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Substance AbuseIn this FAQ...
How many individuals have substance use disorders? Although the terms change, the fundamental problems associated with these disorders remain constant. The accepted Institute of Medicine terminology is “substance use disorders.” According to the National Institutes of Health, nearly 14 million adult Americans—one of every 13—meet the diagnostic criteria for alcohol dependence or alcohol abuse. About 50 percent of adults have or have had a close family relative with one of those disorders. In addition, more than 70 percent of individuals who consume alcohol exceed moderate drinking guidelines (up to two drinks per day for men and one drink per day for women and older people). More than 50 percent of college students who drink alcohol say that they drink to “get drunk.” Although alcohol is legal for adults, the abuse of alcohol has become a serious problem in the United States. Approximately 12.8 percent of men and women experience symptoms of alcohol dependence at some time in their lives. Of those individuals, approximately 700,000 are treated annually. Experts use the following definitions to identify the severity of an individual’s problem with alcohol.
Drug addiction involves a loss of control over drug-taking behavior and an overwhelming compulsion to take drugs. It is a chronic, relapsing disorder; relapse can occur long after drugs are gone from the body. An addict will ignore the adverse consequences of drug use and is tolerant, physically dependent and psychologically dependent. Addiction begins with alcohol and other drug abuse when an individual makes a conscious choice to use alcohol and other drugs, but addiction is not simply “a lot of alcohol and other drug use.” Recent scientific research provides overwhelming evidence that not only do alcohol and other drugs interfere with normal brain functioning by creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity. At some point, changes occur in the brain that can turn alcohol and other drug abuse into addiction—a chronic, relapsing illness. Those addicted to alcohol and other drugs suffer from a compulsive craving for and use of alcohol and other drugs and cannot quit by themselves. Treatment is necessary to end this compulsive behavior. The National Survey on Drug Use and Health (NSDUH) indicates that alcohol is the most common substance use disorder problem. According to the 2002 survey, approximately one of every two Americans over age 12 was a current alcohol user, about one of five was a binge drinker, and about one of every 15 was a heavy drinker. Current, binge and heavy alcohol use are defined as follows.
According to the same survey, an estimated 19.5 million Americans over age 12 (8.3 percent) reported using illicit drugs in the past month during 2002. Marijuana, the most commonly used illicit drug, was used by 75 percent of current drug users. Studies show that some individuals who use alcohol also use other drugs. Of the 15.9 million heavy drinkers, approximately one-third (5.2 million) also were current illicit drug users. Although documented rates of heavy alcohol and illicit drug use are highest for the unemployed, substance use is a problem that disproportionately affects working Americans. Of the 15.2 million Americans age 18 and older who were heavy drinkers in 2002, 12 million (79 percent) were either full-time or part-time workers. Of the 16.6 million illicit drug users age 18 and older, 12.4 million (74.6 percent) were employed either full-time or part-time.
What are the latest advances in addiction treatment? The latest advance in addiction treatment is the recognition that addiction must be treated like other chronic diseases, rather than as acute or episodic ones. In this context, treatment is best viewed as a continuum of different types and intensities of services. A phrase commonly used in the current treatment field is “recovery management,” referring to the structured process of accessing and completing the range of services on the road to health and self-sufficiency. Under the continuum of care model, individuals with substance use disorders move through the spectrum of treatment and other social services. A service network of different programs that provide a multifaceted and multidisciplinary approach is ideal. These services should encompass the various types of substance use occurring in the community, should account for differences in client characteristics (e.g., age, gender, racial or ethnic group identification, socioeconomic level), and should be formally linked with other agencies that provide other supportive services—such as health care, education and housing programs—to ensure that patients can obtain help with associated physical, social and psychological problems. In fact, measures of success in treatment systems should be based not only on reduction or elimination of drug use, but also on the ability of the individual to gain access to and make progress in other areas (job training, housing, family skills, etc.). Some agencies and organizations are comprehensive enough to provide several types and modalities of treatment; however, most treatment providers specialize in one or a few treatment modalities. Clinical case management can be an effective tool for ensuring linkages with various agencies and for ensuring that individuals have access to the most appropriate types of services to meet their needs. The continuum of treatment involves four key stages:
Stage 1: IdentificationFor an individual with a substance use disorder to receive treatment, the disorder first must be identified. Many people who come into contact with potential clients are in a position to set them on the road to recovery. Some may self-identify their disorder, but spouses, parents, employers and teachers commonly are the first line of identification. In other cases, health care institutions, the criminal justice system, or the child welfare system will identify potential clients as a result of adverse consequences stemming from substance or alcohol use. An important principle that has emerged in the treatment field is “no wrong door to treatment,” meaning that, regardless of the source or type of identification, clients will be given access to the full continuum of treatment and recovery management. This is absolutely critical, because many public and private institutions will address alcohol or substance use disorders only to the extent that they affect the client’s present involvement in those institutions. This acute, episodic approach cannot appropriately address the range of complex issues that face clients with these disorders. As a result, they are much less likely to demonstrate long-term effectiveness. Stage 2: AssessmentClinical assessment is the first stage of formal intervention with those who have been identified. A comprehensive appraisal of the individual’s substance use disorder, how it affects his or her health and functioning, and the other types of social services required are vital for selecting treatment resources that best meet his or her needs. Assessment includes a determination of many factors, including:
When an individual is assessed, an initial treatment plan is devised, placing the individual in the appropriate treatment setting for the appropriate time and securing services that match his or her needs and strengths. Under the care model, the individual is continually reassessed throughout treatment, and any necessary changes are made in the treatment setting, time frame and/or services. Stage 3: TreatmentTreatment is designed to help the patient reduce his or her dependence on alcohol or other drugs and attain a higher level of physical, psychological and social functioning. A successful program may involve a combination of specific treatments and may change over time, depending on the individual. Incorporating management of psychological problems as a component of any rehabilitation program is crucial to the ongoing success of a patient’s treatment. Successful outcomes depend on retaining patients in treatment programs for a sufficient length of time. Whether a patient remains in a program can be attributed to individual factors—such as motivation and support from family or friends, and factors associated with the treatment program—such as positive relationships between counselors and patients. Counselors who establish such a relationship will be better equipped to identify and address patients’ needs and ensure successful treatment. The availability of different treatment options is important in achieving the overall goal of rehabilitation for the patient. Because each patient is different, a particular modality of treatment that may work best for one individual will not work for another. Rehabilitation and treatment can occur in both residential and outpatient settings, depending on the needs of the patient. Stage 4: Ongoing Recovery Management—Relapse PreventionAddiction is a chronic disorder, making prevention of relapse a critical element of effective treatment. It is not unusual for addicts to relapse within one month following treatment, nor is it unusual for addicts to relapse 12 months after treatment. Although relapse is a symptom of addiction, it is preventable. Relapse prevention methodologies help patients learn the skills needed to regulate their thinking, feeling, memory, judgment and behavior. To stabilize patients, they may receive help with:
Can you treat addiction with pharmaceuticals? Referred to as “pharmacotherapy,” pharmaceuticals can be an effective treatment for some individuals with substance use disorders. As defined by the Substance Abuse and Mental Health Services Administration (SAMHSA), “ ... in the context of substance abuse, pharmacotherapy is the treatment of drug or alcohol dependence with medication to achieve one of three ends: detoxification, relapse prevention, or opioid maintenance.” Although any one treatment will not be effective for all individuals, pharmacotherapy, in combination with other treatment modes such as counseling, has proven a great aid in recovery since its inception in the 1960s. Two general types of pharmacotherapeutic drugs exist for relapse prevention and opioid maintenance: agonists and antagonists. Agonists are chemicals that bind to and stimulate opiate receptors, creating a similar, but less intense, effect to opiate drugs of abuse. Antagonists are chemicals that bind to, but do not stimulate opiate receptors. Also available are partial agonists, chemicals that bind to and stimulate opiate receptors, but have a “ceiling effect”—a point after which, even if ingestion increases, intoxication does not increase. Methadone is the most common agonist medication used in relapse prevention and maintenance in opioid addiction therapy. Methadone has been used effectively for more than 30 years in the treatment of heroin and morphine addictions. Because opioid drugs produce an excess quantity of dopamine (a chemical released in the brain during times of pleasure) that places addicts at a higher need for dopamine, a key to treating opioid addiction among serious addiction cases is to mitigate the low-dopamine periods. Methadone binds to pleasure receptors in the brain, stimulating them to produce many effects similar to heroin or morphine, but without the detrimental effects on the body. The only approved settings for using methadone to treat addictions in the United States are specially licensed clinics and hospitals. Methadone therapy requires daily administration of doses; depending on the individual addict’s need and tolerance, the dose can be between 60 milligrams to 120 milligrams. The fact that there is an abuse potential has contributed to the Food and Drug Administration’s requirement that methadone be provided only in a tightly controlled environment. Despite the associated risks, the benefits of methadone treatment are numerous. Patients who have undergone methadone treatment have retained employment and avoided crime. Public health benefits include a lower risk of HIV-infection through reduced injection drug use and drug-related, high-risk sexual activity. Methadone treatment is cost-effective from a government perspective, as well. The Office of National Drug Control Policy reports that methadone treatment costs approximately $13 per day, compared to $40 per day for incarceration. In addition, for every $1 spent on methadone maintenance therapy, $4 in economic benefit accrue. Naltrexone is the most common antagonist medication. As an antagonist, naltrexone binds to pleasure receptors in the brain but does not produce pleasant effects. Furthermore, it blocks the pleasing effects of other opiates (heroin, morphine, etc.) and alcohol. Essentially, to an addict, this causes opiate use to become futile—no pleasure can be gained from it while on naltrexone therapy. Unlike methadone, naltrexone can be self-administered daily or clinically administered on a schedule. Self-administration is a viable option for naltrexone because it has a low-risk of abuse. A clinical setting generally administers the prescribed medication for those whose work might bring them into contact with opiates or who need a more structured program. Typical doses