Appendix F

Workforce Standards for Substance Use Disorder (SUD) Care

Addiction treatment is changing (McCarty et al., 2010): medications are increasingly effective, payers require treatment providers to use evidence-based behavioral therapies, and the workforce is changing to include more individuals with graduate degrees. At the same time, however, linkages with medical practice remain weak. The 2010 and 2011 National Drug Control Strategies promote a new vision for the U.S. addiction treatment system (ONDCP, 2010, 2011). Because the Patient Protection and Affordable Care Act of 2010 will reduce the numbers of uninsured and increase access to primary care, the Office of National Drug Control Policy (ONDCP) calls for the nation’s primary care clinics and clinicians to become more active in the treatment of addiction. Addiction treatment services will be integrated into primary care, and ONDCP has directed the Health Resources and Services Administration and the Indian Health Service to allocate resources to support the expansion of addiction treatment services in primary care settings. This represents a major change in federal strategy. For the first time, addiction treatment resources are being directed to primary care rather than to specialty care settings. Health plans and Accountable Care Organizations will become the dominant payers for addiction treatment. These payers are unlikely to support the continued use of credentialed counselors; they will require that licensed practitioners deliver addiction treatment services.

HISTORICAL OVERVIEW

Addiction treatment has a legacy of segregation in nonmedical facilities because hospitals and health care practitioners had little interest in



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Appendix F Workforce Standards for Substance Use Disorder (SUD) Care Addiction treatment is changing (McCarty et al., 2010): medications are increasingly effective, payers require treatment providers to use evidence- based behavioral therapies, and the workforce is changing to include more individuals with graduate degrees. At the same time, however, linkages with medical practice remain weak. The 2010 and 2011 National Drug Control Strategies promote a new vision for the U.S. addiction treatment system (ONDCP, 2010, 2011). Because the Patient Protection and Affordable Care Act of 2010 will reduce the numbers of uninsured and increase access to primary care, the Office of National Drug Control Policy (ONDCP) calls for the nation’s primary care clinics and clinicians to become more active in the treatment of addiction. Addiction treatment services will be integrated into primary care, and ONDCP has directed the Health Resources and Ser- vices Administration and the Indian Health Service to allocate resources to support the expansion of addiction treatment services in primary care set- tings. This represents a major change in federal strategy. For the first time, addiction treatment resources are being directed to primary care rather than to specialty care settings. Health plans and Accountable Care Organizations will become the dominant payers for addiction treatment. These payers are unlikely to support the continued use of credentialed counselors; they will require that licensed practitioners deliver addiction treatment services. HISTORICAL OVERVIEW Addiction treatment has a legacy of segregation in nonmedical facili- ties because hospitals and health care practitioners had little interest in 361

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362 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES treating men and women who were dependent on alcohol and addicted to illicit drugs, many of whom were uninsured with a limited ability to afford professional care. Women and men who found stable recovery through participation in self-help became the foundation for the addiction treatment workforce. Their personal experience with recovery guided oth- ers seeking sobriety. Working with alcoholics and drug addicts, moreover, helped newly sober counselors maintain and enhance their commitment to recovery. Chapter 1 of the “Big Book” (Alcoholics Anonymous World Services, 1939, p. 14) briefly reiterates Bill W’s vision and recipe for sobriety. While I lay in the hospital the thought came that there were thousands of hopeless alcoholics who might be glad to have what had been so freely given me. Perhaps I could help some of them. They in turn might work with others. Bill W continues, noting that during his first 18 months of his sobriety, working with other alcoholics helped him maintain his sobriety. I was not too well at the time, and was plagued by waves of self-pity and resentment. This sometimes nearly drove me back to drink, but I soon found that when all other measures failed, work with another alcoholic would save the day. Many times I have gone to my old hospital in despair. On talking to a man there, I would be amazingly lifted up and set on my feet. It is a design for living that works in rough going. (Alcoholics Anony- mous World Services, 1939, p. 14) Maintaining sobriety by helping others gain sobriety continues to be an essential facet of recovery for many women and men. They freely vol- unteer assistance and provide support both through personal commitment to 12-step programming and through training and employment as alcohol and drug counselors. When Prohibition ended in 1933 in the United States, an addiction treatment system did not exist. There was little demand for alcohol treat- ment. Rates of problem drinking and cirrhosis declined dramatically in the United States during Prohibition (Blocker, 2006). The Federal Narcotic Treatment programs in Lexington, Kentucky, and Fort Worth, Texas, were in development. Alcoholics and addicts were sometimes treated in psychiat- ric hospitals, but in most cases, the drunk tank and the county work farm were the primary system of care. Beginning in 1935 in Akron, Ohio, Alco- holics Anonymous offered a self-help approach to recovery. Individuals in recovery reached out to help others seeking recovery. These early pioneers became the roots of the recovery movement. During the 1950s and 1960s, Councils on Alcoholism formed and evolved from public advocacy orga-

