Recovery Month Kit

Health Care Providers:  Understanding the Savings of Treating Substance Use Disorders

Substance use disorders affect millions of Americans of all ages and backgrounds, and health care providers play an integral role in recognizing these disorders and guiding people on a path of recovery. Treatment for substance use disorders is cost effective and beneficial to the person in need, with almost 4 million receiving treatment in 2005.¹ Furthermore, substance use disorders can cause a variety of related illnesses, such as heart or liver disease, directly contributing to an increase in health care costs.² By recognizing substance use disorders and referring people to treatment, health care providers can help defray these costs, as well as improve the health and well-being of affected families and the entire community.

At 15, I began experimenting with alcohol and pot with the neighborhood kids. I was riveted by the experience, striving to quiet the anger and fear I felt growing up. My lifestyle propelled me in many directions until I began recovery in 1985. Then, the world I thought I knew crashed around me as I realized the ways I was destroying myself through my alcohol and drug use, my actions, and thinking. After years in recovery, it became clear that my drinking and drugging were never about relaxing or socializing, but fueled by the part of me that wanted to die. I thank my counselors and therapy group, 12-step supports and my Higher Power for teaching me to meet these fears, and for helping me change how I relate to them. Today I dont need alcohol or drugs to flee from their shadows. My recovery journey continues to deepen my experience of self and my fullness of living.

Debbie Dettor
Coordinator, Maine Alliance for
Addiction Recovery

A substance use disorder* (See Glossary near the end of this page for definitions of bolded and starred terms) involves the dependence on, or abuse of, alcohol and/or drugs, including the nonmedical use of prescription drugs. Substance use disorders can affect people regardless of their age, race, ethnicity, class, employment status, or community.³ Therefore, like other chronic physical and mental disorders, substance use disorders are medical conditions that can be treated effectively.^{4, 5}

Untreated substance use disorders have an impact on families, communities, and the overall health of the country. In 2005, more than 22 million people aged 12 or older were classified with a substance use disorder.⁶ Health care providers play a distinctive role in their ability to recognize, refer, and in some cases, personally treat people with substance use disorders. With that in mind, this document will provide an overview of the benefits of assessment and treatment*, as well as referral tips and ways for you to contribute to the better health and lives of your patients, while reducing the costs of substance use disorders.

The Health and Financial Benefits of Investing in Treatment

Research shows that substance use disorders are medical conditions that can be effectively treated, just as many illnesses are treatable.^{7, 8} A major study published in 2000 in the Journal of the American Medical Association is one of several that demonstrate the effectiveness of treatment for substance use disorders. This study found that treatments for drug use disorders are just as effective as treatments for other chronic conditions, such as high blood pressure, asthma, and diabetes.⁹

Treatment for substance use disorders positively impacts individuals who are dependent on alcohol and/or drugs, their families, and the entire community. In addition to reducing alcohol and/or drug use, treatment improves mental and physical health and contributes to fewer family problems. Getting people with substance use disorders into treatment is directly related to improvements in the public’s health and safety, and reductions in health costs.^{10, 11} Alcohol- and drug-related medical visits decline 53 percent following treatment.¹²

Different groups of people are often provided with distinct methods of treatment that may work better for them. For example, a family-oriented approach to treatment can be most effective among adolescents with substance use disorders.¹³ Older adults with substance use disorders have been shown to respond well to age-specific, supportive, and nonconfrontational group treatment that aims to build or rebuild self-esteem.¹⁴

It is particularly important to watch for substance use disorders among patients with serious psychological distress* (SPD), which is associated with substance use disorders. People with a substance use disorder and SPD at the same time are said to have a co-occurring disorder. Since co-occurring mental and substance use disorders are fairly prevalent, ensuring that treatment is available and accessible for both disorders is essential to providing a successful path of recovery*. According to the Substance Abuse and Mental Health Services Administration’s Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Health Disorders, the treatment of both mental health and substance use disorders can help prevent the exacerbation of other health problems, including cardiac and pulmonary diseases.¹⁵

Investing in treatment for mental and substance use disorders also makes sense financially. Many studies show a positive return on investment when money is spent on treatment. Research suggests at least a 2:1 benefit-to-cost ratio, with other studies allowing for a return of $7 for every dollar spent on treatment.^{16, 17} Another study discovered as much as a $23 return for every dollar spent on treatment.¹⁸ While the return on investment varies from state to state and program to program, evidence supports the overall positive financial gain to society when investing in the treatment of people with substance use disorders.