for opiate addicts are 50 milligrams for self-administration and 100 milligrams to 150 milligrams for clinical visits. Alcoholics generally require a dose of 25 milligrams per day. However, naltroxene therapy for opiate addiction may begin only following a medical detoxification and at least seven days free of opiates (10 days for those transferring from methadone therapy); alcoholics may begin treatment as soon as withdrawal symptoms cease. Earlier introduction of naltrexone into an opiate addict’s system can produce severe withdrawal symptoms. Naltrexone therapy has proven successful among addicts who are highly motivated to quit. Successful patients typically include those whose situation in life demands total abstinence, such as parolees, probationers and work-release prisoners, as well as those with workplace exposure to opiates, such as health care professionals. Patients who undergo naltrexone therapy experience few physical effects and can function normally, allowing them, as with methadone, to retain employment and avoid crime. The public health benefits associated with naltrexone therapy are identical to those associated with methadone—relapse prevention reduces risk of HIV infection and high-risk sexual activity. Recently joining the battery of pharmacotherapies is buprenorphine, a partial agonist that was approved by the FDA in October 2002. As a partial agonist, buprenorphine binds to pleasure receptors in the brain and stimulates them. The stimulation, though, is significantly less than experienced through heroin, methadone and morphine. The treatment reduces the cravings adequately, while allowing the addict to continue with daily functions. In addition, a slow rate of metabolization allows for less frequent administration and less severe withdrawal symptoms. Buprenorphine is unique in its approval for use in an office-based setting by primary care providers. Addicts who might shy away from treatment in a methadone clinic might be more comfortable receiving care from their doctor. Buprenorphine, which provides some pleasurable effects, is unsuitable for self-administration. Buprenorphine has a “ceiling effect,” a point at which greater feelings of pleasure plateau regardless of increased ingestion. Chemical ingenuity produced an additional method of addressing the diversion problem—suboxone. Suboxone is a tablet combining buprenorphine and naloxone. When placed beneath the tongue, the buprenorphine partial agonist component provides its desired effect. However, when dissolved and injected intravenously, the tablet’s antagonist naloxone component takes precedence and produces an unpleasant withdrawal effect. A fourth pharmacotherapeutic treatment, LAAM (levo-alpha-acetyl-methodol), was approved for use in 1993 as an agonist therapy but was discontinued in 2004 due to serious detrimental effects on the heart. For more information about pharmacotherapy, see A Guide to Substance Abuse Services for Primary Care Clinicians, USDHHS/SAMHSA/CSAT. (http://ncadi.samhsa.gov/govpubs/BKD234/24i.aspx).
What are the latest advances in the treatment of co-occurring mental illness and addiction? The term “co-occurring disorders” refers to the presence of two or more illnesses or disorders in a person at the same time. An estimated 10 million people who have substance use disorders have a co-occurring mental illness. Mental health and addiction treatment professionals face the daunting task of recognizing the additional condition or conditions, referring the individual to the proper provider for diagnosis of the co-occurring condition, and ensuring care coordination. Due to the enormous human and economic toll caused by co-occurring disorders, policymakers, providers and funders have long sought better means to assess individuals and the most appropriate treatments. Historically, seamless provision of services has been an elusive goal. Substance abuse and mental health systems generally operate independently of each other. As such, both have developed their own unique cultures, languages and jargon, administrative structures and funding mechanisms. A key challenge in treating those with co-occurring disorders is ensuring mental health and addiction professionals are cross-trained to understand their counterpart’s system, establish common assessment tools and data standards, and establish flexible funding streams to guarantee that funds are available for the right system at the right time. Such measures compose the “no wrong door” approach to treatment of co-occurring disorders. In this approach, services appear seamless and coordinated to the individual who receives the care. A joint task force of the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol/Drug Abuse Directors (NASADAD) proposed—in a 2002 report National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders—a new conceptual framework to give policymakers, providers and funders a common platform from which they can discuss the issue. The proposal for more effective communications was the quadrant system, a new diagnostic tool and language for determining the severity of each condition, and thus the system/provider best equipped to lead the individual’s treatment. The four quadrants are (see figure 1):
The first and last categories are those most likely to require significant funding. Category I includes many children and adolescents, the key state targets for early intervention in which disorders would be prevented from increasing. Those in Category IV are individuals who most likely are encountered in inappropriate settings—including jails/prisons, emergency rooms or living on the streets—and who consume the most resources and have the worst outcomes. The two middle categories require special focus in that the system presently caring for the individual might not be providing the necessary services to address the co-occurring disorder. Corresponding to the four categories of illness severity are four loci/settings of care and four levels of care coordination. The four loci of care are (figure 2):
The four levels of care (figure 3) coordination include
Level I care coordination involves the basic means of informal provider-to-provider communication (e.g., requests for information and advice by telephone or e-mail). Levels II and III involve more formal communication and greater personal interactions (e.g., conferences among providers from the different systems to determine the appropriate course of care for a particular individual). Level IV requires concerted, coordinated effort in which functions and services of the different systems merge into a single program for the individual.
