Addiction Medicine: Closing the Gap between Science and Practice

© CASAColumbia 2013

A Report by

CASAColumbia®

October 17, 2012

ADDICTION MEDICINE:

CLOSING THE GAP

BETWEEN SCIENCE AND

PRACTICE


Drew E. Altman, PhD (Chair) President and Chief Executive Officer,

The Henry J. Kaiser Family Foundation

Harvey V. Fineberg, MD, PhD President, Institute of Medicine

Mark S. Gold, MD University of Florida College of Medicine and

McKnight Brain Institute

Departments of Psychiatry, Neuroscience, Anesthesiology,

Community Health & Family Medicine

Chairman, Department of Psychiatry

Shelly F. Greenfield, MD, MPH Chief Academic Officer, McLean Hospital

Professor of Psychiatry, Harvard Medical School

Director, Clinical and Health Services Research and Education

Division on Alcohol and Drug Abuse, McLean Hospital

Elizabeth R. Kabler President, Rosenstiel Foundation

Myles V. Lynk, JD Peter Kiewit Foundation, Professor of Law and the

Legal Profession; Faculty Fellow, Center for Law, Science &

Innovation’s Program in Public Health Law and Policy

University, Sandra Day O’Connor College of Law

Arizona State University

2

June E. Osborn, MD President Emerita, Josiah Macy, Jr. Foundation

Manuel T. Pacheco, PhD President Emeritus, University of Arizona

and University of Missouri System

The Honorable Jose R. Rodriguez Circuit Judge, Ninth Judicial Circuit of Florida

Reverend Msgr. Stephen J. Rossetti, PhD, DMin Clinical Associate Professor

Associate Dean for Seminary and Ministerial Programs

The Catholic University of America, The School of Theology and Religious

Studies

Former President and Chief Executive Officer

Saint Luke Institute, Inc.

Leonard D. Schaeffer Judge Robert Maclay Widney

Chair & Professor

University of Southern California

Steven A. Schroeder, MD Distinguished Professor of Health and Health Care, Department of Medicine

Director, Smoking Cessation Leadership Center

University of California, San Francisco

Louis W. Sullivan, MD President Emeritus, Morehouse School of Medicine

National Advisory Commission

on Addiction Treatment


Funders

• The Annenberg Foundation

• The Diana, Princess of Wales Memorial Fund and The Franklin Mint

• The New York Community Trust

• Adrian and Jessie Archbold Charitable Trust

3


Methodology

• Review of more than 7,000 scientific articles, reports, books

• Secondary analysis of 5 national data sets

• 176 key informants

• Focus groups/national population survey of attitudes and beliefs of

1,303 adults

• New York State surveys

83 treatment program directors

141 staff treatment providers

4


Methodology (continued)

• National panel of treatment providers/online survey of 1,142

members of professional associations involved in addiction care

• Online survey of 360 individuals with history of addiction who are

managing the disease

• In-depth analysis of state/federal governments’ and professional

associations’ licensing and certification requirements for treatment

providers, facilities and programs; accreditation requirements for

facilities and programs

• Case study of addiction treatment in New York State and New York

City

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…addiction is not about drugs, it’s about brains. It is not the

substances a person uses that make them an addict; it is not even the

quantity or frequency of use. Addiction is about what happens in a

person’s brain when they are exposed to rewarding substances or

rewarding behaviors, and it is more about reward circuitry in the brain

and related brain structures than it is about the external chemicals or

behavior that “turn on” that reward circuitry.

--American Society of Addiction Medicine. (2011).

Definition of addiction: Frequently asked questions

6


Language Matters

Terms used to describe different levels of involvement with addictive

substances – experimentation, use, misuse, excessive use, abuse,

dependence:

• Lack precision

• Obscure important differences in nature and severity of illness

• Complicate ability to intervene and treat

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Addiction Is a

Complex Brain Disease

• Nicotine, alcohol, controlled illicit drugs and prescription drugs all

affect pleasure and reward circuitry of brain in similar ways

• Continued use can physically alter structure and function of brain

• Significant behavioral characteristics, including compulsion to obtain

and use addictive substance even in the face of negative

consequences

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Risky Use of

Addictive Substances

• Risky users are those who:

Currently use tobacco products

Exceed the USDA Dietary Guidelines for safe alcohol use

Misuse controlled prescription drugs

Use illicit drugs

Engage in some combination of the above

But do not meet the clinical criteria for addiction

• Risky use can result in devastating and costly health and social

consequences, including the disease of addiction

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A Public Health Problem


How Big is the Problem?

