From full wraparound treatment programs to tweaks in the ED, hospitals have ample opportunity to address chemical dependency and prevent deaths.
This article first appeared in the March 2017 issue of HealthLeaders magazine.
Addiction is seen by some as a moral weakness or a character flaw, but as healthcare leaders point out, it is a brain disease—a chronic medical condition that providers must approach and treat with the same skill and compassion as cancer and heart disease.
"Simply put, you have to invest in behavioral medicine. It's a brain disorder, so you treat it like any other organ that you're treating, and it makes sense for addiction medicine to become a service line that you value and that you integrate into the other components of your health system," says Clay Ciha, president and CEO of Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Illinois.
While not new, this way of looking at and treating addiction has only recently gained favor in the American healthcare industry, granted clinical credibility in Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health.
"Over the past few decades, we have built a robust evidence base on this subject. We now know that there is a neurobiological basis for substance use disorders with potential for both recovery and recurrence," wrote Vivek H. Murthy, MD, MBA, vice admiral, U.S. Public Health Service, Surgeon General, in his office's December 2016 report.
"We have evidence-based interventions that prevent harmful substance use and related problems, particularly when started early," Murthy continued. "We also have proven interventions for treating substance use disorders, often involving a combination of medication, counseling, and social support. Additionally, we have learned that recovery has many pathways that should be tailored to fit the unique cultural values and psychological and behavioral health needs of each individual."
For hospitals and health systems, leveraging this knowledge means doing more than pumping stomachs, administering fluids, or giving emergency opioid-reversal drugs. Such treatments, while life-saving, address only the surface of addiction.
According to a National Institutes of Health study, more than 23 million American adults have struggled with substance use disorder at some point in their lives. Addiction medicine service lines could unearth and manage the complexities of chemical dependence at their deepest levels, oftentimes repeatedly for each individual patient, as suggested by healthcare leaders.
Success key No. 1: Optimize the moment of crisis using a care continuum approach
"You have a very small window—of 48 to 72 hours—to try and get people engaged in ongoing management before they are likely to start backsliding," says Gregory Teas, MD, chief medical officer of the behavioral medicine service line for AMITA Health Behavioral Medicine, which includes Alexian Brothers Behavioral Health Hospital.
AMITA's addiction medicine services span a continuum of behavioral and medical treatments across a range of acute and ambulatory settings, says Ciha. "We are able to address every aspect of addictions at every level of care."
However, an organization needn't become a major behavioral health institution to play a key role in patients' recovery, Ciha says.
For example, systems can work closely with surgeons to build awareness of best practices in prescribing and monitoring postop pain medication, enhance physician education around pain management, and create pathways from various points of care to behavioral health resources.
With these steps, "and by being integrated with other providers, we are able to work collaboratively in the best interest of the patient to ensure we are not creating problems by eprescribing," Ciha says.
One of the opportune settings to convert rescue into recovery is the emergency department, says Kyle Martin, MD, medical director of emergency services at St. Mary's Hospital in Madison, Wisconsin, part of SSM Health, a nonprofit health system that includes 20 hospitals and more than 60 outpatient care sites.
The ED is where many patients suffering from addictions interface with the healthcare system, he notes. "A lot of them don't have primary care physicians, and aren't accessing care in any other way than through the ED, so that's really the only place we're going to be able to touch their lives," Martin says.
Outreach during that critical window can make all the difference. "I'd imagine people have seen some adverse effects of their addictions, but it's a powerful moment to wake up in the ED and have a physician explain that you were basically dead."
Martin's ED in Madison, which receives about 38,000 visits per year, saw more than 180 cases of opioid overdoses in 2015—or about one every other day.
In the hopes of bringing overdose rates down, St. Mary's has launched a program modeled after the Rhode Island–based Providence Center's AnchorED, which deploys "recovery coaches" to the ED to counsel patients treated for opioid overdose and introduce them to resources for addiction recovery. The coaches, all of whom have overcome their own addictions and received special training in counseling, also follow up with patients after meeting in the ED to help them stay engaged in the process.
Similar programs exist or are in development at hospitals in New York, Pennsylvania, New Hampshire, and Massachusetts.
Martin says he hopes to see his hospital's pilot succeed and expand throughout SSM Health and beyond. "We in the ED can get into this cycle in which someone comes in and they have overdosed; we reverse them and watch them for a while, but don't actually know how to break the cycle. That's what this program hopefully will be able to accomplish."