While treatment can solve many subsequent health problems, many people who have substance use disorders are unaware that they have a problem that requires treatment. In 2005, almost 21 million people had a substance use disorder and did not receive treatment, with more than 94 percent thinking they did not need treatment.¹⁹ This information is important to health care providers so they can properly assess and refer people with substance use disorders to treatment programs, including those with co-occurring disorders who are unaware they have a problem.

Substance Use Disorders Are Common in the Health Care System—And Costly

Substance use disorders cost Americans a great deal, both in terms of the illnesses and injuries associated with misusing alcohol and/or drugs and the financial costs of the services given as a consequence of untreated substance use disorders in physicians’ offices, hospitals, and emergency rooms. Although substance use is more common among younger adults, the misuse of alcohol and/or drugs is increasing among adults aged 50 or older.^{20, 21} In 2002 and 2003, nearly 10 million older adults (or 12.2 percent) reported binge drinking* and approximately 2.5 million (or 3.2 percent) reported heavy alcohol use*. ²² An estimated 1.4 million (or 1.8 percent) older adults had used an illicit drug in the past month. Additionally, people aged 65 and older consume one-third of all medications and are more likely to be prescribed long-term and multiple prescriptions, which could lead to unintentional misuse. Prescription drug misuse—even inadvertent misuse—is prevalent among older adults, who are more vulnerable to the medicine’s effects.²³

Adults with SPD are more likely than those without to be dependent on or abuse alcohol and illicit drugs. Among adults with SPD in 2005, 5.2 million people (or 21.3 percent) had a co-occurring substance use disorder.²⁴ Of this, about half of adults with both SPD and a substance use disorder received mental health or substance use treatment at a specialty facility*; only 8.5 percent received treatment for both mental health problems and a substance use disorder.²⁵

All people with substance use disorders have a greater risk of suffering from additional diseases and a greater chance of death. In fact, heavy drinking contributes to illness in each of the top three causes of death: heart disease, cancer, and stroke. The 10^th leading cause of death—liver disease—is largely preventable, as nearly half of all cirrhosis deaths are linked to alcohol.²⁶ Drinking also causes accidents and other bodily injuries.^{27, 28, 29} Illicit drug use is associated with hepatitis, tuberculosis, and indirect causes of death, such as falls and motor vehicle crashes.³⁰

Life seemed normal to me before my car crash. I wanted to be cool and began drinking in my mid-teen years. I became a stunt car driver after high school, and I was also an alcoholic, although I didnt know it at the time. On November 30, 1979, I went out partying with 2 friends and we totaled my 69 Mustang that my dad had rebuilt. He put a lot of time, money, and effort into this car, only for it to be destroyed in mere seconds. I ended up being paralyzed and having to use a wheelchair permanently. No one else was permanently hurt or died, but I had a severe enough disability that it completely changed my life. After I got hurt, I was mean, bitter, and blaming, but I didnt realize I needed to take a look in the mirror. I didnt recognize I had an alcohol problem until 14 years after my car crash. It took quite a few years of therapy and hard knocks to get myself together, but I did. I finally went to rehab on my own and stayed as an inpatient for 1 year and outpatient for 6 months. It was the best thing that ever happened to me. I went to college, had a wonderful and sober social support network, and have remained clean and sober for over 13 years. I graduated with honors and then went on more recently to work toward becoming a Credentialed Alcoholism and Substance Abuse Counselor (CASAC).

