Advances in the Treatment of Addiction:
Shifting the Treatment Paradigm Again
Thomas E. Freese, Ph.D.
UCLA Integrated Substance Abuse Programs
Disproportionate Impact on Persons with MI/SUDs
• 20.4% SMI and 18.2% other mental disorder are uninsured,
compared to 11.4% w/o mental disorder
• 111 million Americans covered by group commercial
insurance; 29 million covered by state/local governments
– 98% of policies cover MH & 92% cover SA but with
unequal coverage and/or processes
– MI/SUD are usually pre-existing conditions when seeking
coverage
• 3 million (16.3%) full-time workers w/o health insurance
needed substance use treatment in past year (SAMHSA
national survey), particularly among 18-25 year olds (24.4%)
& males (19.2%)
Disproportionate Cost Implications - 1
• Medical costs of persons w/co-morbid physical & BH
disorders
– 5% of population accounted for almost 50% of total
costs due to chronic conditions & multiple co-morbidities,
severe mental illness, and services that are fragmented
among multiple providers
• Costs for persons w/ these illnesses are disproportionately
high and services are increasingly provided in integrated
settings
– 20.3% of MH spending is in general medical settings
– 23.2% of mental health spending is for psychotropic
drugs (2007)
Health Insurance Reform Goals
President’s Principles:
– More stability & security for those who
have insurance
– Affordable coverage options for those
who do not
– Lower costs for families, businesses,
and governments
Distribution of Alcohol (or Drug) Problems
Severe
Specialized
Treatment
Substantial
Moderate
Brief
Intervention
Mild
Prevention
None
20.9 Million People Need But Do Not Receive
Treatment For Illicit Drug or Alcohol Use
Did not feel that
they needed treatment
Felt that they needed
Tx, but made no effort
Felt that they
needed Tx, and
did made an effort
Source: SAMHSA, 2007 National Survey on Drug Use and Health (Sept 2008).
Distribution of Alcohol (or Drug) Problems
2.3 Million
Severe
22.2 Million
Substantial
Moderate
??????
Mild
None
Current
Funding
Sources
Current Tx
System
HCR
Funding
Sources
Residential
Outpatient
MediCal
Block Grant
Medical
Detox
System
Insurance
MediCal
OTP SUD
services
Insurance
Self pay
Self pay
Recovery
Support
Block Grant
It’s time for another
paradigm shift…
• Specialty treatment system will need to be
able to bill for individual services
• Specialty treatment system will need to
respond to patient choice
• A whole new group of patients will enter the
system through the health care system
• The healthcare system will be able to
provide some of our services
WORKFORCE INTEGRATION
ISSUES
ASAM
Doctors
5,000
Addiction
Psychiatry
1,200
Psychologists
Addiction
Treatment
Social
Work
36,000
Nursing
Marriage
and Family
Therapists
2,500
Practitioners Specializing in Addiction Treatment through Various
Certification or Certificate Programs (9/2010)
Provider/practice barriers
• Differing practice styles
• Differing practice cultures and language
• Difficulty in matching provider skills with patient
needs
• Heavy reliance on physician services
• Tension between direct patient care services
(reimbursable) and integrative (non-reimbursable)
services
Provider/practice barriers
• Lack of recognition of provider limitations
• Lack of MH knowledge in PC providers and lack
of health knowledge in BH providers
• Lack of clinical competence in integrated service
models (MH/SU and BH/PC) and selection of
proper integration model based on practice
context
• Differing coding and billing systems
• Provider resistance
Regulatory, licensure, and
scope of practice barriers
• Licensure and scope of practice is set at the state
level - many variations in laws and professional
regulations/certification standards
• Varying standards across disciplines governing the
types of services that can provided and the extent to
which clinicians can practice independently in
different settings
• Confidentiality laws and sharing of case information
can be affected (HIPPA, CFR 42)
FINANCIAL BARRIERS
• Payors have strict requirements of who can bill
for what service
• Increase in Medicaid necessitates provider and
workforce capability to bill this payor
• Payment for health/recovery coaches and use
of peers is slow to emerge
• Allowances for payment for
services in new job
classifications areas,
such as Care Managers
Overall: Essential Workforce Skills
Patient
Centered/Whole
person care
Coordination &
Transitions of
Care
Integration of
Care
System-based
care
Practice &
Population
Management
Quality,
Performance, &
Practice
Improvement
Practice-based
learning
Chronic disease
management
Information
Technology
Communication
&
Professionalism
Teamwork
Borkan, J. (2009). Workforce Training for PCMH:
What are We doing to Equip the Team?
Behavioral Health Practice Models: Workforce Implications
What is “Primary Care Integration”?