Success key No. 2: Identify funding opportunities
The St. Mary's recovery coach program would not be possible without the organization's partnership with Safe Communities Madison and Dane County, a $7,500 grant from the Wisconsin Medical Society Foundation, and $15,000 from Dane County, Martin says.
He recommends that healthcare systems reach out to their outpatient addiction communities to learn about organizations that may be able to help.
"Often, I think the outpatient and inpatient worlds are kind of operating in isolation, or in parallel. The key is making a bridge through an organization like Safe Communities so you can get people who have real-world experience in the community and are really plugged in," he says.
With the passage of the 21st Century Cures Act in December 2016, which includes $1 billion in state grants over two years to address opioid abuse and addiction, such opportunities may expand.
The appropriation of these funds notwithstanding, addiction medicine is among the most cost-effective services a healthcare organization can provide in an increasingly value-driven environment, says Ciha.
"If you can offer people a treatment option and give them a structure for prolonged recovery, that's going to be more cost-effective than if you treat people as they show up in the ED," he says. "But remember that there is a lot of relapse in addiction treatment—because it's a hard thing to treat. We try to pull out everything in our arsenal to help somebody in their recovery, because ultimately it's a lot cheaper to treat somebody in a behavioral health setting than in an ED setting."
The cost saving isn't limited to payers and providers, notes Teas. "According to government statistics, for every dollar you spend on addiction treatment of people who get into the criminal justice system, you save $5–$7 for the taxpayer."
What's more, up to 40% of all patients in acute care hospitals, if carefully inspected, would meet diagnostic criteria for an alcohol use disorder, Teas says. "By not identifying and treating these individuals, you're going to see recidivism and increased organ system disease that will only mount medical costs in the future."
"For every dollar you spend on addiction treatment of people who get into the criminal justice system, you save $5–$7 for the taxpayer."
Success key No. 3: Watch for recidivism
While a degree of relapse is inevitable, lower recidivism rates are a key indicator of service line success, says Ciha. "You definitely want to look at your EDs and see how many patients come in again for drug-related detox or drug-seeking behavior and then try to engage them in long-term recovery that will decrease the need for episodic inpatient treatment."
At St. Mary's, leaders will be watching those metrics, as well as overdose rates, to gauge the success of their recovery coach pilot. "The most powerful question will be whether we're able to get [patients] to their own homes and maintain a recovery program so they don't have to come back to the ED."
One way to curb the revolving-door effect is to use the time substance-addicted patients do spend in hospitals more productively, says Teas. "A lot of detoxification throughout our country is done in medical units without any behavioral health component. A lot of these individuals are simply lying in bed watching TV and not receiving any programming related to recovery."
But introducing elements such as motivational interviewing and resource education to detoxification settings in medical units can go a long way toward reducing relapse rates, according to Teas. "And those are numbers that really have to be paid attention to in this modern era of value-based care."
Finding clinicians and counselors qualified to handle addiction medicine is easier said than done, however. Addictionologists—psychiatrists who specialize in addictions—are in particularly short supply, says Ciha.
"As it becomes more difficult to recruit, I think you're going to see a focus on training exceptional midlevel professionals to provide these services, which would include advanced practice nurses and physician assistants, who can help extend the reach of the psychiatrist and maintain quality care," he says.
In addition, Teas says he expects to see more primary care physicians willing to provide medication-assisted therapy. "The real future, from my perspective, is with the licensed independent providers who can join forces with the physicians to expand our coverage for the population we're talking about."
Success key No. 4: Help maintain patient recovery in the real world
Even with access to comprehensive addiction medicine services, going about sober life in the real world can be fraught with difficulty.
To help patients maintain their recovery, AMITA Health is experimenting with an array of smartphone applications that patients in recovery can use to identify triggers that can cause them to use drugs or alcohol, and that clinicians can use to analyze data about places or people that might influence an individual to relapse.
"There's a whole host of apps designed for addictions—including some that allow you to message with patients—and we're going to be incorporating them into our treatment programs," Ciha says. "I think that's the way things are going, and to not explore them is to miss an opportunity to help people better succeed in their recovery."
Debra Shute is the Senior Physicians Editor for HealthLeaders Media.