Study: Healthcare Utilization Rates After Treatment Are Equivalent Among Abstinent and Low-Risk Drinkers

A fascinating new study will add to the small, but growing, treatment literature suggesting that low-risk drinking is a viable option for people receiving treatment for alcohol-use disorders. The paper, published this month in Alcoholism: Clinical and Experimental Research, measured healthcare utilization rates and associated costs over a 5-year period among clients receiving treatment in a large Northern California healthcare system. The results show that outcomes for abstainers and lower-risk drinkers were equivalent (and far better than the high-risk drinkers), despite the fact that the abstinence-based treatment received by all groups was the same.

According to the authors, "The finding that lower-risk drinkers did not differ from those of abstinent individuals, in inpatient use in particular, even when controlling for patient characteristics, suggests that a health policy perspective may consider benefits of lower-risk drinking."

Here's the abstract via Wiley:

Background

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications.

Methods

Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group.

Results

Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p < 0.01) and ED (p < 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p < 0.05) and inpatient (p < 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time.

Conclusions

Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.

Figure 1 shows Adjusted odds ratios of utilization by 6-month drinking group over time:

Figure 2 shows Adjusted average costs per member month by 6-month drinking group over time:

                                               






As mentioned above, these are the results from patients who attended abstinence-based treatment. It will be
interesting to see if these results are replicated among patients who are instructed on low-risk drinking. What experience do readers have with this issue? Do results like these make those directing abstinence-based programs think twice about the policy? It would be great to hear from you.

Hat tip: Thanks, Dr Reid Hester, for bringing this study to our attention.

Source: Kline‐Simon, A. H., Weisner, C. M., Parthasarathy, S., Falk, D. E., Litten, R. Z., & Mertens, J. R. (2013). Five‐Year Healthcare Utilization and Costs Among Lower‐Risk Drinkers Following Alcohol Treatment. Alcoholism: Clinical and Experimental Research.
http://onlinelibrary.wiley.com/doi/10.1111/acer.12273/abstract

SAMHSA Releases State and National Behavioral Health Barometer

The federal Substance Abuse and Mental Health Services Administration recently released its yearly report on the general state of behavioral health needs and services in the US. Based on population and treatment-facility data sets from state to state, the Behavioral Health Barometer is a sweeping, in-depth look into adolescent and adult drug use, treatment and mental health service utilization.

Among the highlights:
- Nationally, youth and young adult use of nonmedical pain relievers is declining in general.
- Past-month cigarette use among teens nationally and locally is declining, although Minnesota saw a small increase in 2011-2012
-Over 50% of Minnesota adolescents, and over 60% of adolescents nationally, did not receive treatment for their past-year depressive episode.
-In Minnesota, only 6.6% of people with past-year alcohol dependence received treatment. For illicit drugs, the number is 14.6%
-In Minnesota, while the number of people receiving methadone treatment has increased by nearly 1000 people since 2008, the number of people receiving buprenorphine has actually decreased in that time (owing to a sharp drop from 2008-2009.

The national report is here:
http://www.samhsa.gov/data/StatesInBrief/2K14/National_BHBarometer.pdf

Read the MN report here:
http://store.samhsa.gov/shin/content/SMA13-4796/SMA13-4796MN.pdf

And find your state here:
http://store.samhsa.gov/product/Behavioral-Health-Barometer-2013/SMA13-4796

Wacky Progressives and Scientific Illiteracy

In a disturbing article in the New York Times, Amy Harmon chronicles the tale of a brave county councilman on the island of Kona, Hawaii, who refused to be steamrolled by those who categorically believe that genetically modified organisms (GMOs) are dangerous and should be banned across the board. He actually took the time to look into the scientific research, to consult with scientists who know about this, and he attempted to draw a reasonable conclusion. He is faced, however, with a group of true believers, who keep repeating obscure claims based on long-discredited "research." They shout down their opponents and make outlandish claims that have no scientific basis or rationale. They demonize their opponents, and constantly shift the arguments when faced with scientific facts. Most disturbing of all was the refusal of his fellow council members to even allow scientists to testify, instead giving the floor repeatedly to unqualified zealots who continued to make broad, unsupportable statements. 

It turns out, then, that it's not only climate-change deniers and birthers who maintain passionately held beliefs that have no scientific basis. Worse, it shows how repeating false claims becomes a sort of echo chamber for those with similar beliefs. Finally it shows that such behavior is not limited to Tea Party fanatics or religious zealots, but applies equally to so-called progressives on the left side of the political spectrum. I write about this because it applies as well to too much in the fields of psychotherapy, behavior change and addiction treatment.

