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4 Changing Standards of Care for Substance Use Disorders T he committee’s review of the Department of Defense’s (DoD’s) poli- cies and programs for prevention, diagnosis, treatment, and man- agement of substance use disorders (SUDs) included the strongest and most up-to-date evidence in the scientific and industry literature. This chapter reflects on the standards and expectations for SUD care and how they are evolving in a rapidly changing health care environment. Although DoD may be exempt from facets of health care reform, a contemporary set of prevention and treatment services for the U.S. military will embrace the state of the art, encourage evidence-based practices, and reflect emerging standards of care. In addition to health care reform, emerging expectations from the Office of National Drug Control Policy and the National Quality Forum will affect alcohol and other drug prevention and treatment services. HEALTH CARE REFORM AND PARITY REQUIREMENTS The Patient Protection and Affordable Care Act of 2010 (hereafter referred to as the Affordable Care Act) aims to better control health care expenses, enhance the quality of health care, and reduce the proportion of individuals who are uninsured. The act is likely to add many millions of individuals to state Medicaid plans (Sommers et al., 2011), and a num- ber of these new enrollees are likely to have alcohol and other drug use disorders (Barry and Huskamp, 2011; Buck, 2011; Garfield et al., 2011). Requirements that state exchanges must cover treatment of alcohol, other drug, and mental health disorders as essential benefits promote access to treatment services for SUDs (Barry and Huskamp, 2011; Buck, 2011). 85

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86 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES Under the Affordable Care Act, Medicaid and other health plans will become primary payers for most addiction treatment services. The current system of direct grants and contracts will dissipate as treatment provid- ers’ reimbursement from Medicaid and commercial health plans increases. State and federal appropriations designated for addiction prevention and treatment are likely to decline as Medicaid health plans become major payers (Buck, 2011). The substance abuse counseling workforce is likely to change because health plans are typically selective in their purchase of service contracts and screen for evidence of quality care. Practitioners that provide evidence of quality care are likely to have competitive advantages. Medicaid and commercial health plans are likely to limit reimbursement to practitioners with graduate degrees and professional licensure (McCarty et al., 2010). The workforce impact may be substantial because only about 50 percent of counselors in most addiction treatment centers have gradu- ate degrees (i.e., 42 percent of total counselors, 58 percent of outpatient counselors) (McCarty et al., 2007a). With the increasing medicalization of substance abuse treatment services (Buck, 2011), freestanding addic- tion treatment centers that rely on experientially trained counselors and/or counselors with alcohol and drug certification (but not clinical licensure) may struggle to survive (McCarty et al., 2010). The training of the addic- tion treatment workforce will also need to evolve to meet new requirements. Accountable Care Organizations and Integrated Care The Affordable Care Act generally promotes the integration of mental health and SUD treatment with primary care services and makes inte- grated care a priority for community-based accountable care organizations (ACOs).1 ACOs reflect emerging standards and expectations for integrated, patient-centered care provided within a medical home that is financially responsible for coordinating a patient’s health care, including care for mental health disorders and SUDs. The National Committee for Quality Assurance (NCQA) met with consumer advocates, purchasers of care, and health plans and released accreditation standards for ACOs in November 2011. The ACO accreditation standards encourage coordination of mental health and SUD services with the development of primary care medical homes and address seven dimensions of care (see Box 4-1). ACOs will support the integration of behavioral health and primary care. Recognition is increasing that general medicine practitioners “should become the first line ‘experts’ for substance abuse” (O’Connor and Samet, 2002, p. 398). Alcohol and other drug use is prevalent among patients 1 Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong. (March 23, 2010).