• 15.9% (40.3 million) have the

disease of addiction – more than

have heart conditions (27.0

million), diabetes (25.8 million) or

cancer (19.4 million)

• 31.7% (80.4 million), while not

addicted, engage in use of

addictive substances in ways

that threaten health and safety

(risky users)

10


The Consequences

Are Enormous

Risky substance use and addiction:

• Account for 32.3% of all hospital inpatient costs

• Result in more than 20% of deaths

• Are causal and contributing factors in more than 70 other conditions

requiring medical care

• Drive a wide range of other costly social consequences

11


The Spending Gap

• In 2010, the U.S. spent:

$43.8 billion to treat diabetes (affecting 25.8 million)

$86.6 billion to treat cancer (affecting 19.4 million)

$107.0 billion to treat heart conditions (affecting 27.0 million)

$28.0 billion to treat addiction (affecting 40.3 million)

• 95.6 cents of every dollar spent by federal and state governments

on risky substance use and addiction go to pay for the

consequences; only 1.9 cents go to prevention and treatment

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Clear Risk Factors

• Genetic predisposition

• Structural/functional brain vulnerabilities

• Psychological and environmental influences

• Age of first use: 96.5% of cases of addiction start with substance

use before age 21 when brain is still developing

13


Multiple Substances

Frequently Involved

• Among risky substance users, 30.6% use more than one substance

• Among those who are addicted, 55.7% are risky users of one or

more other substances and 17.3% have addiction involving multiple

substances

14


As With Other

Health Conditions…

• Addiction frequently co-occurs with other health problems

• Addiction can be a chronic disease

• Individually-tailored interventions and treatments are required

• Addiction should be addressed within the medical system

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Screening and Intervention

for Risky Use

• Effective tools available

• Can be used in a variety of settings

and populations

• Can reduce risky use and prevent

addiction

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Effective Treatment

Options Exist

• Pharmaceutical therapies

To reduce cravings/withdrawal

symptoms

To reduce reward of addictive

substances

Maintenance

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• Psychosocial therapies

Motivational

Cognitive behavioral

Community reinforcement

Contingency management

Behavioral/couples/family

• Combined therapies


Best Treatment

Practices Require

• Diagnostic evaluation

• Comprehensive assessment

• Stabilization

• Acute care

• Chronic disease management

• Ancillary services and peer support

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The Treatment Gap

19

77.2 72.9 71.2

10.9

Hypertension¹ Diabetes² Major Depression³ Addiction³(excluding

Nicotine*)

P

E

R

C

E

N

T

Individuals with Select Medical Conditions Who Receive Treatment

1 Ages 18 and older; Ostchega, Y., Yoon, S.S., Hughes, J. & Louis, T. (2008).2 All ages; Centers for Disease Control and Prevention. (2011).3 Ages 12 and older; CASA Columbia analysis of The National Survey on Drug Use and Health (NSDUH), 2010

* Due to data limitations.

No data exist on the treatment gap for those who are nicotine dependent.

Most People in Need of Treatment Do Not Receive It


Most Don’t Complete Treatment

The highest completion rates were from venues with the fewest

admissions:

• 14.8% of admissions were to short-term residential services

which had the highest completion rate of 54.8%

• 11.4% of admissions were to longer-term residential treatment

which had a completion rate of 45.5%

• 73.8% of admissions were to non-residential services which had

the lowest completion rate of 39.1%

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Less Than Half (42.1%) of Treatment Admissions Result

in Treatment Completion


Treatment Referrals

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0.6

1.4

5.7

10.6

12.1

25.3

44.3

Employers

Schools

Health Care Providers

Addiction Treatment Providers

Community Sources

Individuals

Criminal Justice System

P

E

R

C

E

N

T

Sources of Referral to Publicly-Funded Addiction Treatment (Excluding Nicotine)

Source: CASA Columbia analysis of The Treatment Episode Data Set (TEDS), 2009.

