Part II: Looking into the "crystal ball"

Before a crowd of about 800 at this year’s State Associations of Addiction Services (SAAS) and NIATx Summit, three key officials—SAMHSA administrator Pamela Hyde, ONDCP deputy director Tom McLellan, and NIDA division director Wilson Compton—highlighted federal efforts and initiatives that will impact funding, care methodologies, care delivery, and technology implementation for providers of behavioral health and substance use treatment services now entering into what Hyde called “the brave new world” shaped by national health reform and parity.

Now, Part II—continued from last week’s online exclusive.

Compton calls for “medicalizing addiction”
Noting the huge disparity between the estimated 23 million Americans who meet diagnostic criteria for substance use disorders and the 2.3 million currently in treatment, Compton outlined a new vision for mainstreaming addiction into general medicine, or as he said, “medicalizing addiction.”

“We’ve got to go there or we will be left behind in terms of improving public health and making an impact on the wide range of social costs and consequences of addiction,” said Compton. At present, however, two problems stand in the way: a lack of awareness among individuals with substance use problems and a lack of follow-up by physicians.

“People don’t think they’re addicted, even though they meet diagnostic criteria. But they’re showing up somewhere—emergency rooms, for example—and doctors aren’t picking it up,” said Compton. “ER and primary care doctors often see addiction as more of a social disease, not a medical problem.”

McLellan agreed, stating that doctors could pick up on substance use issues through brief screening and interventions. “Just two or three questions can help a doctor identify patients who are drinking too much or using too often. Although these patients represent just 20 percent of the primary care population, they represent 50 percent or more of the visits to ERs and trauma centers.”

The key, he added, is to “let doctors know that they can do it” and to support additional screening and intervention by simplifying paperwork and increasing payments. “If they look carefully, they’ll see that it’s often the excess alcohol use that’s screwing up their treatment for diabetes; the undiagnosed marijuana use that’s screwing up treatment for asthma; so it is very much in the interest of better healthcare.”

Compton presented study results that showed even modest interventions could have health impacts. One study showed that, among patients presenting with substance use concerns, a 10-minute peer intervention helped significantly reduce substance use rates over a six-month period. Even a visit to primary care—without the peer intervention—led to improvements over the longer term. “It’s clear that SBIRT and similar approaches can make a difference in all kinds of settings, all over the world.” For that reason, Compton said that NIDA has been increasing funding for SBIRT-related studies since 2008.

McLellan: Serve the 90 percent who are now unserved
Both speakers agreed that primary care providers must expand their role in first-level addiction treatment. Despite a wide range of available therapies—CBT, MBT, community reinforcement/family training—and medications, McLellan says that many addiction treatment providers lack the professional personnel (doctors, psychiatrists) and range of training necessary to administer these more complex treatments. To help fill this gap, McLellan said that the government is turning to 7,000 federally qualified health centers (funded by HRSA), and 250 more centers funded by the Indian Health Service. “They have the people, the infrastructure, and the EHR systems to implement this approach. Now, we’re asking that they focus on it.”

McLellan pointed out that “they’re not going to be taking your funding, your treatment opportunities, or your business referrals.” He said that they would “bring in new patients” from among the 90 percent who remain unserved.

“If this program works, then primary care doctors who do not now know how to treat substance use disorders will learn. And if they’re unsuccessful in first-level treatment, they’ll make referrals to specialty care centers like yours—that is, if you have a relationship with them, if you can bill Medicaid, if you have the ability to handle electronic health records and, therefore, to meet their needs. It’s a new line of business, folks; you’re not losing anything, you’re going to gain. And what the country’s going to gain is whole lot more access and availability of care where the rest of healthcare is delivered. That’s the plan.”