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CHANGING STANDARDS OF CARE 87 BOX 4-1 ACO Accreditation Standards 1. ACO Structure and Operations 2. Access to Needed Providers 3. Patient-Centered Primary Care 4. Care Management 5. Care Coordination and Transitions 6. Patient Rights and Responsibilities 7. Performance Reporting and Quality Improvement SOURCE: NCQA, 2012. treated in primary care (Manwell et al., 1998). Habitual alcohol and/or other drug use increases the likelihood of developing or exacerbating dis- orders of the heart, liver, and gastrointestinal system and conditions such as diabetes and hypertension (Gourevitch and Arnsten, 2005). Despite con- sensus among medical leadership on the need for a more integrated system (APA, 1994), progress has been slow. Reforms in the health system under the provisions of the Affordable Care Act could eliminate the long-standing separation of training and treatment for SUDs from routine medical care (IOM, 2006). There are many approaches to integrated care. Most attempt to (1) create a medical home; (2) use health care teams; (3) titrate care based on level of need and capacity for self-care; and (4) differentiate the severity of behavioral health and primary care needs into four quadrants—low primary care and low behavioral health need, low primary care and high behavioral health need, high primary care and low behavioral health need, and high primary care and behavioral health need—with patients with higher needs being referred to specialty services (Collins, 2010). The need for integrated primary care, mental health, and SUD services is further illus- trated by increases in prescribed opioids for pain in primary care settings. Analyses by Kaiser Permanente Northern California and Group Health of Seattle suggest significantly higher opioid use for pain in patients with SUDs (Weisner et al., 2009). The Buprenorphine and HIV Care Evaluation and Support demonstra- tion (sponsored by the HIV/AIDS Bureau of the Health Resources and Services Administration) is a recent example of the value of integrated care. In this study, 10 HIV clinics provided integrated medication-assisted opioid treatment. Study data documented reductions in opioid use (Fiellin et al.,

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88 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES 2011), increased engagement in HIV care (Altice et al., 2011), improved quality of life (Korthuis et al., 2011b), and improved quality of HIV care (Korthuis et al., 2011a). Participating patients voiced strong preferences for buprenorphine integrated into HIV care over referral to an opioid treat- ment program (Korthuis et al., 2010). This demonstration showed that the advantages of integrated care innovations can extend to patients in HIV primary care and supports the extension of this approach to primary care for patients without HIV infection. Patient Placement and Levels of Care Many health care systems use the American Society of Addiction Medi- cine’s (ASAM’s) Patient Placement Criteria to determine appropriate levels and intensity of addiction treatment services. The ASAM criteria provide guidelines for continued service and transfer/discharge for those with addic- tive disorders. Clinical placements and treatment plans reflect assessment of the criteria’s six dimensions (see Box 4-2). Patients with high potential for withdrawal, comorbid health conditions, and a poor recovery environ- ment may require treatment in more restrictive environments. Alternatively, employed individuals with a home and family support can be treated suc- cessfully in less-intensive ambulatory settings after medical monitoring for withdrawal. The value of the ASAM placement criteria, first released in 1991 (­ offman et al., 1991), is supported by two decades of experience. Cur- H rently, at least 30 states mandate their use (ASAM, 2012). The current edition, ASAM Patient Placement Criteria for the Treatment of Substance- Related Disorders, Second Edition-Revised (Mee-Lee, 2001), includes cri- teria for comorbid mental health and substance-related disorders. The BOX 4-2 Dimensions of American Society of Addiction Medicine’s (ASAM’s) Patient Placement Criteria 1.  Acute Intoxication and/or Withdrawal Potential 2.  Biomedical Conditions and Complications 3.  motional, Behavioral, or Cognitive Conditions and Complications E 4.  Readiness to Change 5.  elapse, Continued Use, or Continued Problem Potential R 6.  Recovery Environment SOURCE: http://www.asam.org/publications/patient-placement-criteria.

