Transcript A Review of PA State Programs

Substance Use Disorder Treatment:
A review of Commonwealth Initiatives
Ken Martz, Psy.D. CAS
Special Assistant to the Secretary
Pennsylvania Department of Drug and Alcohol Programs
1
Overview
•
•
•
•
Background
Overview key treatment issues
Initiatives
Recommendations/Discussion
2
Fast Facts
•
•
•
•
Every dollar spent in AOD treatment saves 7$
If medical expenses are included that rises to 11$
Effective treatment works.
Clinically appropriate levels of care work.
– But what is that?
• Why care about drug and alcohol treatment?
– 1 in 4 people has substance abuse in their families
– 1 in 4 people with addiction will die as a result
3
Cost/Benefit
In 2007, the cost of illicit drug use alone (Does not include alcohol abuse) totaled
more than $193 billion. Direct and indirect costs attributable to illicit drug use are
estimated in three principal areas: crime, health, and productivity.
•
•
•
Crime: includes three components: criminal justice system costs ($56,373,254), crime victim costs
($1,455,555), and other crime costs ($3,547,885). These subtotal $61,376,694.
Health: includes five components: specialty treatment costs ($3,723,338), hospital and emergency
department costs for non-homicide cases ($5,684,248), hospital and emergency department costs
for homicide cases ($12,938), insurance administration costs ($544), and other health costs
($1,995,164). These subtotal $11,416,232.
Productivity: includes seven components: labor participation costs ($49,237,777), specialty
treatment costs for services provided at the state level ($2,828,207), specialty treatment costs for
services provided at the federal level ($44,830), hospitalization costs ($287,260), incarceration costs
($48,121,949), premature mortality costs (non-homicide: $16,005,008), and premature mortality
costs (homicide: $3,778,973). These subtotal $120,304,004.

Taken together, these costs total $193,096,930, with the majority share attributable to lost productivity. The
findings are consistent with prior work that has been done in this area using a generally comparable
methodology (Harwood et al., 1984, 1998; ONDCP, 2001, 2004).

This report by ONDCP does not include alcohol related costs, which would add to these numbers
 For Pennsylvania this cost for illicit drug use would be $8,289,740,227
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Cost Savings from Substance Abuse Services
Criminal Justice System
Impact
Health System Savings
Substance Use Disorders:
Snapshot
•
Treatment Gap
Numbers in Thousands Needing Treatment for Illicit
Drugs or Alcohol, 2011
–
30,000
25,000
23,523 23,090
In Pennsylvania we do a little better;
about 13 percent of those needing
services get them
21,579
•
20,000
Did Not Receive
Specialty
Treatment
•
Received
Specialty
Treatment
15,000
10,000
5,000
According to the NSDUH report,
nationally we offer enough drug and
alcohol treatment to address the needs of
10.8% of individuals who need it.
•
2,627
2,579
2,325
2009
2010
2011
0
Source: Substance Abuse and Mental Health Services Administration (SAMHSA), Results from
the 2010 and 2011 National Survey on Drug Use and Health: Summary of National Findings,
NSDUH Series H-44, HHS Publication No. (SMA) 12-4713, Chart 5.51A. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 2012.
According to data from the Survey of
Inmates in Local Jails, in 2002 more than
two-thirds of jail inmates were found to be
dependent on or to abuse alcohol or drugs
Substance abuse expenditures represented
1.3 percent of all healthcare expenditures
in 2003 ($21 billion for substance abuse
vs. $1.6 trillion for all health
expenditures).
The 2010 U.S. Drug Control Strategy cites
that untreated addiction costs society over
$400 billion annually with $120 billion of
that in wasted or inappropriate health care
procedures.
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Overview of Substance and Drug Use
Past-Year Initiates for Specific Illicit Drugs
Among Persons Age 12 or Older, 2008
Source: Substance Abuse and Mental Health Services Administration.