Who pays for addiction treatment services? Addiction treatment is paid by federal government, state/local government and private insurance. In FY 1997, $11.9 billion was spent on treatment for substance use disorders. Between 1987 and 1997, the average annual growth rate of expenditures for substance use disorders was 2.5 percent. The Substance Abuse and Mental Health Administration (SAMSHA) data for FY 1997 show that the majority of funding for substance use treatment expenditures was from public sector funding (64 percent). The Substance Abuse Prevention and Treatment Block Grant provides approximately 40 percent of the public funds spent on treatment and prevention in the states. Entitlement programs, such as Medicaid, are another important source of funding. Funding of substance use prevention and treatment services for substance use disorders is provided by federal, state and local governments. State and federal governments share financial responsibility in the area of Medicaid, where states are increasingly using managed care systems to administer benefits. Coverage of substance use treatment varies widely among private insurers. However, many states have laws that mandate coverage of some level of benefits for the treatment of substance use disorders. A small number of states require at least an offering of benefits, while still others do not address the issue at all. Federally funded programs primarily operate as block grants, entitlements or categorical grants, and research grants. Medicaid, Medicare, TRICARE, supplemental security income (SSI) and social security disability insurance (SSDI) are entitlement programs that enable eligible recipients or states to receive income support maintenance and health care. All these programs have services that can be used for substance use treatment and services. P.L. 104-121, signed by President Clinton in 1996, eliminated addictions as a qualified disability for SSI/SSDI. As a result, SSI as a mandatory Medicaid eligible was not available for those with addictions. SSDI and its link to Medicare were lost. However, those with addictions were not excluded from Medicaid and Medicare per se. The denial applied immediately to any new or preceding claim for benefits. Benefits were terminated on January 1, 1997, for individuals who were receiving benefits based on substance use disorders; costs were shifted to state and local programs. Many other grants are available from the federal government through various federal agencies, including the Centers for Medicare and Medicaid Services, the Social Security Administration, the Department of Education, the Administration for Children and Families, the Department of Justice, the Department of Veterans Affairs, Housing and Urban Development, and the Department of Defense. Substance Abuse Prevention and Treatment (SAPT) Block Grant The Center for Substance Abuse Treatment within the Substance Abuse and Mental Health Services Administration is the lead agency to administer the block grant. The block grant contains several requirements:
Of the funds allocated to the block grant program, 95 percent are distributed to states through a formula prescribed by the authorizing legislation. Factors used to calculate the allotments include total personal income; state population data by age groups (total population data for territories); total taxable resources; and a cost of services index factor. Discretionary Grant Programs A number of discretionary grant programs are made available to states by the Center for Mental Health Services (CMHS), the Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse Treatment (CSAT) in accordance with the mission and purpose of SAMHSA. Programs of Regional and National Significance (PRNS) is a discretionary grant included in SAMHSA’s authorizing legislation (P.L. 102-321, as amended by P.L. 106-310) that complements SAMHSA’s block grants to the states. They enable SAMHSA to target funds to priority populations or health concerns, respond quickly to emerging needs, and implement and promote adoption of evidence-based practices. Evaluation of the PRNS grants further helps SAMHSA ensure that federal service funds are well spent. These grants are not always coordinated with state programs. SAMHSA’s PRNS grants fall into two categories, knowledge application (KA) programs and targeted capacity expansion/response (TCE) programs. KA programs are designed to bridge the gap between scientific knowledge and community-based practice and to encourage wide-scale adoption of new research-tested effective practices. TCE programs provide targeted funding to implement focused responses to emerging needs using proven practices, such as treatment and prevention issues unique to a population or geographic area. State Funding Each state has designated a single state agency to be responsible for effective allocation and use of federal and state sources that are specifically targeted for substance use treatment services. State government is the largest single purchaser of treatment services for substance use disorders through block grants in most states. Funding from state government sources include, but are not limited to:
Each state appropriates money to its substance abuse agency for the prevention and treatment of substance use disorders. States also appropriate money to other agencies for purposes related to substance use disorders, such as Medicaid for treatment, children and families for screening and treatment, education for prevention, housing for screening and referral, justice for treatment and drug courts, and so forth. An alcohol tax serves the dual purposes of primary prevention and revenue enhancement for the state. The additional cost deters some individuals, particularly teenagers, from purchasing alcohol. Everyone who uses alcohol contributes a tax fund used for the prevention and treatment of alcoholism and alcohol abuse. Generally, a majority of people favor the tax, particularly if revenues are tied to prevention and treatment.
