1 Substance Use Disorder Treatment:A review of Commonwealth Initiatives Ken Martz, Psy.D. CAS Special Assistant to the Secretary Pennsylvania Department of Drug and Alcohol Programs

2 Overview Background Overview key treatment issues InitiativesRecommendations/Discussion

3 Fast Facts Every dollar spent in AOD treatment saves 7$If medical expenses are included that rises to 11$ Effective treatment works. Clinically appropriate levels of care work. But what is that? Why care about drug and alcohol treatment? 1 in 4 people has substance abuse in their families 1 in 4 people with addiction will die as a result

4 Cost/Benefit In 2007, the cost of illicit drug use alone (Does not include alcohol abuse) totaled more than $193 billion. Direct and indirect costs attributable to illicit drug use are estimated in three principal areas: crime, health, and productivity. Crime: includes three components: criminal justice system costs ($56,373,254), crime victim costs ($1,455,555), and other crime costs ($3,547,885). These subtotal $61,376,694. Health: includes five components: specialty treatment costs ($3,723,338), hospital and emergency department costs for non-homicide cases ($5,684,248), hospital and emergency department costs for homicide cases ($12,938), insurance administration costs ($544), and other health costs ($1,995,164). These subtotal $11,416,232. Productivity: includes seven components: labor participation costs ($49,237,777), specialty treatment costs for services provided at the state level ($2,828,207), specialty treatment costs for services provided at the federal level ($44,830), hospitalization costs ($287,260), incarceration costs ($48,121,949), premature mortality costs (non-homicide: $16,005,008), and premature mortality costs (homicide: $3,778,973). These subtotal $120,304,004. Taken together, these costs total $193,096,930, with the majority share attributable to lost productivity. The findings are consistent with prior work that has been done in this area using a generally comparable methodology (Harwood et al., 1984, 1998; ONDCP, 2001, 2004). This report by ONDCP does not include alcohol related costs, which would add to these numbers For Pennsylvania this cost for illicit drug use would be $8,289,740,227

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6 Cost Savings from Substance Abuse ServicesHealth System Savings Criminal Justice System Impact

7 Substance Use Disorders: SnapshotAccording to the NSDUH report, nationally we offer enough drug and alcohol treatment to address the needs of 10.8% of individuals who need it. In Pennsylvania we do a little better; about 13 percent of those needing services get them According to data from the Survey of Inmates in Local Jails, in 2002 more than two-thirds of jail inmates were found to be dependent on or to abuse alcohol or drugs Substance abuse expenditures represented 1.3 percent of all healthcare expenditures in 2003 ($21 billion for substance abuse vs. $1.6 trillion for all health expenditures). The 2010 U.S. Drug Control Strategy cites that untreated addiction costs society over $400 billion annually with $120 billion of that in wasted or inappropriate health care procedures. Treatment Gap Numbers in Thousands Needing Treatment for Illicit Drugs or Alcohol, 2011 Source: Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the and 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) , Chart 5.51A. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

8 Overview of Substance and Drug UsePast-Year Initiates for Specific Illicit Drugs Among Persons Age 12 or Older, 2014 Past-Year Initiates for Specific Illicit Drugs Among Persons Age 12 or Older, 2008 Source: Substance Abuse and Mental Health Services Administration. (2009). Results From the 2008 National Survey on Drug Use and Health: National Findings Rockville, Maryland.

9 Past Month Heroin Use among People Aged 12 or Older, by Age Group: 2002-2014Source: Substance Abuse and Mental Health Services Administration. (2014). Results From the 2015 National Survey on Drug Use and Health: National Findings Rockville, Maryland.

10 Overdose Deaths in PennsylvaniaDrug Overdose Deaths in Pennsylvania Year Number of Deaths PA Population Rate per 100,000 2012 2,026 12,763,536 16.3 2011 1,909 12,742,886 15.4 2010 1,550 12,702,379 12.5 2008 1,522 12,448,279 12.6 2006 1,344 12,440,621 11.2 2004 1,278 12,406,292 10.6 2002 895 12,335,091 7.5 2000 896 12,281,054 7.4 1998 628 12,001,451 5.4 1996 630 12,056,112 1994 596 12,052,410 5.1 1992 449 11,995,405 3.8 1990 333 11,881,643 2.7 Based on Pennsylvania Department of Health data, overdose deaths have been on the rise over the last two decades with an increase in the rate of death from 2.7 to 16.3 per hundred thousand Pennsylvanians

