Transcript Accessed 6/9/2010. - The Association of Substance Abuse Programs

1
Texas Initiative Program Success and
Sustainability (TIPSS) Conference
June 14, 2010
Under the Influence:
Impact of Alcohol & Substance Abuse on the Safety Net
Ron J. Anderson, MD, MACP
President & CEO—Parkland Health & Hospital System—Dallas, Texas
2
Long-recognized Problem
From Emergency Medicine Annual, 1984. Volume III, pps 1-36
3
Alcohol & Substance Abuse
Numbers Have Stayed Steady
• Relatively unchanged since 2002
(Changes in survey make comparison to earlier years difficult).
• 2007 National Survey on Drug Use and Health (NSDUH):
National Findings for Americans 12 years and older
• 19.9 million (8%) used an illicit drug,
• 70.9 million (28.6%) used a tobacco product, and
• 126.8 million (51.1%) used alcohol
Source: http://oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.pdf Accessed 6/8/2010.
4
Drug and Alcohol Use in Texas
• National Survey of Drug Use and Health:
• Illicit drug use
• 2006-2007: 6.4% of the Texas population age 12 and older had used an illicit
drug in the past month, which is below the national average of 8.0%. 2.7
percent of Texans were dependent on or abused an illicit drug in the past year,
as compared to 2.8% nationally
• 2004–2006: 6.5 percent of the population age 12 and older in the Dallas
metropolitan area and 6.2 percent in the Houston area had used any illicit drug.
• Alcohol is the primary drug of abuse in Texas.
• 2008: 63% of Texas secondary school students (grades 7–12) had used alcohol,
and 30% had drunk alcohol in the last month.
• Lifetime use decreased by 5% and past-month use decreased by 3% between
2006 and 2008.
• Of particular concern is heavy consumption of alcohol, or binge drinking, which
is defined as drinking five or more drinks at one time. In 2008, 12% of all
secondary students said that when they drank, they usually drank five or more
beers at one time, and 13% reported binge drinking of liquor, which has
remained relatively stable since 1992
Source: Texas Department of State Health Services. Substance Abuse Trends in Texas June 2009.
http://www.utexas.edu/research/cswr/gcattc/documents/Texas2009_002.pdf Accessed 6/9/2010.
Alcohol & Substance Abuse
Related Deaths in Dallas County,
2002
5
1,070
Total
Direct
Indirect
850
436
319
220
117
Alcohol-related
Drug-related
Source: Texas Department of State Health Services. http://www.tcada.state.tx.us/research/statistics/deaths01.php
Data after 2002 is not available online. A special request from the statistics group is required.
6
Alcohol & Substance Abuse Costs
Are Difficult to Calculate
• Two important problems:
• Establishing causation to differentiate between costs
caused by, not just associated with, drug abuse
• Many costs can’t be measured directly, i.e., lost
productivity, pain and suffering
• Among national estimates of the costs of illness for
33 diseases and conditions:
• Alcohol ranked 2nd
• Tobacco ranked 6th
• Drug disorders ranked 7th
Sources: About.com. Estimating the Economic of Alcoholism. http://alcoholism.about.com/cs/alerts/l/
blnaa11.htm Accessed 6/9/2010. and SAMHSA CSAP Substance Abuse Prevention Dollars and Cents: A Cost-Benefit
Analysis. http://download.ncadi.samhsa.gov/prevline/pdfs/SMA07-4298.pdf Accessed 6/9/2010.
7
Everyone Agrees the Expenses
Are Staggering
• Estimates of the total costs of substance abuse in the US—
including health- and crime-related costs and losses in
productivity—exceed 500 billion dollars annually.
• $181 billion for illicit drugs
• $168 billion for tobacco
• $185 billion for alcohol
• Numbers do not fully describe the breadth of deleterious
public health and safety implications:
•
•
•
•
•
•
Family disintegration
Loss of employment
Failure in school
Domestic violence
Child abuse
Etc.
Sources: National Institute on Drug Abuse. NIDA InfoFacts: Understanding Drug Abuse and Addiction.
http://www.drugabuse.gov/infofacts/understand.html Accessed 6/9//2010.
