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After watching "Expanding Treatment Capacity to Meet All Needs," you will likely have many questions, such as:
You can ask these questions and many more as part of a "live" online discussion with David Rosenbloom, Ph.D., Director, Join Together and Professor at Boston University School of Public Health on Wednesday, April 16, 2003 from 3 to 4 p.m. EST. Be a part of this lively exchange. Mark your calendar today and post your questions in advance. Flier for Webcast on 4/2/03 and Web chat on 4/16/03: Expanding Addiction Treatment Capacity to Meet All Needs Chat Transcript Moderator: The Web chat will begin in 5 minutes. Welcome to the Recovery Month 2003 Web chat. Our host today is David Rosenbloom, Ph.D., Director of Join Together and Professor at Boston University School of Public Health. Our topic today is Expanding Addiction Treatment Capacity to Meet All Needs. This online discussion will explore our Nation's continuing efforts to make addiction treatment services more available to everyone in need. Please note that the views and opinions expressed by non-CSAT staff members in the Web chats and Webcasts should not be interpreted as official CSAT policy, but as the views and opinions of the individuals participating in these events. Now we are ready for the first question. As we know, the older adult population will be growing rapidly over the next 50 years. What is being done to provide treatment for the elderly living in isolation who abuse prescription drugs? David Rosenbloom: Both problems are real … substance abuse among elderly where there is not enough focused treatment and prescription drug abuse and misuse. On the prescription abuse problem, Medicare and the manufacturer need to step forward with better coverage. The research institutes need to fund research on issues of abuse and misuse. Because many older people have Medicare coverage, appropriate Medicare policy should make access to care for this group relatively easy. Moderator: This question was previously submitted. Are there programs to address teens [who] are suffering from marijuana usage? If so, are there funds available to encourage teens who have substance abuse problems to seek treatment? David Rosenbloom: Outpatient adolescent treatment varies in supply by community. In some communities, treatment is relatively accessible for outpatient. In others, it is very scarce. Many young people who use marijuana have other problems related to adjustment and depression. Primary care doctors and families often can get help for these problems when they are properly addressed. This may reduce the need for formal drug treatment for many teens. George Marcelle: There's increased treatment funding now, but at the expense of prevention. How does JTO look at these separate, competing areas of public health? David Rosenbloom: We do not view them as competing. There is not enough money for either. brownsg: How will the new Federal Dollars for treatment and faith-based communities be distributed to the States across the US? Is there a formula? David Rosenbloom: To date, no formula has been announced. States [that] are interested in participating will file applications. It is my understanding that the Federal Government will review the applications on a competitive basis, rather than distribute them on a formula. Moderator: This question was previously submitted. With health insurance coverage limited and pending cuts in Medicaid programs across the nation, what do you see as a method of obtaining funding for treatment? David Rosenbloom: Local activists and people seeking treatment need to be sure that their insurance policies actually comply with coverage requirements in State law. A recent study by the Center for Ensuring Solutions to Alcohol Problems at George Washington University found that many of the most commonly sold insurance and HMO products in many large States violate the State law by failing to meet State requirements for substance abuse treatment. A group in Pennsylvania, for example, has gotten the insurance commission to agree that State law requires HMOs and insurance companies to provide up to 30 days of inpatient care-whenever a treating physician orders it. Very few plans in Pennsylvania have been obeying this law. With this ruling, doctors will be able to get access once again to care for their patients. Moderator: This question was previously submitted. I work with Native Americans here in Spokane, WA. The resources are so limited for treatment of any type. Are there plans to develop more culturally appropriate treatment programs, including outpatient services? David Rosenbloom: The Robert Wood Johnson Foundation sponsored a program called Healthy Nations, which developed model programs in conjunction with a number of Native American communities. Information about these programs may be available on the RWJ Foundation Web site [www.rwjf.org]. George Marcelle: Are today's doctors adequately trained to recognize and address adolescent drug use? How many are prepared to confront teens and their parents? David Rosenbloom: Most health professionals are poorly trained to identify substance abuse problems in adolescents or adults. Surveys show that patients expect doctors to ask questions about drugs and alcohol. Unfortunately, they rarely do. In selecting a pediatrician, parents should make clear that they expect the pediatrician to discuss these issues with their children. George Marcelle: The JTO wire is invaluable in helping me stay current on ATOD topics. Has it been evaluated? Do you know what impact it is having on professional understanding of ATOD problems? David Rosenbloom: Thank you for the nice words about JTO direct. Three years ago, we asked participants in a national survey if they felt better informed and less isolated than they did 5 years before the survey. The vast majority said they did feel well informed and less isolated. These answers correlated well with JTO users. Mathios: Since addiction is a disease, why is it that the insurance industry deals with this issue differently than other diseases? Is there consensus on the disease theory of addiction within the insurance industry? Does consensus exist on this within other medical communities? David Rosenbloom: There is an emerging consensus in the insurance industry that this is a disease. And in general, there is improving coverage. The big difference is higher deductibles and copayments for substance abuse and mental health treatment than other diseases. David Rosenbloom: This form of discrimination is a primary impediment to people getting care. The insurance companies and managed care companies point the finger at employers for these higher copays and deductibles, but many employers point the finger back to the insurance