william frank barker, lpc, mac diane diver, lmsw, cac ii
TRANSCRIPT
Where Are We Going?
William Frank Barker, LPC, MAC
Diane Diver, LMSW, CAC II
The FieldPhysician’
sOffice
Mental Health
Institutions
Alcoholics Anonymou
s
Minnesota Model
Outpatient
Legal System &
Jail
Key Forces
Health Care
Reform
Clinical Trends
WORKFORC
E
Healthcare
Healthcare $ 28 Billion spent in 2010 to treat
addiction which affects 40 million people
Versus
$107 Billion to treat heart disease which affects 27 million people
Relapse Rates Are Similar for Drug Addiction & Other Chronic Illnesses
100
Type I Diabete
s
Drug Addiction
0102030405060708090
Hypertension Asthma
40 t
o 6
0%
30 t
o 5
0%
50 t
o 7
0%
50 t
o 7
0%
Perc
en
t of
Pati
en
ts W
ho R
ela
pse
McLellan et al., JAMA, 2000.
Healthcare
Healthcare
Parity
HealthcareEstimated U.S. Economic Cost to Society Due to Substance Abuse and Addiction
Illegal Drugs - $181 billion/yearAlcohol - $185 billion/yearTobacco - $158 billion/year
Total - $524 billion/year
Source: Surgeon General’s Report, 2004; ONCP, 2004; Harwood, 2000.arwood, 2000. Surgeon General’s Report, 2004; ONDCP, 2004; Harwood, 2000.
Healthcare
How Its Funded
Healthcare
17%
20%
14%
45%
5%
Current Spending on Substance Abuse Treat-
mentPrivate FundingMedicaidOther FederalOther State and LocalMedicare
Healthcare
More people with 3rd party insurance Shifts cost and focus: deductibles, reimbursement
rates, outcome orientation, primary care physician
Healthcare
Shift from management and administration of block grants to focus on “best practices,” grants, and outcome measurements.
Healthcare
Healthcare
Healthcare
Healthcare
Healthcare
Healthcare
2 Million people in US dependent/abuse opioids
18,582 Physicians are certified to prescribe buprenorphine.
9% of SA facilities are Opioid Treatment Programs (OTP) in 2011
Individuals receiving buprenorphine prescriptions in 2010 was 800,000 with only 5% coming from treatment programs
Emergency department visits involving buprenorphine increased from 3,161 in 2005 to 30,135 visits in 2010 as availability of the drug increased.
Source: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (April 23, 2013). The N-SSATS Report: Trends in the Use of Methadone and Buprenorphine at Substance Abuse Treatment Facilities: 2003 to 2011. Rockville, MD.
Healthcare/Medical
52.00%
24.00%
13.00%
10.00%
2010 Emergency Department Visits Involving Buprenorphine by Type
Nonmedical Use of PharmaceuticalsSeeking Detoxifica-tion/Treatment ServicesAdverse ReactionOther
Source: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (January 29, 2013). The DAWN Report: Emergency Department Visits Involving Buprenorphine. Rockville, MD.
Clinical Trends
NIDA’s Principles of Treatment• No single treatment is appropriate for all
individuals.
• Treatment needs to be readily available.
• Treatment must attend to multiple needs of the individual, not just drug use.
• Multiple courses of treatment may be required for success.
• Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
Clinical Trends
Clinical TrendsNIDA’s Principles of Treatment
Behavioral Therapies: Cognitive Behavioral Therapy Contingency Management
Interventions/Motivational Incentives Community Reinforcement Approach Plus Vouchers Motivational Enhancement Therapy The Matrix Model 12-Step Facilitation Therapy Family Behavior Therapy Behavioral Therapies
Clinical Trends
“You can’t do cognitive therapy from a manual any
more than you can do surgery from a manual.”
-Aaron T. Beck, New York Times
Clinical Trends 1900s “Being on the wagon”
1930s “Not drinking alcohol”
1980 Sober is being totally chemically free
1990-2000 Relapse is a part of recovery
Clinical Trends
Audrey Kishline
2000 Evidence based practices• Moderate drinking• Fewer drinking days
ASAM Definition of Addiction
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
ASAM Definition of Addiction
Addiction is characterized by the inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or death.
What is different about this definition?
The focus in the past has been generally on substances associated with addiction.
The new definition clarifies that addiction isn't about drugs, it’s about brains.
It is not the substance or the quantity or frequency of use that makes them an addict. Addiction is about what happens in the reward circuitry of the brain when exposed to a rewarding substance or behavior.
Clinical Trends
Detoxification
Residential Treatment
Day Treatment
Intensive Outpatient Treatment
General Outpatient Treatment
More Severe
Less Severe
The Acute Model Vs. ASAM Levels of Care
Concerns About DSM-5 Changes
1. Would significantly increase the number of people being diagnosed with addiction.
2. The APA has not allowed enough discussion regarding these changes (secondary gain).
3. It could create false epidemics and medicalication of everyday behavior.
4. Possible boundary issues between DSM panel members and the pharmaceutical companies.
Clinical Trends
ACCOUNTABILITY COURTS
Implications for Clinicians
Health Care
Reform
Clinical Trends
WORKFORC
E
Peer Recover
y Support
s
HighlyTrained
CONCLUSIONS Medication Assisted Treatment
Physician Office/Counselor Embedded Treatment
Technology becomes a major tool Increased qualifications for workforce
Serve More people Prison/Drug courts may become
converted to one payer