8
Alcohol and Drugs Played a Significant
Role Healthcare in 2006
• Short-stay hospital discharges
• 430,000 people had first-listed alcohol diagnoses
• An additional 1,718,000 had an alcohol diagnosis not listed first
• Emergency Department visits
• 1.9 million (about 1.6% of total) associated with alcohol and/or
drug use
• Hospital admissions for psychiatric and general medical reasons
higher for those with diagnoses of substance use disorders
• Compared with others with behavioral health disorders,
individuals with diagnoses of substance use disorders had
significantly higher expenditures for physical health problems
Source: National Institute on Alcohol Abuse and Alcoholism. Alcohol-related Short-stay Hospital Discharges.
http://www.niaaa.nih.gov/Resources/DatabaseResources/QuickFacts/HospitalDischarges/default.htm
Accessed 6/9/2010, SAMHSA. Drug Abuse Warning Network, 2007:National Estimates of Drug-Related
Emergency Department Visits. https://dawninfo.samhsa.gov/files/ED2007/DAWN2k7ED.pdf Accessed
6/9/2010 and Clark, Samnaliev and McGovern. Impact of substance disorders on medical expenditures for
medicaid beneficiaries with behavioral health disorders. Psychiatr Serv. 2009 Jan;60(1):35-42.
http://www.ncbi.nlm.nih.gov/sites/pubmed Accessed 6/9/2010.
9
Parkland Patients with Alcohol
Diagnoses-- 10/1/2008-9/30/2009
All Alcohol Diagnostic Codes
Emergency Department
• 2,594 encounters
• 2.7% of all ED encounters
Inpatients
• 2,380 encounters
• 4.3% of all admissions
Selected Alcohol Diagnostic Codes
alcohol withdrawal delirium; non-dependent abuse of drugs; liver disease & cirrhosis
Emergency Department
• 2,217 encounters
• 85.5% of all ED patients with
alcohol diagnoses (2,594)
• Payment shortfall = $1,208,914
Source: Parkland Health & Hospital internal data.
Inpatients
• 385 encounters
• 16.2% of all admissions with
alcohol diagnoses (2,380)
• Payment shortfall = $3,260,713
10
Alcohol’s Impact on Trauma Is
Huge and Under-reported
• Alcohol-related car crashes are the #1 killer of teens. Homicide and suicide,
the 2nd, and 3rd leading causes of death among teens have also been linked
to alcohol consumption.1
• Alcohol is associated with:
•
•
•
•
•
40 to 50 percent of traffic fatalities;
25 to 35 percent of nonfatal motor vehicle injuries;
up to 64 percent of fires and burns;
48 percent of hypothermia and frostbite cases; and
about 20 percent of completed suicides.2
• These numbers likely represent the tip of a much larger iceberg because they:
• Do not include non-intoxicated victims involved in car crashes, assaults etc.
• Miss people who are under the influence but do not present with obvious
symptoms of intoxication
1 Marin
Institute. Health Care Costs of Alcohol. http://www.marininstitute.org/alcohol_policy/health_care_
costs.htm Accessed 6/9/2010.
2Lowenfels, A., and Miller, T. Alcohol and Trauma. Ann Emerg Med 13:1056-1060, 1984.
11
Alcohol’s Impact on Trauma Recidivism
• Survivors of car crashes and other injury events who test
positive for alcohol or drug use are more than 2 times as likely
to die in just a few years from a subsequent injury under
similar circumstances as those who do not test positive.1
• Trauma patients who were intoxicated on 1st admission were
2.5-fold as likely to be readmitted than those not intoxicated.2
• Risk of alcohol-impaired driving recidivism among first
offenders more closely resembles that of second offenders than
that of non-offenders. Any alcohol-related driving violation—
not just convictions—is a marker for future recidivism 3
1http://alcoholism.about.com/library/blsap0111119htm?terms=trauma=centers
2http://jama.ama-assn.org/cgi/content/abstract/270/16/1962
3 Rauch, et. al. Risk of Alcohol-Impaired Driving Recidivism Among First Offenders and Multiple
Offenders. Am. J. Pub. Health: V 100_5, May 2010.
12
Parkland’s Trauma-Related Admissions
with Positive Alcohol Levels, 2008 & 2009
Parkland’s Trauma-Related Admissions with Positive Alcohol Levels, 2008 and
2009
4000
3500
3000
Trauma-Related
2500
Admissions
2,849
2000
2,481
Positive Ethanol Levels
1500
1000
500
684
658
0
2008
2009
These figures are substantially low because many patients are not tested, and many
patients are kept overnight because they are too drunk to leave but are not admitted.