Susan Massara
Recovery Advocate

Illnesses and emergency department visits directly impact societal health care costs attributed to substance use disorders. A SAMHSA study found in 2004 that nearly 1.3 million drug-related emergency department visits were associated with drug misuse or abuse.³¹ People who misuse alcohol average four times as many days in the hospital as nondrinkers, mostly due to drinking-related injuries. Lastly, there are substantial health care costs for people who do not have substance use disorders, but are harmed by the behavior of those who do, such as motor vehicle accidents caused by individuals operating under the influence.³²

Health-related costs in 2002 were projected to total $16 billion for drug use, representing an increase of $5.1 billion since 1992.³³ The overall costs of substance use disorders are comparable to those of other devastating, and often treatable, diseases. Based on 1990s' estimates that employed comparable methodologies, the total economic cost of the consequences of drug abuse (about $180.9 billion in 2002) and alcohol abuse (about $184.6 billion in 1998) was equivalent, if not higher than:

• Heart disease: $183.1 billion
• Cancer: $96.1 billion
• Diabetes: $98.2 billion
• Alzheimer’s disease: $100 billion
• Stroke: $43.3 billion^{34, 35, 36, 37}

Even when only comparing these diseases to the health-related costs of drug abuse—$51 billion in the 1990s—it still is one of the more costly health problems in the nation.³⁸ These facts underscore that substance use disorders are widespread and cost people their health and hard-earned dollars. Investing in treatment can help offset these costs and improve the health and lives of millions of Americans.

Tips to Help People With Substance Use Disorders

As a health care provider, you are in a unique and vital position to refer people who are aware of their substance use disorder to the appropriate method of care. You also have a responsibility to know and recognize the signs and symptoms so you can help people who are unaware of their need for treatment. The following sections will provide a broad overview of the signs of substance use disorders, the importance of assessment, and how to refer people to treatment.

Does Your Patient Have a Substance Use Disorder?

Even if you do not work primarily in the substance use or mental health fields, it is still important for you to recognize the symptoms of dependence so all patients with substance use disorders can be directed to treatment and ultimately improve their health and lives. Nurses, physician’s assistants, aides, and doctors play a valuable role in recognizing the symptoms of substance use disorders in all instances, such as screening at routine visits.

General symptoms of substance use disorders include evidence of reclusive behavior, such as long periods of isolation; lying or stealing; involvement with law enforcement; deteriorating family relationships; and changes in behavior or attitude, such as the onset of depression symptoms. Check for physical symptoms such as dilated pupils, restlessness, slurred speech, or decreased attention span.³⁹ Do not be afraid to ask your patients questions that may shed light on those signs. Some of the key questions to ask to decide if a full assessment is required are:

• Has anyone in your family or close to you expressed concern about your substance use?
• Has anyone ever told you that you are a different person when you drink and/or use drugs?
• Have you tried to quit or cut down on your alcohol consumption on your own?
• Do alcohol and/or drugs make you feel better?
• Do you ever wish that you did not use alcohol and/or drugs?⁴⁰

Patients of different age groups may have different identifying symptoms. For example, when seeing older patients, watch out for the following:

• Memory trouble after having a drink or taking medicine
• Loss of coordination (walking unsteadily, frequent falls)
• Changes in sleeping habits
• Unexplained bruises and chronic pain
• Being unsure of oneself
• Irritability, sadness, depression
• Changes in eating habits
• Wanting to be alone much of the time⁴¹

Just as people of different ages show certain symptoms, keep in mind that not all substances cause the same symptoms. For example, people who abuse opiates or narcotics may experience an accelerated heart rate or euphoric state, whereas people who misuse alcohol might experience bruises from a loss of coordination.^{42, 43}

Assessment

People who may have substance use disorders should be appropriately assessed* to embark on a path to recovery and improved health. When individuals visit your office, this is the time when you can apply your knowledge of the symptoms of substance use disorders to help those in need. More than two-thirds of people with substance use disorders see a primary or urgent care physician every six months, giving health care providers numerous opportunities to recognize the problem and refer people to treatment.⁴⁴

Since co-occurring mental and substance use disorders are common, when treating patients with a known mental disorder, be sure to assess them for symptoms of substance use disorders. People with certain physical or mental disabilities are also more likely to have a substance use disorder. Twenty-five to sixty-eight percent of people with traumatic brain injuries also have addiction histories.⁴⁵ Additionally, the percentage of individuals in treatment who have disabilities is roughly 33 percent.^{46, 47} More information about treatment for people with disabilities and substance use disorders can be found in Treatment Improvement Protocol (TIP) Series #29, Substance Use Disorder Treatment For People With Physical and Cognitive Disabilities (DHHS Publication No. (SMA) 98-3249). It can be ordered free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at 1-800-729-6686 or 1-800-487-4889 (TDD), or online at www.ncadi.samhsa.gov.