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APPENDIX F 363 nizations to treatment services offering detoxification, residential care, and outpatient treatment. Men and women with personal experience in recovery were the primary workforce. Independent grassroots initiatives became systems of care when the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (Public Law 91-616) formed the National Institute on Alcohol Abuse and Alcoholism, mandated the development of Single State Agencies to plan and support alcohol prevention and treatment services, and authorized federal funding for alcohol prevention and treat- ment services. The Drug Abuse Office and Treatment Act of 1972 estab- lished the Special Action Office for Drug Abuse Prevention (SAODAP) and authorized federal funding for drug abuse treatment. SAODAP morphed into the National Institute on Drug Abuse in 1974. States used federal funding to stimulate the development of alcohol and drug treatment systems and used their regulatory authority to set minimum standards for treatment services. In most states, programs must be licensed or approved to provide services, but in some states, compliance with the standards may have voluntary elements. The regulations establish minimum criteria for qualifying as a treatment facility. These criteria are intended to protect consumers from unqualified providers, and program licensure or approval usually is required to qualify for state contracts and third-party reimbursement. Program rather than practitioner licensure has been the primary regula- tory mechanism because of the reliance of the alcohol and drug treatment workforce on men and women in recovery. Counselors with experiential training (their personal recovery) strengthen services with a pragmatic orientation and the ability to provide role models for recovery. Individuals seeking services often express a preference for a counselor in recovery. Some consumers and many payers, however, are concerned that individuals who counsel without the benefit of formal training and advanced degrees may not be appropriately qualified to provide services for patients. Counselor certification emerged as a way to recognize individuals with work experi- ence and training in the absence of professional licensure. Counselor certification has been an important strategy to legitimize the field and document that individuals are qualified to provide treatment and counseling services. In the early 1980s, with support from the National Institute on Alcohol Abuse and Alcoholism, a coalition of trade and advo- cacy groups collaborated to develop credentialing guidelines and specify 12 core competency areas (Birch and Davis Associates, Inc., 1984). For the most part, credentialing is a trade group activity, and the federal and state roles tend to be more indirect. Certification requirements vary by state; the Addiction Technology Transfer Center website summarizes state require- ments (Addiction Technology Transfer Center Network, 2012).

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364 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Nationally, two professional trade organizations seek to standardize certification standards for alcohol and drug counselors. The International Certification and Reciprocity Consortium (IC&RC) and the National Cer- tification Commission provide nationally recognized certification. Accord- ing to the IC&RC website, IC&RC certification is recognized in 44 states, the District of Columbia, and three branches of the U.S. armed forces; more than 40,000 individuals hold IC&RC certification (IC&RC, 2012). IC&RC grew out of a coalition of regional state certification boards in 1981, expanded nationally in 1989, and became international in 1992 with the participation of boards in Canada. The National Certification Commis- sion began in 1990 as an independent entity affiliated with the National Association of Alcohol and Drug Abuse Counselors (National Certification Commission, 2012). Both certification bodies offer basic and advanced certification; certification requires completing verified hours of work experi- ence with supervision and passing a written exam. An analysis of state requirements found that, compared with require- ments for mental health counselors, states require less formal education and more work experience for alcohol and drug counselors (Kerwin et al., 2006). Twenty-five states require alcohol and drug counselors to have a license or certification (44 states require licensure for mental health counsel- ors), and licensure or credentialing is not available in 11 states. To become an alcohol and drug counselor, only 3 states require a master’s degree (47 states require a master’s degree for mental health counselors). The substan- tial disparity in state requirements for certification and licensure suggests that substance abuse counselors as a group are less trained and perhaps less qualified than mental health counselors to work effectively with the most complex patients. THE SUD WORKFORCE Assessments of the alcohol and drug abuse treatment workforce began in the 1970s. They described a workforce with few licensed professionals ­ and estimated the proportion of counselors with a graduate degree as r ­anging between one in five (Camp and Kurtz, 1982) and one in three (Birch and Davis Associates, Inc., 1984). A comparison of the workforce in 1976 and 1991 found little change in the presence of psychiatrists (1 per- cent), other physicians (1 percent), psychologists (3 percent), social workers (6 percent), and nurses (9 percent) (Brown, 1997). Yet change is apparent. More recent analyses suggest that counselors with graduate degrees are more prominent in the workforce, representing about 50 percent of coun- selors (Gallon et al., 2003; McCarty et al., 2007; Mulvey et al., 2003). The workforce survey completed within the National Drug Abuse Treatment Clinical Trials Network offers the most complete description of