Sources: Tammy Morgan, Trauma Registry; Sue Pickens, Population Medicine
13
Parkland’s Trauma Volume
Is Twice National Average
Total Trauma Admissions, 2006
3,940
2,086
Parkland
National Avg.
Source: PHHS Trauma Registry, CY 2006 & National Trauma Data Bank, Report 2007 National Average is a 5 year
average 2002-2006
14
Why Intervention Is Important
• Trauma Centers can be effective intervention sites
because the occasion of an alcohol- or drug-related injury
produces a “teachable moment” when the patient is more
open to hearing information about treatment options.1
• Sommers, et. al. did interviews with binge drinkers hospitalized as a
result of alcohol-related car crashes and found for almost 60% of
those admitted that alcohol had played a role in the crash.2
• Gentilello, et. al. showed a 47% reduction in injuries requiring ER or
Trauma admission after a year in a group of BAC+ patients who
received a brief alcohol intervention, compared to a control group.3
1
http://www.jointogether.org/news/features/2002/arcane-laws-hinder-er-for.html?print=t
2Sommers, et. al. 2000, American Journal of Critical Care
3Gentilello, et. al. 1999. Annals of Surgery. 230:4 473-483
15
Why Intervention Is Cost Effective
• Gentilello, et. al., found that a brief alcohol
intervention reduced recidivism and therefore costs:
“The benefit in reduced health expenditures resulted
in saving of $3.81 for every $1 spent on screening
and intervention…If interventions were routinely
offered to eligible injured adult patients nationwide,
the potential net savings could approach $1.8 billion a
year.”
Gentilello, et. al. 2005. Annals of Surgery 241:541-550
16
Why Intervention Is Not Common
• Lack of knowledge among trauma physicians
• A 1999 study by Danielsson, et. al. listed reasons
given by surveyed trauma surgeons for not screening:
• Lack of time was most commonly cited reason
• 76% were not familiar with commonly-used screening
questionnaires
• 83% reported they had no training in alcohol screening
• 88% would be willing to devote time if shown that screening and
intervention was effective1
1http://archsurg.ama-assn.org/cgi/content/abstract/134/5/564
17
Some Trauma Centers Must Screen But
Mechanism Is Not Mandated
• American College of Surgeons-Committee on
Trauma requires that:
• Level I and Level II trauma centers have a
mechanism to identify problem drinkers
• Level I centers have the capability to provide brief
interventions for screen-positive patients
• Level I and II trauma centers represent only 34% of
all trauma centers in the US
• Parkland began a screening and referral program
before the ACS-COT requirement was announced
Source: AAMHSA. SBI in Trauma Centers. http://sbirt.samhsa.gov/trauma.htm Accessed 6.11.2010, 2009
National Trauma Data Bank Annual Report, http://www.facs.org/trauma/ntdb/ntdbannualreport2009.pdf.
Accessed 6/11/2010, and intenal data from Parkland Health & Hospital System.
18
Screening Is Still Less Common
than Is Desirable
• 35% of trauma victims screened for alcohol; 13.9% positive
• 22% screened for drugs; 11% positive
• 28% and 33% respectively were listed as NK/NR; if the trend
among tested victims held for this group several thousand
more people would have been found to be impaired
Source: 2009 National Trauma Data Bank Annual Report, based on 627,644 2008 admissions from
567 facilities. http://www.facs.org/trauma/ntdb/ntdbannualreport2009.pdf. Accessed 6/11/2010.
19
Economic Barriers to Screening
• A decades-old law, the Uniform Accident and Sickness
Policy Provision Law (UPPL) allows insurers to sell
health and accident insurance policies that will not pay
for injuries that occur while the insured person is under
the influence of alcohol or drugs.
• In a 2005 study, 24% of trauma surgeons reported an
alcohol- or drug-related insurance denial in the past six
months.
• Over 50% don’t routinely measure blood alcohol
concentration (BAC) even though 91% believe such
testing is important.
Sources: University of Texas School of Public Health. Screening, Brief Intervention and Referral to Treatment.
http://www.sph.uth.tmc.edu/uploadedFiles/Centers/IHP/SBIRT_Booklet%20Jan%202010.pdf Accessed 6/9/2010. Genitlello,
Donato, Nolan, Mackin, Liebich, Hoyt and LaBrie. Effect of the Uniform Accident and Sickness Policy Provision Law on
Alcohol Screening and Intervention in Trauma Centers. J Trauma. 2005;59:642-631). Accessed 6/92010.