Being aware of these facts will help you be more informed and better able to properly assess your patients for substance use disorders, just as you would screen them for any other condition. Several tools are available to help health care providers assess people with substance use disorders, including GAIN (Global Assessment of Individual Needs), an assessment tool developed as part of a SAMHSA-sponsored project.⁴⁸ Additional screening tools are described in depth in Treatment Improvement Protocol (TIP) Series #24, A Guide to Substance Abuse Services for Primary Care Clinicians (DHHS Publication No. (SMA) 97-3139). It can be ordered free of charge from SAMHSA's NCADI at 1-800-729-6686 or 1-800-487-4889 (TDD), or online at www.ncadi.samhsa.gov.

Referral

Health care providers who notice patients who may have a problem or have assessed them for substance use disorders should have tools and resources available to refer* them to treatment. When referring a patient, you must take into account individual factors, such as the severity of substance use, presence of any co-occurring disorders, age, maturity level, cultural background, gender, and family environment.⁴⁹

Because recovery involves many elements—physical, mental, emotional, and/or spiritual, President Bush established the Access to Recovery (ATR) grant program to promote the individualized nature of recovery and the option to choose among treatment programs. This program, administered by SAMHSA, empowers individuals by allowing each one to choose among providers and programs in their community for the one that best meets their needs.

You can consult SAMHSA’s Substance Abuse Treatment Facility Locator at http:// find treatment.samhsa.gov/ to determine treatment options and facilities in your local area that can best serve the differing needs of each of your patients. Providers can also call SAMHSA’s National Helpline toll-free at 1-800-662-HELP.

The American Psychiatric Association (APA) offers an eight-hour training for physicians to qualify for Center for Substance Abuse Treatment certification to be eligible to request a waiver to practice medication-assisted addiction therapy with buprenorphine. The training also is for physicians who are interested in learning more about the office-based prescribing of buprenorphine for the treatment of opiate dependence. For more information, visit www.psych.org/edu/bup_training.cfm.

Health Care Coverage

Public and private insurance is typically a common and important source of financing for substance use treatment. However, cost or insurance issues continue to be barriers for people with substance use disorders.^{50, 51} Nearly 44 percent of people who received alcohol or illicit drug use treatment in the past year paid at least a portion of the cost of their last or current treatment with their own savings or earnings, more than any other reported source.⁵² The Centers for Medicare and Medicaid Services recently added two new reimbursement codes for insurance claims, one for addiction screening and the other for brief intervention services. The new codes are essential for the expansion of screening and brief intervention programs for substance use disorders into places such as community health centers and public hospitals.⁵³ More information can be found at Ensuring Solutions to Alcohol Problems’ Web site at www.ensuringsolutions.org.

Health care and treatment providers can help ease the burden on their patients by advocating for insurance plans to cover treatment for substance use disorders just as they cover treatment for other chronic diseases. While providing extensive coverage might be challenging in today’s economic climate, studies have consistently shown that investing in treatment offsets any costs and that integrating treatment for substance use disorders with medical treatment can actually cut the cost of medical treatment in half.^{54, 55, 56} By encouraging adequate insurance coverage, you can ensure that more of your patients will get the treatment they need and ultimately improve their health.

