Transcript No Slide Title

H
Segregating Addiction from
Mainstream Healthcare:
Why it should
Will stop
A. Thomas McLellan
7/17/2015
©Treatment
©Treatment
Research
Research
Institute,
Institute,
20132012
Closing Thoughts
“Substance use disorders” will soon be
part of mainstream healthcare:
1. SUDs are too common, dangerous & expensive
in healthcare to be ignored
2. Public understanding that addiction is an
illness not a sin
3. Mainstream healthcare can do this!
o Chronic Care Management protocols are appropriate
1
Part 1
“Substance Use Disorders”
And why they matter
Use – Driven by availability
Abuse – Harmful Use –
Driven by lack of consequences
Addiction – Compulsive Use
Driven by gene expression &
changing brain structure/function
4
Substance Use Prevalence
Very
Serious
Use
In Treatment ~ 2,300,000
Addiction ~ 23,000,000
Harmful – 40,000,000
Use
Little/No
Use
Little or No Use
National Institute on Alcohol Abuse and Alcoholism
 Alcohol involved in 52% of all injuries
among 12-25 year olds
 YET:
• 24% of youth12-25 drink above risk levels
• 32% of college students drink above risk
 AND – Kids who start earlier/drink at home
– Drink the MOST
(Source: CDC, ARDI, 2009)
What Are Low-Risk Drinking Limits?
Source: NIAAA, Rethinking Drinking: Alcohol and Your Health, 2009
45
40
35
Age 21-24
30
Percent
National Institute on Alcohol Abuse and Alcoholism
Harmful Drinking Among Young People
25
20
Age 18-20
24
15
10
5
10 or more drinks
0
In College
Not In College
What Causes Accidental Death?
#1 Opioid Overdose
#2 Automobile Accidents
#3 Gun Accidents
Source: CDC, 2013
1
Part 2
Addiction is Different
It’s not just a lot of partying
Addiction is Different
Addiction is profound loss of voluntary
control over use due to:
A – Gene expression
B – Changed brain structure & function
Esp. in – motivation and inhibition
If not addressed early it can become a
chronic illness with no cure
Partial Recovery of Brain from
Methamphetamine After Abstinence
3
0
ml/gm
Normal Control
METH Abuser
(1 month detox)
METH Abuser
(24 months detox)
Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
Heritability Estimates
Twin Studies
Eye Color
1.00
ASTHMA (adult only)
.35 - .70
DIABETES (insulin depend)
.70 - .95
HYPERTENSION
.25 - .50
ALCOHOL addiction
.55 - .65
OPIATE addiction
.35 - .50
COCAINE & MARIJUANA
.30 - .60
Substance Use & Addiction
Addiction – like other chronic
illnesses has an “at risk” period
Adolescence
94% of all addictions initiate
between 12 - 25
In Summary
Substance Use and Abuse can be predicted,
prevented, identified and reduced before
“abuse” becomes “addiction”
Addiction is qualitatively different – it is an
acquired chronic illness – like diabetes.
But even serious addictions can be treated
and managed - Recovery is now an
expectable outcome of good treatment
1
Part 3
The Existing Addiction
Treatment System
There ARE effective
Treatments - many
• Therapies
– Cognitive Behavioral Therapy
– Motivational Enhancement Therapy
– Community Reinforcement and Family Training
– Behavioral Couples Therapy
– Multi Systemic Family Therapy
– 12-Step Facilitation
– Individual Drug Counseling
• Medications
– Alcohol (Disulfiram, Naltrexone, Accamprosate,
Topiramate, Nalmafene)
– Opiates (Naltrexone, Nalmafene, Methadone,
Buprenorphine)
– Cocaine (Disulfiram, Topiramate, Vaccine?)
– Marijuana (Rimanoban)
– Methamphetamine – Nothing Yet
BUT – Almost none
are available in programs
13,200 specialty programs in US
• 60% have NO physician
• 44% have NO nurse, SW or psychol.
• Counseling is the major profession
• 82% primarily government funded
Private insurance <15%
Sources – NSSATS, 2012; D’Aunno, 2008
Traditional Insurance Benefits
Very
Serious
Use
In Treatment ~ 2,300,000
Addiction
Addiction ~ 23,000,000
“Harmful – 40,000,000
Use”
Little/No
Use
Little or No Use
• 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
In Summary
There are effective medications, therapies
and social services to treat addictions
But the US addiction treatment system is:
1. Not structured or financed to deliver them
2. Based on an acute care treatment model
Mainstream Healthcare could deliver
effective care for SUDs but that has not been
part of mainstream medicine for 100 years!
1
Part 4
Why “…burden healthcare
with care for those people..?”
