Separate is Never Equal

Separate is Never Equal Inequities in Addiction Treatment Joe Parks, MD Aaron Williams , MA

Today’s Presenters • Joe Parks, MD • Aaron Williams, MA

Background Joe Parks, MD Aaron Williams, MA Senior Director of Addiction Training and Technical Assistance, National Council of Behavioral Health 16 years of experience providing training and technical assistance to behavioral health providers • Medical Director, National Council for Behavioral Health • Distinguished Professor of Science, MIMH • Practicing Psychiatrist • Previously • Missouri Medicaid Director • MO Dept. of Mental Health Medical Director

The National Council for Behavioral Health • Over 3000 Members providing or supporting treatment for Mental Illnesses and Addiction • Services • Mental Health First Aid – over 1 million trained • Center for Integrated Health Solutions (HHS) • CDC National Networks • Improving Business & Clinical Practices • Advocacy and Policy • Medical Director Institute

Current Substance Use Trends National and Local Trends

Numbers of People Aged 12 or Older with a Past Year Substance Use Disorder: 2017 Note: Estimated numbers of people refer to people aged 12 or older in the civilian, noninstitutionalized population in the United States. The numbers do not sum to the total population of the United States because the population for NSDUH does not include people aged 11 years or younger, people with no fixed household address (e.g., homeless or transient people not in shelters), active-duty military personnel, and residents of institutional group quarters, such as correctional facilities, nursing homes, mental institutions, and long-term care hospitals. Note: The estimated numbers of people with substance use disorders are not mutually exclusive because people could have use disorders for more than one substance. FFR1.39

Past Year Opioid Misuse among People Aged 12 or Older: 2017 Note: Opioid misuse is defined as heroin use or prescription pain reliever misuse. Note: The percentages do not add to 100 percent due to rounding. FFR1.20

National Overdose DeathsNumber of Deaths Involving All Drugs

National Overdose DeathsNumber of Deaths Involving Opioids

National Overdose DeathsNumber of Deaths InvolvingOpioid Pain Relievers (excluding non-methadone synthetics)

National Overdose DeathsNumber of Deaths Involving Other Synthetic Opioids (Predominately Fentanyl)

National Overdose DeathsNumber of Deaths Involving Heroin

Receipt of Mental Health Services and Specialty Substance Use Treatment in the Past Year among Adults Aged 18 or Older with Past Year Mental Illness and Substance Use Disorders: Percentages, 2017 FFR1.77 Note: Mental health service is defined as having received inpatient care or outpatient care or having used prescription medication for problems with emotions, nerves, or mental health. Specialty substance use treatment refers to treatment at a hospital (inpatient only), rehabilitation facility (inpatient or outpatient), or mental health center in order to reduce or stop drug or alcohol use, or for medical problems associated with drug or alcohol use. Note: The percentages do not add to 100 percent due to rounding.

Perceived Need for Substance Use Treatment among People Aged 12 or Older Who Needed but Did Not Receive Specialty Substance Use Treatment in the Past Year: 2017 FFR1.66

Reasons for Not Receiving Substance Use Treatment in the Past Year among People Aged 12 or Older Who Felt They Needed Treatment in the Past Year: Percentages, 2017 FFR1.67 Note: Respondents could indicate multiple reasons for not receiving substance use treatment; thus, these response categories are not mutually exclusive.

Vermont Opioid Data • 2015 to 2017, the rate ofdeaths from opioid overdose in Vermont increased from 1.9 to 2.5 deaths per 10,000population. • 2017 overdosedeaths: • Accidental (non-suicide) drug deaths involving opioids: 101(up from previous year) • Accidental (non-suicide) drug deaths involving prescription opioids- 33 (same as previous year) • Accidental (non-suicide) drug deaths involving heroin 39 (down from previous year) • Accidental (non-suicide) drug deaths involving fentanyl 67 (up from the previous year) Source: Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE).

