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2008 Conference Archive

2008 SAAS Conference and NIATx Summit

Future of the Field Questions Answered

The following questions were presented by audience members to the "Future of the Field" panelists (Dr. Terry Cline, Dr. David Gustafson, Melody Heaps, Dr. Tom McLellan) during a plenary session on Tuesday, July 24, 2008 at the SAAS Conference / NIATx Summit in Orlando, Florida. There was not enough time to answer all the questions, so we have posted the questions and panelist written responses we have received to date.

Our Agency has been providing Integrated Behavioral Health (SA & MH) services for many years. The ASI is the standard assessment tool in the addiction field. My Clinical Staff has always opposed our use of ASI for new admits because they say it doesn't address MH. So they would have to use two assessment tools instead of the one integrated tool they use now. Please comment – Are they mis-informed?

Tom McLellan: The ASI is used widely in the MH and increasingly in primary care to assess the levels of impairment produced by co-occurring disorders. The ASI is not really an index – it has seven separate scales and thus should more properly be called the Addiction Severity Scales except the acronym is not all that appealing.

The scales include Medical Status, Employment and Self Support, Alcohol and Drug Use, Legal Status, Family/Social Function and Psychiatric Status. In each scale there are two time periods: lifetime and past 30 days – providing a measure of long term and short term severity. There is free software that produces a JCAHO approved biopsychosocial assessment and a treatment plan and a narrative report. The assessment takes about 30 - 40 minutes and there is a self administered version. It is free and in the public domain. What else can I tell you?

How are MIS departments and funding supposed to keep up with/or support the move toward using technology in this field? Where does the money and time come from?

Tom McLellan: I hope this is a rhetorical question. There are never enough funds to maintain technological advances - and smart, enterprising directors always find some money to keep up. Some of the sources are part of Block Grant dollars, several foundations offer technology expansion grants and shared resource (e.g. information system) grants.

Our Agency has been providing Integrated Behavioral Health (SA & MH) services for many years. The ASI is the standard assessment tool in the addiction field.
My Clinical Staff has always opposed our use of ASI for new admits because they say it doesn't address MH. So they would have to use two assessment tools instead of the one integrated tool they use now. Please comment - Are they mis-informed?

Tom McLellan: The ASI is used widely in the MH and increasingly in primary care to assess the levels of impairment produced by co-occurring disorders. The ASI is not really an index - it has seven separate scales and thus should more properly be called the Addiction Severity Scales except the acronym is not all that appealing.

The scales include Medical Status, Employment and Self Support, Alcohol and Drug Use, Legal Status, Family/Social Function and Psychiatric Status. In each scale there are two time periods: lifetime and past 30 days - providing a measure of long term and short term severity. There is free software that produces a JCAHO approved biopsychosocial assessment and a treatment plan and a narrative report. The assessment takes about 30 - 40 minutes and there is a self administered version. It is free and in the public domain. What else can I tell you?

How are MIS departments and funding supposed to keep up with/or support the move toward using technology in this field? Where does the money and time come from?

Tom McLellan: I hope this is a rhetorical question. There are never enough funds to maintain technological advances - and smart, enterprising directors always find some money to keep up. Some of the sources are part of Block Grant dollars, several foundations offer technology expansion grants and shared resource (e.g. information system) grants.

With agencies facing staff retention problems due to low pay in correlation to their education, why couldn't there be some sort of student loan forgiveness program for counselors in the addiction field? Like teachers in low income areas.

Tom McLellan: I had proposed to the current administration of SAMHSA that Addiction Treatment should be declared by the Department of Labor to be a "Distressed Industry." This is a designation that helped the electronics field, waste management and farming to advance. The designation provides low cost loans and loan forgiveness programs and student assistance grants as well as technology development grants (See above). I do not know if they ever applied for this designation.

What role does harm reduction have in changing the field?

Tom McLellan: It is hard to argue that "harm reduction" is a bad thing on the face of the words used - sort of like "pro-choice" or "pro-life." But "Harm reduction" is a blanket term for a number of interventions whose true ability to reduce or minimize harms are regularly debated.

For example, methadone and Buprenorphine have been labeled as harm reduction strategies because they reduce the harms to the affected individual that would be caused by injection drug use. At the same time, these medications do not require a commitment to total abstinence - essentially the most clinically desirable and legally acceptable outcome. Most clinicians and even policy makers recognize the broad and significant evidence basis for the inclusion of these medications in the therapeutic armamentarium.

