July 2012

When the Supreme Court affirmed the Affordable Care Act (ACA) on June 28, the plan to expand insurance coverage for millions of Americans who need addiction treatment got back on track.  A minority of those newly-covered people will seek formal addiction treatment.  Most will not; they will be found in general healthcare settings, not even interested in treatment.  That’s where our customers really are.

This expansion of insurance coverage was good news for everyone committed to expanding addiction treatment.  Also, in June, the National Center on Addiction and Substance Abuse at Columbia University (CASA) released a wide-ranging, 586-page report on “Addiction Medicine: Closing the Gap between Science and Practice”.  This five year national study provides an impressively comprehensive look at the definition, prevalence and consequences of addiction; and where addiction screening, intervention and treatment currently is, and where it needs to go.

The news was not good.

Here are some of the Findings and Recommendations of the CASA Report that I grouped together in related categories.  Consider the implications for addiction treatment and addiction medicine in the changing environment of healthcare reform.

TIP 1

Rate how addiction services in your region compare and contrast with these Findings.

1. “Inadequate Integration of Addiction Care into Mainstream Medical Practice”

“Addiction prevention and treatment are for the most part removed from routine medical practice.”  Ponder the lost opportunity to identify and intervene earlier in addiction.

• 80% of Americans visited at least one physician or other health care professional in the past year
•  More than 2/3 of people with addiction are estimated to be in contact with a primary or emergency care physician about twice a year
• Yet most physicians and other health professionals do not identify or diagnose addiction; focus only on the secondary and tertiary complications of addiction; and do not know what to do with patients who present with identifiable and treatable signs and symptoms

Implication:

→ This allows a public health epidemic to advance unchecked.

2.  “Inadequate Education and Training of Addiction Treatment Providers” and “The Education, Training and Accountability Gap”

“The report exposes the fact that most medical professionals who should be providing treatment are not sufficiently trained to diagnose or treat addiction, and most of those providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of evidence-based services, including pharmaceutical and psychosocial therapies and other medical care.”

(http://www.casacolumbia.org/templates/NewsRoom.aspx?articleid=678&zoneid=51)

Implications:

→ Need for improved addiction identification, intervention and treatment with Screening, Brief Intervention, Referral and Treatment (SBIRT) – See the April 2008 edition of Tips and Topics (https://changecompanies.net/tipsntopics/2008/04/april-2008)

→ Get better training in the range of biopsychosocial theories and modalities of treatment – Google

“Evidence-Based Practices in Addiction Treatment”.  I got 2,600,000 results in 0.35 seconds!

→ Increase interdisciplinary functioning and teamwork – Together Everyone Achieves More

3.  “Inadequate Accountability for Addiction Treatment Providers” and “Less than Half of Treatment Admissions Result in Treatment Completion”

“While a wide range of evidence-based screening, intervention, treatment and disease management tools and practices exist, they rarely are employed.” (CASA Report)

 

Implications:

→ Addiction treatment is still not well individualized and based on a comprehensive multidimensional assessment (ASAM Criteria).

→ Much addiction treatment is still provided in a program-driven setting where people are discharged for a relapse or slip (discharged for a flare up of their disease).

→ Most providers have no formal feedback system to track outcomes and the quality of the therapeutic alliance in real-time.

→ Dropout rates are addiction treatment’s dirty little secret which usually gets explained away by blaming clients and patients for being non-compliant.

4.  “A Lack of Standardized Terminology Compromises Effective Interventions” and “Establish national accreditation standards for all addiction treatment facilities and programs that reflect evidence-based care”

“Addiction treatment facilities and programs are not adequately regulated or held accountable for providing treatment consistent with medical standards and proven treatment practices.” (CASA Report)

Since 1991, the ASAM (American Society of Addiction Medicine) Criteria has offered a common language and organizing principles that promote evidence-based care.