Most Referrals to Publicly-Funded Treatment Come

from the Criminal Justice System


Addiction Treatment Workforce

• Size of “treatment” workforce unknown

• Treatment providers include: physicians, physician assistants,

nurses, psychologists, mental health counselors and therapists,

social workers, acupuncturists and addiction counselors

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Few Medical Professionals

Treat Addiction

• Little education required in addiction science, prevention and

treatment:

Separate courses in addiction medicine rarely taught in medical school

Required addiction-related content on board exams is minimal and often

identified only as possible sub-topics

• Of 985,375 active physicians, there are only about 1,200 practicing

addiction medicine specialists and 355 self-identified practicing

addiction psychiatrists

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Treatment Providers Usually

Addiction Counselors No Medical Training Required

• 14 states: do not require all addiction counselors to be licensed or

certified

• 6 states: no minimum degree requirements

• 14 states: minimum requirement of high school degree or GED

• 10 states: minimum requirement of associate’s degree

• 6 states: minimum requirement of bachelor’s degree

• 1 state: minimum requirement of master’s degree

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Regulatory Requirements

• Addiction treatment facilities and programs are not adequately

regulated or held accountable for providing treatment consistent with

medical standards and proven treatment practices

• Only 10 states require residential treatment programs to have a

physician either as medical director or on staff; 8 states require the

same of outpatient treatment programs

• Most regulators define medical care as detoxification, opioid

replacement therapy or treatment of co-occurring disorders only

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Do Not Recognize Addiction Treatment as Medical Care


Addiction Care

• No national standards for who may provide addiction treatment in

the U.S.; varies by state and payer

• No other disease where appropriate medical treatment is available

is as neglected by the health care system

• Patients must turn to a broad range of practitioners largely exempt

from medical standards

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Largely Disconnected from Mainstream Medical Practice


Where is the Medical

Profession?

• 1956 – AMA declared alcoholism an illness that can and should

be treated within the medical profession

• 1989 – AMA adopted a policy declaring addiction involving other

drugs, including nicotine, to be a disease

• 47% of Americans would turn to a health professional if someone

close to them needed help for addiction

• Yet < 6% of referrals to publically-funded addiction treatment

come from a health care provider

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Public-Private Spending

for Treatment Most Funding for Addiction Treatment Comes

from Public Sources

• Private payers (including private insurers and self-payers)

responsible for:

55.6% ($1.4 trillion) of medical expenditures in the U.S.

But only 20.8% ($5.8 billion) of addiction treatment spending

• Public spending concentrated in non-residential services operated

outside of mainstream health care

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Public Attitudes about Addiction

CASAColumbia’s NABAS survey found that:

• The public does not recognize the role of genetics and biological

factors in the development of addiction

• 60% of respondents identify mutual support programs as a

“treatment” intervention

• Public perceptions do not distinguish between risky substance

use and the disease of addiction

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Out of Sync with Science


Formidable Barriers to

Receiving Treatment Patients Face Obstacles to Addiction Treatment Due To:

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• A misunderstanding of the disease

• Negative public attitudes and

behavior toward those with the

disease

• Privacy concerns

• Insufficient insurance coverage for

treatment

• Lack of information on how to get

help

• Limited availability of services

including a lack of addiction

physician specialists

• Insufficient social support

• Negative perceptions of the

treatment process

• Legal barriers


IT IS TIME FOR HEALTH CARE

PRACTICE TO CATCH UP WITH THE

SCIENCE

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Recommendations

and Next Steps

• Reform health care practice

• Use leverage of public policy to speed reform

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Reform Health

Care Practice

• Incorporate into routine medical practice screening and intervention

for risky substance use, and diagnosis, treatment and disease

management for addiction

• Incorporate screening and intervention for risky substance use into

routine practice for non-physician health professionals (physician

assistants, nurses, dentists, pharmacists, graduate-level clinical

psychologists, social workers, counselors)

33


Reform Health

Care Practice

• Develop core clinical competencies for physicians and for non-

physician health professionals in addressing risky substance use

and preventing and treating addiction

• Assure that core clinical competencies and specialized training are

required components of all:

Medical school curricula, residency training programs, licensing

exams, board certification exams and continuing medical

education (CME) requirements, including maintenance of

certification programs

Professional health care program curricula, graduate fellowship

training programs, professional licensing exams and continuing

education (CE) requirements

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Reform Health

Care Practice

• Develop improved screening and assessment instruments

• Establish national accreditation standards for all addiction treatment

facilities and programs that reflect evidence-based care

Professional staffing: full time certified addiction physician specialist

and professional staff trained in core competencies

Intervention and treatment services: comprehensive assessment and

tailored, evidence-based treatment for addiction involving all

substances

Quality assurance: process and outcome measurements

35


Reform Health

Care Practice

• Standardize language used to describe the full spectrum of

substance use and addiction

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Public Policy Leverage

to Speed Reform

• Condition government grants and contracts for addiction services on

provision of quality care

• Educate non-health government workers who come into contact with

significant numbers of individuals who engage in risky substance use

or who may have addiction about evidence-based practices

• Identify patients at risk in government programs and services where

costs of risky use and addiction are high and provide appropriate care

• Develop tools, practice guidelines and outcome measures to improve

quality of service delivery

• License addiction treatment facilities as health care providers

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Public Policy Leverage

to Speed Reform

• Require adherence to national accreditation standards that reflect

evidence-based care

• Require that all insurers provide comprehensive coverage for

screening, intervention, diagnosis, treatment and disease

management for addiction, including specialty care

• Expand the addiction medicine workforce

• Implement a national public health campaign to educate the public

about all forms of risky substance use and addiction

• Invest in research and data collection to improve and track progress

and search for a cure

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Ending Addiction

Changes Everything

www.casacolumbia.org


Speaker Notes Slide 6: • Addiction is a complex primary disease of the brains circuitry related to reward, motivation and

memory,

• Reflected in pathological pursuit of reward or relief by substance use and other behaviors.

• Not limited to the rewards provided by nicotine, alcohol and other drugs but extends to other

rewarding behaviors such as gambling, compulsive overeating, and sexual behaviors. • We tend to talk about addiction as if there are multiple diseases; in fact there are different

manifestations of one disease and those manifestations often co-exist or vary with circumstances. • Due to data limitations, this study focuses on addiction involving nicotine, alcohol and other drugs.

Slide 7: • There are many terms used to describe different levels of involvement with addictive substances

such as: experimentation, misuse, excessive use, abuse, dependence.

• This imprecision in our language:

• Obscures important differences in the nature and severity of illness

• And complicates our ability to intervene and treat effectively.

• Even the term “treatment” lacks precision with regard to addiction, since historically it has been

used to refer to a host of interventions, many of which are not based in the clinical and scientific

evidence as are treatments for other diseases.

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Speaker Notes Slide 8: • This is consistent with the revisions recently published in the DSM-V for substance use disorders.

• All of these substances affect the brain’s reward circuitry in similar ways.

• Continued use can change both the structure and function of the brain.

• There also can be pre-existing structural and functional differences in the brain predisposing one

to the disease.

Slide 9: • It is essential to distinguish the disease of addiction from the public health problem of risky use of

addictive substances that does not meet the threshold for addiction.

• Risky users are those who do not meet clinical criteria for addiction but use addictive substances

in ways that threaten health and safety, including:

• Any tobacco/nicotine use

• Drinking in excess of the USDA dietary guidelines, and

• Any illicit drug use or misuse of controlled prescription drugs.

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Speaker Notes Slide 10: • Risky substance use and addiction together constitute America’s largest health problem.

• About 16% of the U.S. population age 12 and over--40 million people--have addiction involving

nicotine, alcohol or other drugs:

• That is more than the number with heart conditions, diabetes or cancer

• Probably an undercount because, due to data limitations, we are only counting those who report

meeting behavioral criteria and not those who have the disease but who are managing it

effectively or who may not have yet displayed behavioral symptoms

• Nor does it include the institutionalized population.

• The population of risky users is double that size--about 80 million people.

Slide 11: • It also is our most costly health problem.

• For example, approximately 1/3 of all hospital inpatient costs are a result of risky substance use

and addiction.

• It accounts for at least 1/5 of all deaths and drives more than 70 other diseases requiring medical

attention

• And it is a major factor in a broad and devastating range of other health and social consequences

including:

• Motor vehicle crashes

• Homelessness, domestic violence

• Child abuse and neglect, a host of property and violent crimes.

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Speaker Notes Slide 12: • Instead of paying for effective prevention and treatment services, we pay to cope with the

consequences.