companies. Moderator: This question was previously submitted. What can help teens to stop using drugs, alcohol, and tobacco? David Rosenbloom: Many young people start using drugs, alcohol, and tobacco in response to some other problem they are having … they are self medicating their problem. Parental attention and involvement may help identify these problems and help teens address them in ways that do not include alcohol or drugs. Schools can play similarly constructive roles and the community as a whole can and should provide more activities for teens in the after school hours so they are not isolated and likely to develop problems. Law enforcement has the most limited role to play with these kinds of problems. Other teens use drugs and alcohol as part of thrill-seeking behavior. The community and parents need to help [teens] develop more appropriate ways to satisfy their yearning for excitement. gholloway: What can we do to improve primary care physician's knowledge of the disease of addiction? Many times, the problem is "disguised" in terms of physical and or mental health disorders. David Rosenbloom: The training programs and examination programs for physicians are the first line of attack in improving skills. The second is for patients to make clear that they expect their physicians to ask about these issues. The third important step is for health plans to implement a requirement that alcohol and drug screening be a routine part of all primary care visits and that there be appropriate evidence in the record that a referral, formal assessment, and care has been made when screening can identify a potential problem. David Rosenbloom: This kind of screening could be done in less than 3 minutes for most patients. John DeYoung-VICE-CHAIR OF RAFT: Is there any way that we in the recovery community can be more effective in educating doctors and the public at large about the disease of addiction? David Rosenbloom: Your members all have physicians; they can start with them. Chapters can ask for meetings with county medical society officials and try to get information about drug screening and alcohol screening onto the county medical society agenda. In many cases, doctors do not ask about a drug or alcohol problem because they do not know what resources are available for referral. And treatment organizations in most communities are not well organized to accept referrals from physicians and report back to the physician that contact has been made with the patients the way other medical specialties do. Chapters can work on developing local agendas to help physicians solve these problems. andrea: What being done to expand treatment options in rural areas where resources are more limited? David Rosenbloom: Not much. The reality is that access to all sorts of services is limited in rural areas. There are some interesting demonstrations under way that link patients in remote locations to online therapy. These may develop into expanding treatment options in the future. Waits: What needs are the most unmet by the current treatment infrastructure? Are there any needs that receive more funding/attention than what they merit? David Rosenbloom: The pattern differs by community, but, in general, access to long-term residential care is the hardest to come by for anybody. Access to outpatient care seems to be reasonably available when there is coverage. No form of treatment that I am aware of is over funded; however, one of the problems in the entire treatment system is that we still think about funding treatment organizations or slots rather than prescribing for each patient's need and making those services available. George Marcelle: Do you see any hope of integrating effective health promotion/risk-reduction strategies into traditional abstinence-only programs? David Rosenbloom: Yes. I think that the approach can be made compatible … particularly health promotion strategies that encourage people to stop smoking, get more exercise, smoke less, [and] eat more appropriately. All of the approaches are about risk reduction in some way. The artificial and ideological divisions may be softening at the edges. gholloway: We are looking at drastic reductions in public treatment funds in our State. Do you have any other resources or recommendations? David Rosenbloom: States are going to have to solve these problems with their own resources. There will be, in my judgment, no white knight riding in on a white horse. In many States, there are laws on the books requiring access to at least some treatment. These laws are not being obeyed, and I would urge that the first line of reaction would be to try to get these laws enforced. That will open treatment to many people who are in the workforce and relieve pressure on the public system. Some States are debating increases in alcohol and cigarette taxes. And, in some cases, agreeing to use at least part of the money to protect or expand treatment. I would certainly encourage local activists to try to support both increased taxes on alcohol and cigarettes and [the] dedication of at least part of that money to treatment expansion. David Forsell: How can we support level of care reimbursement versus "slot" or "program" requirements? David Rosenbloom: We can support appropriate individualized treatment by arguing for it with the payers. There is strong evidence that individualized treatment is more effective than putting a patient in a standard program. Part of the problem is treatment programs themselves [that] have not developed the staff and the skills to provide individualized treatment. George Marcelle: How could RAFT and others encourage medical schools to increase and improve physician education about substance abuse? David Rosenbloom: Frankly, I think RAFT should do what it can do best in the communities where it is organized. If there is a medical school in that community, then find physicians in recovery … go meet with the dean. Adjusting medical school curriculum is very hard for anyone outside the medical school to affect. Bill: What about prevention? The money for that seems to be drying up and DARE is pulling out of schools now. David Rosenbloom: Communities and parents need to develop their own prevention strategies, and school is only one part of it. The solution is going to be at the community level; and if credible programs are presented in the community, then [the programs] will garner resources from it. The most important actor in a prevention program is an involved parent. laura: Can we, as a community, implement confidential recovery advice in schools? David Rosenbloom: That depends on the school board or policy. There is no rule for or against it. You need to work with your local school board. Many school boards have been reluctant to have voluntary groups engaged in these kinds