3 Issues Likely to Affect

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3 Issues Likely to Affect Addiction
Treatment and Recovery

• Thomas McLellan
• from
• The Treatment Research Institute

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Before We Start
I am not in recovery - I do not pretend to
speak for you I dont know the future Im
guessing based on what I see I am honored to
speak with you - you can make a big difference
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Changes in the Patient Population
Customer
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Substance Use Pyramid
In Spec Treatment 2,100,000
?
Abuse/Dependent 23,000,000
Harmful Users ??,000,000
Low Level Use
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Why Dont Patients Want Treatment?
Sources 4 Review Articles Rapp et al. JSAT
2005 Stanton JMFT 2004 Appel et al. AJDA
2004 Tsogia et al. JMH 2001
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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 !

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Integration of Addiction Treatment

• Why the special system?

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Addiction Specialty Care
11,500

• 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 lt12
• Sources NSSATS, 2002 DAunno, 2004

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Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM,
2001)
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• CONCLUSION
• It is not possible to deliver safe or adequate
  healthcare without simultaneous consideration of
  general health, mental health and substance use
  issues.

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Specialty Care Negatives

• 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

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Disorders with Higher Prevalence Among Substance
Abusers
Percent
Substance abusing patients 747 Matched
controls 3,690
Weisner et al. Arch Intern Med. In press.
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PRISM
Chronic Illness Care

• Program of Research to Integrate Substance Use
  Information into Mainstream Healthcare

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The PRISM Approach

• 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

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Risk of Mortality Drinks/Day
1.4
1.3
1.2
1.1
Risk of Mortality
1.0
0.9
0.8
0.7
0.6
3
4
7
6
5
0
2
1
Drinks per Day
Di Castelnuovo et al. Arch. Int. Med.
2006166(22)2437
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Alcohol and Hypertension

• McFadden et al. Am J Hypertension. In press.

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Systematic Review Findings

• 11 randomized controlled trials
• Dose related effects
• lt 2 drinks/day or 10/week usually decrease
• gt 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

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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

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Relation Between Insurer Employer
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• Regular Advertisement in
• WSJ NYT
• Employers!
• An employee managing his diabetes costs you
  14,000/year.
• An unmanaged diabetic costs you 44,000/year

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Points

• 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?

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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

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Continuum of Care Circa 2010
Screening/Brief Interventions (10-20 min, in Med
settings, Schools, etc.)
Continuum of Care Circa 1980
Detoxification (7-10 Days)
Detoxification (3-5 Days in Hosp, Res or MH
Centers)
Residential Treatment (28-180 Days Hosp, Res or
TC)
Residential Recovery-Oriented Treatment (10-28
Days Residential Center)
AA/Mutual Help
IOP/ Outpatient Continuing Care (30-180 Days,
Outpatient program of declining intensity, 3-5
sessions/week to 1-2 sessions/month)
Tele/Internet Continuing Care (1-2 contacts/mo.)
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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

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Implications for Recovery Community

• Make Recovery Good Behavioral Choices Self
  Management Health
• Dont be defined by what you dont 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

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- The End -
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A New Treatment Model ?
Lessons from Physician Health Plans
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Physician Health Plans

• 49 PHPs
• All authorized by state licensing boards
• Most treat many types of health professionals
• Continuously Manage treatment
• Assess, Intervene, Evaluate, Refer, Monitor,
  Report and Advocate
• All under authority of Board

DuPont et al., 2008, (in review).
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Formal Treatment

• Signed contract 3 5 years
• Protection from adverse actions
• Diagnostic evaluation w/Family
• Monitoring with report to Board 4 yrs
• Formal Treatment 1 yr
• Residential 60 days IOP 6 months
• Return to practice month 3
• Aftercare 6 months

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Monitoring Support

• Monitoring Support 4 yrs
• AA Personal Therapist
• Caduceus Society Family Therapy
• Worksite visits
• Urine Drug Screenings
• Weekly (random during weekdays)

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Results During Contract

802 Physicians Consecutively Enrolled into 16
state Physician Health Programs
Continuers 132 - Still being monitored 132
(16)
Completed 448 - No Longer Being
Monitored 67 - Completed but monitored
voluntarily 515 (64)
Non-Completers (Failed) 85 Voluntarily
stopped / Retired 48 Failed, License
Revoked 22 - Died (6 suicides) 155 (20)
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Results Through Five Years
No Positive Urine Over 5 Years 81
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Results Through Five Years
Second Positive Urine After One Slip 26
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Results Through Five Years
Substance Use In Context of Care 10 cases
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Results After Five Years
Practicing Medicine Completers 92 Continuers
73 Non-Completers 10
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Results After Five Years
Revoked License Completers
2 Continuers 11 Non-Completers 41
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Results After Five Years
Untoward Patient Incidents 500 Physicians
6,000,000 Patients Patient Incidents
55 Patient Harm 1
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- The End -