• The tragedy is that less than 2 cents of every $1 federal and state governments spend on this

problem go to prevention or treatment

• While 96 cents go to cope with the consequences of our failure to prevent and treat it.

• This approach costs every person in America approximately $1500 every year.

Slide 13: • Like other diseases, there are clear risk factors for both risky use and addiction.

• Between 50-75% of the risk of moving from use to addiction appears to be governed by a range of

genetic factors.

• There also are significant influences exerted by:

• The families we grow up in

• Our peers and our communities

• Prescribing practices of health professionals

• And by advertising and media practices.

• Of critical importance is the age of first use of addictive substances.

• Addiction is, in most cases, a developmental disorder associated with the early use of addictive

substances while the brain is still developing.

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Speaker Notes Slide 14: • People often display multiple manifestations of risky use.

• It makes no sense to only screen for risky use or treat addiction involving 1 or 2 substances. We

must address all--including nicotine.

Slide 15: • As with other health conditions:

• Addiction frequently co-occurs with other health problems that also must be addressed.

• It can become a chronic disease and require long-term management.

• A one size fits all approach to treatment does not work.

• Like other diseases, addiction requires medical attention.

• Like treatment for other diseases, proven pharmaceutical and specific behavioral treatments must

be provided in accordance with established treatment protocols and integrated into treatment for

other health conditions.

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Speaker Notes Slide 16: • For risky use, there are effective and tested tools available to screen for this public health problem

• And provide brief interventions as needed.

• They can be used in a variety of settings with different populations.

• Training in the administration of screening and interventions is critical.

• We must screen for all substances and ideally for other risky behaviors.

• We must better calibrate our screening instruments to appropriate definitions of risky use.

Slide 17: • Similarly, a range of treatments have proven efficacy, including:

• Different types of pharmaceutical therapies, and

• Multiple psychosocial therapies.

• In many cases, best results are achieved by a combination of these therapies.

• Again, these treatments must be tailored to the needs of individual patients.

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Speaker Notes Slide 18: • The elements of best practice in addiction treatment are:

1. A diagnostic evaluation to determine the presence of the disease.

2. If the disease is present, a comprehensive assessment of the stage and severity of disease, co-occurring

conditions, and personal circumstances that may affect the treatment.

3. The patient must be stabilized. This means managing cessation of use. Sometimes this can be achieved

with guidance, monitoring and social support, but other times pharmaceutical therapies and/or

hospitalization is required.

4. Then there is the acute phase of treatment, involving pharmaceutical, psychosocial or combined therapies

and treatment for co-occurring conditions that may be offered in a range of office based, outpatient or

inpatient settings, again depending on need.

5. Disease management is critical because as yet there is no cure for addiction.

6. Throughout the process, peer support and ancillary services can be deciding factors in the success of

treatment and disease management.

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Speaker Notes Slide 19: • Only about 11% of those with the disease involving alcohol and drugs other than nicotine receive

any form of treatment at all.

• In this country, we don’t even know the number of people who receive treatment for addiction

involving nicotine.

• Compare that 11% with the 70-80% of people with other diseases like major depression, diabetes

and hypertension who do receive care.

• And of that 11% who receive some form of care, we also know that most do not receive anything

that approximates evidence-base services.

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Speaker Notes Slide 20: • Of those who do receive some form of treatment, less than ½ actually complete the treatment

process recommended.

• The highest rates of completion were from treatment venues to which there were the least

referrals.

Slide 21: • Most referrals to treatment come from the criminal justice system--

• Illustrating how we fail to prevent and treat until a crisis occurs.

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Speaker Notes Slide 22: • Unlike other health conditions, we have no reliable estimate of who is providing addiction

treatment.

• CASAColumbia identified a range of providers (listed), but there are others offering ‘treatment’ that

are even outside this wide range,

• Including religious-based providers and simply entrepreneurs.

Slide 23: • Unlike other diseases, most medical professionals who should be providing treatment are not

sufficiently trained to do so.

• Physicians and other medical professionals make up the smallest share of providers of addiction

treatment.

• Thanks to the work of the American Board of Addiction Medicine, there are efforts underway to

expand capacity, but the gap remains staggering.

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Speaker Notes Slide 24: • Most of those currently providing treatment for this disease are not medical professionals and are

not equipped with the knowledge, skills or credentials necessary to provide the full range of

evidence-based health care services.