20
Uniform Policy Provision Law Is Alive
and Well in Over Half the States
Distribution of Insurers' Liability for Health/Sickness Losses Due to Intoxication
("UPPL"), January 1, 1998 through January 1, 2009
Source: Alcohol Policy Information System. Accessed 6/4/2010.
http://www.alcoholpolicy.niaaa.nih.gov/Insurers_Liability_for_Losses_Due_to_Intoxication_UPPL.html
21
Texas Is Among 28 States
Allowing Denial of Benefits
Insurers' Liability for Health/Sickness Losses Due to Intoxication ("UPPL")
as of January 1, 2009
Source: Alcohol Policy Information System. Accessed 6/4/2010.
http://www.alcoholpolicy.niaaa.nih.gov/Insurers_Liability_for_Losses_Due_to_Intoxication_UPPL.html?tab=maps
22
UPPL Laws and Parity Laws
• UPPL laws address whether an insurer can deny
benefits to persons who are found to be intoxicated
• Parity laws require that health plans—usually group
plans offered by employers—provide the same levels
of benefits for these disorders as they do for medical
and surgical conditions.
• Therefore, states can have a UPPL law that allows
denial of benefits while also having a parity law that
requires that benefits, if offered, must be the same
Source: Alcohol Policy Information System. Accessed 6/4/2010.
http://www.alcoholpolicy.niaaa.nih.gov/Health_Insurance_Parity_for_Alcohol-Related_Treatment.html?tab=Maps
23
Health Insurance Parity for AlcoholRelated Treatment Is Almost Stagnant
Distribution of States with Health Insurance Mandates for Alcohol-Related
Treatment, January 1, 2003 through January 1, 2009
•Must Offer: Health
plans must offer an option
of coverage for treatment
of alcohol-related
disorders, but are not
required to cover unless
offer is accepted.
•Must Cover: Health
plans must cover alcoholrelated disorders.
Source: Alcohol Policy Information System. Accessed 6/4/2010.
http://www.alcoholpolicy.niaaa.nih.gov/Health_Insurance_Parity_for_Alcohol-Related_Treatment.html?tab=Maps
24
Texas Requires that
Coverage Be Offered
Health Insurance Mandates for Alcohol-Related Treatment as of January 1, 2009
•Must Offer:
Health plans must
offer an option of
coverage for
treatment of
alcohol-related
disorders, but are
not required to
cover unless offer is
accepted.
•Must Cover:
Health plans must
cover alcoholrelated disorders.
Source: Alcohol Policy Information System. Accessed 6/4/2010.
http://www.alcoholpolicy.niaaa.nih.gov/Health_Insurance_Parity_for_Alcohol-Related_Treatment.html?tab=Maps
25
Removal of Barriers to Screening
Won’t Solve Our Problems
• While increased screening and intervention will
reduce trauma recidivism and alcohol and drug use
among some patients, those whose addictions require
more long-term interventions may experience
problems finding treatment, especially low-income
individuals seeking in inpatient facilities
26
Many Need Treatment
but Do Not Get It;
Most Did Not Seek Treatment
• In 2008, 20.8 million people
over age 12 (8.4% of that
population) were classified
by DSM-IV criteria as
needing treatment for an
alcohol or drug problem but
did not receive it
Treatment among Persons Aged 12 or
Older Who Needed and Made an Effort to
Get Treatment But Did Not Receive
Treatment and Felt They Needed
Treatment: 2005-2008 Combined
• 95.2% of these felt they did
not need treatment
• 3.7% felt they needed
treatment but made no
effort to seek it
• 1.1 % sought treatment
Source: SAMHSA Results from the 2008 National Survey on Drug Use and Health: National Findings.
http://oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf Accessed 6/9/2010.
