11/3/15
ACA and Addiction Treatment and
Recovery: What Every Addiction
Professional Needs to Know
Misti Storie, MS, NCC
Director of Training
Presented by Eric Goplerud, PhD
NAADAC, the Association for Addiction
Professionals
www.naadac.org
[email protected]
November 4, 2015
www.naadac.org/webinars
Produced By
NAADAC, the Association for Addiction Professionals
www.naadac.org/webinars
CE Certificate
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4.  A CE certificate will be emailed to you within
21 days of submitting the quiz.
1
11/3/15
Webinar Learning Objectives
Using GoToWebinar – (Live Participants Only)
1
§  Control Panel
2
3
§  Asking Questions
Understand the new
health system
landscape as a result of
the ACA
§  Audio (phone
preferred)
Understand how
the ACA affects
your professional
practice
Identify how SBIRT can be
integrated in order to prepare
helping professionals to work
in the framework of the ACA
and the desired integration of
substance abuse services into
primary care
Definitions
Eric Goplerud, PhD
• ACA – Affordable Care Act
Senior Vice President and Fellow
Public Health Department
NORC at the University of Chicago
[email protected]
• MHPAEA - The Mental Health Parity and
Addiction Equity Act
• SBIRT – Screening, Brief Intervention, and
Referral to Treatment
11
Substance use risk did not match health
coverage pre-ACA and pre-MHPAEA
Percentage
100 Over 90% of
use and
90
But likelihood of
coverage for
substance use
increases as
prevalence declines
problems
80
start
70 between the
ages of
60
12-20
People with SUDs die
an average of 22.5
years sooner than those
without a diagnosis
50
High risk alcohol/drug
use in the past year
40
Substance Use
Disorder in the
past year
30
20
•  21.6 million had SUDs (8.2% US pop 12 y.o. and older)
•  47.5 million Americans lacked health insurance
–  14.6% uninsured adults have SUDs
–  Treatment rate uninsured was12.8%
•  33% of those covered by individual insurance had no SUD
coverage;
•  5% in small group insurance no SUD coverage
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
10
0
Health Insurance Coverage for SUD
Pre-MHPAEA and ACA
Age
Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000
13
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Pre-ACA and Pre-MHPAEA: SUDs are Common, But
Treatment Rates are Low
Few Get Treatment:
1 in 20 adolescents,
1 in 18 young adults,
1 in 11 adults
25%
MHPAEA and ACA are about...
coverage and access
20.1%
20%
15%
10%
7.4%
7.0%
5%
0%
1.1%
0.4%
12 to 17
18 to 25
0.6%
Abuse or Dependence in past year
Treatment in past year
26 or older
Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer
file]
The way that ACA and MHPAEA is supposed to
work (and does in Medicaid expansion states)
Medicaid
Expansion
State/Federal
Marketplaces
Employer
Coverage
Extent of MHPAEA and ACA Parity Coverage
ERISA-governed self-insured plans
Yes, cost and size exemptions may apply
ERISA-governed fully insured plans
Yes, size and cost exemptions apply
State-regulated group and individual
insurance markets
Medicaid fee-for-service
Medicaid managed care
Yes, applies to issuers who sell
coverage to employers with 50+ empl.
No, CMS Medicaid standards apply.
Yes, CMS Medicaid managed care
standards apply. 4/10/15 NPRM
Yes
No
No
Yes, Essential Benefit, for small group
and individual offerings
No, but FEHBP adopted MHPAEA.
No, MHPAEA not adopted.
No, churches are exempt
Yes, but plan sponsors may opt out.
Separately administered CHIP plans
Medicare fee-for-service market
Medicare Advantage
Federal and State health insurance
exchanges
The Federal Employee Health Benefits
TriCare
Church plans
Nonfederal public-employee plans
17
Extension of Parity to Medicaid Managed Care
Organizations (~70% of all Medicaid beneficiaries)
Parity and ACA extends Coverage of MH/SUD
Proposed Rule by CMS 04/10/2015
•  if a state uses private health plans or MCOs to provide
any of its state plan benefits under an MCO contract,
enrollees in those MCOs (whether under a voluntary or
mandatory managed care program) must receive the
protections of MHPAEA for MH/SUD services.
•  For beneficiaries who are not enrolled in a MCO (FFS
only) proposed rule would not affect coverage
•  18 months after the date of the publication of the final rule
to comply
New coverage for Expanded MH
MH and SUD care and SUD care
coverage
Total
Individuals currently
3.9
7.1
11
holding individual
Estimates
coverage indicate that 2.8 million adults may receive
Behavioral Health treatment through Medicaid
Individuals currently
1.2
23.2
24.5
expansions,
with coverage and 3.1 million through participation in
health
insurance
under small
group exchanges.
plans
Uninsured
Total
27
---
27
32.1
30.4
62.5
Frank, R. G., Beronio, K., & Glied, S. A. (2014). Behavioral health
parity and the affordable care act. Journal of social work in disability &
rehabilitation, 13(1-2), 31-43.
19
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Substance Use Prevention and Treatment
Mandatory Essential Health Benefits in HIEs
Medicaid expansion and non-expansion states
1. Ambulatory services
6. Prescription drugs
2. Emergency services
7. Rehabilitative and habilitative
services and devices
3. Hospitalization
8. Laboratory services
4. Maternity and newborn
care
9. Preventive and wellness
services and chronic disease
management
5. Mental health and
substance use disorder
services, including
behavioral health treatment
10. Pediatric services, including oral
and vision care
American Mental Health Counselors Association. Dashed Hopes; Broken Promises; More Despair: How
the Lack of State Participation in the Medicaid Expansion Will Punish Americans with Mental Illness.
