Treating Addiction as a Chronic Illness: Why it is Finally Possible. A. Thomas McLellan Treatment Research Institute

Transcription

1 Treating Addiction as a Chronic Illness: Why it is Finally Possible. A. Thomas McLellan Treatment Research Institute 9/29/2014 Treatment Research Research Institute, Institute,

2 The End Because of ACA (but also other forces): 1. We will have access to reimbursement for more and different types of care than ever Addiction Specialty Care referrals could triple 2. Specialty care will NOT be programmatic it will adopt the Chronic Care Model Patient, professional and payment pressures 3. Treatment Goal = self-managed disease control Recovery will be one method of disease control

3 Use Driven by access and availability Abuse Use despite negative consequences Addiction Uncontrolled use driven by use but usually mediated by genes 3

4 Addiction An acquired, genetically mediated, chronic illness like diabetes. Cardinal feature is loss of control over urges to use resulting from sustained (?) changes in brain structure and function. Addictions can be successfully managed but not yet cured. 4

5 Population Prevalence Very Serious Use In Treatment ~ 2,300,000 Addiction ~ 23,000,000 Harmful 40,000,000 Use Little/No Use Little or No Use

6 1 Historical and Modern Treatment Approaches

7 A Nice Simple Rehab Model Substance Abusing Patient Treatment NTOMS Sample of 250 Programs Non- Substance Abusing Patient

8 ASSUMPTIONS Some fixed amount or duration of treatment should resolve the problem Clinical efforts should be put toward correctly placing patients and getting them to complete treatment Evaluation of effectiveness should occur following completion Poor outcome means failure

9 How Do Treatments For Other Illnesses Work? Chronic Illness & Continuing Care

10 A Continuing Care Model Primary Care Specialty Care Primary Continuing Care

11 In Chronic Illnesses. 1 There is no Cure - the effects of treatment do not persist after care stops 2 Patients who are out of contact are at elevated risk for relapse: Retention is essential

12 In Chronic Illnesses. 3 Early, intensive stages prepare patients for less intensive care: ultimately Self-Management 4 - Evaluation is a clinical duty: Good function = continue care Poor function = change care

13 1 Effects on Research and Evaluation

14 Outcome In Hypertension Pre During During During Post Treatment Research Institute

15 Outcome In Addiction Pre During During During Post Treatment Research Institute

16 A Real World Example Two Similar Matching Studies With Very Different Results

17 Project MATCH RCT - 3 Research-Derived Therapies $27 Million Dollar NIAAA Study Different Mechanisms of Action Fixed Interventions All Patients Goal Achieve Lasting Abstinence Post Completion

18 Project Match Fixed Time - Fixed Content Rehab Oriented Treatment Type Post Treatment Evaluations MET CBT 45% 38% 27% 12-Step

19 ALLHAT The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Treatment Research I nstitute

20 ALLHAT $63 million 61 sites Three Groups Different drug actions, Different drug costs Diuretic -$0.10 / pill Calcium Channel Blocker -$1.50 /pill Ace Inhibitor -$4.00 /pill Goal I mprovement on Pre-Specified Criterion DURING TREATMENT

21 ALLHAT Pre-Specified Criteria Adjustment Oriented Start 27% Control DURING Treatment Evaluations Step 1 Step 2 Step 3 Diuretic CCB 42% 55% 64% ACE

22 1 A Bad Habit not an Illness Leads to a Special Approach

23 1 Fundamentals of the Affordable Care Act Without all the Political Crap

24 2010 Healthcare Reform The Affordable Care Act Premises about healthcare: It is a right not a privilege It is a government responsibility Universal health insurance will reduce healthcare costs We will see? Inappropriate, expensive utilization Promote individual responsibility

25 2010 Healthcare Reform The Affordable Care Act Major Elements (Contd.): Health Insurance Expansion 22m Required Participation (payment) Medicaid the major mechanism Focus on Accountability Restore Primary Care PCMH Focus on Prevention Focus on Essential Benefits