Alcohol and Substance Abuse Are
Prevalent in Criminal Justice
Populations
27
• At some time in 2008:
• 18.3%, or about 293,000, adults on parole or supervised release from
prison were current illicit drug users
• 23.9%, or about 1,243,000, adults on probation were current illicit
drug users
• Only 7.8% of the general population used illicit drugs
• In a 2004 study:
• 36% of state and 24% of federal prisoners reported committing their
offenses under the influence of drugs
• 56% of state and 50% of federal prisoners reported using illicit drugs
in the month before committing their offenses
Source: SAMHSA Results from the 2008 National Survey on Drug Use and Health: National Findings.
http://oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf Accessed 6/9/2010.and Department of Justice. Drug Use
and Dependence, State and Federal Prisoners, 2004. http://bjs.ojp.usdoj.gov/content/pub/pdf/dudsfp04.pdf
Accessed 6/9/2010.
28
Parkland Is Responsible for Dallas
County Jail Health
• Dallas County Jail
• 7th largest jail in U.S., booking about 275 people/day
• Average daily census is around 6,000
• 74% of inmates are male
• No reliable data on alcohol and drug use at arrest
• 2nd largest mental health facility in Texas, Harris County
Jail being the largest
• Acute and chronic medical/psychiatric conditions screened within 1 hr
• 50% at intake have acute or chronic medical/mental health conditions
• 2600+ patients receive medications daily for both medical and mental
health conditions
• Average monthly admission to psychiatric services is 998
• Average daily mental health census is 20% or 1200+ patients
Source: Parkland Health & Hospital System internal data.
29
Alcohol & Substance Abuse Data Is
Better for Prisons, but Outcomes Are Not
“if all inmates who needed treatment and aftercare received such services, the nation
would break even in a year if just over 10% remained substance and crime free and
employed. Thereafter, for each inmate who remained sober, employed and crime free the
nation would reap an economic benefit of $90,953 per year”
Source: Center for Substance Abuse Research (CESAR). Few U.S. Inmates with Substance Use Disorders
Receive Treatment While Incarcerated. CESARFax Vol.19, Issue 22, April 5, 2010. Accessed 6/11/2010.
30
Alcohol and Substance Abuse Problems
Often Occur with Mental Health
Problems
• Best data available is from Epidemiologic Catchment Area (ECA)
Survey (administered 1980-1984) and the National Comorbidity
Survey (NCS), administered between 1990 and 1992.
• 42.7 percent of individuals with a 12-month addictive disorder had at
least one 12-month mental disorder.
• 14.7 percent of individuals with a 12-month mental disorder had at
least one 12-month addictive disorder.
• 47 percent of individuals with schizophrenia also had a substance
abuse disorder (more than four times as likely as the general
population).
• 61 percent of individuals with bipolar disorder also had a substance
abuse disorder (more than five times as likely as the general
population).
Source: National Alliance on Mental Illness. Dual Diagnosis and Integrated Treatment of Mental Illness and Substance
Abuse Disorder http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm
&TPLID=54&ContentID=23049 Accessed 6/9/2010.
31
Diagnosed Psychiatric Disorder Is a
Predictor for Substance Abuse
• Again the best data is
not new, coming from
a 2004 National
Institute of Mental
Health study
• What the chart means:
Someone suffering
from schizophrenia is
at a 10.1 percent
higher-than-average
risk of abusing drugs
and/or alcohol.
Increased Risk for Substance Abuse
Based on Diagnosed Psychiatric Disorder
Psychiatric Disorder
Antisocial Personality Disorder
Increased Risk for
Substance Abuse
15.5%
Manic Episode
14.5
Schizophrenia
10.1
Panic Disorder
4.3
Major Depressive Episode
4.1
Obsessive-Compulsive Disorder
3.4
Phobias
2.4
Source: Cigna. Dual Diagnosis. http://www.cignabehavioral.com/
web/basicsite/bulletinBoard/dualDiagnosis.jsp Accessed 6/9/2010.
