1. Public SUD Treatment ●Information on SUD treatment is provided by data that are reported routinely to the national SUD treatment monitoring system known as the Treatment Episode Data System (TEDS). (SAMHSA, 2007) ●In general, facilities reporting to TEDS receive government funds or licensure to provide SUD treatment. (SAMHSA 2007, 2012) ●Public SUD treatment accounts for 77% of all available care, leaving 23% funded by private insurers, philanthropy, or out-of-pocket payments. (Mark et al., 2007) ●Anyone can attend public SUD treatment, but this system is generally utilized by individuals with a more severe SUD disorder and fewer economic resources. (White, 2012) ●Consequently, TEDS does not represent the total national demand for SUD treatment, but it does comprise a significant proportion of all SUD treatment and it includes those treatments that place a significant burden on public funds. (SAMHSA, 2007)

2. SUD Treatment System of Care Publicly-funded SUD treatment system is complex. Depending on funding and political priorities, services are offered within 5 broad levels of care (LOC) (as defined by American Society of Addiction Medicine [ASAM]): 1.Early intervention 2.Outpatient services 3.Intensive outpatient & partial hospitalization 4.Residential & inpatient services 5.Medically-managed inpatient services

3. SUD Treatment Services Include Continuing Care/Aftercare Programs Intensive/Regular Outpatient Treatment Sober Living Environment (SLE) Long-term Residential Treatment Short-term Residential Treatment Detox/ Inpatient Detox/ Outpatient Medication Assisted Treatment *Start Here*

4. Caution: DMC benefits are being revised now!

5. Detoxification ●Detoxification safely manages the physical symptoms of withdrawal  just medical ●Detoxification is not treatment, it is stabilization ●It is only the first stage of SUD treatment, and not considered sufficient treatment without an other level of care as it does little to change long-term substance use

6. Outpatient Treatment Less than 9 hours/week of contact Most commonly used level of SUD treatment Services: evaluation, one on one (individual), group, and random drug testing Delivered by SUD treatment personnel and credentialed clinicians Addresses SUD severity, behavioral changes, and mental functioning To be effective, programs must address personal lifestyles, attitudes, and behaviors that can support or undermine treatment goals

7. Who Can Benefit from Outpatient Treatment? Could be an initial phase of SUD treatment (early action stage of change) OR a step- down phase of care, after having completed more intensive treatment (maintenance stage of change) Useful for individuals who are not ready or willing to commit to a more intensive recovery program OR for those with low motivation to change SUD behaviors or who are “resistant” to change (pre-contemplation or contemplation stage of change)

8. Outpatient Services Covered by Drug Medi-Cal (DMC)

9. Intensive Outpatient Services (IOP) 9 or more contact hours/week –Credentialed staff –Comprehensive assessments –Individualized treatment plans –Counseling and education –Addresses co-existing disorders –If needed, partial hospitalization: 20+ hrs/week

10. IOP Services Covered by Drug Medi-Cal (DMC)

12. Residential Treatment Intensity is matched to degree of SUD severity –Short-term: <30 days –Long-term: >30 days

16. Residential Services Covered by Drug Medi-Cal (DMC)

18. Opioid Treatment Programs Different names for the same type of care –Medication-assisted treatment (MAT) –Opioid addiction treatment (OAT) –Narcotic replacement treatment (NRT) Most common - Methadone maintenance treatment (MMT) Other medications now exist, i.e., buprenorphine, buprenorphine/naltrexone

19. Who are Treatment Providers Usually licensed or certified individuals –Licensed providers have a degree (in therapy related area, i.e., MFT) –Certificate programs, both State and National, to establish expertise in Substance Abuse Treatment

20. We’re Only Beginning to Understand the “Black Box” of SUD Treatment We’re Only Beginning to Understand the “Black Box” of SUD Treatment What is done during SUD treatment?

21. Assessments Match treatment to SUD severity –No single treatment is appropriate for all individuals Chronic, complex conditions need comprehensive treatment –Effective treatment attends to multiple needs of the individual (medical, psychological, social, vocational, and legal problems), not just his/her substance use Need to treat the whole person

22. SUD Treatment Core Components and Comprehensive Services Medical Mental Health Vocational Educational Legal AIDS / HIV Risks Financial Housing & Transportation Child Care Family Continuing Care Case Management Urine Monitoring Self-Help (AA/NA) Pharmaco- therapy Group/Individual Counseling Abstinence Based Intake Assessment Treatment PlansCoreTreatment Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)

