Transcript Health Care Reform: Opportunities to Improve Treatment of SUDs

Mady Chalk, PhD., MSW
Treatment Research Institute
November, 2013
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Addiction as a chronic illness, with
expected readmissions to treatment
SBI + --- brief counseling in primary care
settings
Use of medications in treatment
Integrated care --- SBI +, medication
prescription, monitoring, and management,
care coordination, referral to specialty care
and return to primary care for follow-up
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Tracking recovery during treatment (not
evaluating it AFTER treatment)
Peer-to-peer and organizational recovery
supports
Community-based offender treatment --RANT, TASC models, use of medications
Episodes of care, bundling of services
OTPs as medical homes
Under the ACA, including parity and essential
health benefits:
 Prevention
◦ Screening and brief interventions
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Early Intervention
◦ Brief Counseling and Treatment in primary care
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Office-based Treatment
◦ Medications, monitoring, management,
coordination of care in primary care
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Referral to Specialty Care as Needed and Back
for Continuing Care
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“Harmful substance use” is identified in 2-3
questions
◦ Prevalence estimates are 20-50% in healthcare
◦ About 60% of emergency room visits
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A few brief counseling visits (10 minutes) in
primary care produce lasting changes and
cost savings to health care
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Alcohol consumption @ ANY DOSE accelerates
tumor growth in breast and prostate cancer
Alcohol @ MORE THAN 2 DRINKS/DAY reduces
treatment response in hypertension and
diabetes
Alcohol @ ANY DOSE 2 hours before bedtime
reduces sleep quality
Alcohol @ MORE THAN 2 DRINKS/DAY
produces 30-50% reduction in medication
adherence
BUT simply asking patients to reduce their use
can improve clinical outcomes (PRISM,, 2011)
Under the ACA:
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Emphasis/expansion health/medical
home services
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Will “specialty care” fill this role?
Role of Block Grant is likely to change
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Recovery-oriented services NOT covered
under Medicaid or commercial health plans
Opioids:
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Methadone
Buprenorphine
Naltrexone – oral
Naltrexone (Vivitrol) – long-acting, injectable
Alcohol:
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Naltrexone – oral
Naltrexone (Vivitrol) – long-acting, injectable
Acamprosate
Disulfram (antabuse)
All medications for treatment of moderate and
severe addiction to opioids have shown clear
clinical evidence of effectiveness in:
 reducing opioid use and opioid-use related
symptoms of withdrawal and craving and,
 risk of infectious diseases and crime when used
as part of a comprehensive approach in
appropriate doses.
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Effectiveness of these medications is true only
when used as maintenance treatments.
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There is NO evidence of enduring benefits from
any of these medications when used in any type
of “detoxification only” regimen that does not
include continuing treatment and recovery
supports.
Under-utilization is severe and is being driven by:
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State licensing requirements that place restrictions on hiring
of physicians in substance use treatment programs
Federal restrictions on numbers of patients that waivered
physicians may treat with buprenorphine (100 patient limit)
State restrictions on use of some medications in residential
treatment
State legislative interference in dosage and day limits for use
of medications, and
Ideological issues in the workforce
Recent research has shown:
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Use of ANY of the medications has been shown to
produce cost-offsets related to reduced emergency
room visits and fewer inpatient admissions of all
types (alcohol- and drug-related or not).
Despite the addition of medication costs, total
healthcare costs (incl. inpatient, outpatient, and
pharmacy costs) are almost 1/3 lower for patients
who receive medications. (Baser, Chalk, et al.2011)
Transparency:
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Despite the recent announcement of the Parity rules,
under the ACA patients will need considerable
assistance to discover and assure that they have access
to medications as part of their treatment regimens.
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The assistance will need to come from clinicians and
managed care plans both in the private and public
sectors.
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Workforce Issues:
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A significant amount of work is needed now and on a
continuing basis to credential and improve the capacity
of the workforce in both the primary and specialty
sectors to increase the use of medications in treatment.
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This work needs to include increased capacity of the
workforce to understand the interactions of other chronic
illnesses and their treatment (which may include
medications) on treatment of addictions with
medications.
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