <ul><li>Specialist - Reads all testing and notes – on EHR </li></ul><ul><li>Actions - </li></ul><ul><li>Writes note to PCP – using EHR </li></ul><ul><li>Tests/Prescribes/tortures </li></ul><ul><li>Evaluate – discuss w/pt - repeat </li></ul><ul><li>Refers w/note back to PCP - EHR </li></ul>
    47. 47. <ul><li>Cultural Assumptions… </li></ul><ul><li>It’s the PCP’s patient </li></ul><ul><li>Specialist is available, and will communicate in same language and on same EHR </li></ul><ul><li>Patient will return to PCP no matter what for continuing care/mgmt </li></ul>
    48. 48. Maybe this is why…
    49. 49. Referral Sources <ul><li>Source 1990 2006 </li></ul><ul><li>Criminal Justice 38% 59% </li></ul><ul><li>Employers/EAP 10% 6% </li></ul><ul><li>Welfare/CPS 8% 16% </li></ul><ul><li>Hosp/Phys 4% 3% </li></ul>
    50. 50. Re-Thinking Treatment for Serious Addiction Lessons from Physician Health Plans
    51. 51. Physician Health Plans <ul><li>49 PHPs </li></ul><ul><ul><li>All authorized by state licensing boards </li></ul></ul><ul><ul><li>Most treat many types of health professionals </li></ul></ul><ul><li>Do NOT provide treatment </li></ul><ul><ul><li>Assess, Intervene, Evaluate, Refer, Monitor, Report and Advocate </li></ul></ul><ul><ul><li>All under authority of Board </li></ul></ul>DuPont et al., 2008, (in review).
    52. 52. Evaluation and Contracting <ul><li>Phase 1 - Evaluation (1 – 2 mos.) </li></ul><ul><ul><li>Evaluate referred physician </li></ul></ul><ul><ul><li>Explain PHP and Contract </li></ul></ul><ul><ul><li>Full diagnostic evaluation – often with family </li></ul></ul><ul><ul><li>Intervention where appropriate </li></ul></ul><ul><li>Result is signed contract </li></ul><ul><ul><li>3 – 5 years in duration </li></ul></ul><ul><ul><li>Protection from immediate adverse actions </li></ul></ul><ul><ul><li>Monitoring with report to Board – 4 yrs </li></ul></ul>
    53. 53. Formal Treatment <ul><li>Phase 2 ~1 yr </li></ul><ul><ul><li>Selected residential treatment 30 – 90 days </li></ul></ul><ul><ul><li>Referral to IOP or OP ~ 6 months </li></ul></ul><ul><ul><ul><li>Return to practice ~ month 3 </li></ul></ul></ul><ul><ul><li>Aftercare program ~ 3-6 months </li></ul></ul>
    54. 54. Monitoring & Support <ul><li>Phase 3 – 3 - 4 yrs </li></ul><ul><ul><li>AA attendance - usually mandatory </li></ul></ul><ul><ul><li>Caduceus Society meetings - mandatory </li></ul></ul><ul><ul><li>Personal Therapist </li></ul></ul><ul><ul><li>Family Therapy </li></ul></ul><ul><ul><li>Worksite visits </li></ul></ul><ul><li>Urine Drug Screenings </li></ul><ul><ul><li>Weekly - monthly (random during weekdays) </li></ul></ul><ul><ul><li>20 panel testing </li></ul></ul>
    55. 55. Results During Contract ` <ul><ul><li>904 Physicians </li></ul></ul><ul><ul><li>Consecutively Enrolled into </li></ul></ul><ul><ul><li>16 state Physician Health Programs </li></ul></ul>Continuers 132 - Still being monitored 132 (15%) Completed 448 - No Longer Being Monitored 67 - Completed but monitored voluntarily 515 (57%) Non-Completers 85 –Voluntarily stopped / Retired 48 – Failed, License Revoked 22 - Died (6 suicides) 102 –Transferred/Moved 257 (28%)
    56. 56. Urine Testing Over 4 years
    57. 57. Results at 5-7 Years Practicing Medicine Completers 92% Continuers 73% Non-Completers 28%
    58. 58. Results at 5-7 Years Revoked License Completers 2% Continuers 11% Non-Completers 32%
    59. 59. New Purchasing Methods Performance Contracting In Delaware
    60. 60. <ul><li>13,200 programs in US </li></ul><ul><li>65% private, not for profit </li></ul><ul><li>80% primarily government funded Private insurance <12% </li></ul><ul><li>31% treat less than 200 patients per year </li></ul><ul><li>Sources – NSSATS, 2002; D’Aunno, 2004 </li></ul>Addiction Specialty Care
