Drug Use and Health
The American Society of Addiction Medicine (ASAM) just held their Annual Medical-Scientific Meeting in Washington, DC.
At the opening session, Pamela Hyde, J.D., Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) made some introductory remarks that gave me a handle on the big picture of healthcare and where things are going.
I will share her 3 Ps which gives a structure to understand where addiction and mental health treatment is headed. I’ll highlight some issues in each section.
TIP
Focus on People, Partnerships and Performance Measures
P – People
In the big picture of the changing behavioral healthcare system in the USA, there are a few sets of statistics to ponder.
They show there is a huge unmet need for addiction treatment our current treatment system can never accommodate as it is currently designed, funded and delivered.
2006-2009 National Surveys on Drug Use and Health
Each year, SAMHSA conducts a household survey to check on the drug use and health of the USA population. Based on data from SAMHSA’s 2006-2009 National Surveys on Drug Use and Health, the following statistics were found:
· 98.8 percent of the more than 7.4 million American adults aged 21 to 64 with untreated alcohol use disorders don’t believe they need treatment. Or said another way, only 1.2% realizes they do need help.
· Only 506,000 of the nearly 6 million American adults with untreated alcohol dependence recognize they need treatment.
· These findings show “the need to increase public awareness about adult problem drinking, how to identify people with an alcohol problem, how to raise the issue with a problem drinker and how to get help” according to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).
http://news.yahoo.com/s/hsn/20110407/hl_hsn/only12ofalcoholabusersknowtheyneedhelpreport
2009 household survey
Like previous surveys, the 2009 survey shows the same huge number of people who don’t think they have a problem. This diagram shows the results for people aged 12 years and older and covers the nearly 21 million people:
People don’t see they have a problem because of:
· “Denial” and readiness to change issues
· Societal stigma and discrimination
· Funding and insurance coverage often limits addiction treatment;
· Access to care issues (How many public programs do you know that have treatment on demand, with no waiting lists?)
What will happen if, and when, we actually receive more universal healthcare coverage, and mental health and addiction parity with other illnesses?
· For addiction treatment alone, there is an estimated 4 to 6 million new clients who would be seeking treatment if we reached out as assertively as we do now with hypertension and diabetes.
If you feel your caseload is already way too big, imagine what it would be like if we really treated all who need help? Be aware of the world of healthcare planners.
They have their eye on an even bigger picture. What they are discussing is “population health” – a viewpoint/approach to health which aims to improve the health of an entire population, not just a “target” group- i.e those people who come into your program and show up for treatment.
Oh, and did I mention the urgent attention to Federal and State budget deficits. These demand that the current curve of healthcare costs has to bend ‘south’ and flatten out, not keep relentlessly curving northeast and skyward!
P – Partnerships
We struggle already to meet the needs of all who want help, let alone those whose consciousness is yet to be raised and then attracted into health. And I didn’t even talk about statistics for youth substance use, or touch on similar statistics for mental and general health populations.
There is no way that addiction and mental health programs and agencies can meet all these needs in cost effective ways without forming partnerships. Here are some of the partnerships that you might have heard about:
· Partnering with primary care physicians to do Screening, Brief Intervention, Referral and Treatment (SBIRT) to tap into those millions of people with problem drinking, those who would never directly call your addiction treatment center.
· Working with psychiatrists, primary care physicians and addiction medicine specialists who are providing buprenorphine medication assisted treatment for people with opiate dependence.
· Linking mental health and addiction services to provide better integrated services for people with co-occurring conditions.
· Integrating behavioral health services, case management and other services into primary care to create “medical homes” or “health homes” responsible for ALL the care of a certain population of people.
· Developing Accountable Care Organizations (ACOs). In this model, physicians, hospitals and other health care providers partner together in a system that holds the organization accountable for outcomes and effectiveness. It doesn’t just pay them a fee for their healthcare service.
Why are these partnership issues even important to think about- when you are just busy doing your daily work?
We are all expanding our awareness of the magnitude of the national debt and deficit spending which will only worsen without fundamental structural change.
These big picture issues may seem too large to wrap our heads around. Nevertheless we must start looking at how to fundamentally change the structure of the design and delivery of services to date. Partnerships are one of the structural solutions we must pay attention to.
P – Performance Measures
These days we are interested in ‘performance’ in many areas of our lives. Think of yourself as an individual consumer. More than in the past, you probably zero in on how many calories are in the food and drinks you buy.
When considering purchasing a new vehicle, you find yourself interested in the “numbers”- what is the EPA gas mileage for the car you are considering?