We tolerate too much of this type of thinking in our field. How many treatment centers offer "holistic" therapies such as yoga, energy field work, Reiki, or massage, or worse, "nutritional treatment" that is not only unsupported, but may well be harmful? Why are state agencies still allowing such centers to obtain licensure? Why are people paying for brain scans or quantitative EEGs or neurofeedback? And, of course, why do so many people cling to the fiction that 90x90 is effective for most people, or that 12-step approaches are 100% effective if you follow directions? (What treatments for human maladies, short of penicillin for strep throat, can claim 100% effectiveness?)

I'm not arguing that an absence of evidence of effectiveness is evidence of ineffectiveness. There is lots we all do that hasn't been studied well, simply because it is impossible to conduct a large randomized controlled trial on every possible therapy. However, in addiction treatment we have a very large and very strong evidence base from which to draw. It's actually far better than in many other areas of health care. In order to include an approach in a licensed program, at the least, we should require 1) a scientifically plausible rationale for a treatment, 2) that unsupported treatments should not be likely to cause significant harm or cost a significant amount of money, 3) that there is not significant evidence that the approach is not effective, and 4) that there is not a well-supported approach already available.

I'm also not suggesting that yoga, meditation, Reiki, energy field work, reflexology, acupuncture, massage, etc., may not be experienced as beneficial to some people. I recently underwent Rolfing, for example, which I found to be very helpful (if painful). But I didn't expect my health insurance to pay for it, and I reject any large claims concerning what it and similar approaches might accomplish. Such approaches might be made available to clients (at their own expense), but not as presented as a scientifically based health practice.

I have been surprised at how trendy the psychotherapy community is in general, not just in addiction treatment. One current example is the spread of dialectical behavior therapy (DBT) beyond its proven focus on borderline personality disorder. It seems that it's being applied to anyone and for every condition short of psychosis. Another trend is "trauma informed therapy" using eye-movement desensitization and reprocessing therapy (EMDR), DBT, prolonged exposure, or mindfulness. All of a sudden, everyone has "trauma" for which these are appropriate treatments, even though many do not meet criteria for post-traumatic stress disorder (PTSD.) What was psychoanalysis if not focused on trauma? For that matter, "mindfulness" is another trendy approach, with practitioners charging for something the Buddha gave away 2600 years ago and which can be had for free at your local Buddhist meditation center.

At the same time, I seldom encounter high quality cognitive-behavior therapy (CBT) being applied to co-existing anxiety or depressive disorders, in spite of a mountain of evidence supporting their effectiveness. And too many in our field still believe that "I don't believe in it" is an adequate reason to not support anti-relapse medications that also have a strong evidence base. When we have such well-supported therapies, why aren't we using them? Why are we instead embracing half-baked ideas and approaches? Why do we tolerate so much scientific ignorance? Why do we tolerate lack of informed consent, where clients are not given information about what the evidence supports and what it does not, but instead receive biased and incorrect information that deprives them of the opportunity to make an informed decision?

Are Financial Incentives the Answer to SBIRT Implementation?

Researchers from Imperial College London may have found a way to increase alcohol screening and brief intervention in a primary care setting: financial incentives. The results, published online Dec. 26 in the Journal of Public Health, show that offering a points-based incentive for successful screening, brief intervention and referral to specialists significantly increased the number of patients who were screened. As a result, the authors say, more patients with risky alcohol intake were identified and offered care, reducing hazardous and harmful drinking in some.

While the evidence for SBIRT is abundant and well-known, there have been considerable problems in promoting widespread implementation - especially in primary care. Financial incentives could be one effective means of changing this. (Granted, a large-scale effort by the federal government or the insurance companies would likely be required to provide funding. In this study, data was collected from 2008-2011, until the UK's Quality and Outcomes Framework funding was withdrawn.)

Abstract

Introduction Alcohol screening and brief intervention (ASBI) is effective but underprovided in primary care. Financial incentives may help address this. This study assesses the impact of a local pay-for-performance programme on delivery of ASBI in UK primary care.

Methods Longitudinal study using data from 30 general practices in north-west London from 2008 to 2011 with logistic regression to examine disparities in ASBI delivery.