Vermont: Access to Services Are adults seeking help for opioid addiction receiving treatment? • Number of people receiving Medication Assisted Treatment per 10,000 Vermonters age 18-64 205 (down from previous year) • Number of people treated through the ASAM Guided, ADAP provider system 7122 (up from Previous year) • Percent of people giving treatment completion or transfer as the reason for ending treatment 44% (below 50% target)

Challenges to the Treatment System • Only about 10 percent of people with a substance use disorder receive any type of specialty treatment. (NSDUH 2018) • Over 40 percent of people with a substance use disorder also have a mental health condition, yet fewer than half (48.0 percent) receive treatment for either disorder. (NSDUH 2018) • Relapse rate between 40-60 percent ( most within the first 90 days of treatment).* *NIDA Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-treatment

Changing the Addiction Paradigm • Moving from addiction as a moral failing to a chronic brain disorder • Moving from criminal justice approaches to pubic health strategies • Dropping old, stigmatizing language and developing new terminology • Developing a science base that informs policy and practice • Addressing substance use, misuse, and disorders across a full continuum and the lifespan: prevention, treatment, recovery management

Substance Use Disorder Treatment Continuum ofCare • EnhancingHealth • Promoting optimum physical and mental health and wellbeing through health communications and access to health care services, income and economic security and workplace certainty • EarlyIntervention • Screening and detectingsubstance use problems at an early stage and providing brief intervention, as needed, and other harm reduction activities • Treatment • Intervening through medication, counseling and other supportive services to eliminate symptoms and achieve andmaintain sobriety, physical, spiritual and mental health andmaximum functionalability • RecoverySupport • Removing barriers and providing supports to aid the long-term recovery process. Includes a range of social, educational, legal and other services that facilitate recovery, wellness and improvedquality oflife • Primary Prevention • Addressing individual and environmental risk factors for substance use through evidence- based programs, policies and strategies U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. (2016, November). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, andHealth.

Definitions • How “health disparity” and “health equity” are defined affects how a policy is conceptualized • For policy purposes, need to distinguish among: • Disparities in health • Disparities in health care • Health equity • Health inequalities

Definitions: Disparities in Health Care • “Differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, or appropriateness of intervention.”3 • Should policymakers focus on disparities in health or disparities in health care?4

Definition: Disparities in Health • “Differences in the incidence, mortality, and burden of disease and other adverse health conditions that exist among special population groups in the United States”1 • “Differences in health that are not only unnecessary and avoidable, but, in addition, are considered unfair and unjust”2

Definitions: Disparities in Health Care • “Differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, or appropriateness of intervention.”3 • Should policymakers focus on disparities in health or disparities in health care?4

Defining “Health Equity” • “Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential . . . No one should be disadvantaged from achieving this potential”5 • Equity in health care requires that resource allocation and access to health care be determined by health needs” 6

Equality VS Equity

Who deals with health disparity issues in the US? • National Institute of Minority Health and Health Disparities (NIH) • Office of Minority Health (DHHS) • Federal Collaboration on Health Disparities Research (DHHS) • Office of Minority Health and Health Disparities (CDC) • Office of Behavioral Health Equity (SAMHSA) • Office of Health Equity (HRSA)

Health Disparities:The Context • Health disparities are connected to a social context that includes individual, socioeconomic, and political factors which determine health outcomes7 • Historically social policy has contributed to health disparities • Factors may include housing, neighborhood, access to work and educational opportunities, individual lifestyle (age, gender), socioeconomic status, and access to health care • Evidence shows that health disparities among particular racial and ethnic groups have multiple causes that need to be addressed on multiple levels

More Examples of Health Disparities in Mental Health • Hispanic Americans (except those from Puerto Rico), Asian Americans, and Black Americans have a lower incidence of mental disorders than White Americans • The Latino or Hispanic paradox – Hispanic populations have lower rates of illness, but the more time someone from Mexico, Africa, or the Caribbean spend in the US, the higher the rate of disorders • American Indians are at higher risk for PTSD and alcohol dependence, but at lower risk for depression11

How Do We Measure Health Disparity? • Life expectancy, infant mortality, rate of chronic diseases – differences among ethnicities • Health care – what is recommended and what is available or delivered • Access to care – barriers • Geographic and provider-level differences • Availability of culturally-sensitive, trained, bilingual mental health professionals

Causes of Disparities in Mental Health and Substance Use Disorders • Lack of insurance • Geographic and provider-level differences • Poor access • Low quality of care • Health provider assumptions, discrimination • Language barriers • Mental health workforce disparities

Approaches to Reduce or Eliminate Health/Health Care Disparities • Address social disparities (e.g., poor housing, low education, poverty, lack of job opportunities) • Improve access to care • Provide incentives to health care professionals for improving communication, providing appropriate screening and treatment • Increase racial and ethnic diversity in the mental health care workforce to reflect community populations

