Largely driven by opioid usage, there is a strong consensus on a local, state and federal level that substance abuse is at epidemic proportions in the United States. Numerous interventions have been rolled out across America - from equipping law enforcement officials with the opioid antagonist naloxone to efforts aimed at keeping opioid naïve patients from being introduced to highly addictive pain medications. However, a major stumbling block remains for those tasked with treating substance abuse disorders ... need far outstrips capacity.
Barriers to Care
Lawrence Weinstein, MD, ABHM, is chief medical officer for American Addiction Centers (AAC), a national treatment provider headquartered in Middle Tennessee. In his role, Weinstein has oversight of medical staff and operations for the publicly traded company's more than 30 locations across the United States. Triple board certified in psychiatry and neurology, addiction medicine, and holistic medicine, Weinstein joined AAC in August after previously serving as CMO for Humana Behavioral Health.
When discussing the gaps between need and effective intervention, Weinstein said there are multiple issues to be considered. First is the sheer volume of individuals in need of help. "It is upward of 20 million people, and we know that only one in 10 receives treatment," he said. Then, there are resources allocated to addressing addiction. "There is only 1 percent of total medical spend that goes into substance use treatment," Weinstein added.
On the access side of the equation, Weinstein said there are roughly 12,000 treatment centers across the country with about 40 beds on average per facility ... leaving a huge access gap for inpatient services.
"Right now, about 90 percent of all addictions centers are outpatient facilities," he continued, "and we know that 55 percent of all U.S. centers experience a shortage of behavioral health providers."
Weinstein added the provider shortage is even more ominous when drilling down a little deeper. Many of today's providers are nearing retirement age. "Coupled with that, you have a shrinking number o residents going into psychiatry. We're coming into a perfect storm," he noted.
With the growing opioid crisis, he anticipates additional investment in the $35 billion treatment industry. "You will see over the next three to five years expansion in treatment facilities, but you will not have enough providers to see folks," he predicted.
In addition to affordability and access issues, substance abuse continues to be viewed by many in a pejorative manner so that those impacted by the disease feel equal parts shame and discrimination. In an effort to encourage treatment while shielding patients, Title 42 CFR Part 2 was enacted in 1987 to address the confidentiality of alcohol and drug abuse patient records. While care models are increasingly focused on the whole person, Weinstein said the federal law - which includes tighter restrictions than required by HIPAA - has made it very difficult to provide integrated care, particularly for those dealing with substance abuse and comorbid medical conditions.
"By virtue of having these additional restrictions, you make this kind of a discriminatory experience," he said of the regulations. "Really, they stem from the old belief that substance abuse is a moral failing rather than brain disease," Weinstein continued. "Our notion of the disease has evolved over the last 10 to 15 years, but the policies have lagged."
Last year, for the first time in three decades, 42 CFR Part 2 regulations saw some updates. However, the American Psychiatric Association noted the relatively minor changes intended to align better with HIPAA and allow more providers to take value- and team-based approaches lacked the technological solutions to implement significant change. "Until this issue is fully addressed, various components of Part 2 may continue to act as a barrier to integrated care efforts," the organization stated on its website.
A lack of standardization has also exacerbated already fragmented care. Weinstein said there is disagreement across the specialty as to what even constitutes success in a disease that is prone to relapse and requires lifelong self-management, along with professional care, to address addiction.
While there are plenty of issues impacting access to evidence-based, high quality care, Weinstein said there are also several potential solutions being explored.
"It's a multifactorial disease that will require a complex approach ... a multipronged approach ... to address these issues," Weinstein said.
Certainly, he noted, efforts are underway to try to increase interest in the field and encourage more medical students to consider psychiatry and addiction medicine as a specialty. However, he pointed out, this is only one part of the overall strategy and would likely take years to have any real impact considering attrition from retiring providers.
"You can certainly try to influence policy on the state level to allow mid-level providers and extenders to assume more responsibility in a patient's care," he added of more immediate efforts to expand the workforce by allowing other providers to practice to the full scope of their profession.
Technology, Weinstein continued, is a disruptor that holds significant possibilities to expand access ... particularly the use of telepsychiatry. Utilizing telehealth protocols that are already in place for other specialties offers a relatively quick way to reach underserved populations. "We'll need to work with medical boards and regulatory agencies to standardize processes by which providers are allowed to monitor, evaluate and prescribe via telepsychiatry," he added.
Weinstein said the Centers for Medicare and Medicaid Services have only allowed telepsychiatry to be used in rural areas with provider shortages. However, he noted, there are also shortages within metro areas that could potentially be addressed through telehealth platforms. He added, CMS is considering changes to the current policy to expand use.
Weinstein said technology has the potential to not only impact accessibility but also overall affordability to the system. A patient discharged from the inpatient setting still needs outpatient care. If the first available appointment isn't for two or three weeks ... or two or three months ... the risk of relapse dramatically increases, resulting in either a visit to the ED or readmission into an inpatient facility. "Not only is it a costly event but a disruptive event in a person's recovery," he said.
Addressing standardization and quality of outcomes is another area where Weinstein believes technology could play a role. A patient who travels to another state for inpatient treatment should expect continuity of care on an outpatient basis when returning home. "Ideally, we would like to have continuation of treatment regardless of where you came from or are going back to. Currently, you have inconsistent approaches and inconsistent outcomes. Technology can be used to address that fragmentation and inconsistency," Weinstein said.
Broader use of Cognitive Behavioral Therapy (CBT) is also being explored. CBT, which was pioneered by Aaron Beck, MD, in the 1960s, has the benefit of numerous validating studies over the last 50 years. American Addiction Centers, for example, uses CBT to help individuals identify and address self-defeating thoughts and behaviors that often drive addiction. A group out of the University of Louisville has developed a computerized version of the therapy (CCBT) and is currently working toward commercialization.
Weinstein said a number of other companies are developing similar wearable technologies to validate medical adherence, serve as virtual breathalyzers, and support those in recovery. "All of this is on the horizon and will improve access and availability," he said, adding that deploying this type of technology also leads to standardization of protocols.
"With that, the treatment will become less costly by moving out of the inpatient, high acuity setting. It will be more standardized and produce improved outcomes, and that should lead to less readmissions and utilization of the Emergency Department," Weinstein said.
The next step in technology-enabled disruption is the use of artificial intelligence and big data to pinpoint those at risk for relapse, what interventions work best in various populations and how comorbid conditions impact outcomes. "American Addiction Centers will have available data that will be able to identify populations at risk," Weinstein noted of work that has already begun. "We know early intervention leads to much better outcomes."
Finally, Weinstein said research has led to a better understanding of the human brain and a more comprehensive view of the impact of psychoactive substances. "Those studies and that improved understanding of our brains will lead to improved pharmacologic interventions so drug research is another important part of the solution," he concluded.