Treatment for Substance Use Disorder: Opportunities and Challenges Under the Affordable Care Act

Abstract

Addiction is a chronic brain disease with consequences that remain problematic years after discontinuation of use. Despite this, treatment models focus on acute interventions and are carved out from the main health care system. The Patient Protection and Affordable Care Act (2010) brings the opportunity to change the way substance use disorder (SUD) is treated in the United States. The treatment of SUD must adapt to a chronic care model offered in an integrated care system that screens for at-risk patients and includes services needed to prevent relapses. The partnering of the health care system with substance abuse treatment programs could dramatically expand the benefits of prevention and treatment of SUD. Expanding roles of health information technology and nonphysician workforces, such as social workers, are essential to the success of a chronic care model.

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Keywords: Substance use disorder, Affordable Care Act, chronic care model, health information technology, social workforce, screening brief intervention and referral to treatment

Introduction

Substance use disorder (SUD) is among the most serious and costly public health issues in the United States and globally. The estimated costs to the American economy were $223.5 billion in 2006 for excessive alcohol drinking (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011) and $193 billion in 2007 for illicit drug abuse and related problems (U.S. Department of Justice & National Drug Intelligence Center, 2011). The urgency of the problem is epitomized by the sharp rise in the misuse and abuse of opioid analgesics in the United States over the past decade with the associated dramatic increases in death from overdoses (Centers for Disease Controls and Prevention [CDC], 2011; Paulozzi, 2011). This rising problem added an estimated economic cost of $53.4 billion in 2006 (Hansen, Oster, Edelsberg, Woody, & Sullivan, 2011). The epidemic of opioid abuse is particularly poignant in that it relates to the abuse of a medication prescribed by the health care system, highlighting the need for implementing screening and appropriate interventions or referrals for patients with a SUD in primary care settings.

Treatment for SUD has been separated from mainstream health care, partly due to the longstanding "carve-out" of the behavioral health-managed care system. The isolation of behavioral health care from mainstream medical care has impeded the delivery of integrated care and services needed by those with a SUD. Carving out the delivery and financing of behavioral managed care may have helped contain costs and improve the care for the more serious cases of abuse and addiction (Ma & McGuire, 1998), but the disadvantage is that the majority of individuals with mild and moderate substance use problems have missed the opportunity for early detection, timely intervention, and referral at an early stage of substance abuse (Tai, Wu, & Clark, 2012). This problem is amplified by the large proportion of patients with a SUD with comorbid mental health and other medical conditions (Stein, 1999).

On the other hand, the benefits of integrated systems are shown by a randomized clinical trial (RCT) in which individuals with comorbid SUD and physical conditions had significantly higher utilization of inpatient care and emergency room visits when assigned to an independent care group compared to those assigned to an integrated care group (Parthasarathy, Mertens, Moore, & Weisner, 2003). Integration of care is not only more practical for the substance abuser but also serves to educate health care providers and counselors about their unique therapeutic tools and expertise facilitating adoption of medication and behavioral therapies that may have otherwise been dismissed (Carter, 1990; Williams et al., 1999).

Treatments for SUD in the United States have often been viewed as inadequate or ineffective due to the high rates of relapse (McLellan, Lewis, O'Brien, & Kleber, 2000). Acute episodic treatment models, which are the norm for SUD by themselves, are insufficient to prevent subsequent relapses (McKay, 2005; McLellan, McKay, Forman, Cacciola, & Kemp, 2005). Not only does the high rate of relapse demoralize patients and those who care for them, it also negatively affects public opinion by misleading policy makers into thinking that SUD treatment does not work (McLellan, 2002).

Addiction is recognized as a chronic brain disease in that the changes of the brain associated with repeated drug exposures persist for a long time after drug discontinuation (Volkow & Li, 2005). Thus, SUD treatment should not focus solely on temporary abstinence, or acute management of withdrawal symptoms but include long-term strategies for reducing relapse and improving the quality of patients' medical and social lives. However, the tools and infrastructure to support the management of SUD as a chronic disease have been lacking in our health care system. For example, the continuous monitoring and intervening tools needed for the proper care of patients with a SUD are not supported by current payment systems, and there are no collaborative provider teams that can implement them (Anderson & Knickman, 2001; Dennis & Scott, 2012; McLellan, 2010; Rosenthal, Fernandopulle, Song, & Landon, 2004).