• Primary care integration is the collaboration
between SUD service providers and primary
care providers (e.g., FQHC’s, CHC’s)
• Collaboration can take many forms along a
continuum*
MINIMAL
Coordinated
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
Co-located
CLOSE
Integrated
*Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health
Integration in Primary Care. New York: Millbank Memorial Fund; 2010.
MINIMAL
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
CLOSE
minimal
• Mental health (MH) providers and primary
care (PC) providers:
– work in separate facilities,
– have separate systems, and
– communicate sporadically.
MINIMAL
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
CLOSE
Basic AT A DISTANCE
• PC and BH providers have separate systems
at separate sites, but now engage in periodic
communication about shared patients.
• Communication occurs typically by email,
telephone or letter. Improved coordination is
a step forward compared to completely
disconnected systems.
MINIMAL
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
CLOSE
BASIC ON-SITE
• Mental health and primary care professionals
have separate systems but share the same
facility.
• Proximity allows for more communication, but
each provider remains in his or her own
professional culture.
MINIMAL
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
CLOSE
CLOSE PARTIALLY INTEGRATED
• MH professionals and PC providers share the
same facility
– have some systems in common, such as
scheduling appointments or medical records.
• Physical proximity allows for regular face-to-face
communication among providers.
• There is a sense of being part of a larger team in
which each professional appreciates his or her
role in working together to treat a shared patient.
MINIMAL
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
CLOSE
CLOSE – FULLY
INTEGRATED
• The MH provider and PC provider are part of
the same team. The patient experiences the
mental health treatment as part of his or her
regular primary care.
Integration: workforce
considerations
• Regulatory issues including credentialing and licensing
– State laws/rules regarding licensure of mental health and
substance abuse facilities – each with workforce requirements to
deliver care
– State laws/regulations about scope of practice –govern types of
services that can provided and the extent to which clinicians can
practice independently in different settings
• Levels of risk and responsibility depend upon the level of
integration
• The use of paraprofessionals—common in the behavioral
health setting—can be difficult to reimburse in a primary
care site.
MINIMAL
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
CLOSE
Models of integration
1. Improved Collaboration between Separate
Providers
2. Medical-provided Behavioral Health Care
3. Co-location
4. Disease management
Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care
MINIMAL
BASIC
BASIC
CLOSE
At a Distance
On-Site
Partly Integrt Fully Integrt
CLOSE
Models of integration
5. Reverse Co-location (PC co-located in BH
settings)
6. Unified Primary Care and Behavioral Health
7. Primary Care Behavioral Health
8. Hybrid Collaborative System of Care
Collins, Hewson, Munger, & Wade (2010) Evolving Models of Behavioral Health Integration in Primary Care
Where
Do You
Begin?
All healthcare is local. Working out the details
of who does what, for what levels of MH/SA
services requires engaging local partnerships to:
•
Decide your integration goals
•
Determine how you want to achieve those goals
•
Understand your regulations that govern facility
licensure and professional scopes of practice for
MH/SA services
•
Examine current and projected needs for your
workforce
•
Determine payor issues
A key partner…
The Federally Qualified Health Centers
(FQHCs)
What are FQHCs?
• Federally Qualified Health Centers (FQHCs),
designation provided to BPHC grantees (HRSA)
under Section 330 Public Health Service Act
• Private non-profit or public free-standing clinics
serving designated MUAs or MUPs.
• One of few Federal programs for primary care to
the non-institutionalized population
• Must meet additional requirements in order to
participate in BPHC Health Center program
30
Types of “Health Centers”
• Terminology used interchangeably but confusing:
“federally qualified health centers (FQHCs)”, “health
centers”, “community-based health clinics”, “community
health centers (CHCs)
• Several types of FQHCs in the health center program:
– Community Health Centers
– Migrant Health Centers
– Healthcare for the Homeless Program
– Public Housing Program
• FQHC look-alikes
• Others- clinics operated by IHS or tribal authorities,
school-based health clinics, nurse-led clinics
BPHC Health Center Program Requirements
(Health Services)
• Basic health services (primary and preventive care)
• Ensure access to comprehensive health and social
services (e.g. substance abuse and mental health)
• Agreements for hospital referral (e.g. admitting
privileges)
• Additional services may be critical depending upon
population (e.g. occupational health for migrant workers)
BPHC Health Center Program Requirements
(Additional Key Requirements)
• Provide enabling services (e.g. transportation,
translation, in-house pharmacy)
• Provide services regardless of ability to pay (sliding
scale)
• Accessible hours of operation
• Continuous quality improvement
• Community and patient representation on Board
• Reporting requirements (e.g. UDS)
Benefits of FQHC designation
• BPHC grant funding (20% of funding sources)
• Additional grant funding opportunities only open to
FQHCs (e.g. Health Disparities Collaborative)
• Cost-based Medicare reimbursement and
Medicaid prospective payment system
• Prescription drug discount
• Malpractice coverage
• Federal loan guarantees for capital projects
• NHSC site, although soon can qualify as own
ambulatory care teaching site
FQHCs in California
Who do FQHCs serve
• 113 clinic corporations with 1,049 sites
• 3.7 million patients served
• 53% of state’s population below 100% of
Federal Poverty Level (FPL) and 26%
below 200%
• 15% of state’s uninsured residents served
• 46% of total revenues from Medi-Cal
The Role of FQHCs in Providing SUD services
New funds will allow for
• construction of new FQHCs
• expanded behavioral health services
• a dramatic increase in the number of newly
insured Medicaid patients who receive
services from FQHCs.