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APPENDIX F 365 the contemporary addiction treatment workforce (McCarty et al., 2007). Counselors (n = 1,757), managers and supervisors (n = 511), medical staff (n = 522), and support staff (n = 908) completed a survey that captured demographics and assessed attitudes toward the use of evidence-based practices (EBPs). Two of three (66 percent) individuals were women, and women were overrepresented among support staff (74 percent). The diverse workforce included African Americans (22 percent), Hispanics (11 percent), and other minorities (6 percent); African Americans were over­ epresented r among support staff (33 percent). Individuals with a master’s or doctoral degree were most common among counselors (42 percent) and managers/ supervisors (58 percent); counselors working in outpatient settings (53 per- cent) were more likely than their counterparts in residential programs (30 percent) to hold a graduate degree. Professional licensure was most com- mon among medical staff (93 percent). Managers/supervisors (57 percent) and counselors (42 percent) were less likely to have licenses but more likely to hold state certification: counselors = 44 percent, managers/supervisors = 47 percent. Analyses of attitudes found that increased education was associated with more positive attitudes toward the use of medication and other EBPs. Managers/supervisors were most supportive of motivational interviewing, the use of treatment manuals, and the use of contingency management. Medical staff tended to have positive attitudes toward the use of medication in the treatment of addiction. Support personnel, in contrast, were more likely to support discharges for noncompliance and the use of confrontation. Because of the historical segregation of treatment for alcohol and drug use disorders from mainstream health care, relatively few physicians, psychiatrists, and other health care professionals specialize in addiction treatment. Targeted training, specialized credentialing, and continuing edu- cation for health care professionals would enhance the integration of SUD treatment into medical care settings. Three organizations support physicians and provide certification in addiction medicine: the American Society of Addiction Medicine (ASAM), the American Academy of Addiction Psychiatry, and the American Osteo- pathic Academy of Addiction Medicine. Each organization is relatively small and reflects the paucity of physicians who specialize in treating alco- hol and drug use disorders. ASAM traces its roots to the founding of the New York City Medi- cal Committee on Alcoholism in 1951 within the National Council on Alcoholism. Currently, ASAM has about 3,000 members (ASAM, 2012). ASAM has offered a certification examination in addiction medicine since 1983 that is widely recognized by state agencies and insurance carriers as a credible measure of knowledge; more than 4,500 physicians are ASAM- certified. The examination was transferred in 2009 to the newly formed

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366 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES American Board of Addiction Medicine (ABAM). One reason for the for- mation of ABAM was the eventual goal of attaining recognition by the American Board of Medical Specialties (ABMS) (ABAM, 2012). ABAM, incorporated in 2007, accredited its first diplomates in 2009. As of 2011, 2,000 had been designated fellows of ABAM. Of these, 38 percent are psychiatrists, and about the same number are in primary care specialties. A rough estimate by the ABAM Foundation is that more than 6,000 physi- cians trained in addiction medicine will be needed by 2020, assuming 1 for every 1,000 patients in need. However, current levels of fellowship training are inadequate to meet this need (Tontchev et al., 2011). In an effort to fos- ter fellowship training in addiction medicine, ABAM formally recognized 10 such fellowship programs in 2011. The American Academy of Addiction Psychiatry began in 1985 to promote quality care, excellence in addiction psychiatry, public education, and research on addiction (AAAP, 2012). Its current membership is about 2,100. After finishing a psychiatric residency and a year of specialized train- ing, psychiatrists may take an ABMS-approved subspecialty examination in addiction psychiatry. The American Board of Psychiatry and Neurol- ogy’s Subspecialty Board Certification in Addiction Psychiatry is officially recognized by ABMS. The American Osteopathic Academy of Addiction Medicine seeks to improve the health of individuals and families burdened with the disease of addiction (AOAAM, 2011). A small number of osteopaths have completed the American Osteopathic Association’s certification in addiction medicine, and several hundred have completed the ASAM certification. There is also limited expertise among other health professions. With support from the Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration, the Associa- tion for Medical Education and Research in Substance Abuse drafted a strategic plan for interdisciplinary faculty development (Haack and Adger, 2002). The plan heightened the visibility of the need for increased training in addiction across all of the professions working in health care. Recom- mendations addressed training for allied health professionals, dentists, physicians, midwives, nurse practitioners, nurses, pharmacists, physician assistants, psychologists, social workers, and public health workers. In the ensuing decade, however, the incorporation of required SUD curricula into health professions education has been minimal. Graduates in these profes- sions have little experience with and training in treating alcohol and drug use disorders. Certification for expertise in addiction treatment is available for psy- chologists and nurses. In 1996, the American Psychological Association began offering a Certificate of Proficiency in the Treatment of Alcohol and other Psychoactive Substance Use Disorders. More than 1,000 have been