Thus, implementing strategies to prevent medical and social consequences from SUD is required. As introduced above, the necessary transformations in the care of SUD include (a) changing from a reactive model that intervenes when the person is already sick, to a proactive one that emphasizes preventive services such as implementation of screening and brief intervention (SBI) in primary care settings and (b) changing from an episodic acute model into a chronic care model (CCM) attuned to the chronic and relapsing characteristics of SUD. These changes of proactively seeking and screening patients with a SUD (who are often reluctant to seek help) and their long-term engagement in treatment will be able to substantially increase the number of effectively treated SUD patients. These proposed changes fit well within the Affordable Care Act (ACA) of 2010 (CCH Inc., 2010) and the Parity Act of 2008 (U.S. Department of the Treasury, U.S. Department of Labor, & U.S. Department of Health and Human Services, 2010) because this legislation requires that the SUD treatment coverage is "no more restrictive" than all other medical and surgical procedures.

How the ACA Can Improve Preventive Care For SUD

An estimated 22.1 million Americans age 12 or older were classified with dependence or abuse of alcohol and/or illicit drugs during 2010 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). However, only 4.1 million of these individuals received some type of treatment, mostly in either self-help groups or rehabilitation centers, and very few received such care in the medical care systems (SAMHSA, 2011). Thus, the majority of individuals with risky drinking and/or drug use behaviors remain untreated or undertreated (see Figure 1, adopted from Dr. Thomas McLellan's presentation seen in Maslack, 2010).

FIGURE 1

The triangle represents the U.S. population. The terms to the right of the figure refer to subpopulations by drug consumption level and the degree of substance use severity.

In addition, misuse and abuse of prescription drugs has become an alarming public health crisis in the United States that has evolved over the past 20 years. The increase in the diversion and abuse of opioid analgesics has been associated with the sharp rise of unintended overdose deaths in the United States over the past 10 to 15 years (CDC, 2011). Individuals with a SUD are also more likely to have mental disorders and physical health problems, including chronic pain that may require prescriptions of potentially addictive medications. Substance abusers without regular medical and substance abuse care are 10% to 27% more likely to be hospitalized than those with regular medical and/or substance abuse care (Laine et al., 2001). Screening and early intervention offered in the context of regular care, therefore, holds great potential for halting the progression of substance use problems into addiction and for curtailing the deleterious effects of drug abuse on pulmonary, cardiovascular, infectious, and mental diseases.

The primary health care setting is particularly well suited to screen for alcohol and drug use (Green, Cifuentes, Glasgow, & Stange, 2008; Lundberg, 1997; O'Connor & Samet, 2002). The high prevalence of alcohol and drug use problems detected in primary care settings (Pilowsky & Wu, 2012; Saitz, 2005) has made primary care settings key venues for early detection and prevention of alcohol and drug problems. For instance, a survey conducted in 2003 to 2005 in the New England area found that 15% of adolescents presenting at routine medical visits screened positive for alcohol or drug use (Knight et al., 2007). Research data also support the practice of SBI for harmful alcohol drinking in emergency departments and primary care settings (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005). Although universal SBI for harmful alcohol drinking in primary care setting has been recommended (Grade B) by U.S. Preventive Services Task Force since 2004 (U.S. Preventive Services Task Force, 2004; Whitlock, Polen, Green, Orleans, & Klein, 2004), many primary care practices have been slow to adopt it (Bradley et al., 2006).

Evidence to support the feasibility and efficacy of implementing Screening, Brief Intervention and Referral to Treatment (SBIRT) for illicit drugs and prescription medications in medical settings is not yet as extensive as that for licit substances (Saitz et al., 2010), but it is rapidly accumulating (Pilowsky & Wu, 2012). Bernstein et al. (2005) showed in a randomized controlled trial that a single brief motivational interview in a hospital medical visit helped cocaine and heroin addicts achieve abstinence. A large SAMHSA-sponsored demonstration program in six states also showed that implementing SBIRT in various general medical settings including emergency departments, rural health centers, and primary care clinics helped reduce patients' drug use, increased the likelihood of entering specialty treatment, and improved their quality of life and reduced Medicaid costs (Estee, Wickizer, He, Shah, & Mancuso, 2010; Krupski et al., 2010; Madras et al., 2009). A state-funded (State of Florida) implementation project showed that SBI at seniors' homes or centers decreased elderly patients' odds of alcohol abuse, prescription drug misuse, and of depression...