1
1. Because it will improve
general medical care
2. Because it will save money
3. Because it’s the law.
1
1. Because it will improve
general medical care
2. Because it will save money
3. Because it’s the law.
Substance Use Impact on Healthcare
Alcohol and drug use - even at levels below
“addiction” - regularly lead to:
• misdiagnoses,
• poor adherence to prescribed care,
• interference with commonly prescribed medications,
• greater amounts of physician time,
• unnecessary medical testing,
• poor outcomes and
• increased costs
particularly in the management of chronic illness.
Vinson D, Ann Fam Med, 2004. Brown RL, J Amer Board Fam Prac, 2001. Humeniuk R, WHO, 2006. Manwell LB, J
Addict Dis, 1998. Longabaugh R. Alcohol Res Health, 1999. Healthiest Wisconsin 2010, WI DHFS, 2000. USPSTF,
Screening for Alcohol Misuse, 2004. National Quality Forum, National Voluntary Consensus Standards, 2006. Bernstein
J, Drug Alcohol Depend, 2005. Saunders B, Addiction, 1995. Stephens RS, J Consult Clin Psychol, 2000. Copeland J, J
Subst Abuse Treat 2001. Fleming MF, Med Care, 2000. Fleming MF, Alcohol Clin Exp Res, 2002. Gentilello LM, Ann
Surg, 1999. Estee S, Medicaid Cost Outcomes, Interim Report 4.61.1.2007.2, Washington State Department of Social
and Health Services. Yarnall KSH, Am J Public Health, 2003. Solberg LI, Am J Prev Med, 2008. National Committee on
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Prevention Priorities, http://www.prevent.org/content/view/43/71/.
Risk of Mortality & Drinks/Day
1.4
Risk of Mortality
1.3
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0
1
2
3
4
Drinks per Day
Di Castelnuovo et al. Arch. Int. Med. 2006;166(22):2437
5
6
7
1
Alcohol Use and Breast Cancer
Before Diagnosis – heavy drinkers
1.5 times chance of contracting
2.3 times chance w/BRAC2 gene
After Diagnosis – ANY Drinking
Increases risk of relapse
Interferes radio & chemo therapy
1
Potential impact on Safety: Fatal Medical Errors
FME Death Rate
1983 - 2004
Alc/Drg Related
Fatal Errors
Phillips, D. P. et al. 2008;168:1561-1566.
Drug-Drug Interactions – Safety Issues
• BU study of 87 patients with undisclosed opioid
use receiving primary care at BU Medical Center.
• 100% received at least one medication with a
negative drug-drug interaction
• Average number of interactions =
5
• 17% required ED treatment ($$$)
Walley et al., J. Gen Internal Medicine, 24(9): 1007-11, 2009
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
In Treatment ~ 2,300,000
Very
Serious
$40B Addiction ~ 23,000,000
Use
Yr
$80 B
Yr
Little/No
Use
“Harmful – 40,000,000
Use”
Little or No Use
1
Population
Population Prevalence
Prevalence
In Treatment ~ 2,300,000
LOTS
X
Target
Group
Addiction ~ 25,000,000
“Harmful – 60,000,000
Use”
Little or No Use
LITTLE
40
Major Advances in Brief Interventions
• “Harmful substance use” is accurately
identified with 2 – 3 questions.
– Prevalence rates of
20 – 50% in healthcare
– 60% of all ER admissions (10 million/yr)
• Brief counseling (5 – 10 minutes) by
produces lasting changes & savings
41
Washington’s Screening
Brief Intervention & Treatment
Evaluation
• SBIRT in 9 Emergency Depts.
• Case Control Study of 1557 pts
– Matched group – got ER care but no BI
• Measured healthcare utilization and
costs for one year
Medicaid Costs Following SBIRT in
Washington State
Medicaid Costs PM/PM
SBIRT patients = 1557
Matched controls = 1557
$4,000 Savings PM/PY
Estee et al. Medical Care. 2010.
1
1. Because it will improve
general medical care
2. Because it will save money
3. Because it’s the law.
2010 Affordable Care Act
• SA care is “Essential Service”
•
SA is firmly part of healthcare
• 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 Benefits Today
Very
Serious
Use
In Treatment ~ 2,300,000
Addiction
Addiction ~ 23,000,000
“Harmful – 40,000,000
Use”
Little/No
Use
Little or No Use
• Detoxification – 100%
– Ambulatory – 80%
• Opioid Substitution Therapy – 50%
• Urine Drug Screen – 100%
– 7 per year
• 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
In Treatment ~ 2,300,000
Very
Serious
Addiction ~ 23,000,000
Treatment
Use
Early “Harmful – 40,000,000
InterventionUse”
Little or No Use
Prevention
Little/No
Use
Closing Thoughts
Substance use disorders” will soon be a
regular part of mainstream healthcare:
1. SUDs are too common, dangerous & expensive
in healthcare to be ignored
2. Public understanding that addiction is an
illness not a sin
3. Mainstream healthcare can do this!
o Chronic Care Management protocols are appropriate