Policies that promote effective systems of care Policies that promote effective systems of care for substance use disordersfor substance use disorders

Keith HumphreysKeith HumphreysSenior Policy Advisor, White House ONDCPSenior Policy Advisor, White House ONDCP

Professor of Psychiatry, Stanford UniversityProfessor of Psychiatry, Stanford University

Career Research Scientist, Department of Veterans AffairsCareer Research Scientist, Department of Veterans Affairs

Substance Use Disorder Care is a major Substance Use Disorder Care is a major focus of NDCS, but not the only onefocus of NDCS, but not the only one

PreventionPrevention Reduction of Prescription Drug AbuseReduction of Prescription Drug Abuse Drugged DrivingDrugged Driving New models of law enforcement and New models of law enforcement and

community supervisioncommunity supervision Merida Initiative, CBSI, AfghanistanMerida Initiative, CBSI, Afghanistan See See www.whitehousedrugpolicy.gov for for

the full National Drug Control Strategythe full National Drug Control Strategy

Can Countries Achieve “Tipping Points” Can Countries Achieve “Tipping Points” with Substance Use Disorder with Substance Use Disorder

Treatment?Treatment? Some nations have treatment on demand Some nations have treatment on demand

and very high population penetrance and very high population penetrance (Australia, Switzerland, The Netherlands)(Australia, Switzerland, The Netherlands)

Others invest some resources, but have Others invest some resources, but have lower population penetrance (U.S.)lower population penetrance (U.S.)

Critical question is whether there is a Critical question is whether there is a “tipping point” with care expansion“tipping point” with care expansion

In U.S., about one in six persons meeting diagnostic In U.S., about one in six persons meeting diagnostic criteria for illicit drugs received specialty treatmentcriteria 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

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Proportion of all heroin addicted individuals Proportion of all heroin addicted individuals in methadone maintenance, 1993in methadone maintenance, 1993

Source: MacCoun, R. J., & Reuter, P. (2001). Drug war heresies. Cambridge, UK: Cambridge University Press.

France subsequently dramatically France subsequently dramatically expanded opiate agonist treatmentexpanded opiate agonist treatment

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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 ..And apparently achieved a tipping point 1996-2003point 1996-2003

Annual heroin arrests dropped from Annual heroin arrests dropped from 17,328 to 4,02517,328 to 4,025

Annual overdose deaths declined from Annual overdose deaths declined from 465 to 89465 to 89

Only historical U.S. exampleOnly historical U.S. example

From 10/1971 – 3/1973, federal government From 10/1971 – 3/1973, federal government expanded treatment slots 352%expanded treatment slots 352%

First national annual drop in street crime in First national annual drop in street crime in 20 years occurred from 1972-197320 years occurred from 1972-1973

Data systems at the time too crude to Data systems at the time too crude to conduct more fine-grained analysisconduct 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 How will the Obama Administration Increase the Quantity of Care for Increase the Quantity of Care for

Substance Use Disorder?Substance Use Disorder?

Patient Protection and Patient Protection and Affordable Care Act of 2010Affordable Care Act of 2010

Specifies that screening, brief intervention Specifies that screening, brief intervention and treatment for substance use disorders and treatment for substance use disorders are essential healthcare benefitsare essential healthcare benefits

Insures about 5M more people who have Insures about 5M more people who have substance use disorderssubstance use disorders

Extends parity regulations to exchangesExtends parity regulations to exchanges Expands Medicaid to 133% of FPL, covers Expands Medicaid to 133% of FPL, covers

childless adultschildless adults

The Spectrum of Substance Use DisorderThe 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?What is SBIRT?

Screening, Brief Intervention and Referral for Screening, Brief Intervention and Referral for TreatmentTreatment

Targeted at less dependent patientsTargeted at less dependent patients

Strong evidence of effectivenessStrong evidence of effectiveness

Usable in primary care, emergency rooms and Usable in primary care, emergency rooms and otherother

Administration SBIRT proposalsAdministration SBIRT proposals

CMS continue to support billable codesCMS continue to support billable codes

President’s budget request supports their President’s budget request supports their expansion with new funding for monitoring expansion with new funding for monitoring and technical supportand technical support

Expand program to train physicians in Expand program to train physicians in SBIRT methodsSBIRT methods

Selected Administration initiatives Selected Administration initiatives for treatment of addicted individualsfor treatment of addicted individuals Mental health and substance abuse parity Mental health and substance abuse parity

regulationsregulations Expansion of funding in existing health Expansion of funding in existing health

care systems (more on this later..)care systems (more on this later..) Re-entry/diversion initiativeRe-entry/diversion initiative End of ban on federal funding for NEPEnd of ban on federal funding for NEP Increase in NIH fundingIncrease in NIH funding Medicaid expansion?Medicaid expansion?

Will all this increase in Will all this increase in quantity produce a quantity produce a

“tipping point”?“tipping point”?