Results Of 211 834 registered patients, 45 040 were targeted by the incentive (cardiovascular conditions or high risk; mental health conditions), of whom 65.7% were screened (up from a baseline of 4.8%, P< 0.001), compared with 14.7% of non-targeted patients (P < 0.001). Screening rates were lower after adjustment in younger patients, White patients, less deprived areas and in patients with mental health conditions (P < 0.05). Of those screened, 11.5% were positive and 88.6% received BI. Men and White patients were significantly more likely to screen positive. Women and younger patients were less likely to receive BI. 30.1% of patients re-screened were now negative. However, patients with mental health conditions were less likely to re-screen negative than those with cardiovascular conditions.

Conclusion Financial incentives appear to be effective in increasing delivery of ASBI in primary care and may reduce hazardous and harmful drinking in some patients. The findings support universal rather than targeted screening.

Source: http://intljpubhealth.oxfordjournals.org/content/early/2013/12/26/pubmed.fdt121.abstract

If You Build It, They Will Drink

If there were lingering doubts about the effect of alcohol availability on alcohol consumption, a host of new studies seem to lead the reader to the same conclusion: that increases in availability are correlated to increases in consumption. In other words: if you build it (bar, liquor store, etc), we will drink. What's more, in many cases, it's not just drinking that will happen. So-called alcohol outlet density has been linked to interpersonal and intimate partner violence, adolescent consumption and beliefs about alcohol, and even alcohol-attributable deaths. On the other hand, raising the minimum prices or implementing taxes on alcohol sales seems to go a long way in reducing these potential harms.

The journal, Addiction, has published several of these studies online in the past few weeks. Gruenewald and colleagues analyzed survey data from 50 California cities with populations between 50,000 - 500,000. They found "greater on-premise outlet densities were related to greater drinking frequencies and volumes, and use of on-premise drinking places" (like bars and restaurants).  The researchers concluded that, in addition to characteristics of the individual drinkers (e.g. "impulsivity, risky driving), alcohol availability is correlated with consumption and related problems.

Also in-press at Addiction, Paschall and colleagues analyzed the same sample, but instead focused on adolescent drinking. Some 1478 California youths, aged 13-17, responded to survey questions about past-year alcohol consumption, perceived availability, and questions related to underage enforcement and parental views toward drinking. The answers to these questions were then compared against alcohol outlet (bar) density, public policy, law enforcement activity and city demographics. The authors found that adolescent behaviors and attitudes were significantly affected by their environments. For example, past-year alcohol use was positively correlated to bar density and inversely correlated to "the comprehensiveness and stringency of local alcohol policies". In addition, higher rates of adult drinking were associated with greater increases of past-year adolescent drinking over the three-year study period.

Over in Alcohol and Alcoholism, Grubesic and colleagues studied the association between outlet density in Philadelphia and violent crime. Once again, the researchers found consistent association between the two. Here is a pair of maps, the first showing assault density, the second showing outlet density:

Contrary to the popular belief, no association was found between assault density and "transportation nodes and risky retailers". However, alcohol expenditures and general commercial activity were "positively and significantly" associated with assault density. 

The connection between intimate partner violence (IPV) and alcohol outlet density seems to be well established. In 2012, Conradi and colleagues reported that the density of bars in California was positively associated with IPV-related emergency department visits between 2005-2008. Then, earlier this year, Waller and colleagues found alcohol outlet density to be positively correlated to male-to-female physical - but not sexual - IPV among a national sample. Finally, in March, Zhao and colleagues showed that alcohol outlet density was associated with an increase in alcohol-attributable deaths in British Columbia between 2002-2009. In fact, they calculated that a 10% increase in private liquor stores was associated with a 2.45%, 2.36% and 1.99% increase in acute, chronic and total alcohol-associated (AA) mortality rates.

Interestingly, the single policy that seemed to have the biggest impact in turning these numbers around: raising the minimum price for alcohol. A 10% increase in the minimum price was associated with a 31.72% reduction in "wholly AA deaths". Pretty big numbers. As Dr W observed recently, "raising taxes on alcohol would do more for public health than all the treatment in the world." 

What do you think?

Why SBIRT Is Dead in the Water

In the latest issue of Health Affairs, Grace Lin et al. describe an effort to introduce decision-making aids to facilitate shared decision-making regarding back pain and colo-rectal cancer screening. Essentially, nothing changed, in spite of making the aids easily accessible, conducting training sessions, and so on. What's important is the authors' conclusion that "The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy."