(2009). Results From the 2008 National Survey on Drug Use and Health:
National Findings Rockville, Maryland.
Past-Year Initiates for Specific Illicit Drugs
Among Persons Age 12 or Older, 2014
Past Month Heroin Use among People Aged 12 or Older, by Age Group: 2002-2014
Source: Substance Abuse and Mental Health Services Administration. (2014). Results From the
2015 National Survey on Drug Use and Health: National Findings Rockville, Maryland.
Overdose Deaths in Pennsylvania
Drug Overdose Deaths in Pennsylvania
•
Year
Number of Deaths
PA Population
Rate per 100,000
2012
2,026
12,763,536
16.3
2011
1,909
12,742,886
15.4
2010
1,550
12,702,379
12.5
2008
1,522
12,448,279
12.6
2006
1,344
12,440,621
11.2
2004
1,278
12,406,292
10.6
2002
895
12,335,091
7.5
2000
896
12,281,054
7.4
1998
628
12,001,451
5.4
1996
630
12,056,112
5.4
1994
596
12,052,410
5.1
1992
449
11,995,405
3.8
1990
333
11,881,643
2.7
Based on Pennsylvania Department of Health data, overdose deaths have
been on the rise over the last two decades with an increase in the rate of
death from 2.7 to 16.3 per hundred thousand Pennsylvanians
Heroin Related Overdose Deaths in Pennsylvania
Heroin Only and Multidrug Toxicity Deaths
1400
1248
1200
1000
Heroin only
728
800
584
Heroin and other drugs
600
400
200
324
47
356
273
107
*Projection based on overdose
data through July
159
25
0
2009
•
•
•
2010
2011
2012
2013
(Projected)
Based on Pennsylvania Corners Association (PCA) reports in 43 counties, heroin and heroin related
deaths have been on the rise for the past 5 years (PCA, 2013)
Between 2009 and 2013 there 2,929 heroin related overdose deaths identified by county coroners.
Of these, 490 (17%) were heroin only, while 2,439 (83%) involved multiple drugs.
Other drugs commonly found along with heroin overdose include
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Other opiates: Methadone, Oxycodone, Fentanyl, Morphine, Codeine, Tramadol
Other Illegal drugs: Marijuana, cocaine
Other sedating drugs: Alcohol, benzodiazapines
Antidepressant medications: Prozac, Celexa, Remeron, Trazadone, Zoloft
Overdose Deaths in Pennsylvania
History
Pain as the Fifth Vital Sign
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Source of Nonmedical Use of Prescription Drugs
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Naloxone Reversals By Police Officers In Opioid Overdose Events
Number of successful overdose reversals per county
Single asterisks * signify counties with zero PDs carrying naloxone however preparing to launch naloxone programs within the next few months.
Double asterisks ** signify counties that do not have municipal police departments
Municipal Police Reversals = 1,577 PA State Police Reversals = 47
TOTAL REVERSALS = 1,624
Erie
11
*
Forest
**
Venango
Mercer
*
0
11
Beaver
Jefferson
0
2
3
2
*
Westmoreland
29
0
Snyder
0
Cambria
Fayette
*
0
Somerset
*
Montour
0
Blair
4
Huntingdon
**0
36
6
1
0
Carbon
22
Schuylkill
Berks
Lebanon
13
9
Northampton
31
Bucks
Montgomery
Cumberland
Bedford
43
Fulton
* **
Lancaster
York
Franklin
Adams
26
1
258
95
30
Lehigh
8
48
Pike
Monroe
Northumberland
Dauphin
Perry
Lackawanna
13
1
Mifflin Juniata
80
Greene
1
Luzerne
Columbia
Union
1
0
**
*
0
Indiana
Allegheny
Washington
Clinton
Centre
Armstrong
*
Sullivan
Lycoming
Clearfield
1
1
25
**
Wayne
Wyoming
Cameron
0
Susquehanna
Bradford
0
0
Clarion
Butler
*
Elk
Tioga
Potter
1
0
Crawford
Lawrence
McKean
Warren
84
98
Chester
79
356
Philadelphia
Delaware
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Rev 10/12/2016
FDA Warning Labels
• In September 2013 the FDA updated the
warning labels on long acting opioid products.