A brief but important word about expanding treatment in developing countries

International Demand ReductionInternational Demand Reduction

PEPFAR new focus on medication assisted PEPFAR new focus on medication assisted treatment for IDUstreatment for IDUs

Merida Initiative includes support for Merida Initiative includes support for electronic linkage of 300 treatment centers electronic linkage of 300 treatment centers in Mexicoin Mexico

NIDA international scholars and research NIDA international scholars and research programsprograms

Expanding quantity does not Expanding quantity does not resolve concerns about qualityresolve concerns about quality

Alcohol dependence was last among 30 medical Alcohol dependence was last among 30 medical conditions in proportion of care received as conditions in proportion of care received as

evidence would recommendevidence would recommend

Senile cataractSenile cataract 78.7%78.7%

Breast cancerBreast cancer 75.7%75.7%

Prenatal carePrenatal care 73.0%73.0%

HypertensionHypertension 64.7%64.7%

AsthmaAsthma 53.5%53.5%

Diabetes MellitusDiabetes Mellitus 45.4%45.4%

Urinary Tract InfectionUrinary Tract Infection 40.7%40.7%

Atrial FibrillationAtrial Fibrillation 24.7%24.7%

Alcohol DependenceAlcohol Dependence 10.5%10.5%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.

Common quality issuesCommon quality issues Isolation of specialty addiction treatment Isolation of specialty addiction treatment

and mainstream health careand mainstream health care Sub-optimal staff training, morale and paySub-optimal staff training, morale and pay Poor continuity of carePoor continuity of care Inadequate health information technologyInadequate health information technology Minimal use of evidence-based practicesMinimal use of evidence-based practices High process regulation…with weak High process regulation…with weak

performance standardsperformance standardsReferences: 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 What policies might improve the quality of care?improve the quality of care?

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

Incentivizing particular care Incentivizing particular care processes: VA exampleprocesses: VA example

Pool of “off the top” funding set aside at Pool of “off the top” funding set aside at beginning of each yearbeginning of each year

Meeting standards on particular indicators Meeting standards on particular indicators is rewarding financiallyis rewarding financially

Success example: Alcohol screening and Success example: Alcohol screening and identification of problem drinkersidentification of problem drinkers

Rates of identifying substance Rates of identifying substance abuse in VA versus other systemsabuse in VA versus other systems

Washington Circle Identification Measure

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Veteran's Affairs

Administration Proposal: P4P Administration Proposal: P4P for Statesfor States

President’s Budget requests $6M for a President’s Budget requests $6M for a new pay for performance program new pay for performance program

States and Tribes would compete for the States and Tribes would compete for the fundsfunds

Those selected would receive incentive Those selected would receive incentive funds to reward quality in their systemsfunds to reward quality in their systems

Broad latitude allowed for the dimension of Broad latitude allowed for the dimension of care rewardedcare rewarded

A market-based approach to quality: A market-based approach to quality: Access to RecoveryAccess to Recovery

Individuals seeking care receive a voucher, Individuals seeking care receive a voucher, value varies, average around USD1600value varies, average around USD1600

For public sector, provides unusual freedom to For public sector, provides unusual freedom to select (or switch) care optionsselect (or switch) care options

About $100M annually in 3-year cycles, offers About $100M annually in 3-year cycles, offers services to about 160,000 individuals totalservices to about 160,000 individuals total

Obama Administration proposes $9.9M increase Obama Administration proposes $9.9M increase for programfor program

Embedding specialty care within Embedding specialty care within medicine to improve quantity and quality medicine to improve quantity and quality

at onceat once Makes specialty care subject to the quality Makes specialty care subject to the quality

and process regulations of medicineand process regulations of medicine

Brings in the staff and resources to meet Brings in the staff and resources to meet those standardsthose standards

But allows choice because U.S. insurance But allows choice because U.S. insurance system is market basedsystem is market based

Other potential advantages to Other potential advantages to expanding substance use disorder care expanding substance use disorder care within mainstream healthcare systemswithin mainstream healthcare systems

Better integration of care from the outsetBetter integration of care from the outset

Unified health information technologyUnified health information technology

Less stigma to accessing careLess stigma to accessing care

Two care systems for such Two care systems for such expansion, proposed in President’s expansion, proposed in President’s

2011 Budget2011 Budget

HRSA’s Community Health CentersHRSA’s Community Health Centers

Indian Health ServiceIndian Health Service

SummarySummary

Obama Administration is emphasizing brief Obama Administration is emphasizing brief interventions, and, treatment for people with interventions, and, treatment for people with substance use disordersubstance use disorder

A public health “tipping point” A public health “tipping point” may may be achievable be achievable through treatment/brief intervention, but required through treatment/brief intervention, but required amount of expansion is unknown amount of expansion is unknown

Summary, continuedSummary, continued

Administration proposing major investments in Administration proposing major investments in expanding the quantity of treatmentexpanding the quantity of treatment

Expansion of quantity does not necessarily Expansion of quantity does not necessarily improve quality, hence some quality focused improve quality, hence some quality focused proposals as wellproposals as well

Expansion of substance use disorder treatment Expansion of substance use disorder treatment within mainstream healthcare systems may offer within mainstream healthcare systems may offer quantity AND quality benefitsquantity AND quality benefits