Their experience mirrors my own in trying for over 20 years to get substance use addressed in primary care. Most recently, I have two separate but relate experiences here in Minnesota where I essentially ran up against a brick wall. Why? First, primary care doctors are besieged by quality improvement initiatives aimed at reducing variability of practice and improving outcomes for depression, diabetes, heart failure, back pain, asthma, hypertension and many others. These are typically mandated from the top of health care organizations (remember that most primary care physicians are now employees of a large health care organization (HCO.) By attempting to implement not only SBIRT but treatment of alcohol dependence in primary care (I call it Screening, Evaluation and Treatment, or SET, but another term could be SBIRT+) by asking physicians to voluntarily take it on was a non-starter. Typical comments were "It's a good idea but we can't take on anything more right now," or "We're having enough trouble trying to get this clinic's operations running smoothly, and until we do, it wouldn't work." 

A second factor is one of priorities. I have argued for years that universal SBIRT is not cost-effective, but should be more targeted. Related to this is a crucial question: since visit length is not going to increase, what do you want the doctor to stop doing so they can do these new things, like shared decision-making and SBIRT+?  In other words, in a typical visit, the patient has certain expectations about why they are there and what they want, and most patients have multiple chronic diseases like obesity, arthritis, hypertension and diabetes. Oh, and of course they smoke. So, do you want the doctor to not address the patient's presenting complaint (e.g., arthritis pain, insomnia), or not address their hypertensive control so they have the time to spend on shared decision-making for back pain, or to conduct SBIRT+? How do you think patients would feel about this? This applies especially to SBIRT, because it is attempting to identify a problem they patient is unaware of and not concerned about. "Doctor, I came here because my right knee is all swollen and painful, and you want to take 2 out of the 8 minutes you spend with me asking me about drinking!?"

So have come to a similar conclusion: until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT or SET are DOA. My most recent attempt has been to start with something that has the attention of every primary care doctor: pain management. I'm providing training to all the primary care doctors in Allina Health in management of chronic pain, and the response so far has been overwhelmingly positive. I'm hoping that by getting to know so many primary care physicians in this HCO, they will be more receptive to introducing SET. However, it has also become clear that the only way this will occur is if the top leadership of the organization decides that SET is important enough to get it into the queue of quality improvement projects, and thus mandate its implementation. 

Primary care, even with the medical home, is not going to be all things to all people, and choices are going to have to be made about what is important enough to include and what might ideally be included but which doesn't make the cut because it is not cost-effective or clinically significant enough.

Besides, if we were serious about addressing the heavy disease burden associated with heavy drinking, we would triple the taxes on alcoholic beverages. That would have a greater public health impact than implementing SBIRT in every primary care practice in the country. 

MW

Here's the abstract:

An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles

1. Grace A. Lin1, 
2. Meghan Halley2, 
3. Katharine A.S. Rendle3,
4. Caroline Tietbohl4, 
5. Suepattra G. May5, 
6. Laurel Trujillo6 and
7. Dominick L. Frosch7,*

+Author Affiliations

1. ¹Grace A. Lin is an assistant professor in the Division of General Internal Medicine and at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco.
2. ²Meghan Halley is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute, in California.
3. ³Katharine A.S. Rendle is a research associate in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
4. ⁴Caroline Tietbohl is a research assistant in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
5. ⁵Suepattra G. May is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
6. ⁶Laurel Trujillo is medical director of quality at the Palo Alto Foundation Medical Group and chair of the Quality Improvement Steering Committee, both at the Palo Alto Medical Foundation, in Los Altos, California.
7. ⁷Dominick L. Frosch (dominick.frosch@moore.org) is an associate adjunct professor in the Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles.

1. ↵*Corresponding author

Abstract

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010–12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.

Health Care Changes Important to Addiction Treatment

Among the various things I do, I work about half time for a large health care organization (HCO) in Minnesota called Allina Health. Currently Allina is the largest HCO in Minnesota, but it is likely to become the second largest due to continuing consolidation in HCOs. HealthPartners and Park Nicollet, two other HCOs in Minnesota desire to merge, and it does not appear that there will be any barriers from either the MN Attorney General or federal agencies. So it is likely to proceed, which would produce a larger HCO than Allina. Consolidation in health care is almost a torrent right now. It's happening very rapidly. In the Twin Cities area in Minnesota, there are almost no independent primary care practices; they've all been purchased by large HCOs. The health plans like Blue Cross/Blue Shield and HealthPartners are working very closely with the large HCOs to create products that maximize value to the consumer. So the future of health care is one dominated by a few large HCOs that dominate a market. Unfortunately, this is all to familier. Witness the consolidation in airlines and in cable television, internet and wireless services.