23. SUD Treatment Completion and SUD Outcomes ●Nationwide, 46-60% of women and 50-68% of men “complete” public SUD treatment (Brady & Ashley, 2005) ●About 43% to 55% of treated individuals return to substance use, generally within one year of SUD treatment. (Greenfield et al., 2007; Grella et al., 2005; Prendergast et al., 2011) ●Rates vary depending on SUD severity (including substance type), intensity and length of SUD treatment, and other risk and protective factors at both the individual level and the environmental level Note: there is no standard definition of treatment completion (SAMHSA, 2007). In California, decision-making typically considers whether the individual has (1) completed the treatment plan, as usually indicated by the person having met their treatment goals and having remained in treatment for the amount of time recommended by treatment staff and (2) not engaged in recent substance use as self-reported or verified by biological test results (Urada & Gonzales, 2008).

24. Cost-Effectiveness of SUD Treatment  Treatment is less expensive than not treating or incarceration (1 yr methadone maintenance = $4,700 vs. $18,400 for imprisonment)  Every $1 invested in treatment yields up to $7 in reduced drug-related crime and other costs (Ettner et al., 2005; CalDATA)  Savings can exceed costs by 12:1 when health care costs are included

25. Public Health Implications of SUD Treatment  SUD treatment reduces likelihood of HIV infection by 6 fold in injection drug users  In other words, SUD treatment is disease prevention  Also, SUD treatment presents opportunities for screening, counseling, and referral to address other health and social problems

26. SUD Treatment Population in California CA public treatment system is made up of a diverse collection of approximately 1,200 to 1,500 treatment programs that operate in 58 diverse counties under an annual state budget of approximately $500,000,000. Every year, about 168,000 unique adults are admitted into California’s publicly-funded SUD treatment system, accounting for about 200,000 admissions.

27. Who is in SUD Treatment in California? Rawson et al. (2008) at http://www.uclaisap.org/assets/documents/California-ADP-DHCS- Evals/2007-2008_CalOMS%20Report.pdf

28. Who is in SUD Treatment in California? Rawson et al. (2008) at http://www.uclaisap.org/assets/documents/California-ADP-DHCS- Evals/2007-2008_CalOMS%20Report.pdf

29. Who is in SUD Treatment in California? Rawson et al. (2008) at http://www.uclaisap.org/assets/documents/California-ADP-DHCS-Evals/2007-2008_CalOMS%20Report.pdf

30. Who is in SUD Treatment in California? Rawson et al. (2008) at http://www.uclaisap.org/assets/documents/California-ADP-DHCS-Evals/2007-2008_CalOMS%20Report.pdf

31. What Type of SUD Treatment is Received in California? Rawson et al. (2008) at http://www.uclaisap.org/assets/documents/California-ADP-DHCS- Evals/2007-2008_CalOMS%20Report.pdf

32. What Are the Pathways to SUD Treatment in California? Rawson et al. (2008) at http://www.uclaisap.org/assets/documents/California-ADP-DHCS- Evals/2007-2008_CalOMS%20Report.pdf

33. SUD Treatment Services Include Continuing Care/Aftercare Programs Intensive/Regular Outpatient Treatment Sober Living Residence Long-term Residential Treatment Short-term Residential Treatment Detox/ Inpatient Detox/ Outpatient Medication Assisted Treatment Brief Interventions/ Early Intervention *Start Here*

34. Screening, Brief Intervention, Referral to Treatment (SBIRT) SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services For persons with a SUD Those who are at risk of developing a SUD Intervene before more severe consequences occur 34

35. Treatment GAP= SBI Treatment GAP= SBI Screening, Brief Intervention (SBI) Substance abuse leads to significant medical, social, legal, financial consequences. Early, brief interventions are clinically effective and cost-efficient. Excessive drinking, illicit drug use, and prescription drug misuse are often undiagnosed by medical professionals. The brief intervention itself is inherently valuable, and positive screens may not require referral to specialty treatment.

36. LOCATIONS FOR ROUTINE SCREENING AND BRIEF INTERVENTION Primary care settings Emergency rooms/trauma centers Prenatal clinics/OB-GYN offices Medical specialty settings for diabetes, liver, and kidney disease/transplant programs Pediatrician offices College health centers Mental health settings Infectious disease clinics Drinking driver programs 36

37. If you had 30 seconds with a foundation to have your intervention funded… It’s not about what you do, it’s about why you do it. First explain “why,” and then develop trust. Simon Sinek and the Golden Circle - https://www.youtube.com/watch?v=4VdO7LuoBzM SAMHSA - http://www.samhsa.gov/capt/sites/default/files/resources/you-gotta-hear-this-elevator-pitch.pdf