32
Dallas County Hospitals with
Psychiatric Capacity
Total Beds
Psych
Beds
Alcohol/
Drug Beds
Dual
Diagnosis
Beds
Methodist Richardson
205
18
12
0
0
0
Green Oaks*
106
78
0
20
8*
0
Hickory Trail (formerly
The Cedars)
86
28
14
0
30*
14
Timberlawn
144
56
16
0
55*
17
Parkland
968
18
0
0
0
0
Children’s MC
487
0
0
0
12*
0
THR Presbyterian Dallas
898
24
17
0
0
0
Hospital
Dedicated
Adolescent Psych
Beds
Trauma
*Pediatric and adolescent capacity
Source: Texas DSHS Annual Survey, State Licensing DB as of 6/1/2010 and telephone
interviews with facility representatives on services (6/8-9/2010) (Greg Eastin, Population Medicine)
33
Dallas County Residential
Drug/Alcohol Treatment Programs
Facility
Residential
Beds
Trinity Center
(Homeward Bound)
120
Nexus Recovery Center
92
Dual
Diagnosis
Beds
50%
Comments
0
Includes detox
18
Females only
0
Not licensed for
adolescents
National chain
Salvation Army
260
Phoenix House
32
32
Routh Street Residential Center
(Turtle Creek Manor)
32
0
Holmes Street Foundation
12
12
Males only
Gateway Foundation
75
0
Males only
Dallas County Jail (Wilmer)
370
0
70
70
Dallas Co. Juvenile Probation
10%
Adolescent
Beds
Data from telephone conversations with facility representatives 6/2010.
Males only
34
Psychiatric Bed-to-Population Ratios,
US and Other Nations
Nation
Beds per 10,000 Population
Australia*
3.9
Canada*
19.3
Denmark*
7.1
*World Health Organization,
2005.Accessed 6/8/2010.
http://www.who.int/mental_healt
h/evidence/mhatlas05/en/index.
France*
12.0
html
Germany*
7.5
Ireland*
9.4
Japan*
28.4
Netherlands*
18.7
United Kingdom*
5.8
USA*
5.4
Texas**
2.1
Dallas County
Adult***
1.8
Dallas County
Child/Adolescent***
1.7
** Texas Sate Data Center
Population Projections 1002007 scenario. Accessed
06/08/2010.
http://www.dshs.state.tx.us/c
hs/popdat/ST2010.shtm
***Texas DSHS Lic. Data,
Hospital Association Annual
Survey, 2008, and local
interviews with the facilities
6/2010.
Target Psychiatric Bed-toPopulation Ratios for Certificate of
Need Requirements, US States
35
State and Population
Beds per 10,000 Population
Alabama all psychiatric
3.7
Arkansas Adult
3.0
Arkansas Child ages 6-17
3.85
Mississippi Adult
2.1
Mississippi Child/Adolescent
5.5
Michigan Adult
2.9
Michigan Child/Adolescent
1.8
Oklahoma all psychiatric
11.7
Oregon all psychiatric
4.0
Dallas County Adult
1.8
Dallas County Child/Adolescent
1.7
36
The future is not something we enter.
The future is something we create.
Leonard I. Sweet
Theologian, Author, Futurist
How Do We Attack these Problems?
37
Systematic Approach Needed
• Primary: prevent accident
• Median barriers, get safety feature from new cars
• Secondary: accident occurs but injury lessened
• Air bags, roll bars, ignition-interlock devices
• Tertiary: Injury occurs but system in place to prevent mortality
or long-term disability
• High standards of trauma care, regional trauma centers
• Quaternary:
• Many injuries caused by alcohol/substance abuse; in this case
treatment can be prevention
38
Behavioral Health Study for
Dallas County
Opening
(April)
Refine scope and schedule
First meeting with Steering
Committee
Face-to-face meetings with Task
Force members
Finalized work plan specifying
exact dates, interviews, focus
groups, analyses, meetings,
deliverables
Mid-Game
3 Months
Closing
2 Months
Information gathering, interviews,
on-site program observation,
initial focus groups
Deliver Draft Long Term Strategy
Outline to the Task Force, obtain
feedback
Identify existing data sources,
data collection
Complete all field work
Present emerging results to the
Task Force – and accompanying
Short Term Recommendations
Initiate final round of data
collection
Deliver Community Based
Assessment to the Task Force
as basis for long term strategy
Deliver final:
 Vision
 Short Term Recommendations
 Community Based
Assessment
 Long Term Strategy Outline
Forums and communication of
findings and results to stakeholders
39
Manage Alcoholism and Addiction
Like Other Chronic Diseases
• Alcoholism can be silent for
many years even though huge
damage can be done to family,
livelihood, etc.
• Eventually organ damage
occurs and internal medicine
admissions com in a staccato
•
•
•
•
•
•
Model for Management of Chronic Illness
American College of Physicians
Pancreatitis
Alcoholic hepatitis
Neuropathy
Cardio neuropathy
Alcoholic dementia
Withdrawal syndrome
Source: American College of Physicians.