But there are important changes in perspective that will drive a much more pronounced and determined effort to deal with behavioral health issues, including both mental health and addiction. The most important of these is the movement from fee for service to capitated approaches. In fee for service, a clinician is paid a specific amount for providing a service, such as a primary care visit or an addiction counseling session. This rewards providing more services for fewer people, and it drives up costs without regard to quality or outcomes. Increasingly, health plans are moving towards a different model where the HCO is accountable for outcomes, not just whether the service was delivered. In a capitation model, a HCO is given a single fee for treating someone with a given diagnosis. It is up to the HCO to figure out how to do this efficiently and effectively.

This is a good thing. Here's an example. Someone with an addiction goes to a time-limited, intensive rehab program, which is the current standard of care. Let's say that this intensive outpatient program costs $2400. Someone else who was able to produce equivalent outcomes for $1800 would be attractive to a health plan, not to mention someone paying out of pocket. Similarly, a $15,000 or $20,000 residential treatment program would go out of business if it could not produce substantially better outcomes than someone providing office-based treatment for a third of that amount. I think this is quite possible to do, since there is no demonstrated benefit to residential treatment. There is room here for innovation, for modernizing our approach to addiction treatment. It's time for addiction treatment providers to take responsibility for the outcomes of their treatment. It's time to end the idea that treatment failures are the patient's fault. In the future, this isn't going to fly. One of my goals is to make sure this happens. We can generate better outcomes at much less cost.

What if, instead of being paid $30,000 for a residential treatment lasting 28 days regardless of whether that actually produced a good outcome, HCOs were only paid for treatment that worked? What if payment was based on outcomes rather than the treatment provided? I can tell you, that would change the addiction treatment world in a heartbeat. Give patients that same treatment over and over even though it's already proved ineffective? No way! Give everybody the same treatment whether they need it or whether it's been shown to improve outcomes? Forget about it? Changes in how payment is made for services will force change in the treatment delivered. And it's about time.

What's the silver lining? We can lead the way. Many of the very high utilizers of health care have addiction and mental health problems. We have to figure out ways to improve their care and outcomes. That's our challenge and our opportunity.

MW

How Will the Election Affect Treatment for Addiction?

Here's a blog from a guest blogger, Ian McLoone, who is a student in the Integrated Behavioral Health Master's program at the University of Minnesota, as well as a Graduate Research Assistant at the new MN Center for Mental Health, which is focused on treatment for people with co-occurring mental and addictive disorders. Welcome Ian!

MW

P.S. Anyone else want to volunteer? I'm open to blog submissions.

Why the Election Results Are Good News for Addicts and the People Who Treat Them

As Tuesday’s election results trickled in, addiction and mental health professionals throughout the country breathed a collective sigh of relief. President Obama’s re-election means that the Affordable Care Act - affectionately termed, “Obamacare” – is safe from the Romney/Ryan campaign promise of “total repeal” of the law (1). This means that President Obama will have the opportunity to oversee the implementation of his signature first-term accomplishment. What’s more, addiction research will see, at minimum, modest funding increases and the National Institutes of Health (NIH) will avoid the devastating cuts outlined in the Romney/Ryan 2013 budget proposal.

The ACA increases patient access to behavioral health services in several ways. By expanding Medicaid coverage to those at 138% of the federal poverty level, as well as the creation of state-run insurance exchanges, as many as 30 million new people will have access to health insurance (2). Health insurance providers will also be subject to several new provisions which are meant to improve the quality of the care they receive. For example, preventative care and interventions will be emphasized, and in many cases fully covered. The ACA has already awarded upwards of 100 million dollars for the implementation of an evidence-based prevention measure known as SBIRT – Screening, Brief Intervention and Referral to Treatment (3). Prevention efforts can improve outcomes for all people, but those with mental illness and substance use disorders are disproportionately affected with other health problems like diabetes, high blood pressure, asthma, heart disease and stroke (4). This, in addition to guaranteed coverage for patients with preexisting conditions, more coverage for prescription medications, and the carrying-forward of the 2009 “parity” law (which mandates that insurance companies cover treatment for mental health like they would any other condition), means those with addiction or mental illness, and those who treat them, will no longer need to question whether or not these services will be available in the years to come.

