Download National Drug Control Strategy

Reforming Our Response to
Substance Use:
A Drug Policy for the 21st Century
October 10, 2014
Addiction Medicine:
A Case-based Approach to the Integrated Treatment of
Addictive Disorders and Other Mental and Medical Conditions
Harvard Medical School
Boston, Massachusetts
Michael Botticelli, Acting Director
Office of National Drug Control Policy
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.
Reforming Drug Policy
21ST CENTURY APPROACH
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
Office of National Drug Control Policy
• 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
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 system
4) Support Americans in recovery
•
Coordinated Federal effort on
112 action items
•
Signature initiatives:
– Prescription Drug Abuse
– Prevention
– Drugged Driving
Balanced Drug Policy:
Federal Drug Control Spending, FY 2014 Enacted
$12,000
$ in Millions
$10,000
$10,104
$9,274
$8,000
$6,000
$4,048
$4,000
$1,786
$2,000
$0
10/2014
Treatment &
Prevention
Domestic Law
Enforcement
Interdiction
International
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 justiceinvolved 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 justiceinvolved 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
Overdose Prevention and Education
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.
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
Reforming Treatment and Care
CONTINUUM OF CARE
Treatment and Care
From Acute Care Model
To Chronic Care Model
•
•
•
•
•
•
•
•
Enters Treatment
Completes Assessment
Receives Treatment
Discharged
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
Perceived Need for and Effort Made to Receive Specialty
Treatment Among Persons Aged 12 or Older Needing
But Not Receiving Treatment: 2013
Felt They Needed Treatment
and Did Not Make an Effort
(247,000)
Did Not Feel They
Needed Treatment
(5,731,000)
Felt They Needed
Treatment and Did
Make an Effort
(148,000)
3%
2%
75%
19%
Received Specialty
Treatment
(1,483,000)
7,608,000 Needing Treatment at a Specialty Facility
Source: SAMHSA, 2013 National Survey on Drug Use and Health (September 2014).
The HIV Care Continuum in
the United States, 2009
Source: Office of National AIDS Policy, National HIV Strategy: Improving Outcomes, Accelerating Progress along the HIV Care
Continuum , December 2013
Early Intervention and Treatment
Patient Protection and Affordable Care Act
All health insurance sold on Health Insurance Exchanges and
provided in Medicaid programs (ACOs, MCOs, and CHIP) must
include services for substance use disorders.
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.
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 Domenici
Mental Health Parity and Addiction
Equity 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, and
Referral 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 Models
1
• 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
Medications Currently Available
For Nicotine Use Disorder
• Nicotine Replacement Therapies (NRT)
• Bupropion
• Varenicline
For Alcohol Use Disorder
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•
•
•
•
Disulfiram
Naltrexone
Acamprosate
Naltrexone Depot
Topiramate
For Opioid Use Disorder
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•
•
•
Methadone
Naltrexone (Vivitrol)
Buprenorphine
Buprenorphine/Naloxone
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 System
– Vermont 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
– Continuity
– Early reengagement in services during relapse
• Inform and engage recovery community
– What the science says about MAT for opioid use disorders
– Overdose prevention & reversal
– Welcoming and support of those in MAT
Stigma and Language
Addict
Hitting Bottom
Junkie
Crack Head
Substance Abuse/Abuser
Dirty Urine
Clean Urine
Habit/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