– 15 million more people are expected to be
eligible for Medicaid by 2019
Evidence shows that increases in funding to
FQHCs result in an increase in the provision of
behavioral health services.
• Federal government boosted financial
support to FQHCs between 2002 and 2007
– the number of FQHCs increased 43%
– the number of FQHCs providing SUD services
increased 58%.
– newly funded FQHCs were no more likely than
previously funded FQHCs to provide behavioral
health care.
Evidence shows that increases in funding to
FQHCs result in an increase in the provision of
behavioral health services.
• Over half (51%) of FQHCs providing some
type of SUD service.
– there are no data describe what services are
delivered or how they are delivered
• 77% of FQHCs provide mental health
services
– it is not clear why this proportion of FQHCs
have not also incorporated SUD services.
New opportunities ahead
Areas for workforce advocacy
• Transformation of organizational cultures
• Expand diversity of providers (e.g., culture,
language) and assure culturally competent
service delivery
• Define future roles (care manager, navigator,
coach, health educator, others) for peers/family
partners) and
– develop methods to recruit, train and certify
them in these roles
Areas for workforce advocacy
• Identify a set of shared core competencies
– train current staff as well as those in the
educational pipeline
• Engage all community partners for local
PC/MH/SA workforce plans
• Seek adjustments in clinical training programs
and academic curricula to support
collaborative/integrated practice
Two New team members
•
•
•
•
•
•
Consulting Mental
Care Manager/BHC
Health Expert
Educates the individual about
• Caseload consultation
depression/other conditions
for care manager and
Supports medication therapy
PCP (population-based)
prescribed by the PCP
• Diagnostic consultation
Coaches individuals in
on difficult cases
behavioral activation
• Recommendations for
Offers a brief counseling
additional treatment and
referral according to
Monitors symptoms for
evidence-based
treatment response
guidelines
Completes a relapse prevention
plan with each individual
Mauer, B. (2009). Behavioral Health/Primary Care Integration and The Person-Centered Healthcare Home
As the treatment of substance use
disorders (SUDs) moves to the world of
healthcare services………………………
A wide range of SUDs will be addressed, not just the most
severe.
Patients will be viewed as respected healthcare consumers.
Treatments will need evidence of effectiveness
Treatment will be accountable.
Patients will have choice about treatment types and goals.
A diverse set of treatments will be used
for a diverse set of patients
• Screening and Brief Interventions
• Brief Treatments
• SUD treatment delivered in MD offices and primary
care settings
• SUD treatment will be delivered together with mental
health services.
• Evidence-based treatments will be used
• Outpatient services will be increasing combined with
needed social services and housing alternatives.
Evidence-based Treatments:
Medications
• Opiate Addiction: Methadone,
Buprenorphine, Naltrexone
• Alcohol: Naltrexone, Vivatrol, Campral,
Ondansetron
• Nicotine: Nicotine replacement,
Varenicline
Evidence-based Treatments:
Behavioral Approaches
• Brief Interventions
• Brief Treatments for cannabis and other
problem use disorders
• Motivational Interviewing
• Motivational Incentives
• Cognitive Behavioral Therapy
• Combination Therapies (Community
reinforcement approach, Matrix model,
Family therapies)
Consumer Improvement Strategies
• Integration of SUD screening and treatment
into mainstream healthcare settings.
• Increasing focus on consumer satisfaction and
consumer perception of care
• Increasing use to strategies to increase
consumer access to care and appreciation of
care (eg. NIATx)
• Increasing measurement of service
effectiveness and greater provider
accountability
One example of why this is
so difficult…
Physician Management of Opioid
Addiction
• Qualitative analysis of interviews with illicit
drug-using patients and their physicians and
direct observation of patient care
interactions
• Inpatient medical service of an urban
teaching hospital (6/97-12/97)
Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. J Gen
Intern Med. 2002;17:327-333.
Physician Management of Opioid
Addiction: Themes
1. Physician Fear of Deception
Physicians question the “legitimacy” of need for opioid prescriptions
(“drug seeking” patient vs. legitimate need).
“When the patient is always seeking, there is a sort
of a tone, always complaining and always trying
to get more. It’s that seeking behavior that puts
you off, regardless of what’s going on, it just
puts you off.”