– The new labeling adds: "Because of the risks of
addiction, abuse and misuse with opioids, even at
recommended doses, and because of the greater
risks of overdose and death with extendedrelease opioid formulations, reserve [Trade name]
for use in patients for whom alternative treatment
options (e.g., non-opioid analgesics or
immediate-release opioids) are ineffective, not
tolerated, or would be otherwise inadequate to
provide sufficient management of pain."
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Length of Stay
Studies consistently find length of stay as the primary predictor of outcomes, along
with intensity of treatment and continuum of care.
Days in Treatment
Source: Greenfield et al, (2004).
Effectiveness of Long Term Residential
Treatment for Women: Findings from 3
National Studies
Percentage of Clients with New Convictions
NEW CONVICTIONS BY
LENGTH OF STAY
35 %
35%
30%
25%
25%
20%
27%
12%
15%
10%
5%
0%
Number of Days in Treatment
More than 179 Between 90 and 179 Less than 90 Control
Source: Zhang (2002). Does retention matter?
Treatment duration and improvement in drug use.
(4,005 clients)
Source: Pennsylvania Department of
Corrections (1997) Pennsylvania FIR
Evaluation
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Length Of Stay
Studies consistently find length of stay as the primary predictor of
outcomes, along with intensity of treatment and continuum of care.
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Improvements in criminal recidivism and relapse rates are correlated to length of
treatment, with highest rates of improvement among those with 9 months of
treatment, and reduced effectiveness for treatment of less than 90 days (NIDA, 2002)
Highest improvements were found in long term treatment with least improvement
found in methadone maintenance (Friedmann et al, 2004)
Lengths of stay are the number one predictor of outcomes for treatment (President’s
Commission on Model State Drug Laws, 1993)
Average length of stay for Medicaid clients was 90 days (Villanova Study, 1995). Best
outcomes were found for longer lengths of stay and more complete continuum of
care, measured as lack of criminal recidivism, abstinence, employment and higher
paying jobs. No benefit was found for treatment less than 90 days. Currently,
average length of stay in treatment for long term residential is 47 days (DPW, 2011)
Length of stay has a direct linear relationship with improved outcomes (Toumbourou,
1998)
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Treatment Works: But what is treatment?
•Treat addresses a wide range of clinical
issues that cause and exacerbate risks of
substance abuse.
•These include the needs for habilitation and
rehabilitation, including vocational supports,
addressing trauma, learning coping skills, learning
relapse prevention skills, improving relationships
etc.
•This is not to be confused with supporting
services such as detoxification, medications,
peer supports, 12-step programs, housing
and other similar approaches which
complement the core treatment program.
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PCPC
• Importance of Level of Care
– Under treating can lead to treatment resistance or increased
progression of the disease
• What happens if you take a half dose of antibiotic?
• What happens if you take a half dose of insulin?
• What happens if you take a half dose of treatment?
– Answer:
• It doesn’t work
• Individuals get sicker
• Individuals and providers “give up” believing that
there is no hope
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Progression of a Disease and Recovery
No drinking
Social drinking
Drinking feels good
Drink to relax
Drink to escape
Withdrawal from friends
First DUI
Conflict in relationships
Missed time from work
Regular drinking
Amount of drinking increases
Drink to stop feeling bad
Disciplinary action at work
Association with negative peer group
Antisocial beliefs justify behaviors
Increasing health complications
Relationship isolation/ alienation
Late Addiction
“Rock Bottom”, Arrests
Divorce, Loss of Job
Depression,
Hopelessness,
Suicide, Death
Give to others
Optimism
Regain job
Face problems
Honesty
More relaxed
Relationships improve
Begin to develop trust
Resolve legal issues
Self respect returning
Connect with sponsor/
positive peer group
Self examination
Medical stabilization
Thinking begins to clear
Desire for help
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Which Brain do You Want?