Accessed 3/20/2008.
http://www.acponline.org/clinical_information/j
ournals_publications/ecp/augsep98/cdmfg1.htm
40
Barbeque
• “Barbeque” was a 30-something Black man
who lived in a lean-to shelter behind a
barbecue stand in downtown Dallas in the
80s. He was an alcoholic who also developed
a dependence on IV cocaine.
• He was admitted several dozen times for
substance-abuse-related complications until
he was severely burned in a fire that
consumed his makeshift shelter.
• An ER physician commented that he had the
impression that “it would have been cheaper
to put him in a villa on the French Riviera
and give him $50,000 a year” compared to
what was spent on hospitalization over the
last 5 years of his life.
41
What the Dog Saw
• Murray Barr is a hopeless alcoholic
who lives on the streets of Reno,
Nevada, and spends more weekends
than not in hospital or drying out in a
police cell. Barr's routine involves
getting drunk, falling over and being
taken to hospital. When he is
released, he starts all over again.
• Over 10 years Barr's hospital bills
mount up. "It cost us $1m not to do
something about Murray," says one
of the police officers who routinely
arrests Barr.
42
Prevention Is Most Effective Way
to Reduce Addiction
“Currently, treatment
interventions tend to isolate
single problems, but there is
growing evidence that welldesigned prevention
interventions reduce a range of
problems and disorders and
that these efforts are sustained
over the long term,"
• Institute of Medicine report,
Prevention of Mental,
Emotional and Behavioral
Disorders Among Young
People, concluded that
• Prevention of addiction
and mental illness has
been proven to be
scientifically feasible
• Only public-health
approaches are
demonstrably effective.
Source: Join Together. Future of Prevention Funding Lies in Broad, Public-Health Approach.
http://www.jointogether.org/news/features/2010/future-of-prevention-funding.html Accessed 6/9/2010.
43
We Must Re-direct
Funding To Prevention
• For every dollar the federal and state government spent on prevention and
treatment, they spent $59.83 shoveling up the consequences:
• 95.6 % or $357.4 billion of federal and state‡ substance related spending
went to carry the burden to government programs of our failure to prevent
and treat the problem
• Only 1.9 % was spent on preventing or treating addiction
• 0.4 % was spent on research
• 2% was spent on alcohol and tobacco tax collection
• 71.1 percent of total federal and state spending on the burden of addiction is in
two areas
• 58% of federal and state spending on the burden of substance abuse and
addiction (74.1% of the federal burden) is in the area of health care where
untreated addiction causes or contributes to over 70 other diseases requiring
hospitalization.
• 13.1% of substance-related federal and state spending is the justice system
Source: The National Center on Substance Abuse and Addiction at Columbia University. Shoveling It Up II: The
Impact of Substance Abuse on Federal, State and Local Budgets.
http://www.jointogether.org/resources/shovelingup/shoveling-up-ii-final.pdf Accessed 6/9/2010.
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Texas Spending for Substance
Abuse and Addiction
• Texas ranks 41st in per capita spending on that burden: $272
compared to the US average of $420
• Range is $216 (South Carolina) to $1,316 (District of Columbia).
• Texas ranks 16th in the percent of the state budget (15.8%,
compared to an average of 14.8%) devoted to the burden of
Substance Abuse and Addiction on State programs (justice,
education, health, child/family assistance, mental health/
developmental disabilities, public safety and state workforce)
• Range is 4.3% (Wyoming) to 26.9% (Maine)
Source: The National Center on Substance Abuse and Addiction at Columbia University. Shoveling It Up II: The
Impact of Substance Abuse on Federal, State and Local Budgets.
http://www.jointogether.org/resources/shovelingup/shoveling-up-ii-final.pdf Accessed 6/9/2010.
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Not In My Backyard!
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Where Do We Go From Here?
• Prevent abuse and addiction from happening.
• Education, education, education
• Social pressure, positive peer pressure
• Legal ramifications, like strong DUI enforcement,
enforcement of sales-to-minors laws,
• Mitigate the consequences of addictive behavior.
• Early intervention and treatment
• Engineer safety to prevent accidents or minimize
injury
• Optimize the response when addictive behavior leads
to destructive outcomes.
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Prevention is
better than cure.
Desiderius Erasmus
1466-1536
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What a 1971 Fram® Ad said still holds…