-Junior Medical Resident
Physician Management of Opioid
Addiction: Themes
2. No Standard Approach
The evaluation and treatment of pain and withdrawal is extremely
variable among physicians and from patient to patient. There
is no common approach nor are there clearly articulated
standards.
“The last time, they took me to the operating room,
put me to sleep, gave me pain meds, and I was
in and out in two days.. . .This crew was hard!
It’s like the Civil War. ‘He’s a trooper, get out
the saw’. . .’”
-Patient w/ Multiple Encounters
Physician Management of Opioid
Addiction: Themes
3. Patient Fear of Mistreatment
Patients are fearful they will be punished for their drug use by poor
medical care.
“I mentioned that I would need methadone, and I
heard one of them chuckle. . .in a negative,
condescending way. You’re very sensitive
because you expect problems getting adequate
pain management because you have a history of
drug abuse. . .He showed me that he was
actually in the opposite corner, across the ring
from me.”
-Patient
Physician Management of Opioid
Addiction: Conclusions
• Physicians and drug-using patients display
mutual mistrust.
• Physicians’ clinical inconsistency, avoidance
behaviors and fear of deception,
problematically interact with patients’ fear of
mistreatment and stigma.
• Medical education should focus greater
attention on addiction medicine and pain
management.
Treatment of SUDs: Changes
Ahead
SUD Treatment will increasingly become a part
of the healthcare system and less an
extension of the criminal justice system.
Treatments will be required to “attract” patients
based on their effectiveness, convenience
and patient acceptability, rather than relying
on patient coercion.
Scientific evidence and treatment accountabilty
will play increasingly important roles.
Affordable care act – Behavioral health
•
Allows state Medicaid programs to establish medical homes
for those with chronic illnesses –MH/SUD prevention and
treatment among those with chronic illnesses
•
Grants for school-based health clinics to provide MH/SUD
assessments, crisis intervention, treatment, and referral
•
Grants to community MH programs for co-locating primary
and specialty care services
•
Establishes the CLASS Program – voluntary, self-funded
long-term care insurance program for people currently
employed – flexible funds for support services to people
with disabilities, including Mental illness
Hyde, P. (2010). Behavioral Health 2010: Challenges & Opportunities
Affordable care act – Behavioral health
SUPPORT FOR WORKFORCE DEVELOPMENT

Funding for residencies for behavioral health included
with other disciplines (HRSA)
 Loan repayment programs
 Push towards more national certification standards
and re-licensure/re-certification
TRAINING & RESEARCH
 Increased patient-centered health research

Training grants for behavioral health workforce

Training on MH/SUD for Primary Care Extender
Hyde, P. (2010). Behavioral Health 2010: Challenges & Opportunities
Potential Benefits of Linking Primary Care
(PC) and Substance Abuse (SA) Services
• Patient Perspective
– Facilitates access to SA treatment and PC
– Improves substance abuse severity and medical
problems
– Increases patient satisfaction with health care
• Societal perspective
– Reduces health care costs
– Diminishes duplication of services
– Improves health outcomes
Samet JH, Friedmann P, Saitz R. Arch Intern Med. 2001;
Current SAMHSA initiatives

Preparing field (states, providers, consumers, families)
– Capacity to provide mental health and substance use
services (workforce)
– Accessing and developing strategies to improve
infrastructure (data, HIT)
– Facilitating linkage with primary care and other
providers
– Providing enrollment information

Reviewing current block grant spending to focus on
recovery and support services not paid for through
Medicaid or commercial insurance
Current SAMHSA initiatives
 Providing
workforce development to addiction service
providers through the ATTC Network www.attcnetwork.org
 Grants
for screening and brief interventions (SBIRT) for
primary care
National Technical Assistance Center
for Primary Care and Behavioral Health
Integration (SAMHSA/HRSA).
Take away points
• Similar challenges exist in the health and behavioral health
workforces
• Behavioral health workforce is complex with much state level
variation, particularly for the addiction workforce
• Achieving integration will require attention to barriers and
development of current, essential workforce skills
• Workforce-related risks and responsibilities will vary depending
upon which integration model is selected
• Future holds many opportunities to advocate for our respective
workforces and advance workforce development through
financial and technical assistance means.
More Training Coming
SAVE THE DATE
And
PRE-REGISTER for $50
• Tuesday, November 16, 2010
Tehama County
• Thursday, November 18, 2010
Los Angeles County
• Wednesday, December 1,
2010 Merced County
• Tuesday December 7, 2010
Alameda County
Thank you
Thomas E. Freese, Ph.D.
tfreese@mednet.ucla.edu
www.psattc.org
www.uclaisap.org
“Be kind, for everyone you meet is
fighting a great battle.”
Philo of Alexandria