11 Heroin Related Overdose Deaths in PennsylvaniaBased on Pennsylvania Corners Association (PCA) reports in 43 counties, heroin and heroin related deaths have been on the rise for the past 5 years (PCA, 2013) Between 2009 and 2013 there 2,929 heroin related overdose deaths identified by county coroners. Of these, 490 (17%) were heroin only, while 2,439 (83%) involved multiple drugs. Other drugs commonly found along with heroin overdose include Other opiates: Methadone, Oxycodone, Fentanyl, Morphine, Codeine, Tramadol Other Illegal drugs: Marijuana, cocaine Other sedating drugs: Alcohol, benzodiazapines Antidepressant medications: Prozac, Celexa, Remeron, Trazadone, Zoloft

12 Overdose Deaths in Pennsylvania

13 History Pain as the Fifth Vital Sign

14 Source of Nonmedical Use of Prescription Drugs

15 Naloxone Reversals By Police Officers In Opioid Overdose EventsNumber of successful overdose reversals per county Single asterisks * signify counties with zero PDs carrying naloxone however preparing to launch naloxone programs within the next few months. Double asterisks ** signify counties that do not have municipal police departments Municipal Police Reversals = 1,577 PA State Police Reversals = 47 TOTAL REVERSALS = 1,624 Erie 11 Warren McKean Tioga 1 Susquehanna * Potter Bradford Crawford Wayne * 1 ** Forest Wyoming Elk Cameron ** ** Sullivan Lackawanna Venango Lycoming 36 Mercer * * Clinton Pike Clarion Luzerne 1 Jefferson 13 2 Columbia 1 Monroe Lawrence * Clearfield Union Butler 1 Centre Montour 11 1 22 Carbon Northumberland Armstrong Snyder 6 1 Beaver 3 Northampton Schuylkill 30 Indiana 2 8 Lehigh Mifflin ** Juniata 31 Allegheny Cambria Blair Dauphin 25 * 4 Perry 48 Berks Lebanon 13 Bucks Westmoreland 9 84 29 Huntingdon Washington Montgomery 80 Cumberland 98 43 Lancaster Chester Fulton York 95 Fayette Somerset Bedford ** 79 Franklin 258 356 Philadelphia Greene * * * 26 Adams 1 136 Delaware Rev 10/12/2016

16 FDA Warning Labels In September 2013 the FDA updated the warning labels on long acting opioid products. The new labeling adds: "Because of the risks of addiction, abuse and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve [Trade name] for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain."

17 _______________________________________________________Length of Stay Studies consistently find length of stay as the primary predictor of outcomes, along with intensity of treatment and continuum of care. Days in Treatment Source: Zhang (2002). Does retention matter? Treatment duration and improvement in drug use. (4,005 clients) _______________________________________________________ Source: Pennsylvania Department of Corrections (1997) Pennsylvania FIR Evaluation Source: Greenfield et al, (2004). Effectiveness of Long Term Residential Treatment for Women: Findings from 3 National Studies

18 Length Of Stay Studies consistently find length of stay as the primary predictor of outcomes, along with intensity of treatment and continuum of care. Improvements in criminal recidivism and relapse rates are correlated to length of treatment, with highest rates of improvement among those with 9 months of treatment, and reduced effectiveness for treatment of less than 90 days (NIDA, 2002) Highest improvements were found in long term treatment with least improvement found in methadone maintenance (Friedmann et al, 2004) Lengths of stay are the number one predictor of outcomes for treatment (President’s Commission on Model State Drug Laws, 1993) Average length of stay for Medicaid clients was 90 days (Villanova Study, 1995). Best outcomes were found for longer lengths of stay and more complete continuum of care, measured as lack of criminal recidivism, abstinence, employment and higher paying jobs. No benefit was found for treatment less than 90 days. Currently, average length of stay in treatment for long term residential is 47 days (DPW, 2011) Length of stay has a direct linear relationship with improved outcomes (Toumbourou, 1998)

19 Treatment Works: But what is treatment?Treat addresses a wide range of clinical issues that cause and exacerbate risks of substance abuse. These include the needs for habilitation and rehabilitation, including vocational supports, addressing trauma, learning coping skills, learning relapse prevention skills, improving relationships etc. This is not to be confused with supporting services such as detoxification, medications, peer supports, 12-step programs, housing and other similar approaches which complement the core treatment program. _______________________________________________________