What addiction treatment services are covered by Medicaid? Medicaid is a federal-state partnership that provided health care services to 48.9 million low-income Americans in 2002 for treatment of health problems, including substance use disorders. Since expenditures are matched by the federal government, states have substantial flexibility to craft their Medicaid plans. Medicaid spending on substance use disorders rose rapidly at an inflation-adjusted rate of 9.8 percent yearly between 1987 and 1992, although this rate still was slower than the 11.8 percent annual increase in overall Medicaid spending during that period. In the second five-year period, Medicaid programs slowed the rate of increase of spending on substance use treatment to an annual 5.7 percent increase between 1992 and 1997. Federal Medicaid guidelines require a core of basic services, including hospital inpatient and outpatient care; early and periodic screening, diagnosis and treatment of physical and mental illnesses for individuals under age 21; rural health clinic services; physicians’ services; and nurse-midwife services. Some of these may be used to treat Medicaid recipients with substance use disorders. States have discretion to cover additional services, such as substance use treatment programs and inpatient hospital care in mental institutions for those under age 21; services of state-licensed practitioners, such as psychologists, substance use counselors, and medical social workers; rehabilitation option to expand to 10 people; clinic services, such as those offered by outpatient substance use clinics; prescription drugs; and transportation and emergency hospital services. Medicaid does not provide coverage for individuals between the ages of 21 and 65 who receive substance use or mental illness treatment from an institution for mental disease (IMD). (An IMD is defined as any hospital, nursing facility or other institution with more than 16 beds whose primary business is mental health, which includes substance use disorders.) The IMD exclusion generally precludes Medicaid funding to residential, community-based substance use treatment services, such as therapeutic communities. Some states nonetheless have used Medicaid to fund residential programs for fewer than 16 adults or have covered medical services in larger programs. The IMD exclusion is viewed as a barrier to appropriate substance use treatment for vulnerable populations—such as pregnant and parenting women—and effectively shifts the cost of serving these populations to the states and to block grant-funded programs. Section 1115 of the Social Security Act allows states to apply for waivers for demonstration projects as long as the programs are “budget neutral.” Several states have used the 1115 waiver to implement projects that waive the IMD exclusion. In addition, states that are experimenting with managed care delivery systems (some no longer require a waiver, according to the Balanced Budget Act of 1997) or that use 1915b waivers can circumvent the IMD exclusion. Because Medicaid pays managed care systems flat rates with an agreed upon capitation fee, CMS does not require information about the actual services provided. Therefore, Medicaid-approved managed care systems may provide substance use treatment services, provided the costs for these services fall within the agreed upon capitation fee. Medicaid and Managed Care States increasingly rely on managed care as an alternative to traditional fee-for-service financing systems. Under managed care systems, health maintenance organizations (HMOs), prepaid health plans (PHPs) or comparable entities provide a specific set of services to Medicaid enrollees, usually in return for a predetermined periodic payment per enrollee. Managed care programs seek to provide more cost-effective access to quality care. The percentage of Medicaid enrollees participating in a managed care plan increased from 14 percent in 1993 to 54 percent in 1998. States employ four approaches to providing mental health and/or substance use treatment in a managed care model.
Full carve-out programs go a step further; they separate all mental health or substance use services from physical health managed care programs. In stand-alone programs, substance use treatment services are completely independent of any other program. In other words, these programs are not carved-out of a physical health program. Stand-alone programs typically are not associated with Medicaid, but are paid for by Medicaid.