At the other end of the spectrum are needle exchange procedures and drug legalization movements - both also called "harm reduction" strategies because they are thought (still not proven conclusively) to reduce needle sharing and attendant risk of infection. However, many in the field argue that these are harm reduction in only a limited sense, believe they believe these ideas and policies might actually produce harms to the public at large by inadvertently raising the proportion of individuals who become addicted. A majority of the US public still believes drugs should be illegal and most Americans do not support needle exchange.

The 2 major concerns with integration of AOD, Mental Health, and primary health care?M

  • MH and Primary health care has historically been very bad (sometimes anti-therapeutic) with AOD
  • May swallow-up the AOD field

How do we respond to this?

Tom McLellan: These are complex questions and I cannot fully explain them in the detail they warrant here.
From a business as usual, or "this won't fit in our way of treating" or "this may cost me my job" perspective - one has to say that the fact (and it is a fact) that mental health has generally assumed control over addiction services is a bad thing for the addiction treatment workforce. MH as a field requires more training and experience among their clinical staff, they do not provide as much programmatic care and are more likely to use individualized treatments. MH has a history of medication prescription and they are more likely to do these things. Most of these are not part of the skill sets or the traditional ways of handling addiction in specialty addiction programs. As such they threaten a 30+ year history of addiction specialty care.

However, addiction specialty care has not been especially effective. The field is not growing, it is shrinking, the workforce is not growing it is retiring, the patients are not beating down our doors for admission and outpatient drop out rates within the first month are over 40% nationwide. Nobody is satisfied with business as usual.

From a quality of care perspective the recommendations of the Institute of Medicine in its 2005 report on the quality of MH and SA care was pretty clear that it is imperative that patients get simultaneous, informed care that jointly considers physical medicine, mental health and substance use issues. This is very difficult in three separate systems that do not communicate well.

The old - and they are old - arguments about the historically poor care provided to addicted people in MH or primary care environments pre-date the availability of either good MH medications or addiction medications. There are now good reasons to have addiction and MH medicine involved in addiction care. Personally, I think addiction should be part of MH - but this does not mean that I think anyone who has been trained as a psychiatrist or psychologist will automatically understand and be qualified to treat addiction (though many in these general professions appear to believe this). I think there is a need for much greater training about the specific issues in addiction for those in primary, specialty MH and even those currently practicing specialty addiction care. Of course the systems will have to change as well but I think that the age of segregated specialty care for addiction should come to an end - primarily for patient care reasons.

Is technology really the answer? There are many studies that say the business comes first. Haven't you got it backwards? Isn't our job to make sure we get the business right first? Or said another way - Don't we have to make sure we clearly know the problem well first before simply saying technology will solve it?

Tom McLellan: Not sure how to answer this. Not possible to say "no - we don't need to understand the problem - let's just use technology." I do think there are plenty of problems we already understand quite well - like the difficulty in making contact with patients following their formal care and the need to do that. Here technology can be a big help and I think you would have to agree with that. Here's another one. We have to collect a lot of information about patient background and problem severity at the start of treatment - but that takes a long time and many patients drop out right after we do that. Here it is possible to have the patient dial up the internet and answer lots of those questions from the comfort of their homes or at a Starbucks or a library or something. Then when the patient comes in to treatment - the counselor could simply download the information and reduce the time required for the patient and for the paperwork.

How do we make the product sexy?

Tom McLellan: One way is pair it with something the patient actually wants. Dentists have done a lot for their business by providing tooth whitening as part of regular dental checkups - 50% increase in kept appointments. Why don't we offer addiction outpatient care in a health club where getting physically healthy is part of the "product?" Why not offer part of outpatient addiction treatment in the context of famous films (Days of wine and roses, many others) where the patients can enjoy something entertaining and useful - followed by a real discussion of the elements portrayed on the film? These are just examples - many more.

Armed with this knowledge are CSAT/NIDA or the Council on Substance Abuse going to develop any TV ads that educate Americans on high risk drinking or are we going to continue to let the alcohol industry mislead consumers?

Tom McLellan: Yes - the Partnership for Drug Free America has already been working on these - you will see them soon.