 

Implications:

→ Understand and use the multidimensional assessment of the ASAM Criteria as a common

“review of systems” in behavioral health and general healthcare (https://www.changecompanies.net/asamcriteria/asam_products_elearning.php)

→ Design and deliver services across a broad, flexible continuum of levels of care as in the ASAM Criteria (https://www.changecompanies.net/asamcriteria/asam_products_elearning.php)

→ Most providers have no formal feedback system to track outcomes and the quality of the therapeutic alliance in real-time

5.  “Physicians and Other Health Professional Should Be on the Front Line Addressing this Disease” and “Most People in Need of Treatment Do Not Receive It”

“About 7 in 10 people with diseases like hypertension, major depression and diabetes receive treatment; only about 1 in 10 people who need treatment for addiction involving alcohol or other drugs receive it – the number receiving treatment for nicotine is not even known.”

• Forty million Americans ages 12 and older (16 percent) have the disease of addiction involving nicotine, alcohol or other drugs.
• Addiction affects more Americans than heart conditions, diabetes or cancer.
• Another 80 million people are risky substance users – using tobacco, alcohol and other drugs in ways that threaten health and safety.
• In 2010 only $28 billion was spent to treat the 40 million people with addiction. In comparison, the United States spent:
• $44 billion to treat diabetes which affects 26 million people;
• $87 billion to treat cancer which affects 19 million people;
• $107 billion to treat heart conditions which affects 27 million people.

Implications:

→ The people who need treatment don’t come to traditional addiction treatment providers. They are in general healthcare settings.

→ Not only do the addiction and mental health fields need to integrate better, but also behavioral health needs to integrate better with general healthcare.

→ Addiction treatment providers should establish an office or presence in the general health centers and emergency departments  – maybe even in shopping malls!

→ With the ACA and healthcare reform and new financing models of Accountable Care Organization (ACOs), Medical and Health Homes population-based care and financing will increase dramatically.

→ If the ACA really works, there will be millions more clients eligible for definitive addiction treatment who now are not covered by insurance or public funding.

6. “The Importance of Tailored Interventions and Treatment” and “The Profound Disconnect between Evidence and Practice”

“There is a profound gap between what we know about the disease and how to prevent and treat it versus current health and medical practice.” (CASA Report)

 

Implications:

→ Improve skills in individualized assessment, service planning, treatment and documentation.

→  “Respect but not “revere” Evidence-Based Practices, EBPs  (Miller, Zweben, & Johnson, 2005).

→  Use EBPs and ASAM multidimensional assessment to identify treatment needs and strengths, skills and resources in the service of a strong therapeutic alliance with clients.

→  Increase curiosity about the quality of the therapeutic alliance; and establish real time feedback and outcome-informed services – “Practice-based Evidence” not EBPs (Mee-Lee, McLellan, Miller, 2010).

 

7. “Most Referrals to Publicly Funded Treatment Come from the Criminal Justice System”

• Only 5.7% of referrals to publicly funded treatment come from a health care provider.
• In contrast, a full 44.3% are referrals are from the criminal justice system.
• Thus addiction is addressed only at the point when it causes profound social consequences.

Implications:

→ These discrepancies in referral patterns underline the need to expand outreach and integration with general healthcare settings.

→  Increase and improve dialogue between treatment providers and Justice services to move beyond compliance and “doing time” to “doing treatment” that translates into the outcomes everyone wants: decreased legal recidivism; increased public safety; safety for children and families; and accountable self change that lasts way beyond the time when the mandating agency now orders compliance.

References:

1. June 2012: The National Center on Addiction and Substance Abuse at Columbia University (CASA) report on “Addiction Medicine: Closing the Gap between Science and Practice”.

http://www.casacolumbia.org/templates/NewsRoom.aspx?articleid=678&zoneid=51

2.  Miller, W.R., Zweben, J., & Johnson, W.R. (2005). Evidence-based Treatment: Why, what, where, when, and how? Journal of Substance Abuse Treatment, 29:267-276.