Make a Difference During Recovery Month and Beyond

This September, National Alcohol and Drug Addiction Recovery Month (Recovery Month) will be celebrated by hundreds of organizations and communities around the country to highlight the value of investing in treatment for substance use disorders. As part of Recovery Month 2007’s theme, “Join the Voices for Recovery: Saving Lives, Saving Dollars,” take the following steps to contribute to the effort:

• Know the field. Explore the tips and resources provided in this document and research the latest science-based treatment protocols. Increase your understanding of substance use disorders, and look into the health improvements that stem from treatment and recovery.
• Examine your own benefits. Evaluate your own workplace insurance policy to see how your carrier provides for treatment for mental and substance use disorders. Determine if your policy covers family members as well as the primary beneficiary. Fostering a supportive and healthy work environment will boost morale and ultimately help your patients.
• Offer free screenings/seminars. Coordinate with another community event or plan your own to include free screenings and assessments for those who are concerned about a substance use disorder. Or, research potential guest speaking opportunities at local high schools or colleges to discuss the effects substance use disorders have on health.
• Share your story. If you are comfortable sharing your own story of recovery, educate your colleagues and patients that substance use disorders can affect anyone. By sharing your story, you can ultimately help those who have yet to embark on their own path to recovery.

For more resources and organizations that can help health care providers, please consult the “Health Care” section in the “Additional Resources” document on this Web site, or visit the Recovery Month Web site at www.recoverymonth.gov. For additional Recovery Month materials, visit www.recoverymonth.gov or call 1-800-662-HELP.

Glossary

Much has been written about substance abuse, dependence, and addiction; many studies have used different terminology to explain their findings. To foster a greater understanding and avoid perpetuating any stigma associated with these conditions, the phrase “substance use disorders” is used as an umbrella term to encompass these concepts.

Below you will find extensive definitions of substance use disorders, other terms that appear underlined throughout this document, and additional concepts that you may find useful. Unless otherwise noted, more detailed definitions and criteria can be found in the 2005 National Survey on Drug Use and Health: National Findings at www.oas.samhsa.gov/nsduh.htm.

Substance use disorders – Substance use disorders involve the dependence on or abuse of alcohol and/or drugs. Dependence on and abuse of alcohol and illicit drugs, which include the nonmedical use of prescription drugs, are defined using the American Psychiatric Association’s criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4^th edition (DSM-IV). Dependence indicates a more severe substance problem than abuse; individuals are classified with abuse of a certain substance only if they are not dependent on it.⁵⁷

Treatment – Treatment is a path of recovery that can involve many interventions and attempts at abstinence. It is offered in different settings, and types of treatment greatly depend on the substances misused, as well as a person’s individual needs and characteristics. Treatment is offered in residential and outpatient programs and can include counseling or other behavioral therapy, family therapy, medication, or a combination of services.^{58, 59, 60} For more information, please refer to “A Guide To Treatment: Methods To Help People With Substance Use Disorders” in this planning toolkit.

Serious psychological distress/mental health problems – These problems occur in people who exhibit high levels of distress due to any type of mental problem, which may include general symptoms related to phobia, anxiety, or depression.⁶¹ A national organization, Mental Health America, provides greater detail about the types of mental health problems that correlate with substance use disorders. Mental health problems often predate substance use disorders by 4 to 6 years; alcohol and/or drugs may be used as a form of self-medication to alleviate the symptoms of a mental disorder.

Recovery – Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. Individuals from the recovery community and treatment-related service providers developed this definition through the National Summit on Recovery process sponsored by SAMHSA’s Center for Substance Abuse Treatment (CSAT).

Binge use – Binge use of alcohol is defined as drinking 5 or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.⁶²

Heavy use – Heavy use of alcohol is defined as drinking 5 or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on 5 or more days in the past 30 days. Heavy alcohol users also are considered binge users of alcohol.⁶³

Drink – For the purposes of some of the research provided in this document, a “drink” is considered a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with liquor in it.⁶⁴

Specialty facility – Specialty facilities include alcohol or drug rehabilitation facilities (inpatient or outpatient), hospitals (inpatient services only), and mental health centers.⁶⁵

Assessment – Assessment is a broad-based concept that includes screening and diagnosis for a substance use disorder. Screening can actually prevent the initiation or escalation of a substance use disorder.⁶⁶

Referral – This is the recommendation of a treatment program or facility to an individual.

SOURCES