You now consider the “value” of the name-brand medication, soap, cereal or soda product versus the generic or look-alike one. Likewise in our work, that same consciousness has arrived. Increasingly we will be held accountable as to whether what we do is making a measureable difference.
· As yet, our clients and patients might not be as discriminating and demanding of value and performance measures in healthcare (as with their cars or smartphones). However funders and payers are certainly stepping up that pressure. There are no more ‘blank checks’. We must be able to justify that our service is making a positive difference.
· What is the value of what we deliver in treatment? Value is the combination of quality and cost. If your service is high quality but costs an arm and a leg, the value proposition is not there. Naturally, if money is no object, you don’t worry about “value”, you just want what you want. But no one can take that attitude about healthcare except the very rich.
· If your service is low cost, but poor quality, again the value proposition is not there. Unfortunately, the poor and disenfranchised have no choice. But we owe them better than that.
· The focus for all of us needs to be on maximizing value – How do we provide the highest quality in the most cost-effective manner?
Resources are limited. As the demand for “bending the cost curve” becomes more imperative, all of us must start focusing on performance measures now. You have heard the saying:
You can’t manage what you don’t measure. Hard to stick to the speed limit if you don’t have a functioning speedometer. You’ll surely bounce that check if you don’t balance your checkbook. And we’ll serve fewer people if we don’t improve the value of what we do in treatment.
SKILLS
What happens at the individual clinician and counselor level? All this “big picture” view can feel irrelevant, overwhelming and far from the daily pressures of case loads, running groups, seeing clients and doing documentation.
While it is true that much of this is out of our direct control, there are clinical implications that make sense for today. So here are the 3 Ps again, from a clinical perspective.
TIP 1
Identify Where to Start on PEOPLE
Even though you are not focused on population health, on the micro clinical level there is much you can do in prevention, early intervention and treatment:
Encourage Screening, Brief Intervention, Referral and Treatment (SBIRT) for alcohol and other drug problems in your practice, in primary care health providers and emergency health personnel and settings.
For some excellent online training resources from the National Institute on Alcohol Abuse and Alcoholism, see the video cases on “Helping Patients Who Drink Too Much.”
In that learning opportunity, there are 4 interactive, 10-minute video cases using evidence-based clinical strategies for patients with different levels of severity and readiness to change. There are even continuing education credits for physicians.
http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/CME_CE.aspx
If you are in an addiction treatment setting, ensure screening for all mental health conditions.
If you are in mental health, ensure screening for all substance-related conditions. Co-occurring conditions should be ruled out or in for all clients.
When you are working with the identified addiction or mental health client, remember there are significant early intervention and prevention opportunities by working with clients’ families sooner rather than later.
(There are an estimated 28 million children of people with alcohol use disorders. Usually at least 1 or 2 significant others are affected by their loved one’s addiction and/or mental disorder.)
All clients’ addiction and mental health can be greatly enhanced, or negatively impacted by poor physical health and lifestyle choices, like smoking, exercise, nutrition, sleep patterns and work-life balance. In behavioral health, we often neglect assessment and services for these areas of the “whole person”.
I’m sure some of you may be saying- What about adding to the list areas you are passionate about? Trauma informed work, cultural competence; gender-specific or sexual orientation sensitivities; recovery oriented systems of care; drug and mental health courts? The list goes on.
Tip 2
Identify Where to Start on PARTNERSHIPS
Within the behavioral health field, we have been slowly breaking down the walls between mental health, addiction and criminal justice.
Many clients present already involved in multiple systems ( Criminal Justice, Child Protective Services, workplace…) Their needs cut across disciplines and varying missions of many organizations/systems. To treat the whole person requires partnership.
Here are some ways to initiate or strengthen partnerships at the clinical level:
· Ask around and see if your local health clinic, family physician or group practice has an office that could be freed up a couple of hours every other day. You or another clinician could make yourselves available to see referral clients identified during SBIRT screening in the clinic.
· Buddy up mental health and addiction agencies in your county to offer a variety of services:
àcross training on mental health, addiction and co-occurring conditions àinteragency consultation and case conferencing on clients who may be at both agencies
àestablish a co-occurring disorders group; choose one clinician from addictions and one from mental helath; agree to co-lead the group ; billing would work by which agency/ system the client first showed up at.
· Meet with the drug and/or mental health court team. Cover the following areas:
à clarify lines of communication
àclarify respective roles and boundaries – e.g the court mandates treatment and monitors treatment adherence, while clinicians assesses, treats and reports on clinical progress.
· Work with Child Protective Services also. Cover the same topics referenced above re: the Drug and Mental Health teams.
· Develop community partnerships for universal, selected and indicated prevention and early intervention.