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CHANGING STANDARDS OF CARE 89 criteria, originally developed for use with adults, have been modified and updated for use with adolescents (Fishman, 2010). The continuing develop- ment and refinement of the ASAM criteria advance a paradigm shift from • unidimensional to multidimensional assessment, • program-driven to clinically driven treatment, • fixed length of service to variable length of service, and • a limited number of discrete levels of care to a continuum of care. The ASAM criteria advocate for and provide guidelines that promote four goals. First, the criteria require individualized, assessment-driven treatment and the flexible use of a broad continuum of care. Second, the criteria encour- age the use of motivational enhancement therapies in outpatient treatment, especially for those in the early stages of readiness to change, to increase access to care and reduce waits for more intensive levels of residential treatment. Third, the assessment dimensions address multiple needs of the individual (medical, psychological, social, vocational, and legal), not just alcohol and other drug use. Finally, the criteria require continual reviews of treatment plans, with modifications based on treatment response and outcomes. In addition to state mandates to use the ASAM criteria, DoD and national health care organizations and health plans require that an ASAM level-of-care assessment guide treatment plans. The ASAM placement crite- ria provide a common language with which care providers and care manag- ers can communicate about the multidimensional assessment and placement decision for those with SUDs. Parity The Affordable Care Act, together with the Mental Health Parity and Addiction Equity Act of 2008 (hereafter referred to as the Parity Act), is expected to enhance access to and utilization of treatment for alcohol and other drug use disorders. The Parity Act eliminates differential copayments and restrictions on mental health and addiction treatment benefits, which must be similar to benefits for other general and specialty medical care. Initial evaluations of the implementation of parity among federal employees (Goldman et al., 2006) and in Oregon (McConnell et al., 2011) found little increase in the total costs of care. OFFICE OF NATIONAL DRUG CONTROL POLICY’S NATIONAL DRUG CONTROL STRATEGY The Office of National Drug Control Policy (ONDCP) asserts in its 2010, 2011, and 2012 National Drug Control Strategies that addiction

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90 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES treatment must be integrated into mainstream health care (ONDCP, 2010, 2011, 2012). The 2012 National Drug Control Strategy’s seven priorities include two that promote linkages between health care and services for alcohol and other drug use disorders. The ONDCP strategy calls for early intervention opportunities in health care and notes that early intervention saves lives and money (ONDCP, 2012). Screening, brief intervention, and referral to treatment services are increasingly common in emergency departments and are expanding to include schools and universities as well as families involved in child welfare systems. The 2011 National Drug Control Strategy explicitly requires DoD to train health care professionals in providing evidence-based screening and interventions for alcohol and other drug use disorders for beneficiaries served by the Military Health System. Misuse and abuse of pharmaceu- ticals is another priority for early intervention. The 2012 National Drug Control Strategy notes that the Secure and Responsible Drug Disposal Act promotes the development of safe, easy, and affordable drug disposal options. Local authorities are encouraged to collaborate with the Drug Enforcement Agency to collect and dispose of unused and expired prescrip- tion medications. The 2012 National Drug Control Strategy also promotes integrated treatment for SUDs in mainstream health care (ONDCP, 2012), thus sup- porting the Affordable Care Act’s emphasis on integrated care. The Health Resources and Services Administration (HRSA) is directed to improve care for alcohol and other drug use disorders in the nation’s system of com- munity health centers. ONDCP’s National Drug Control Strategy reflects a substantive change in federal policy: for the first time, addiction treatment resources are allocated to primary care settings rather than specialty clinics. The 2011 strategy also instructs federal agencies that address health care needs to meet the National Quality Forum’s voluntary consensus standards for treatment of alcohol and other drug use disorders (see the next section). To help meet these standards, HRSA, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Adminis- tration must train health care practitioners to identify, diagnose, and treat SUDs. To support and promote recovery, ONDCP created a Recovery Branch within the Office of Demand Reduction to develop a national plan for recovery-oriented systems of care. Recovery-oriented systems of care elimi- nate regulatory, policy, and practice barriers to recovery and celebrate and support recovery. As part of its recovery strategy, ONDCP will work with the Department of Veterans Affairs (VA) and DoD to identify “recovery support services for alcohol and drug addiction that are appropriate for active duty military, Veterans, and their families and to ensure that those