Mitt Romney, and his running mate, Paul Ryan, ran on a platform of significant cuts in government spending (“non-defense discretionary spending”), exemplified in Paul Ryan’s 2013 budget proposal. In addition to eliminating the ACA’s Medicaid expansion, their plan included provisions which would have resulted in 14 million more people losing their Medicaid insurance over the next 10 years – an estimated 31 million people, in total (5). While many have criticized Paul Ryan for the lack of specifics within his budget plan, the White House estimates of the impact on NIH-funded grants are sobering: 1,600 fewer grants in 2014 and 16,000 fewer over the next 10 years (6).

While we cannot yet say for certain exactly what the impacts of the ACA will be, we can expect some significant improvements in behavioral health coverage for all Americans. Expanded coverage means more patients seeing doctors, more clients with access to therapists and counselors, and more money to pay for drug and alcohol abuse treatments. Certain states have indicated an interest in “opting-out” of the Medicaid expansions, and their right to do so was recently upheld by the Supreme Court. Voters in these states will have to hold their lawmakers responsible for ensuring that they have the same access to healthcare that the rest of the country does. In the meantime, President Obama has an opportunity to do even more for the behavioral health community over the next four years. It will be important to remind him that we expect investments in addiction and mental health research. He has the chance to encourage innovations that could change the way we see addiction and its treatment throughout the 21^st century.

1. http://www.huffingtonpost.com/2012/09/10/romney-obamacare-repeal_n_1872667.html

2. http://www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-CoverageEstimates.pdf

3. http://mentalhealthcarereform.org/affordable-care-act-prevention-grants-will-support-sbirt-tobacco-cessation/ , http://www.samhsa.gov/newsroom/advisories/1207254120.aspx

4. http://www.samhsa.gov/data/2k12/NSDUH103/SR103AdultsAMI2012.pdf

5. http://www.americanprogressaction.org/issues/poverty/report/2012/09/11/11945/romney-ryan-plan-slams-the-poor-showers-more-money-on-the-rich/

6. http://www.whitehouse.gov/blog/2012/03/21/ryan-republican-budget-consequences-imbalance

Program Thinking: The Bane of Addiction Treatment

I appreciate the two comments on my last blog, and they prompt a couple of responses from me. (If you didn't read them, click on the "Comments" link at the bottom of the blog.)

First, I'd like to clarify something in response to Dr. Dawson's comments. I was not arguing that people who are living in a sober structured environment do not need programming, or do not benefit from it. What I am saying is that there is no such thing as "residential or inpatient treatment." That is, studies have shown that staying overnight in the same place while receiving treatment has no outcome advantages over going home or to some other place, like a sober residence. So, there is treatment, and there is housing structure. Just like addiction psychotherapy, addiction pharmacotherapy, vocational counseling, psychiatric treatment, treatment for conditions below the neck (CBTN) (often but erroneously called "physical or medical" as opposed to "psychiatric," as if psychiatric conditions were somehow not organ-based or medical), transportation, family or marital therapy, and so on, addiction psychotherapy and housing structure are two very important, but essentially independent components of an interdisciplinary approach to comprehensive modern addiction treatment.

Marrying addiction psychotherapy to a residential treatment bed leads to "program thinking." Program thinking promotes a number of undesirable behaviors or characteristics. First, there is constant pressure to "keep the beds full." Thus, inclusion/exclusion criteria become flexible depending on bed occupancy, and people who could be treated quite well as outpatients are instead admitted to a residential program. This constant push leads to excessive costs without adding to outcome. Second, program thinking leads to cookie-cutter programming, because it's like running a factory, churning out patients and it is too difficult to have completely individualized lengths of stay or treatment plans. For example, the old joke in rehab is that we conduct a comprehensive individualized assessment and then send the client to group. It works much better to have the same groups for everyone, the same treatment for everyone, every time. Third, it leads to inappropriate levels of housing and of treatment services. Some people who need longer-term housing are pushed out at the end of the "program," while others who don't need sober housing are forced into it (and to pay for it.) Some patients need more intensive and comprehensive treatment services for a long time, but their treatment is interrupted arbitrarily, often with devastating consequences such as recurrent addiction along the way to connecting with some (different) outpatient follow up (inappropriately called "aftercare" rather than "care"). When treatment services are provided independently, then there is no disruption of services when a patient moves from one level of housing structure to another. Lack of continuity is compounded when the residential facility is geographically distant from the patient's home, which is often the case. It is always tempting to "send the patient away" to a distant facility so we don't have to worry about whether they are safe, but if we did that with every condition, we'd be sending out of control diabetics, not to mention almost all adolescents, to residential treatment too. We used to hospital people for long periods for psychiatric disorders such as depression and anxiety too, but when it became clear that that was actually harmful and expensive, it was stopped. It is long past time to stop it for addiction treatment too.