Who will drive the changes necessary to serve the 25 million? It would seem our funding streams (Fed & State) is it a top down (Bottom up or BOTA)?

Tom McLellan: : My own bet is that someone will develop a "You can do it - We can help" approach to addiction treatment (the Home Depot). This is interesting because Home Depot only makes about 45% of its revenues from the sale of do-it-yourself supplies - the majority of their funds come from contacting work when the customer finds he CAN'T do it himself. It is the clearest form of motivation ever - and when they fail, they go back to the guys that tried to help them. I think this will happen in addiction and most likely NOT from an existing program - probably from a related business or an entrepreneur that sees the majority of those who are simply having trouble controlling their use (not addicts) and tries to build services they want and find useful - that will catch on I think and if it doesn't work it will lead to more referrals for professional contractors!

How do you see the social medicine program proposed in the presidential election impacting our field and funding?

Tom McLellan: I am sorry - I am not familiar with it - can't comment. I have not heard word one about addiction from either candidate.

What is being done to motivate private insurance sector to adjust to changes and eliminate loopholes they use to deny services?

Tom McLellan: Very interesting. For various reasons (mostly legislative) many insurance companies are "carving IN" alcohol, drug and mental health benefits - back into general health care insurance. This has big ramifications. Because it is all one pot now in many states - it is possible for the insurers to see that an investment in improved behavioral health has very significant and immediate dividends in reducing the costs of ER visits and hospital stays. I see the future looking very good for this area of business - I see new models of addiction consultation-liaison work within primary care clinics where the chronic illnesses that are treated there are being adversely affected by alcohol and drug use (again, sometimes addiction, but mostly "unhealthy" or "hazardous" use). I think addiction clinics within medicine will begin to sprout up because this is a necessary part of the much larger effort to improve the quality and cut the costs of care for chronic illnesses.

By the way - it ain't the insurers for the most part that determine what is paid for in healthcare - it's the employers. Insurers will build any plan the employers want. Employers have walked away - figuring it is easier to fire and hire new than to rehab an employee. I think this is changing too. In PA we have - what else, a brand new prison and there are positions for 50 guards (@$50,000 per year). Of the first 200 applicants for the positions - only 4 passed the application drug test! Yes, just an anecdote but the labor force is riddled with addiction problems and employers would go for a sensible drug-court kind of plan for integrating addiction treatment into the workplace.

In the current 2008 presidential election process, I have not heard substance abuse mentioned once. What can we do to make it a priority national issue?

Tom Mclellan: Boy - I agree and I don't know the answer. I do hear debates about the cost of healthcare and as I said above, I think it is time that addiction help (add value to) these efforts by showing that you can improve the quality and efficiency of management for chronic, expensive illnesses like sleep, pain, diabetes, cancer etc - by managing alcohol use in these patients.

No argument about medication assisted treatment but how can it be made affordable? High cost currently of Naltrexone and Buprenorphine means lots of people do not have access to the meds.

Tom McLellan: I hear this all the time and frankly it's not true. Look at the pharmaceuticals used in the treatment of almost any other disease and you are talking about hundreds of dollars a month. Most insurers are happy to pay these costs because they reduce hospital stays. We have simply not made this case - at $4.00 a day, Buprenorphine is a real bargain.

I agree that changes need to be made and as a field, we need to be much more effective and efficient. However, the most labor consuming processes are complying with multitudes of regulations chart requirements (All different for different funders). How do the federal and state authorities and accrediting bodies plan to change their systems to allow for technology and creative approaches? No one on the panel has discussed this.

Tom McLellan: : Here's one I agree with. I do not know why federal agencies do not establish a common set of questions they need answers to at admission and at various points thereafter. By the way - I would not specify the format of an instrument - just specify the format of the answers they need - and set this out as the official information for the field. This would make a market for commercial software programs that could produce decision support programs to collect, process and provide reports on these questions - we are the only field I know that doesn't have this. But wait, there's more. I would provide a small bonus to the state Block grant to any state that

  • sent that information in via an electronic format (that would save CSAT so much processing time and effort)
  • required ONLY that same information for their state uses. In other words you will be paid more to adopt federal forms - and eliminate that duplication.
  • I would also set out federal licensing and inspection standards and I would train and deputize any state personnel who agreed to use federal standards for their L&I work - this would basically pay the states to do it (many do not) and prevent them from having an entirely separate and redundant L&I system.

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