Normal healthy view.
Top down surface view.
Full, symmetrical activity
During substance abuse
One year drug and alcohol free
Notice the overall holes and shriveled appearance during abuse
and marked improvement with abstinence.
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Which Brain do You Want?
Normal healthy view.
Top down surface view.
Full, symmetrical activity
Effects of other substances:
Long term alcohol 57 y/o 30 years
abuse
marijuana abuse
(underside view)
39 y/o – 25 years
frequent heroin use
40 y/o, 7 years on
methadone.
Heroin 10 years
prior.
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Elements of the Warm Handoff
•County Drug and Alcohol Agency
(SCA) helps ensure active funding
stream (e.g. Medicaid, county
funding, etc)
Client
SUD
Treatment
Medical
Providers
•Their role is to identify payment
sources, to complete an initial
assessments, and to connect
individuals to treatment
•DDAP has led efforts to address
each of these areas, with specific
action steps.
Evidence Based Practice
• Warm handoff procedures are evidence based as an
effective approach with substantial research support
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–
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O'Neil, S. H. (2009). Addiction treatment providers needed for 'warm handoff' from EDs.
Alcoholism & Drug Abuse Weekly, 21(38), 1-3.
Koenig, C. J., Maguen, S., Daley, A., Cohen, G., & Seal, K. H. (2013). Passing the baton: A
grounded practical theory of handoff communication between multidisciplinary providers in
two department of veterans affairs outpatient settings. Journal of General Internal Medicine,
28(1), 41-50.
Boudreaux, Edwin D., Haskins, B., Harralson, T., & Bernstein, E. (2015) The remote brief
intervention and referral to treatment model: Development, functionality, acceptability, and
feasibility, Drug and Alcohol Dependence, 155(1), 236-242.
Sammer, J. (2015). Warm handoffs serve as the first step toward accountable care.
Behavioral Healthcare, 35(3), 24-27.
Bernstein, E., Ashong, D., Heeren, T., Winter, M., Bliss, C., Madico, G., & Bernstein, J.
(2012). The impact of a brief motivational intervention on unprotected sex and sex while high
among drug-positive emergency department patients who receive STI/HIV VC/T and drug
treatment referral as standard of care. AIDS and Behavior, 16(5), 1203-16.
Bernstein, S. L., & D'Onofrio, G. (2013). A promising approach for emergency departments to
care for patients with substance use and behavioral disorders. Health Affairs, 32(12), 2122-8.
Prescribing Guidelines
Prescribing Guidelines
Key elements include:
Before initiating pain therapy, have
a complete history including
SUD history
Use of NSAIDS as first line
analgesic therapy
Acetaminophen has been shown
to be synergistic with NSAIDS
Use local anesthetics whenever
possible
Prescribing Guidelines
If an opioid is to be administered:
Choose lower dose/duration
Use PDMP to determine
concurrent medications
Opioids should not be
administered in combination
with benzodiazepines
Care should be used when
prescribing opioids for those
with obstructive sleep apnea
Provide instructions on safe
storage and disposal
Prescribing Guidelines
If an opioid is to be administered:
Choose lower dose/duration
Use PDMP to determine
concurrent medications
Opioids should not be
administered in combination
with benzodiazepines
Care should be used when
prescribing opioids for those
with obstructive sleep apnea
Oral Implications of Substance Use
• Oral Implications of Alcohol Use/Abuse
– Excessive Bleeding or Bleeding Disorders: Alcoholism may damage the
liver and bone marrow resulting in excessive bleeding during dental
treatment.