    61. 61. Delaware Situation 2002 <ul><li>11 Outpatient Providers </li></ul><ul><li>Limited Budget </li></ul><ul><li>No success with outcome evaluation </li></ul><ul><li>Providers won’t/can’t use EBPs </li></ul>
    62. 62. Delaware’s Performance Based Contracting <ul><li>2002 Budget – 90% of 2001 Budget </li></ul><ul><li>Opportunity to Make 106% </li></ul><ul><li>Two Criteria: 80% Utilization/Occupancy Active Participation </li></ul><ul><li>Audit for accuracy and access </li></ul>
    63. 63. Delaware’s Results Years 1 & 2 <ul><li>One program lost contract </li></ul><ul><li>Two new providers entered, did well </li></ul><ul><ul><li>Mental Health and Employment Programs </li></ul></ul><ul><li>Programs worked together </li></ul><ul><ul><li>First, common sense business practices </li></ul></ul><ul><ul><li>Second, incentives for teams or counselors </li></ul></ul><ul><li>5 programs learned MI and MET </li></ul>
    64. 64. Utilization
    65. 65. % Attending
    66. 66. <ul><li>Specialty care system is in trouble </li></ul><ul><ul><li>Customers Do Not Want the Product </li></ul></ul><ul><ul><li>Ruled by Gov, Not Market Forces </li></ul></ul><ul><li>System Change is Necessary </li></ul><ul><ul><li>Public Health Value thru Patient Value </li></ul></ul><ul><ul><li>Reach Deeper into “Problem User” group </li></ul></ul><ul><ul><li>Meet Customer Needs – Offer New Options </li></ul></ul>CONCLUSIONS
    67. 67. - The End -
    68. 68. Substance Use Pyramid In Spec Treatment – 2,100,000 Abuse/Dependent – 23,000,000 “ Harmful Users” – ??,000,000 ?
    69. 69. What’s Different Since 2000 <ul><li>Five pharmaceutical companies </li></ul><ul><li>Push for Evidence Based Practices </li></ul><ul><li>National Parity Legislation </li></ul><ul><li>SBIRT – Physician Pay Codes </li></ul><ul><li>Prescrip. opiates as “entry drug” </li></ul><ul><li>Performance Contracting </li></ul>
    70. 70. Forces That May Affect Addiction Treatment <ul><li>Conceptual Shifts </li></ul><ul><ul><li>Addiction is a bad habit Addiction is a chronic illness </li></ul></ul><ul><ul><li>Addiction treatment is an art Addiction treatment is a science </li></ul></ul><ul><ul><li>Patient progress judged by provider Progress judged on standard measures </li></ul></ul><ul><ul><li>Addicted patients need special program Patients need generic care/services </li></ul></ul>
    71. 71. Forces That May Affect Addiction Treatment <ul><li>Scientific Discoveries </li></ul><ul><ul><li>Medications (4 co’s now – many considering) </li></ul></ul><ul><ul><ul><li>Look for Vaccines w/in 5 years </li></ul></ul></ul><ul><ul><li>Cheap, effective monitoring </li></ul></ul><ul><ul><li>Internet information for purchasers </li></ul></ul><ul><ul><li>Brain/Genetic science may consolidate addictions with other impulse disorders </li></ul></ul>
    72. 72. Forces That May Affect Addiction Treatment <ul><li>Market Forces </li></ul><ul><ul><li>Consumer’s Report information </li></ul></ul><ul><ul><li>Performance Contracting </li></ul></ul><ul><ul><li>Bundled Purchasing </li></ul></ul><ul><ul><ul><li>May force consolidation </li></ul></ul></ul><ul><ul><li>“ Carve In” of Behavioral Health </li></ul></ul><ul><ul><li>Entry of Primary Care (medications) </li></ul></ul><ul><ul><li>Sentence Reform/Prison Overcrowding </li></ul></ul><ul><ul><ul><li>Drug Court models </li></ul></ul></ul>
    73. 73. Forces That May Affect Addiction Treatment <ul><li>Other Forces </li></ul><ul><ul><li>IOM 2006 Report </li></ul></ul><ul><ul><ul><li>Pending Suits </li></ul></ul></ul><ul><ul><li>Insurance Parity </li></ul></ul>

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