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CHANGING STANDARDS OF CARE 91 services are made available to our military families to the greatest extent possible” (ONDCP, 2011, p. 42). NATIONAL QUALITY FORUM’S VOLUNTARY CONSENSUS STANDARDS Clear documentation of substandard care for addiction (McGlynn et al., 2003) led to the development of the first set of national standards for addiction treatment. The National Quality Forum’s consensus standards for treatment of substance use conditions identify four domains (and sub- domains) of expected services for addressing addiction: (1) identification of substance use conditions (screening and case finding, diagnosis and assessment), (2) initiation of and engagement in treatment (brief interven- tion, promoting engagement, withdrawal management), (3) therapeutic interventions to treat substance use illness (psychosocial interventions and pharmacotherapy), and (4) continuing care management of substance use illness (NQF, 2007). Box 4-3 details each subdomain contained in the vol- untary consensus standards. For the first time, a national trade organization recommended that its membership implement specific evidence-based therapies for treating tobacco, alcohol, and other drug use disorders. The standards are appli- cable to all members of the National Quality Forum (national consumer advocacy groups, health professional trade associations, health systems, health plans, groups that purchase health plans, pharmaceutical companies, and research institutes). Health care organizations and health plans no longer can ignore the need to better address addiction problems in primary care and acute care settings. As noted, the 2011 National Drug Control Strategy advocates for widespread adoption of the National Quality Forum standards for addiction treatment (ONDCP, 2011). PRACTICE IMPROVEMENT EFFORTS The Institute of Medicine’s Quality Chasm reports challenged the U.S. health care system to adopt process improvement strategies that would reduce errors that contribute to morbidity and mortality and facilitate the adoption of evidence-based practices (IOM, 2000, 2001, 2006). The Insti- tute for Healthcare Improvement (IHI), a leader in quality improvement for health care, works with provider and hospital systems to facilitate quality improvement at the patient-provider level by changing systems. Measure- ment is a key element in the IHI Model for Improvement, a simple yet power­ ul tool for accelerating improvement that has been used successfully f by IHI and hundreds of health care organizations in many countries to

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92 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES BOX 4-3 National Quality Forum’s Voluntary Consensus Standards for the Treatment of Substance Use Conditions • Identification of Substance Use Conditions –  atients in general and mental health care settings should be P screened for at-risk alcohol use problems. –  Health care providers should employ a systematic method to iden- tify patients who use drugs. – Patients who have a positive screen should receive further assessment. • Initiation and Engagement in Treatment –  ll patients with at-risk alcohol or tobacco use should receive a brief A motivational counseling intervention. –  Providers should promote patient initiation of care and engagement in ongoing treatment for alcohol and other drug use disorders. –  Pharmacotherapy should be provided to manage withdrawal symp- toms and consequences. • Therapeutic Interventions to Treat Substance Use Illness –  ll patients should receive empirically validated psychosocial treat- A ment interventions. –  harmacotherapy should be recommended and available to all P adult patients diagnosed with opioid dependence, alcohol depen- dence, and nicotine dependence and without contraindications. Pharmacotherapy should be linked with psychosocial treatment. • Continuing Care Management of Substance Use Illness –  atients should be offered long-term, coordinated management of P their care. SOURCE: Adapted from NQF, 2007. improve numerous health care processes and outcomes. For example, Mercy Hospital (Buffalo, New York) has sustained zero ventilator-­ ssociated pneu- a monias in the intensive care unit (ICU) by reliably implementing the IHI Ventilator Bundle, with a special focus on reducing the amount and dura- tion of sedation for patients on ventilators in the ICU. An example of a system quality-improvement approach applied specifi- cally to SUD care is NIATx (formerly the Network for the Improvement of Addiction Treatment) (Capoccia et al., 2007; Gustafson and Johnson, 2012; Hoffman et al., 2008; McCarty et al., 2007b). NIATx promotes practice and system change using a simplified version of the IHI Model for Improvement. Behavioral health care organizations learn to use Plan-Do- Study-Act change cycles to reduce days to admission, improve retention

