Mady Chalk, PhD., MSW Treatment Research Institute November, 2013

 Addiction as a chronic illness, with expected readmissions to treatment  SBI brief counseling in primary care settings  Use of medications in treatment  Integrated care --- SBI +, medication prescription, monitoring, and management, care coordination, referral to specialty care and return to primary care for follow-up

 Tracking recovery during treatment (not evaluating it AFTER treatment)  Peer-to-peer and organizational recovery supports  Community-based offender treatment --- RANT, TASC models, use of medications  Episodes of care, bundling of services  OTPs as medical homes

Under the ACA, including parity and essential health benefits:  Prevention ◦ Screening and brief interventions  Early Intervention ◦ Brief Counseling and Treatment in primary care  Office-based Treatment ◦ Medications, monitoring, management, coordination of care in primary care  Referral to Specialty Care as Needed and Back for Continuing Care

 “Harmful substance use” is identified in 2-3 questions ◦ Prevalence estimates are 20-50% in healthcare ◦ About 60% of emergency room visits  A few brief counseling visits (10 minutes) in primary care produce lasting changes and cost savings to health care

 Alcohol ANY DOSE accelerates tumor growth in breast and prostate cancer  MORE THAN 2 DRINKS/DAY reduces treatment response in hypertension and diabetes  ANY DOSE 2 hours before bedtime reduces sleep quality  MORE THAN 2 DRINKS/DAY produces 30-50% reduction in medication adherence BUT simply asking patients to reduce their use can improve clinical outcomes (PRISM,, 2011)

Under the ACA:  Emphasis/expansion health/medical home services Will “specialty care” fill this role?  Role of Block Grant is likely to change Recovery-oriented services NOT covered under Medicaid or commercial health plans

Opioids: ◦ Methadone ◦ Buprenorphine ◦ Naltrexone – oral ◦ Naltrexone (Vivitrol) – long-acting, injectable Alcohol: ◦ Naltrexone – oral ◦ Naltrexone (Vivitrol) – long-acting, injectable ◦ Acamprosate ◦ Disulfram (antabuse)

All medications for treatment of moderate and severe addiction to opioids have shown clear clinical evidence of effectiveness in:  reducing opioid use and opioid-use related symptoms of withdrawal and craving and,  risk of infectious diseases and crime when used as part of a comprehensive approach in appropriate doses.

 Effectiveness of these medications is true only when used as maintenance treatments.  There is NO evidence of enduring benefits from any of these medications when used in any type of “detoxification only” regimen that does not include continuing treatment and recovery supports.

Under-utilization is severe and is being driven by :  State licensing requirements that place restrictions on hiring of physicians in substance use treatment programs  Federal restrictions on numbers of patients that waivered physicians may treat with buprenorphine (100 patient limit)  State restrictions on use of some medications in residential treatment  State legislative interference in dosage and day limits for use of medications, and  Ideological issues in the workforce

Recent research has shown:  Use of ANY of the medications has been shown to produce cost-offsets related to reduced emergency room visits and fewer inpatient admissions of all types (alcohol- and drug-related or not).  Despite the addition of medication costs, total healthcare costs (incl. inpatient, outpatient, and pharmacy costs) are almost 1/3 lower for patients who receive medications. (Baser, Chalk, et al.2011)

Transparency:  Despite the recent announcement of the Parity rules, under the ACA patients will need considerable assistance to discover and assure that they have access to medications as part of their treatment regimens.  The assistance will need to come from clinicians and managed care plans both in the private and public sectors. 13

Workforce Issues:  A significant amount of work is needed now and on a continuing basis to credential and improve the capacity of the workforce in both the primary and specialty sectors to increase the use of medications in treatment.  This work needs to include increased capacity of the workforce to understand the interactions of other chronic illnesses and their treatment (which may include medications) on treatment of addictions with medications. 14