An Example of an Integrated Model of Care Addressing Health Disparities • An organization that addresses health disparities is: • “Culturally and linguistically competent, • Responsive to the community, • Resides in a reasonable location, • Has flexible hours of operation”, and • “Committed to addressing social determinants of health disparities” (e.g., health literacy, socioeconomic status, housing) • See handout for schema14

Equity in Mental and Substance Use Disorders Health Care Policy • Mental Health Parity Act of 1996 • 9 USC § 1185a - Parity in mental health and substance use disorder benefits • Olmstead v. L.C, 527 U.S. 581 (1999) • People have a right to live in the community in the least restrictive environment • Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 • Expanded MHPA to include substance abuse treatment • Pending in Congress • S. 2474: Health Equity and Accountability Act of 2012 introduced by Senator Akaka

Health Disparities and the Patient Protection and Affordable Care Act • There are numerous provisions in the PPACA that address reducing health disparities and increasing health care equity • These fall under six domains: • Consistent data collection • Workforce diversity • Cultural competence training and education • Funding health disparities research • Prevention program promotion • Addressing disparities in health insurance reform

PPACA and Integration • ACA has a number of provisions to integrate primary and behavioral health care • SAMHSA states that: • “For consumers of mental health services or those in recovery from addiction disorders, the law’s provisions and the general movement toward integration are important steps that can lead to improved overall health”13 • How do the 6 domains address health disparities and how can they be incorporated into integrated care models? • Discussion: How does your county mental health and public health agencies address these 6 domains, and what models of integrated behavioral health care are being implemented?

Achieving Health Equity for All: An Organizational Model for Change • How does an agency address health disparity issues and ensure that those it serves gets equitable health care? • Key step is an organizational self assessment to determine which issues need to be addressed, the organization’s ability to address these issues, and its readiness to implement changes • The Bay Area Regional Health Inequities Initiative (BARHII) toolkit for organizational self-assessment is one collaborative model that shows how one community is dealing with their health inequities14

BARHII Organizational Assessment –Organizational Characteristics and Workforce Competencies15 Organizational Characteristics Workforce Competencies Passion, self-reflection, and listening skills Knowledge of a public health framework Able to integrate social, environmental, and structural determinants of health Knowledge of the community/Leadership skills Ability to collaborate/Community organizing skills Problem solving skills/Cultural sensitivity • Institution/agency’s commitment to addressing health inequities • Willingness to hire • A structure that will support collaborations/partnerships • Staff support • Transparent communication • Creative use of categorical funds • Community-accessible data and planning • A smooth administrative process

Additional Models for Organizational Self Assessment • National Center for Cultural Competence, Innovative self assessment and strategic planning - focus on cultural and linguistic competence (http://nccc.georgetown.edu/documents/Contra%20Costa.pdf) • State of New Jersey, Department of Health and Human Services Health Disparities Self Assessment (http://www.state.nj.us/health/omh/documents/2009self_assessment_survey_report.pdf) • Developing a Self Assessment Tool for CLAS in Local Public Health Agencies (http://www.minorityhealth.hhs.gov/assets/pdf/checked/LPHAs_FinalReport.pdf)

Equity Beyond Race, Ethnicity, and Gender Identity • Disparities exist in other populations • Older adults • Higher rates of suicide • The LGBT community (in particular, older adults) • Access to health care • Higher rates of smoking, alcohol and drug use, suicide and depression • Persons who live in rural areas • Lack of healthcare professionals, specialists • High poverty levels

Health Equity Beyond Race, Ethnicity, and Gender Identity • Disparities in Access to SUD Treatment • Disparities in coverage • Disparities in rates • Disparities in authorization, medical necessity, ect • Disparities in Data Informed Treatment • Care Coordination • Care Management • Quality Improvement • Persons who live in rural areas • Lack of healthcare professionals, specialists • High poverty levels

Food for thought… • What is your organization doing or hoping to do to eliminate health disparities? • What approach are you using/wish to identify disparities? Develop programming? Measure impact? • What is 1 thing you can/will to address health disparities and advance health equity within your organization?

Creating a Health Disparities Impact Statement Developing a Plan to Address Health Disparities

Source: Images generated from http://changematrix.org/2016/wp-content/uploads/cm-bhdis_12922976.pdf

Separate is Never Equal