20 PCPC Importance of Level of Care Answer: It doesn’t workUnder treating can lead to treatment resistance or increased progression of the disease What happens if you take a half dose of antibiotic? What happens if you take a half dose of insulin? What happens if you take a half dose of treatment? Answer: It doesn’t work Individuals get sicker Individuals and providers “give up” believing that there is no hope

21 Progression of a Disease and RecoveryPrevention (Relapse)Prevention No addiction Late Recovery Outpatient Treatment Give to others Optimism Regain job Face problems Honesty More relaxed Relationships improve Begin to develop trust Resolve legal issues Self respect returning Connect with sponsor/ positive peer group Self examination Medical stabilization Thinking begins to clear Desire for help No drinking Social drinking Drinking feels good Drink to relax Drink to escape Withdrawal from friends First DUI Conflict in relationships Missed time from work Regular drinking Amount of drinking increases Drink to stop feeling bad Disciplinary action at work Association with negative peer group Antisocial beliefs justify behaviors Increasing health complications Relationship isolation/ alienation Early Addiction Middle Recovery Intensive Treatment Middle Addiction Early Recovery Late Addiction “Rock Bottom”, Arrests Divorce, Loss of Job Depression, Hopelessness, Suicide, Death

22 Which Brain do You Want? Normal healthy view. Top down surface view. Full, symmetrical activity During substance abuse One year drug and alcohol free Notice the overall holes and shriveled appearance during abuse and marked improvement with abstinence.

23 Which Brain do You Want? Effects of other substances:Normal healthy view. Top down surface view. Full, symmetrical activity Effects of other substances: Long term alcohol abuse 57 y/o 30 years marijuana abuse (underside view) 39 y/o – 25 years frequent heroin use 40 y/o, 7 years on methadone. Heroin 10 years prior.

24 Client SUD Treatment Medical Providers Elements of the Warm HandoffCounty Drug and Alcohol Agency (SCA) helps ensure active funding stream (e.g. Medicaid, county funding, etc) Their role is to identify payment sources, to complete an initial assessments, and to connect individuals to treatment DDAP has led efforts to address each of these areas, with specific action steps.

25 Evidence Based PracticeWarm handoff procedures are evidence based as an effective approach with substantial research support O'Neil, S. H. (2009). Addiction treatment providers needed for 'warm handoff' from EDs. Alcoholism & Drug Abuse Weekly, 21(38), 1-3. Koenig, C. J., Maguen, S., Daley, A., Cohen, G., & Seal, K. H. (2013). Passing the baton: A grounded practical theory of handoff communication between multidisciplinary providers in two department of veterans affairs outpatient settings. Journal of General Internal Medicine, 28(1), Boudreaux, Edwin D., Haskins, B., Harralson, T., & Bernstein, E. (2015) The remote brief intervention and referral to treatment model: Development, functionality, acceptability, and feasibility, Drug and Alcohol Dependence, 155(1), Sammer, J. (2015). Warm handoffs serve as the first step toward accountable care. Behavioral Healthcare, 35(3), Bernstein, E., Ashong, D., Heeren, T., Winter, M., Bliss, C., Madico, G., & Bernstein, J. (2012). The impact of a brief motivational intervention on unprotected sex and sex while high among drug-positive emergency department patients who receive STI/HIV VC/T and drug treatment referral as standard of care. AIDS and Behavior, 16(5), Bernstein, S. L., & D'Onofrio, G. (2013). A promising approach for emergency departments to care for patients with substance use and behavioral disorders. Health Affairs, 32(12),

26 Prescribing Guidelines

27 Prescribing GuidelinesKey elements include: Before initiating pain therapy, have a complete history including SUD history Use of NSAIDS as first line analgesic therapy Acetaminophen has been shown to be synergistic with NSAIDS Use local anesthetics whenever possible

28 Prescribing GuidelinesIf an opioid is to be administered: Choose lower dose/duration Use PDMP to determine concurrent medications Opioids should not be administered in combination with benzodiazepines Care should be used when prescribing opioids for those with obstructive sleep apnea Provide instructions on safe storage and disposal

29 Prescribing GuidelinesIf an opioid is to be administered: Choose lower dose/duration Use PDMP to determine concurrent medications Opioids should not be administered in combination with benzodiazepines Care should be used when prescribing opioids for those with obstructive sleep apnea

31 _______________________________________________________The Solution Prevention Permanent Drop Boxes for medication disposal over 16,000 pounds collected Proper Storage Procedures (ie. lockbox in the home, pill organizers) Pennsylvania Youth Survey Treatment Medicaid Expansion offers coverage to a wider range of Pennsylvanians so that those with substance abuse can access care Warm Handoff Connections are invaluable to transition individuals into SUD care. _______________________________________________________