3.  Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change”  Eds Barry L. Duncan, Scott D. Miller, Bruce E. Wampold, Mark A. Hubble.  Second Edition.  American Psychological Association, Washington, DC. pp 393-417

Last month (in Stump the Shrink) a reader raised the question:   -> When do we increase the level of care for a person who is NOT progressing well?  (https://changecompanies.net/tipsntopics/2012/06/june-2012-tips-topics/#more-3422) This month’s question is about the person who IS progressing well. -> When do we transfer them to ongoing maintenance services? Here’s the question: “In the stages of change, I recall you saying-or at least I understood it as-that the Action stage of change is the first six months of a patient’s recovery, and that Maintenance begins around six plus months? Is that correct? I was wondering because we have been completing people in our program at a “start point” of 4 months. We are not time-based, but we begin to really look at moving them from ASAM Level II.1, Intensive Outpatient to Level I maintenance groups around 3-4 months. Can you give me some information about this?” Kaylum James Paletta Licensed Substance Abuse Counselor / Prevention Specialist Four Corners Community Behavioral Health Inc. Price, Utah 84501 E-mail: kpaletta@fourcorners.ws Kaylum’s question raises a few points worth addressing. TIP 1 When clients are doing well and making progress, transfer them to “maintenance” services based on function and outcomes, not based on time in treatment. When is a client considered to be in the Maintenance stage? According to Prochaska and DiClemente’s Transtheoretical Model of Change, this occurs once a person has achieved at least 6 months of stable change and recovery in their Action stage. This raises another question: When do you move a person from any level of clinical care to a less intensive level? Firstly, we should NOT base our decision on the following: The time a client has spent in treatment at their present level of care. For example- I know Kaylum has embraced the ASAM Criteria to make decisions on placement in levels of care.  He knows the ASAM Criteria has no fixed lengths of stay for each level of care.  He affirms: “we are not time-based”.  YET… it is hard for the treatment field to transition to individualized treatment, because even in his program “….we have been completing people in our program at a “start point” of 4 months.” On the client’s Stage of Change alone. It is helpful to identify a person’s stage of change- to gauge how treatment is proceeding (or not); to examine their readiness to embrace recovery (or not).  However… Here are the following “howevers”: However……Clients are commonly at different stages of change for different issues they have: solidly at Action for stopping alcohol and other drugs, but ambivalent (Contemplation) for giving up all their unhealthy or toxic relationships.  At Action for stopping alcohol, but not so sure/ambivalent about stopping marijuana.  At Action for dealing with depression and anxiety, but ambivalent about delving into their trauma and on and on. In Stages of Change theory, the “Maintenance” stage starts at 6 months of sustained change.  However, if at 4 months, you start thinking about transferring your client from Intensive Outpatient, in fact, that thinking is “time-based” rather than based on function and progress. However……Always be focused on your client’s progress, function and outcomes.  Again why?  Because an individual can continue their “Maintenance” work in Level I, Outpatient services if they are not needing increased structure which is present in Residential (III.5), Partial hospital (II.5), or Intensive Outpatient (II.1).  To reiterate what’s already been stated: clients are not monolithically at just one stage of change – it depends on the issue(s) being focused on. It is possible that a client can work on multiple issues no matter what level of care they are in- even issues they are ambivalent about OR even those they are simply not ready to face fully. However…..Continue asking yourself the question: Where can my client receive his/her clinical services in the safest way, at the same time in the least intensive care level? Why the least intensive? Because this is best for clients, as well as the most efficient use of all available resources- personal, clinical, agency, financial etc… First, identify your client’s most serious problem (amongst the longer list of problems they usually come in with). Then move them to whatever care level will be the best one for treating their most serious issue safely – even if that jumps one or two levels of intensity.  There’s no moving automatically up the intensity ladder; or sequentially down the intensity ladder of levels of care.  Again, decisions are made on the client’s function and progress (or not). TIP 2 Begin to delete “completing” clients from your clinical vocabulary. If the focus is on function, progress and outcomes, our vocabulary shifts to “transferring” or “linking” people to the next level of care rather than “completing” people from a program or level of care. As with any other ongoing, potentially relapsing illness, in addiction we also place clients in whatever level of care matches their severity of illness and level of function.  When to transfer? Answer: it depends on their progress and outcome in the level of care to which they were admitted. It is not then a matter of “completing them in the program” at a certain point in their Stages of Change.  It involves transferring them to whatever level is the least intensive level, which can safely provide the services they need. Example 1 A person may have been active in AA , been ready to embrace recovery, but relapsed and needed Level II.1, Intensive Outpatient  (IOP) to help get back on track.  If she/he is stable and doing well even after a week in II.1, and was ready to get back to their home AA group, that client is ready to be transferred to Level I, Outpatient services.  There, they can safely receive more clinical monitoring to supplement their AA attendance. They wouldn’t need to be in IOP for two or three months. Example 2 A client receives treatment for the first time, but continues to be ambivalent about the seriousness of his condition.  However he is no longer so unstable that he would immediately return to substance use with serious consequences. In this case, the client could transfer to/be linked to a less intensive level of care.  That could be after a few days or weeks, not months. Bottom Line: Addiction care continues to need improvement.  To address those needed changes discussed in SAVVY this month, it will take a committed process of change in our attitudes, knowledge, skills and application of proven and promising best practices. Stump the Shrink highlighted some of those this month.  Thanks, Kaylum, for getting us all thinking. Reference: Prochaska, JO; Norcross, JC; DiClemente, CC (1994):  “Changing For Good”  Avon Books, New York