• Oral Implications of Prescription Medication Use/Abuse
– Common implications include xerostomia, clenching/grinding, caries and
periodontal disease. A routine, thorough oral exam is recommended.
Identifying the particular prescription drug will reveal more complete oral
implications.
• Oral Implications of Meth Use/Abuse
– Dental Caries: Meth mouth, or crank decay, is commonly observed in
methamphetamine users. The cause of meth mouth is multifactorial. Meth
users commonly experience drug-induced cravings for high-calorie
carbonated beverages.
Source: Oral Implications of Chemical Dependency &
Substance Abuse for the Dental Professionals (2013)
The Solution
• Prevention
– Permanent Drop Boxes for medication disposal over
16,000 pounds collected
– Proper Storage Procedures (ie. lockbox in the home, pill
organizers)
– Pennsylvania Youth Survey
• Treatment
– Medicaid Expansion offers coverage to a wider range of
Pennsylvanians so that those with substance abuse can
access care
• Warm Handoff
– Connections are invaluable to transition individuals into
SUD care.
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The Solution (cont.)
• Continue /Expand current initiatives
– Prescriber Practices Workgroup
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Emergency Department Pain Treatment Guidelines
Opioid to Treat Non-Cancer Pain
Opioids in Dental Practices
Obstetrics and Gynecological Pain
Geriatric Pain
Dispensing of Opioids
Prescription Drug Monitoring Program
CME’s
Medical School Core Competencies
Naloxone
Good Samaritan
Access: SCA’s, 800-662-4357(HELP)
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The Solution (cont.)
• Awareness of Insurance and other Protections
– Act 106 of 1989
• Protects group health insurance plans
– Act 152 of 1988
• Protects services in Medicaid plans
– Mental Health and Parity and Addiction Equity Act
• Requires SUD to be treated with equivalent coverage as other medical
conditions
– Patient Protection and Affordable Care Act
• Requires the coverage of SUD as an essential benefit
– 42CFR Confidentiality
• Protects confidentiality of SUD patients from adverse effects from the stigma
associated with the disease
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Parity?
Addiction Treatment Coverage:
•
•
•
Detoxification – 100%
Opioid Substitution Therapy – 50%
Urine Drug Screen – 100%
–
7 per year
• Wide variety in coverage across states
Diabetes Coverage:
•
•
•
•
•
•
•
•
•
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
Source: (McLellan, 2013)
Recommendations
Why Treatment Fails
Why Treatment Works
Length of Stay (Less than 90 days)
Length of Stay (More than 90 days)
Undertreating (Giving OP instead of TC)
Appropriate Level of Care
Fragmented care
(Detox only, 12-step only)
Full Continuum of Care
Weak Enforcement of Insurance Law
Enforcement of State and Federal Laws
Medicating all Pain
Appropriate Prescribing
Stigma (Seeing individuals as “bad”)
Humanizing (Treating those with disease)
Locking up Drug Users
Treating those with Substance Use
Disorder
Thinking There is a Silver Bullet
Clinical Integrity
What Works: Clinical Integrity
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What Can I Do? 10 Simple Steps
• Are my programs trained in cross-system needs (criminal justice, child
welfare, medical etc)?
• Are my system partner programs trained in drug and alcohol
treatment?
• Are we using adequate lengths of stay or terminating based on
funding?
• Are we educating on safe storage and disposal practices
• Are we educating on proper prescribing practices?
• Does our county have medication take back boxes?
• Are we expanding the use of Naloxone to save overdose victims?
• Are we co-prescribing Naloxone with opioids?
• Are we supporting our community efforts for prevention, to reach long
term improvement.
• Are we doing SOMETHING? Pick one and keep moving forward.
Contact Information
Ken Martz, Psy.D. CAS
Special Assistant to the Secretary
Pennsylvania Department of Drug and Alcohol Programs
02 Kline Village
Harrisburg, PA 17104
[email protected]
(717)783-8200
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