of activities inside of the school. However, it is not impossible to work these arrangements out. andrea: Alcohol and drug abuse runs rampant on many college campuses. Do college students have access to the treatment they need? Is anything being done to expand treatment options for students? David Rosenbloom: Many colleges have significantly expanded both their psychological services and their treatment specific services in recent years. They also have begun to pay attention to environmental issues and policies to reduce excess drinking on and around their campuses. You can get more information on these activities from the Higher Education Center at the educational development corporation in Newton, MA. The AMA and the RWJ Foundation also sponsor programs on college campuses to reduce and prevent underage drinking. Information about these programs is available from the AMA. George Marcelle: Many drinkers involved in serious alcohol problems, including college students, do not meet criteria for alcoholism. Do they belong in treatment? Is it wrong to use scarce treatment to intervene in their ATOD use patterns? David Rosenbloom: There are many more people who get into trouble and cause social mayhem by problematic drinking than there are serious alcoholics. Both need different kinds of attention. In many cases, an intervention as brief as 15 minutes can reduce problematic drinking. These brief interventions are entirely appropriate and need more resources. Waits: What type of behavior warrants involuntary treatment? In what scenarios has involuntary treatment been shown to be effective? David Rosenbloom: There is very good evidence that involuntary treatment is as effective as voluntary treatment. The reality is most people go to treatment under some coercion, whether from their family, employer, or criminal justice system. The key to treatment success is keeping the patient long enough for the patient to become engaged in the process. Formal or informal coercion often plays a critical role in solving this problem. David Forsell: Can you cite the strong evidence I may be able to use to argue for individualized treatment? David Rosenbloom: I suggest that you look at both the NIDA Web site and the Join Together Web site for references to studies supporting individualized treatment. A short publication by NIDA, "Principles of Effective Drug Treatment," which is available on the Join Together Web site, can lead toward this literature. George Marcelle: Should brief interventions with problematic drinkers be separate from treatment and prevention? Is this politically possible? David Rosenbloom: Many brief interventions should take place in primary care offices and never involve the formal treatment system. andrea: In some areas, patients may be bumped from treatment programs due to capacity limitations. What are your thoughts on what's being done to alleviate this problem? David Rosenbloom: These problems are going to have to be addressed community by community; there is no real overall solution. For outpatient treatment, it is relatively easy to expand capacity as long as there is coverage. It is harder to expand capacity for inpatient care quickly, but even that will respond if coverage is available. RECOCLYDE RAFT: Why do you think these insurance companies have such a hard time understanding that to pay for treatment will, in the long run, save them money when it comes to treating health problems related to substance abuse? David Rosenbloom: Insurance companies do not plan for the long run. They base their prices solely on the money they expect to spend for services during the 1-year contract period. Long-term savings arguments fall on deaf ears at the insurance carriers. In fact, there are immediate deductions in use of regular medical care when people get drug or alcohol treatment. But those reductions do not happen fast enough to show up completely in the first year. Employers who expect to be responsible for an individual or family's care for a number of years may be more amenable for the arguments that show the benefits of investing in care. Sean: Although you said prevention and treatment should not be in competition, if good treatment were more widespread and available, might this have secondary prevention effects, perhaps with children of addicted parents? David Rosenbloom: Yes. In fact, one of the most important improvements that can be made in treatment is to involve the family and children of anyone receiving treatment. It is very likely that other members of the family are at high risk for developing drug or alcohol problems that [could] be effectively prevented by taking a family approach. George Marcelle: Why does stigma against alcoholics/addicts persist even after decades of public education and the powerful message of the recovery movement? David Rosenbloom: The powerful message of the recovery movement is largely hidden. Most people do not see very much of the recovery success. Second, stigma remains in part as a rational response to the discrimination that people with alcohol and drug problems face in employment, healthcare, and housing. We believe that attacking these forms of discrimination will be a major contributor to reducing stigma. Last week, Join Together issued a national policy panel recommendation on how to fight discrimination against people with drug or alcohol problems. The report is available at the Join Together Web site [www.jointogether.org]. I encourage people to read it and act on it. George Marcelle: If effective, evidence-based, and culturally accessible prevention was more widespread, wouldn't the need for more costly treatment be reduced? David Rosenbloom: The answer is no in the short run. The short run is a very long time. There are millions of people who need treatment. The most effective prevention programs will reduce, but not eliminate, the development of drug and alcohol problems. Every community needs both effective prevention and effective treatment. Moderator: Our hour has concluded. For more information, visit CSAT's Recovery Month Web Site at http://www.recoverymonth.gov. Visit the multimedia area (http://www.recoverymonth.gov/2003/multimedia/) to see a list of upcoming Web chats and Webcasts on various topics. You also can watch the archived version of the Webcast that complements this Web chat at http://www.recoverymonth.gov/2003/multimedia/w.aspx?ID=197. We would like to thank our host, David Rosenbloom from Join Together and Boston University School of Public Health, for his participation in this online event as well as our participants for their questions. This transcript will be available shortly so that others may benefit from the dialogue. The chat has now officially ended. | ||||||||||||||||||||||||
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