Like millions of others around the globe, I watched the impressive and colorful parade of nations in the opening ceremony of the London 2012 Olympic Games.  Maria Sharapova was the flag bearer for her native Russia.  Maria certainly attracts your attention – not just for her physical beauty, but more importantly for her mental toughness.  She is committed to her career and her support team. She works hard and has shown stick-to-it-iveness in the face of tough losses. She speaks of drawing strength from her parents and family.   If you are not into tennis, you may not know much about Maria.  She is now only 25. However……….. She won her first Major Tennis Tournament at Wimbledon at the age of 17. Just last month, she won the French Open Tennis title completing a career Grand Slam.* *(A Grand Slam is winning all four major tennis tournaments: Wimbledon, the Australian Open, the US Open and the French Open.)   So what’s the big deal about Sharapova?  With this latest win, she regained number 1 in the world of women’s tennis. Additionally, she is one of only ten women in tennis who have achieved a career grand slam. (Maria didn’t do as well at Wimbeldon this year, so now is just No.3 in the world.) What gets my attention though is that because of a chronic shoulder injury, she had dropped in ranking to No. 126 in the world. The setbacks! Four years ago, she had shoulder surgery; was forced to take off ten months from her career.  In the four years of getting back into her game, she faced multiple defeats and setbacks.  There were lots of reasons for her to self-doubt, to give-up, to stop believing that physical recovery was possible, let alone getting back to work at anywhere near the level of performance that she had before. –> How many of us and our clients get disabled and give up?  How often do we quickly get our clients on disability payments, which too easily locks them in a “damaged goods” mentality, which works against fighting back?  How easy is it to not even bother trying? As you might imagine, Maria Sharapova has many assets (internal and external), which our clients probably don’t have.   As people helping other people, this just 25 year old can teach us a lot. Maria solves problems with a mixture of planning (game plans developed with her coach) and intuition (in the tough moments she has confidence to trust her own instincts and abilities -Self Efficacy in psychological terms). She works hard. She doesn’t give up easily. She obtains support and coaching from others (sort of like an Alcoholics Anonymous group and a Sponsor; or trusted allies and a Supervisor). →As people helping people, our job is to hold up hope for recovery; to turn disability into ability; to help people help themselves; to believe in themselves even if we are the first person in their life to encourage that belief. My other favorite Maria? Maria von Trapp – as depicted in the film version of Sound of Music.  There’s a lot of shared qualities between the two Marias.  Maybe it would be a good idea to inspire ourselves and our clients by watching some tennis…… or The Sound of Music – one more time!

See you again in late August. Thanks for reading.

David