32 _______________________________________________________The Solution (cont.) Continue /Expand current initiatives Prescriber Practices Workgroup Emergency Department Pain Treatment Guidelines Opioid to Treat Non-Cancer Pain Opioids in Dental Practices Obstetrics and Gynecological Pain Geriatric Pain Dispensing of Opioids Prescription Drug Monitoring Program CME’s Medical School Core Competencies Naloxone Good Samaritan Access: SCA’s, (HELP) _______________________________________________________

33 _______________________________________________________The Solution (cont.) Awareness of Insurance and other Protections Act 106 of 1989 Protects group health insurance plans Act 152 of 1988 Protects services in Medicaid plans Mental Health and Parity and Addiction Equity Act Requires SUD to be treated with equivalent coverage as other medical conditions Patient Protection and Affordable Care Act Requires the coverage of SUD as an essential benefit 42CFR Confidentiality Protects confidentiality of SUD patients from adverse effects from the stigma associated with the disease _______________________________________________________

34 Parity? Addiction Treatment Coverage:Detoxification – 100% Opioid Substitution Therapy – 50% Urine Drug Screen – 100% 7 per year Wide variety in coverage across states Diabetes Coverage: Physician Visits – 100% Clinic Visits – 100% Home Health Visits – 100% Glucose Tests, Monitors, Supplies – 100% Insulin and 4 other Meds – 100% HgA1C, eye, foot exams 4x/yr – 100% Smoking Cessation – 100% Personal Care Visits – 100% Language Interpreter – Negotiated Source: (McLellan, 2013)

35 Recommendations What Works: Clinical Integrity Why Treatment FailsWhy Treatment Works Length of Stay (Less than 90 days) Length of Stay (More than 90 days) Undertreating (Giving OP instead of TC) Appropriate Level of Care Fragmented care (Detox only, 12-step only) Full Continuum of Care Weak Enforcement of Insurance Law Enforcement of State and Federal Laws Medicating all Pain Appropriate Prescribing Stigma (Seeing individuals as “bad”) Humanizing (Treating those with disease) Locking up Drug Users Treating those with Substance Use Disorder Thinking There is a Silver Bullet Clinical Integrity _______________________________________________________ What Works: Clinical Integrity

36 What Can I Do? 10 Simple StepsAre my programs trained in cross-system needs (criminal justice, child welfare, medical etc)? Are my system partner programs trained in drug and alcohol treatment? Are we using adequate lengths of stay or terminating based on funding? Are we educating on safe storage and disposal practices Are we educating on proper prescribing practices? Does our county have medication take back boxes? Are we expanding the use of Naloxone to save overdose victims? Are we co-prescribing Naloxone with opioids? Are we supporting our community efforts for prevention, to reach long term improvement. Are we doing SOMETHING? Pick one and keep moving forward. The trainer will review the requirements of Act This information is included in the training to provide participants with more knowledge that could be used in advocating for the appropriate LOC for the individual they are helping. Act 106 overview can be found in the manual…Appendix 9, page 142 Act 106 of 1989 requires all commercial group health plans, HMOs, and the children’s Health Insurance Program to provide comprehensive treatment for alcohol and other drug addictions. Minimum benefits: 1. Up to 7 days detox per admission, 4 admissions per lifetime (hospital or non-hospital residential detox 2. 30 days rehabilitation per year, 90 days per lifetime (non-hospital residential) 3. 30 sessions of outpatient/partial hospitalization per year, 120 sessions per lifetime 4. Family counseling and intervention services 5. Additional treatment beyond the above, 30 additional outpatient/partial hospitalization sessions are provided which can be utilized on a two-to-one basis to provide 15 additional non-hospital, residential treatment days. Per the PA Insurance department (PA Bulletin Notice )…the only lawful prerequisite before an insured obtains non-hospital residential and outpatient coverage for treatment is a certification and referral from a licensed physician or licensed psychologist. The same prerequisite applies for inpatient detoxification coverage. The certification and referral in all instances controls both the nature and duration of treatment. The certification and referral in all instances controls both the nature and duration of treatment. The location of treatment is subject to the insuring entity's requirements regarding the use of participating providers. 36

37 Contact Information Ken Martz, Psy.D. CAS Special Assistant to the Secretary Pennsylvania Department of Drug and Alcohol Programs 02 Kline Village Harrisburg, PA 17104 (717)