The explicit goal of insurance parity legislation is to ensure equality in insurance coverage of substance abuse—typically bundled in parity legislation with mental health benefits—and physical health benefits. A federal law—the Mental Health Parity Act (MHPA) of 1996—essentially required health plans that provide mental health coverage to provide those benefits at the same level as physical health coverage. The World Health Organization (WHO) and the American Psychiatric Association (APA) define substance abuse as mental illness, leading some to assume the MHPA included substance abuse. As passed, however, the bill contained several provisions that allowed insurers to maintain their benefit packages at prior levels and excluded substance abuse treatment benefits. Spurred by the passage of the act, lawmakers in many states sought some form of parity between substance abuse and physical benefits in all health plans. The question of whether to include benefits under mental health parity laws has complicated the overall parity debate. Underlying the discussion are two issues: 1) the stigmatization (discussed in question about barriers to entry to treatment), and 2) the fear of skyrocketing treatment costs for taxpayers (discussed in question about treatment funding). Several arguments against inclusion of substance abuse parity typically surface when mental health parity legislation is considered. The first contends that the cost of substance abuse parity would be prohibitive because it would inflate premiums for consumers (thus pricing many people out of the market) and ultimately lead to a higher rate of uninsurance. The second argument is that many professional definitions of mental illness are too broad, particularly those in the APA’s Diagnostic and Statistical Manual (DSM IV). According to critics, the DSM IV includes even such maladies as jet lag in its definition of mental illness—a juxtaposition that trivializes substance abuse parity. Proponents of parity offer several answers to counter these arguments. A 1999 report from the Substance Abuse and Mental Health Services Administration, for example, estimated that the average yearly cost increase for insurance with full parity for substance abuse treatment would be $5 per person. A 1994 study—Evaluating Recovery Services: The California Drug and Alcohol Treatment & Assessment (CALDATA)—found that every $1 spent on treatment saved state taxpayers $7 in future costs (emergency health care, imprisonment, court costs, etc.). Legislators in many states also have found success through tailoring definitions in the DSM IV and the WHO International Classification of Disease manual to their state’s unique needs. Weighing each of these arguments, state legislators have sought greater balance and equity through three modes: full parity, minimum mandated benefits and mandated offerings. Because no firm, commonly accepted definition of parity exists, NCSL uses these three terms to categorize state approaches to paint a clearer picture of what states are requiring of health plans. Full Parity: A state’s law qualifies as parity under these classifications only when it requires equality between substance abuse and physical care services across five categories:
To date, under these standards, only seven states—Connecticut, Delaware, Maine, Minnesota, Vermont, Virginia and West Virginia—have full parity for substance abuse. Two states—North Carolina and South Carolina—offer substance abuse parity, but only in the state employees’ health plan. Mandated Benefits: Minimum mandated benefit is the classification assigned to state laws that mandate coverage for substance abuse treatment but do so at levels that are less than equal to physical care services across the five categories mentioned previously. Under these requirements, a state law may require parity across as many as four of the five categories and still be a minimum mandated benefit because benefits are unequal in the remaining category. Laws in 15 states—Alaska, Hawaii, Kansas, Maryland, Massachusetts, Michigan, Montana, Nevada, New Hampshire, North Dakota, Oregon, Pennsylvania, Rhode Island, Texas and Washington—fall under the minimum mandated benefit category for comprehensive substance abuse treatment. Another three states—Illinois, Mississippi and Ohio—fall under this classification, but only for treatment of alcohol dependency. Mandated Offering: Actions in several states—Arkansas, Florida, Georgia, Kentucky, Louisiana, Missouri, New Jersey, New York, North Carolina, Ohio, South Carolina, Tennessee and Utah—have taken the form of a mandated offering. A law is a mandated offering if it either,
As with minimum mandated benefits, several additional states—Alabama, California, Colorado, Nebraska, New Mexico and Wisconsin—have a mandated offering for alcohol dependency only.
