Michael Botticelli, Acting DirectorOffice of National Drug Control Policy

October 10, 2014

Addiction Medicine:A Case-based Approach to the Integrated Treatment

ofAddictive Disorders and Other Mental and Medical

ConditionsHarvard Medical School

Boston, Massachusetts

Reforming Our Response to Substance Use:

A Drug Policy for the 21st Century

Disclosure

• Neither I nor any member of my immediate family has a financial relationship with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients relevant to the content I am presenting.

• My content will not include discussion/reference to commercial products or services.

• I do not intend to discuss an unapproved/investigative use of commercial products/devices.

21ST CENTURY APPROACHReforming Drug Policy

Knowledge of Addiction: 20th Century Versus

21st Century Approach

Myths & Misconceptions

• Morally Flawed• Lacking in

Willpower

• Punitive Responses

What Does the Science Tell Us?

• Disease of the Brain

• Health Problem• Therapeutic

Responses

• Component of the Executive Office of the President

• Coordinates drug-control activities and related funding across the Federal Government

• Produces the annual National Drug Control Strategy

Office of National Drug Control Policy

National Drug Control Strategy

• The President’s science-based plan to reform drug policy:

1) Prevent drug use before it ever begins through education

2) Expand access to treatment for Americans struggling with addiction

3) Reform our criminal justice system4) Support Americans in recovery

• Coordinated Federal effort on 112 action items

• Signature initiatives:– Prescription Drug Abuse– Prevention– Drugged Driving

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$2,000

$4,000

$6,000

$8,000

$10,000

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Treatment &Prevention

Domestic LawEnforcement

Interdiction International

10/2014

Balanced Drug Policy:Federal Drug Control Spending, FY 2014

Enacted

Reforming Criminal Justice

Criminal Justice Response

• Supporting– Sentencing changes that use data

– Evidence-based alternatives to incarceration that offer treatment for substance use disorders

– People with substance use disorders as they reenter their communities

• Promoting– Connections to care for justice-

involved people

– Effective and appropriate treatment in justice settings

• Encouraging– Hiring of people with

criminal records who are not a threat to the community

– Policies that help justice-involved people address the basic needs of housing, education, and employment

Criminal Justice Reform in 2014

• Fair Sentencing Act

• Smart on Crime

• Federal Interagency Reentry Council

Overdose Law Policy Infographic

The National Drug Control Strategy supports comprehensive overdose prevention efforts, to include:

•Public education campaigns about signs of overdose, emergency interventions, “Good Samaritan” laws where they exist, and connecting people to substance use disorders treatment.

•Training and availability of emergency interventions, naloxone for first responders (including campus police).

•Education among health care providers to inform patients using opioids (and their family members/caregivers) about overdose.

•Naloxone co-prescribing.

Overdose Prevention and Education

Opioid Overdose Resuscitation

•The American Society of Anesthesiologists (ASA) has created a card explaining how to recognize and respond to an opioid overdose.

• The card, called “Opioid Overdose Resuscitation,” is available for download on the ASA Web site. We ask all of you to disseminate this card as widely as possible. • To download the card, go to: http://www.asahq.org/WhenSecondsCount/resources

CONTINUUM OF CARE

Reforming Treatment and Care

Treatment and Care

From Acute Care Model

• Enters Treatment• Completes

Assessment• Receives

Treatment• Discharged

To Chronic Care Model

• Prevention• Early Intervention• Treatment • Recovery Support

Services

Source: McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, Gourevitch M, Stein J, Oros M, Horton T, Lindblad R, Jennifer McNeely J. Can substance use disorders be managed using the chronic care model? Review and recommendations from a NIDA consensus group. Public Health Reviews. 2014;34: epub ahead of print

7,608,000 Needing Treatment at a Specialty Facility

Felt They Needed Treatment and Did

Make an Effort(148,000)

Did Not Feel They Needed Treatment(5,731,000)

Felt They Needed Treatment and Did Not Make an Effort

(247,000)

3%

19%

75%

Source: SAMHSA, 2013 National Survey on Drug Use and Health (September 2014).

Perceived Need for and Effort Made to Receive Specialty Treatment Among Persons

Aged 12 or Older NeedingBut Not Receiving Treatment: 2013

Received Specialty Treatment(1,483,000)

2%

The HIV Care Continuum inthe United States, 2009

Source: Office of National AIDS Policy, National HIV Strategy: Improving Outcomes, Accelerating Progress along the HIV Care Continuum , December 2013

U.S. Health Care reforms will extend access to and Parity for substance use treatment and mental health services for an estimated 62 million Americans and help integrate substance use treatment into mainstream health care.1

Coverage for expanded Medicaid population is likely to create an increased need for substance abuse treatment services and staff.