I'll respond to the other comment later.

Keep the comments and dialogue coming!

MW

Families' Health Costs Reduced After Addiction Treatment

This is a the second blog about healthcare costs and substance use disorders (SUD). The first one (6 Sept 2012) dealt with healthcare costs among patients who presented for treatment for SUD. This one is from the same great health services research group founded and anchored by Connie Weisner at UCSF, and addresses a novel topic: the healthcare costs of family members of patients with SUD, and the effect of SUD outcomes (abstinence vs. non-abstinence) in the index patient on family members’ healthcare costs (Weisner, Parthasarathy et al. 2010).

In this study, a group of patients who presented for treatment for SUD (and who were thus likely to have chronic or recurrent, and more severe, SUD, compared to people not presenting for treatment) were followed for 5 years. One year following treatment entry, they were asked questions pertaining to their current (past 30 day) use of a wide variety of intoxicants. Those who had used none in the previous 30 days were considered abstinent for study purposes, while those who had used anything were considered non-abstinent. (Note that in other studies as well as this one, 30-day abstinence at the 12 month time point is strongly related to longest continuous period of abstinence over the entire five years.) Also over this 5 year period, healthcare costs of family members were also tracked, and family members whose index patient were abstinent at 1 year were compared to those who were not. Just to avoid confusion, I’ll state that differently: healthcare costs for families over a 5 year period were compared between those whose family member was either abstinent or not for the past 30 days 1 year after treatment entry.

The results were both surprising and encouraging. First, the authors point out that in the first year following treatment entry, healthcare costs for family members may well go up, as they attend to medical, SUD and psychiatric problems they neglected due to the crisis associated with escalating use and problems in the SUD patients. Thus, it is important to long past the one-year point. Thus, a major strength of the study is that they studied costs over five years. Another strength is that they compared both groups to matched controls without SUD.

And sure enough, in the first two years, healthcare costs were higher among both groups of family members of SUD patients compared to non-SUD control families but were not different between abstinent and non-abstinent groups. However, beginning in the third year the abstinent began to diverge from the non-abstinent families. By year 5, the abstinent family members’ costs were not different from the non-SUD controls, while the non-abstinent family members’ were significantly higher. Average cost for abstinent family members at year five was $3 per member per month, while average cost for non-abstinent family members was $36 per member per month, a 12-fold difference!

In summary, 30-day abstinence one year after treatment for SUD strongly predicted the costs for their family members over the ensuing four years. Healthcare costs of family members of SUD patients abstinent at one year began to go down three years following treatment and by year five, did not differ from control families without SUD. However, costs for family members of SUD patients not abstinent at one year were 12 times higher than for either abstinent SUD families or for control families! Thus, SUD outcomes are strongly related not only to healthcare costs of the SUD patients themselves but to their families as well!

A lot of money could be saved (not to mention the misery that could be avoided) by improving rates of abstinence following SUD treatment. Other studies, by this and other groups, have found that providing ongoing continuing care over long periods is associated with improved rates of abstinence and reduced healthcare costs among SUD patients (see previous blog.)

To me, these findings have two implications:

1)    Current, evidence-based treatment needs to be more widely available to people and, to encourage them to come, they need to include a lot more consumer choice about path to recovery, as well as form and place of treatment, and

2)    We need more research on how to improve rates of abstinence, which are far too low to be acceptable. This will require more money. The only way to get more money for addiction research is advocacy by the people affected: people with SUD, recovering from SUD, and their friends and families. We need to advocate not just for more treatment, but for more money for research. More on this later.

Weisner, C., S. Parthasarathy, et al. (2010). "Individuals receiving addiction treatment: are medical costs of their family members reduced?" Addiction 105(7): 1226-1234.