Is funding addiction treatment cost effective for states? Substance abuse costs states billions of dollars each year, most of which pays for ancillary costs in areas such as criminal justice, Medicaid, mental health and public safety. As substance abuse and addiction become increasingly significant burdens on public programs, states will want to consider cost-effective strategies to address substance abuse. The allocation of funding for treatment is proving to be a wise investment in this capacity. Prevention and treatment efforts seem to have had a payoff for states. A 2004 study conducted by researchers in South Carolina found that youths who received multi-systemic therapy cost more than $1,000 less in the months post-treatment than their untreated counterparts. A 14-year longitudinal study by Holder and Blose published in the Journal for Study of Alcohol cited a 24 percent reduction in cost to health plans from previously diagnosed alcoholics following initiation of treatment. Another study published by the Journal of Substance Abuse Treatment in 2001 found that Medicaid participants who had been identified but not treated for substance abuse cost $761 per month; treated participants cost only $224. There are more promising findings from a cost-offset perspective. A 1994 analysis of California’s public system revealed a $7 return on every $1 spent on treatment. In 1995, Oregon’s public system also reported a $7 return on each $1. The economic benefits of substance abuse treatment are especially evident in women. Harwood et al. (1998) found that savings were 4 times the cost of treatment of women. Savings are even greater for pregnant women. In 1997, Svikis et al. published a study noted that while treated women cost about 900 dollars, untreated women cost as much as $12,200 in NICU and birth expenses. Berkowitz et al. (1996) found that while pregnant or parenting offenders who receive treatment cost $3,000, the cost of incarceration is $17,000. Treatment is also associated with a reduced incidence of recidivism in criminal offenders of both genders, translating into even further savings over time. Some types of substance abuse treatment are more cost-effective than others. Several studies (Alterman et al., 1994; Bachman et al., 1992; Schneider et al., 1996) have shown that, while outcomes are the same, day treatment costs less than half as much as inpatient care. Weisner et al. (2001) noted that, while day treatment that makes the transition to intensive outpatient care costs $1,600, intensive outpatient care alone costs only $900 with no substantial difference in outcome. Cost-effectiveness increases with duration of treatment. Results of a recent study in Washington indicated that untreated chemically dependent supplemental security income (SSI) recipients had $414 per month more than Medicaid, medical mental health, and nursing home costs than did treated recipients—$252 per month after adjusting for the cost of chemical dependency treatment.1 In a Washington study of 534 patients discharged from a residential chemical dependency treatment program for people with co-occurring disorders (chemical dependency and mental health), overall Medicaid-paid medical and psychiatric services decreased by 44 percent, from almost $5 million in the year before treatment to $2.8 million in the year after treatment.2 A separate study of 735 patients discharged from a residential chemical dependency involuntary commitment program in Washington, the cost of patients’ Medicaid-paid medical and psychiatric services decreased from $3.8 million in the year before admission to $2.7 million in the year following discharge.3
What are drug courts, diversion programs and sentencing reform? Prison overcrowding and recidivism forced states to develop new means of alleviating growing pressures on the criminal justice system. With limited funds for construction of new facilities and a revolving door for people who were convicted of drug-related crime, states and localities sought means to break cycles and control costs. States found the three most effective methods to achieve these goals were sentencing reform, drug courts and diversion programs. Sentencing reform developed in recognition of the fact that stiff and lengthy incarcerations issued under mandatory minimum sentencing laws were overcrowding facilities and not preventing recidivism. States have revised, eliminated and enacted new sentencing grids in pursuit of reform. Some states have also eliminated or revised their punitive scoring systems. Sentencing reform provides states with immediate cost savings. As the population of those incarcerated declines, the state realizes savings through reduced need for and use of facilities. However, sentencing reforms alone have not sufficiently addressed the issue of recidivism. Often, sentencing reforms are used in combination with drug courts and diversion programs. Underlying these methods is the notion that recovery from addiction and abuse and reform from criminal behavior best occurs outside of the traditional correctional settings of jails and prisons. The theory is that mandatory treatment in lieu of incarceration will reduce dependence on drugs and, thus, drug-related crime. As the body of research supporting this notion has grown, so has the number of jurisdictions that use these approaches. Although similar in intent, drug courts and diversion programs differ. Diversion programs primarily are programs overseen by a case manager or probation officer. Many diversion programs offer offenders (generally those with no or few prior offenses) the option of waiving a jury trial and entering treatment instead. Noncompliance with program rules or failure to complete the program may result in a trial. However, the reward for successful completion of the program may be dismissal of the case. Conversely, drug courts are programs with strong judicial oversight. In the drug court model, the trial judge supervises a defendant’s case in conjunction with treatment professionals, probation officers, the prosecutor, the defense counsel, and law enforcement and educational/vocational professionals. Because the model is an alternative to incarceration, the judge has great flexibility to impose sentences and punishments for noncompliance with program rules or failure to complete the program. The Office of Justice Programs Drug Court Clearinghouse and Technical Assistance Project (OJP) reported that, as of November 2003, 1,093 drug courts were active in the 50 states, the District of Columbia, Guam, Puerto Rico and one federal district court, with an additional 414 in the planning phase. The sharp increase in the number of active drug courts since 1989, when the first such opened in Dade County, Florida, is attributable to the model’s success in controlling costs and reducing criminal behavior. A Columbia University study estimated that, for every $1 spent on drug courts, a jurisdiction realizes $10 in savings. A comparison between the daily cost of drug courts and incarceration reveals similar results. The average daily cost of a drug court in 2001 ranged between $8 and $14 dollars, depending on services and level of supervision provided. Average daily incarceration costs in 2001 were approximately $40 per day, excluding any considerations of facility construction costs. Research also highlights the efficacy of drug courts in reducing recidivism. A December 2000 OJP study reported that three-quarters of drug court participants were incarcerated previously—nearly 225,000 of 300,000 participants. Drug courts retained more than 70 percent of all enrolled offenders, with a corresponding reduction in recidivism rates of up to 29 percent. Recidivism rates average 48 percent for the offender population who are not involved in drug courts. Evidence further shows, through mandatory weekly drug testing in the drug court model, that drug use decreases as length of time in the program increases. Overall benefits to the community found in research include retention or obtainment of employment, retention or obtainment of custody of children, and an increase in births of drug-free babies.
