©Treatment Research Institute, /5/2015 Why Integrate Addiction Care into Mainstream Medicine? ©Treatment Research Institute, 2013 A. Thomas McLellan Treatment 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 integration o 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 Use Little/No Use Very Serious Use 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 outcomes increased costs Particularly in chronic illness. Substance Use Impact on Healthcare Vinson D, Ann Fam Med, Brown RL, J Amer Board Fam Prac, Humeniuk R, WHO, Manwell LB, J Addict Dis, Longabaugh R. Alcohol Res Health, Healthiest Wisconsin 2010, WI DHFS, USPSTF, Screening for Alcohol Misuse, National Quality Forum, National Voluntary Consensus Standards, Bernstein J, Drug Alcohol Depend, Saunders B, Addiction, Stephens RS, J Consult Clin Psychol, Copeland J, J Subst Abuse Treat Fleming MF, Med Care, Fleming MF, Alcohol Clin Exp Res, Gentilello LM, Ann Surg, Estee S, Medicaid Cost Outcomes, Interim Report , Washington State Department of Social and Health Services. Yarnall KSH, Am J Public Health, Solberg LI, Am J Prev Med, National Committee on Prevention Priorities, 5

1

Alcohol Use and Breast Cancer Before 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: Alc/Drg Related Fatal Errors FME Death Rate P otential 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): , 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. s.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 money 3.Because it’s the law.

Substance Use Cost in Healthcare Addiction ~ 23,000,000 “Harmful – 40,000,000 Use” Little or No Use Little/No Use Very Serious Use In Treatment ~ 2,300,000 $80 B Yr $40B Yr

1 1.Because it will improve general medical care 2. Because it will save money 3.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 Use Little/No Use Very Serious Use 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 Use Little/No Use Very Serious Use In Treatment ~ 2,300,000 Insurance for “Substance Use 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 Use Little/No Use Very Serious Use In Treatment ~ 2,300,000 Prevention Early Intervention Chronic Care Model

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 sin SUDs 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 teach substance use disorders 2. Stop buying sub-standard care 3.Educate consumers to demand quality

1 1.Require state schools to teach substance use disorders 2. Stop buying sub-standard care 3.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 Results Years 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

% Attending

Buy the Continuum of Care: Not the Pieces

The Current 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

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 Housing

Why continue the segregation?

Crossing the Quality Chasm a new HEALTH system for the 21 st 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 teach substance use disorders 2. Stop buying antiquated care 3.Educate Consumers – help them understand & buy quality

All Programs Are Not Created Equal: Kathleen Meyers, PhD & John Cacciola, PhD Supported by NIDA P50DA Using a Comparative Consumer Guide to measure the availability of effective treatment for teens ©Treatment Research Institute,

©Treatment Research Institute, /5/2015 Why a Consumer Guide Approach to Measuring (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, /5/2015 Why a Consumer Guide Approach to Measuring (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

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

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%