26 2009 Parity Act MHPAEA If a health plan covers MH/SA benefits should be comparable to those of similar physical illnesses - Requires Insurer transparency 2010 ACA MH/SA coverage is mandatory - Essential Services

27 Why are SA Benefits Essential Very Serious Use In Treatment ~ 2,300,000 Addiction ~ 23,000,000 Little/No Use $120B/yr Harmful 40,000,000 Use Little or No Use

28 1 Implications for Substance Use Disorders

29 ACA Will Transform SA SA care is Essential Service SA is firmly part of healthcare Funds full continuum of care Prevent, BI, Meds, Spec Care Benefits will change The nature of benefits The payment mechanisms More/different providers

30 SUD Benefits Today Very Serious Use Addiction In Treatment ~ 2,300,000 Addiction ~ 23,000,000 Harmful 40,000,000 Use Little/No Use Little or No Use

31 Detoxification 100% Ambulatory 80% Opioid Substitution Therapy 50% Urine Drug Screen 100% 7 per year Note Great variability state to state

32 1 Medicaid Diabetes benefit

33 Physician Visits 100% Clinic Visits 100% Home Health Visits 100% Glucose Tests, Monitors, Supplies 100% Insulin and 4 other Meds 100% HgA1C, eye, foot exams 4x/yr 100% Smoking Cessation 100% Personal Care Visits 100% Language Interpreter - Negotiated

34 Physician Visits 100% Screening, Brief Intervention, Assessment Evaluation and medication Tele monitoring Clinic Visits 100% Home Health Visits 100% Family Counseling Alcohol and Drug Testing 100% 4 Maintenance and Anti-Craving Meds 100% Monitoring Tests (urine, saliva, other) Smoking Cessation 100%

35 Care of Substance Use Disorders Very Frequent Use Specialty/Chronic Care Disease Spectrum in Population to be Treated & Managed Office-Based Primary Care Prevention & Early Intervention Very Rare Use

36 Elements of a Chronic Care Model 1. Continually Measurable goal Disease Control = reduced symptoms, improved function, low costs Simple, accurate measurement during care 2. Diagnostic/Functional Assessment To produce an individualized treatment plan 3. Potent, Varied Therapeutic Components Medications, therapies, social services 4. Ability to Adjust Care According to Results

37 Tobacco (NRT, Varenicline, Vaccine) Alcohol (Naltrexone, Accamprosate, Disulfiram) Opiates (Naltrex., Methadone, Buprenorphine) Cocaine (Disulfiram, Topiramate, Vaccine) Marijuana Nothing Yet Methamphetamine Nothing Yet

38 Cognitive Behavioral Therapy Motivational Enhancement Therapy Community Reinforcement and Family Training Behavioral Couples Therapy Multi Systemic Family Therapy 12-Step Facilitation Individual Drug Counseling

39 Wait a Minute Yes We Do! 1. Continually Measurable goal Disease Control could equal negative urines & simple functional measures during care 2. Diagnostic/Functional Assessment Several available ASI, GAIN, ASAM 3. Potent, Varied Therapeutic Components Medications, therapies, social services 4. Abililty to Adjust Care According to Results Oh yeah we have programs that s how we have always been paid!

40 SPECTRUM OF ILLNESS & CONTINUUM OF CARE: Type 2 Diabetes Substance Use Disorders What is Needed? Pre- Diabetes Screening those at risk Motivational education Behavioral Interventions Electronic Monitoring Clinically Managed Diabetes Behavioral Interventions Medications Family/Peer Support Close Monitoring Personally Managed Diabetes Electronic Monitoring Social/Environment Services Family/Peer Supports

41 Chronic Care Model for Addiction 1. Stabilization If Needed 2. Clinical Management Setting(s), Components & Duration determined by: Patient Registry Data to start, then Concurrent Recovery Monitoring Results 3. Patient Self-Management

42 The End Because of ACA (but also other forces): 1. We will have access to reimbursement for more and different types of care than ever Addiction Specialty Care referrals could triple 2. Specialty care will NOT be programmatic it will adopt the Chronic Care Model Patient, professional and payment pressures 3. Treatment Goal = self-managed disease control Recovery will be one method of disease control

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