What barriers prevent people from entering treatment? The stigma of addiction can be a substantial barrier for individuals who need treatment. Numerous reasons abound for refusal to seek treatment. Historically, society viewed addiction as a moral weakness and failing. A great number still hold that perspective, despite addiction’s medical classification as a chronic relapsing brain disorder. Addicts may feel a sense of shame or humiliation at what they perceive as their own failing. Many may fear ostracism by family and friends for their condition. Social pressures continue to push a marked stigma upon those with addictions, preventing disclosure of the illness and pursuit of treatment. The further pressures of potential legal, personal and professional repercussions are additional barriers to treatment. One of the first barriers encountered by many addicts is the paucity of screenings for addiction. Few providers are trained to screen for addiction. In some cases, however, state law serves as a barrier to screening. Uniform Accident and Sickness Policy Provision Laws (UPPL) allow insurers to deny claims precipitated by drug- or alcohol-fueled mishaps. A UPPL discourages providers— through denial of claims and, thus, reimbursement—from screening patients for substance use disorders. In 2001, the National Association of Insurance Legislators advised the repeal of the UPPL. To date, Maryland, North Carolina and Washington have revised their statutes. Disclosure of an addiction is a particularly frightening prospect for those who are using illegal substances. Fear of criminal penalties may prevent many from stepping forward with their problem. Following a criminal conviction for a drug offense, addicts find themselves denied a multitude of public assistance programs—education, housing and human services—that commonly are available to others seeking to recover and rebuild their lives. The Drug-Free Student Aid provision of the federal Higher Education Act of 1998 denies assistance to those who are convicted of drug offenses for a length of time determined by the number and type of convictions. Proven completion of an approved substance abuse treatment program can restore aid benefits, however. Federal law stipulates denial of housing assistance—such as the Section 8 program—to those who are involved with illegal drugs or are convicted of drug offenses. Housing agencies have limited flexibility to prevent eviction of tenants; as with education assistance, benefits can be restored only following completion of a treatment program. Most addicts who seek financial aid lack the financial means to fund treatment independently, though. The welfare reform act (the Personal Responsibility and Work Opportunity Reconciliation Act of 1996), however, did not provide for treatment exceptions. Section 115 stipulated that those convicted of drug offenses are subject to a lifetime ban from cash assistance and food stamps. Through Temporary Assistance for Needy Families (TANF), states have begun to break down some barriers to care. Incentives to businesses that hire welfare recipients, addresses a key issue mentioned by many addicts as a reason for not seeking treatment—a negative effect on employment. Frequently, but tacitly, addiction is the reason that many are denied employment or further promotion, and occasionally are fired. For many who work in professions that require licensure and certification, there is a fear that admission of an addiction will result in sanctions up to and including loss of licensure and certification. Many employers have acted of their own volition to institute employee assistance programs (EAPs) for the express purposes of allowing confidential help. The Employee Assistance Professionals Association estimates that approximately 20 percent of all voluntary (self) referrals and between 50 percent and 78 percent of all manager/supervisor referrals to EAPs involve substance abuse issues. Studies during the past decade have proven EAPs to be effective in helping those with substance use disorders maintain employment while saving the employer money. If a substance abuse problem forces a business to fire an employee, the process of hiring and training a replacement is substantial. A U.S. Department of Labor study estimated that, for this reason—and for others such as less frequent use of sick leave—a company will realize between $5 and $16 of savings for every $1 invested in its EAP. Family plays an important role in any treatment and recovery program. For some people, however, shame and humiliation may be the greatest with their family. Those with substance use disorders fear disintegration of or ostracism from their family. Custody concerns loom large as well. Parents may fear being labeled as a bad parent and losing custody of their children following entry into treatment. The value of laws that protect children from neglectful and harmful scenarios cannot be underestimated. However, the combination of shame and fear stands as a significant obstacle to treatment.
Staff Contact:
Non-government organizations that address substance use disorders:
Good sources for research studies about substance use disorders:
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