3 Issues Likely to Affect Addiction Treatment and Recovery

1. This is basically the charge of the current talk 1 – I have tried to put myself and the research literature I have reviewed into the position of a legislator faced with the difficult public health and public safety problems associated with addiction – BUT with competing demands for resources and reservations about what can really be expected from addiction treatment Will the public really get its money’s worth? What should we expect? How can we tell whether we are getting the best impact for the most reasonable (not necessarily the cheapest) expense? These are the issues addressed here.This is basically the charge of the current talk 1 – I have tried to put myself and the research literature I have reviewed into the position of a legislator faced with the difficult public health and public safety problems associated with addiction – BUT with competing demands for resources and reservations about what can really be expected from addiction treatment Will the public really get its money’s worth? What should we expect? How can we tell whether we are getting the best impact for the most reasonable (not necessarily the cheapest) expense? These are the issues addressed here.

4. Substance Use Pyramid

6. Top Patient Reasons  Abstinence Only Goal 64% 2) No Confidence in Trt 51% 3) Bad Trt Experience 36% 7) Lack of Services needed 22% WOW !

7. Why the “special” system?

8. 13,200 specialty programs in US 31% treat less than 200 patients per year 65% private, not for profit 80% primarily government funded Private insurance <12% Sources – NSSATS, 2002; D’Aunno, 2004

9. Crossing the Quality Chasm The Quality Chasm report well documented that quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized. It concluded that trying harder will not work: changing systems of care will! To help change the system, the chasm report articulated: six aims for quality health care, ten rules that redesigned healthcare should follow to achieve the Aims, and priority components of the health care system that should be the focus of redesign efforts. In the next few slides, I will briefly review the Quality Chasm Aims, Rules, and redesign principles, which served as the analytic framework for this present study on improving the quality of health care for mental and substance-use conditions.The Quality Chasm report well documented that quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized. It concluded that trying harder will not work: changing systems of care will! To help change the system, the chasm report articulated: six aims for quality health care, ten rules that redesigned healthcare should follow to achieve the Aims, and priority components of the health care system that should be the focus of redesign efforts. In the next few slides, I will briefly review the Quality Chasm Aims, Rules, and redesign principles, which served as the analytic framework for this present study on improving the quality of health care for mental and substance-use conditions.

10. CONCLUSION “It is not possible to deliver safe or adequate healthcare without simultaneous consideration of general health, mental health and substance use issues.” Consideration of the high rates of co-occurrence of general, mental and SU problems and illnesses lead to the committee’s first conclusion and recommendation: (refer to slide) . . . . . . and underpin all of the committee’s more detailed recommendations. Consideration of the high rates of co-occurrence of general, mental and SU problems and illnesses lead to the committee’s first conclusion and recommendation: (refer to slide) . . . . . . and underpin all of the committee’s more detailed recommendations.

11. Segregated from mainstream health Separate culture, training, staff and information Isolated and insular systems Graying infrastructure No political constituency Patients or staff Funding much more diffuse and unpredictable More sources but not stable Specialty Care Negatives

12. Disorders with Higher Prevalence Among Substance Abusers

13. Program of Research to Integrate Substance Use Information into Mainstream Healthcare PRISM

14. Physicians want better information to manage chronic illnesses Commission systematic reviews of the role of substance use in those illnesses Goal: improve management of chronic illnesses, by managing substance use The PRISM Approach

16. Alcohol and Hypertension

17. Systematic Review Findings 11 randomized controlled trials Dose related effects < 2 drinks/day or 10/week – usually decrease > 3 drinks/day or 14/week – significant increase Magnitude of effect about the same as salt intake Effect of alcohol greatest in subjects with pre-existing hypertension

18. Results so Far Practice Research in 4 primary care societies - 230,000 physicians American College of Physicians American Geriatrics Society Society of General Internal Medicine American Academy of Family Physicians New alcohol management strategies to manage chronic illness 3 Insurers “Carving In” B/H

20. Regular Advertisement in WSJ & NYT Employers! “An employee managing his diabetes costs you $14,000/year. An unmanaged diabetic costs you $44,000/year…” Consideration of the high rates of co-occurrence of general, mental and SU problems and illnesses lead to the committee’s first conclusion and recommendation: (refer to slide) . . . . . . and underpin all of the committee’s more detailed recommendations. Consideration of the high rates of co-occurrence of general, mental and SU problems and illnesses lead to the committee’s first conclusion and recommendation: (refer to slide) . . . . . . and underpin all of the committee’s more detailed recommendations.

21. Chronic illnesses are THE medical problems in the US 70% of all cases/costs Self Management (Read Behavior Probs) is second biggest factor in outcomes/cost Second only to genetics Payers know that Purchasers can affect behaviors But what are the implications? Points

22. Predictions  By 2015… 70%+ of “Substance Abuse” will be treated by Primary Care Physicians 10 - 20 New Medications “Addiction” programs will receive 30% referrals from PCPs Psych/SA convergence/consolidation - 50% increase in “Behavioral Health” care Model = Residential – Home visit – telehealth Goal – Reduce expensive healthcare

24. Predictions  By 2015… Employers will be applying pressures on employees to get and stay healthy Incentives for pro-health – Penalties for poor “lifestyle” or “behavioral choices”

25. Implications for Recovery Community  Make Recovery = Good Behavioral Choices; Self Management; Health Don’t be defined by what you don’t do! Get the message to employers – they drive insurance & policy – thus healthcare and research. There are dangers here Visibility = vulnerability Popularity = potential mission creep, others may speak for you

26.

28. Physician Health Plans

29. Formal Treatment

30. Monitoring & Support

31. Results During Contract

32. Results Through Five Years

33. Results Through Five Years

34. Results Through Five Years

35. Results After Five Years

36. Results After Five Years

37. Results After Five Years

38.