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CHANGING STANDARDS OF CARE 93 in care, and reduce no-show rates. As agencies build capacity for change, they apply the model to foster the use of evidence-based practices. NIATx, like IHI, demonstrates that system change can lead to improved clini- cal and administrative practices. Agencies adopting process improvements have increased the use of medications for specific diagnoses, screening and brief intervention in primary care settings, and adoption of evidence-based psychosocial clinical interventions; enhanced posttreatment aftercare; and facilitated case management, wrap-around, and supportive services. See the NIATx website for case studies.2 To improve the effectiveness of interventions for SUDs, Humphreys and McLellan (2011) urge policy makers to implement process-focused quality improvement strategies like those of NIATx and patient-focused strategies that reward patients and practitioners for improvements. Pay- for-performance (or value-based purchasing) strategies hold promise for promoting enhanced performance during treatment and better treatment outcomes. A focus on outcomes during treatment helps providers and patients address the ongoing symptoms of SUDs and build a strong founda- tion for a stable recovery. A performance contracting initiative in Maine, for example, used performance-based contracting and measurement of effi- ciency and effectiveness to effect system improvements in access to care and retention in treatment. SUD programs entered into fee-for-service withholds with increased payments for achieving performance targets. An evaluation analysis, however, suggested that there was little improvement in outcomes and performance (Brucker and Stewart, 2011). CLINICAL PRACTICE GUIDELINE OF THE DEPARTMENT OF VETERANS AFFAIRS AND DoD The VA and DoD jointly issued a clinical practice guideline to standard- ize quality care for SUDs for veterans and military service members. The VA/DOD Clinical Practice Guideline for Management of Substance Use Disorders (VA and DoD, 2009) outlines principles and best practices for the treatment of SUDs, including behavioral and pharmacological inter- ventions. It consists of five modules that address interrelated aspects of care: Screening and Initial Assessment for Substance Use, Management of SUD in Specialty SUD Care, Management of SUD in General Healthcare, Addiction-Focused Pharmacotherapy, and Stabilization and Withdrawal Management. Each module consists of a detailed decision algorithm and recommendations for each step in treatment. The decision algorithms are based on a review process that included ranking the level of evidence and achieved consensus among a panel of VA/DoD SUD experts, representatives 2 See http://www.niatx.net (accessed May 29, 2012).

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94 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES from academia, and a private-sector guideline facilitator. A detailed review of the guideline and its implementation within DoD is included in Chapter 6 of this report. SUMMARY Standards of care are changing to reflect research-based behavioral and pharmacological therapies. Health care reform and federal parity legislation enhance access to health insurance and mandate that commercial health plans provide similar coverage for general health care, mental health care, and care for alcohol and other drug use disorders. Advocates and policy makers have called for increased integration of addiction treatment and primary care, and DoD is uniquely positioned to take advantage of this opportunity. Greater integration of prevention and treatment services with primary care could reduce the stigma of alcohol and other drug use disor- ders and encourage individuals to seek care. REFERENCES Altice, F. L., R. D. Bruce, G. M. Lucas, P. J. Lum, P. T. Korthuis, T. P. Flanigan, C. O. ­Cunningham, L. E. Sullivan, P. Vergara-Rodriguez, D. A. Fiellin, A. Cajina, M. Botsko, V. Nandi, M. N. Gourevitch, and R. Finkelstein. 2011. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: Results from a multisite study. Journal of Acquired Immune Deficiency Syndromes 56(Suppl. 1):S22-S32. APA (American Psychiatric Association). 1994. Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed.). Washington, DC: American Psychiatric Association. ASAM (American Society of Addiction Medicine). 2012. Patient placement criteria. http:// www.asam.org/publications/patient-placement-criteria (accessed May 29, 2012). Barry, C. L., and H. A. Huskamp. 2011. Moving beyond parity—mental health and addiction care under the ACA. New England Journal of Medicine 365(11):973-975. Brucker, D. L., and M. Stewart. 2011. Performance-based contracting within a state substance abuse treatment system: A preliminary exploration of differences in client access and ­client outcomes. Journal of Behavioral Health Services & Research 38(3):383-397. Buck, J. A. 2011. The looming expansion and transformation of public substance abuse treat- ment under the Affordable Care Act. Health Affairs 30(8):1402-1410. Capoccia, V. A., F. Cotter, D. H. Gustafson, E. F. Cassidy, J. H. Ford, L. Madden, B. H. Owens, S. O. Farnum, D. McCarty, and T. Molfenter. 2007. Making “stone soup”: Improvements in clinic access and retention in addiction treatment. Joint Commission Journal on Qual- ity and Patient Safety 33(2):95-103. Collins, C. 2010. Evolving models of behavioral health integration in primary care. New York: Milbank Memorial Fund. Fiellin, D. A., L. Weiss, M. Botsko, J. E. Egan, F. L. Altice, L. B. Bazerman, A. Chaudhry, C. O. Cunningham, M. N. Gourevitch, P. J. Lum, L. E. Sullivan, R. S. Schottenfeld, and P. G. O’Connor. 2011. Drug treatment outcomes among HIV-infected opioid-dependent patients receiving buprenorphine/naloxone. Journal of Acquired Immune Deficiency Syndromes 56(Suppl. 1):S33-S38.

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