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APPENDIX F 367 certified. The International Nurses Society on Addictions (IntNSA) is a specialty organization founded in 1975 for nurses committed to preven- tion, intervention, treatment, and management for addictive disorders. IntNSA’s mission is to advance excellence in nursing care for the prevention and treatment of addictions for diverse populations across all practice set- tings. With the American Nurses Association, IntNSA has established the Scope and Standards of Addictions Nursing Practice (IntNSA et al., 2004), a foundation upon which the certification in addiction nursing (Certified Addictions Registered Nurse [CARN] and CARN-Advanced Practice) is based. IntNSA has about 700 members (IntNSA, 2012). REFERENCES AAAP (American Academy of Addiction Psychiatry). 2012. Mission statement. http://www2. aaap.org/about-aaap/mission-statement (accessed June 15, 2012). ABAM (American Board of Addiction Medicine). 2012. About ABAM. http://www.abam.net/ about (accessed June 15, 2012). Addiction Technology Transfer Center Network. 2012. Certification information. http://www. attcnetwork.org/find/certinfo (accessed June 15, 2012). Alcoholics Anonymous World Services. 1939. Alcoholics Anonymous. New York: Works Publishing, Inc. AOAAM (American Osteopathic Academy of Addiction Medicine). 2011. Mission statement. http://www.aoaam.org/content.php?pg=11 (accessed June 15, 2012). ASAM (American Society of Addiction Medicine). 2012. Membership. http://www.asam.org/ membership (accessed June 15, 2012). Birch and Davis Associates, Inc. 1984. Development of model professional standards for counselor credentialing (Vol. 1). Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Alcohol Abuse and Alcoholism. Blocker, J. S., Jr. 2006. Did prohibition really work? Alcohol prohibition as a public health innovation. American Journal of Public Health 96(2):233-243. Brown, B. S. 1997. Staffing pattern and services for the war on drugs. In Treating drug abusers effectively, edited by J. A. Egertson, D. M. Fox, A. I. Leshner, and M. M. Fund. Malden, MA: Blackwell. Pp. 99-124. Camp, J. M., and N. R. Kurtz. 1982. Redirecting manpower for alcoholism treatment. In Prevention, intervention and treatment: Concerns and models. Rockville, MD: U.S. De- partment of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Alcohol Abuse and Alcoholism. Pp. 371-397. Gallon, S. L., R. M. Gabriel, and J. R. W. Knudsen. 2003. The toughest job you’ll ever love: A Pacific Northwest Treatment Workforce Survey. Journal of Substance Abuse Treatment 24(3):183-196. Haack, M. R., and H. Adger, Jr., eds. 2002. Strategic plan for interdisciplinary faculty de- velopment: Arming the nation’s health professional workforce for a new approach to substance use disorders. Providence, RI: Association for Medical Education and Research in Substance Abuse. IC&RC (International Certification and Reciprocity Consortium). 2012. Setting global stan- dards for addiction professionals. http://internationalcredentialing.org (accessed May 28, 2012).

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368 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES IntNSA (International Nurses Society on Addictions). 2012. Our mission. http://www.intnsa. org/home/index.asp (accessed June 15, 2012). IntNSA, ANA (American Nurses Association), and NNSA (National Nurses Society on Ad- dictions). 2004. Scope and standards of addictions nursing practice. Washington, DC: Nursesbooks.org, NNSA, ANA. Kerwin, M. E., K. Walker-Smith, and K. C. Kirby. 2006. Comparative analysis of state re- quirements for the training of substance abuse and mental health counselors. Journal of Substance Abuse Treatment 30(3):173-181. McCarty, D., B. E. Fuller, C. Arfken, M. Miller, E. V. Nunes, E. Edmundson, M. Copersino, A. Floyd, R. Forman, R. Laws, K. M. Magruder, M. Oyama, K. Prather, J. Sindelar, and W. W. Wendt. 2007. Direct care workers in the National Drug Abuse Treatment Clinical Trials Network: Characteristics, opinions, and beliefs. Psychiatric Services 58(2):181-190. McCarty, D., K. J. McConnell, and L. A. Schmidt. 2010. Priorities for policy research on treatments for alcohol and drug use disorders. Journal of Substance Abuse Treatment 39(2):87-95. Mulvey, K. P., S. Hubbard, and S. Hayashi. 2003. A national study of the substance abuse treatment workforce. Journal of Substance Abuse Treatment 24(1):51-57. National Certification Commission. 2012. National certification program. http://www.naadac. org/index.php?option=com_content&view=article&id=478&Itemid=129 (accessed June 15, 2012). ONDCP (Office of National Drug Control Policy). 2010. National drug control strategy, 2010. Washington, DC: ONDCP. ONDCP. 2011. National drug control strategy, 2011. Washington, DC: ONDCP. Tontchev, G. V., T. R. Housel, J. F. Callahan, M. M. Miller, and R. D. Blondell. 2011. Special- ized training on addictions for physicians in the United States. Substance Abuse 32:84-92.