All health insurance sold on Health Insurance Exchanges and provided in Medicaid programs (ACOs, MCOs, and CHIP) must include services for substance use disorders.

Early Intervention and Treatment Patient Protection and Affordable

Care Act

1 Berino, K., Rosa, P., Skopec, L. & Glied, S. (2013). Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 Million Americans. Research Brief. Assistant Secretary for Planning and Evaluation (ASPE). Washington, D.C .

Paul Wellstone and Pete DomeniciMental Health Parity and

AddictionEquity Act of 2008

Medicaid Managed Care Organizations, Children’s Health Insurance Program, and Alternative Benefit (Benchmark) are required to meet the provisions within Application of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.

Screening, Brief Intervention, andReferral to Treatment (SBIRT)

• Enhances access and care for people with substance use disorders.

• Need to focus on integration of substance use disorders into primary care.

• Screening is essential for case identification and clinical decision making.

• Referrals to specialty treatment are critical to increased access to care.

• Brief Interventions do not appear to be as effective for reducing drug use as for reducing alcohol use.*

• We need to find new/better interventions in primary care.

* Brief Intervention for Problem Drug Use in Safety-Net Primary Care Settings: A Randomized Clinical Trial. Peter Roy-Byrne, et al. JAMA. 2014;312(5):492-501. doi:10.1001/jama.2014.7860. Screening and Brief Intervention for Drug Use in Primary Care: The ASPIRE Randomized Clinical Trial. Richard Saitz, MD, et al. JAMA. 2014;312(5):502-513. doi:10.1001/jama.2014.7862.

Three Distinctions Among Collaborative Models1

• Coordinated: Routine screening for behavioral health problems in primary care settings, but delivery of services may occur in different settings.

• Co-located: Medical services and behavioral health services located in the same facility.

• Integrated: Medical services and behavioral health services located either in the same facility or in separate locations.

1 Collins, C. Hewson, D., L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. Milbank Memorial Fund .

Evidence-Based Practices: Adoption in Drug Treatment

2006 2011

HIV testing 29.7% 27.9%

HepC screening 22.9% 23.1%

TB screening 33.9% 35.5%

HIV education/counseling

53.1% 57.8%

Transportation assistance

35.3% 39.4%

Psychiatric meds 34.0% 36.3%

Nicotine replacement 12.9% 20.5%

Naltrexone 12.8% 17.3%

Buprenorphine 11.0% 19.6%

Source: N-SSATS 2006 and 2011 results, SAMHSA

For Opioid Use Disorder•Methadone•Naltrexone (Vivitrol)•Buprenorphine•Buprenorphine/Naloxone

Medications Currently Available

For Nicotine Use Disorder •Nicotine Replacement Therapies (NRT)•Bupropion•VareniclineFor Alcohol Use Disorder•Disulfiram•Naltrexone•Acamprosate•Naltrexone Depot•Topiramate

Principles of Drug Addiction Treatment, National Institutes of Health – National Institute on Drug Abuse

Recovery Support Services

• Services and supports for persons prescribed buprenorphine in office-based settings– Vermont’s Hub & Spoke SystemVermont’s Hub & Spoke System– Vermont Recovery NetworkVermont Recovery Network

• Recovery support services and engagement with broader recovery community for persons in opioid treatment programs

• Service coordination for individuals in MAT, both office-based and through opioid treatment programs– ContinuityContinuity– Early reengagement in services during relapseEarly reengagement in services during relapse

• Inform and engage recovery community– What the science says about MAT for opioid use disordersWhat the science says about MAT for opioid use disorders– Overdose prevention & reversalOverdose prevention & reversal– Welcoming and support of those in MATWelcoming and support of those in MAT

Stigma and Language

AddictHitting Bottom

JunkieCrack Head

Substance Abuse/AbuserDirty UrineClean UrineHabit/Drug Habit

In Recovery

2014 Headlines

“Tennessee will criminalize moms

who use drugs during pregnancy”

“Case Tests Whether Methadone Treatment During Pregnancy Is

Abuse”

Recovery Month at the White House

Recovery Month at the White House: Celebrating 25 years!

For More Information:

WHITEHOUSE.GOV/ONDCP