• The largest group providing addiction treatment is the addiction counselors and

• In most states their minimum degree requirements are a GED or high school diploma.

• 14 states do not even require all addiction counselors to be licensed or certified.

• There simply are no national standards for who may provide addiction treatment in the U.S.

Slide 25: • Regulatory requirements for treatment providers vary dramatically by state and by payor.

• For the most part, providers are not required to be regulated as medical providers.

• Even if physicians are required to be on staff of treatment programs, they frequently are on call for

other ‘health problems’ and not to treat addiction.

• In fact, most regulators exclude addiction treatment from their definition of medical care--with the

exception of providing opioid replacement therapy which is not universally available.

• While about 30 states require a clinical or program director to oversee services, only 8 states

require a minimum of a master’s degree for the position--there is no medical degree requirement.

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Speaker Notes Slide 26: • Much of what passes for “treatment” bears little resemblance to the treatment offered for other

health conditions, and much of what is offered in addiction “rehabilitation” programs has not been

subject to rigorous scientific study.

• This is inexcusable given decades of accumulated scientific evidence attesting to the fact that

addiction is a brain disease for which there are effective interventions and treatments.

• It also is unfair to the thousands of addiction counselors who struggle, in the face of extreme

resource limitations and no medical training, to provide help to patients with the disease of

addiction and numerous co-occurring medical conditions.

Slide 27: • This profound gap between the science of addiction and current practice is a result of decades of

marginalizing addiction as a social problem rather than treating it as a medical condition.

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Speaker Notes Slide 28: • This gap between science and practice also is reflected in how we pay for treatment,

• With a concentration of public resources linked to the health and social problems that result from

our failure to prevent and treat the disease

• And in services operating outside of mainstream health care.

Slide 29: • Many outmoded attitudes about addiction reside in the public consciousness, although these

attitudes are changing.

• Recent surveys suggest that about 80% of Americans now recognize addiction as a disease,

• But, as you see here, they lack critical information to understand it.

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Speaker Notes Slide 30: • What all this means for patients and their families is that they face enormous barriers in gaining

access to effective care

• Including how and where to get help

• And what help should entail.

Slide 31: • It is long past time for health care practice related to risky use and addiction to catch up with the

science.

• Failure to do so causes untold human suffering

• And it is a profligate waste of scarce taxpayer dollars.

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Speaker Notes Slide 32: • Our full report has a wide range of recommendations to accomplish this transition.

Slide 33: • We must incorporate screening, intervention, diagnosis, treatment and disease management into

routine health care practice--in a sustainable way.

• Including both medical providers and the appropriate array of other health professionals.

• Backed by specialty care addiction physicians (addiction medicine physicians and addiction

psychiatrists).

• The team approach is the future of health care practice, but each team member must be highly

trained.

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Speaker Notes Slide 34: • To assure appropriate training, we need to develop core clinical competencies for physicians

• And for the range of non-physician health professionals working as part of the team.

• And we need to assure that those clinical competencies are required components of the relevant:

• Educational curricula

• Residency and fellowship training programs

• Licensing and certification exams

• And continuing education requirements.

Slide 35: • We need to align our screening, assessment and diagnostic instruments with the science and with

definitions of risky use and addiction.

• We must establish national accreditation standards for addiction treatment facilities and programs

that reflect evidence-based care.

• We need to standardize our language as it relates to these health conditions and their prevention

and treatment.

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Speaker Notes Slide 37: • The levers of public policy can be employed to speed this change.

• Examples include:

• Assuring appropriate screening, intervention and treatment for patients in government funded

programs where costs of not doing so are high--health care and justice

• Requiring that all addiction treatment facilities and programs be licensed as health care

providers

Slide 38: • Requiring adherence to national accreditation standards reflecting evidence-based care.

• Requiring expanded and comprehensive insurance coverage

• Jump-starting the addiction medicine workforce

• Implementing a national public health campaign to educate the public about:

• This disease

• Its risk factors

• What they can to prevent it, and

• When and where to get help.

• Developing ways to better measure outcomes and track progress

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Addiction Medicine: Closing the Gap between Science and Practice

Health & Medicine

Transcript of Addiction Medicine: Closing the Gap between Science and Practice