20
(2014). http://www.amhca.org/assets/content/AMHCA_DashedHopes_Report_2_21_14_final.pdf
ACA requires Private Health Plans to cover
Preventive Services
• Includes: •  Self-­‐insured employer plans (ERISA plans) •  Individual insurance plans (plans purchased by individuals) •  Small and Large group plans (plans employers buy for workers) •  Plans that are “grandfathered” are exempt Preven,ve Services Covered w/o Cost Sharing Cancer Chronic Condi,ons Vaccines Healthy Behaviors Pregnancy ü Breast Cancer ü Cardiovascular health ⁻  Hypertension screening ⁻  Lipid disorders screenings ⁻  Aspirin ü Td booster, Tdap ü Alcohol misuse screening and counseling (all adults) ü Type 2 Diabetes ü  Hepa,,s A, B –  Mammography for women 40+* –  GeneHc (BRCA) screening and counseling –  PrevenHve medicaHon ü Cervical Cancer ‒  Pap tesHng (women 21+ ) ‒  High-­‐risk HPV DNA tes,ng ♀
ü Colorectal Cancer ⁻ 
• Requirement also applies to plans that are available in the state Marketplaces because prevenHve services are considered an EssenHal Health Benefit screening (adults w/ elevated blood pressure) ü MMR ü Meningococcal ü Pneumococcal ü Zoster ü Influenza, ü Depression screening (adults, when follow up supports available) ü Varicella ü Osteoporosis One of following: screening (all women fecal occult blood 65+, women 60+ at tesHng, colonoscopy, high risk) sigmoidoscopy ü HPV (women and men 19-­‐26) ü Depression screening and brief counseling ü Tobacco counseling (all adults) Counseling and behavioral intervenHons (obese adults) intervenHons ü Alcohol misuse screening/counseling ü Rh incompa,bility screening ü  Gesta,onal diabetes ⁻ 
⁻ 
and cessa,on interven,ons ü Interpersonal and domes,c violence screening and counseling ♀
ü Diet counseling (adults w/high cholesterol, CVD risk factors, diet-­‐related chronic disease)
ü Obesity Screening ü Tobacco and cessa,on screenings♀ 24-­‐28 weeks gesta,on First prenatal visit (women at high risk for diabetes) ü Screenings ⁻ 
⁻ 
⁻ 
⁻ 
⁻ 
HepaHHs B Chlamydia (<24, hi risk) Gonorrhea Syphilis Bacteriurea ü Folic acid supplements (women w/repro capacity) ü Iron deficiency anemia screening ü Well-­‐woman visits ü BreasYeeding supports, ⁻  counseling , consulta,ons and equipment rental♀ Reproduc,ve and Sexual Health ü STI and HIV counseling (adults at high risk; all sexually-­‐
ac,ve women♀) ü Screenings: ⁻  Chlamydia (sexually acHve women <24y/o, older women at high risk) ⁻  Gonorrhea (sexually acHve women at high risk) ⁻  Syphilis (adults at high risk) ⁻  HIV (adults at high risk; all sexually ac,ve women♀) ü Contracep,on (women w/repro capacity) ♀ ⁻  All FDA approved methods as prescribed, ⁻  Steriliza,on procedures ⁻  Pa,ent educa,on and counseling SOURCE: U.S. DHHS, “Recommended Preventive Services.” Available at http://www.healthcare.gov/center/
regulations/prevention/recommendations.html.
Health Exchanges – Individual & Small Group Markets
• Federally Facilitated Exchanges (38 states), and
State-Operated Exchanges (12 and DC).
• Third enrollment period started November 1, 2015
and runs through January 2016.
• Scope is uninsured adults above 133 percent of the
Federal poverty level (plus discounted 5 percent of
income).
• Premium subsidies up to 400% poverty level
•  From 133% poverty in Medicaid expansion states
•  From 100% poverty in non-expansion states
What Healthcare Plans Are Available?
•  Platinum: Insurance pays 90
percent of covered medical
expenses.
•  Gold: Insurance pays 80 % of
covered medical expenses.
•  Silver: Insurance pays 70 % of
covered medical expenses.
•  Bronze: Insurance pays 60
percent of covered medical
expenses.
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11/3/15
Coverage in Medicaid Expansion States
Individual mandate
•  Require all citizens and legal residents (there are
some exceptions) to have health coverage in 2014.
•  What happens if someone does not meet this
deadline?
•  Will they go to jail?
NO!
•  Exceptions: Religious objections, Undocumented
immigrant, Incarcerated, American Indians and
Alaskan Natives, Income below the tax filing
threshold, The lowest cost plan option exceeds 9.5
percent of an individual’s income
Medicaid Expansion
Coverage in non-Medicaid Expansion States
So, what is happening and projected
to happen?
Parity
Coverage
Location of care
Implications of MHPAEA and ACA for SUD Prevention
and Treatment
Integrating behavioral health
and primary care
Implications of MHPAEA and ACA for SUD Prevention
and Treatment
• SUD treatments will be provided within the primary care
setting.
Increasing eligibility of
coverage for children up to
age 26 under their parents’
plans
• Reimbursement for treatment will be similar to other
chronic diseases needing long-term management.
Emphasizing prevention of
high risk alcohol use
Eliminating lifetime caps on
SUDs will be treated, managed, and monitored over a
essential benefits and
lifetime like other chronic illnesses.
supporting health care homes
• Preventive services for alcohol use risk is covered (e.g.,
routine screening of substance use and related problems,
brief intervention, and referral to treatment).
Allowing individuals with a
• Previously uninsured individuals (due to a pre-existing
pre-existing condition to have condition) will have insurance coverage for SUD treatment.
insurance coverage
• Individuals who received SUD treatment in the public
sector or from other specialty programs will receive SUD
care in the mainstream health care system.
Expanding Medicaid
Young adults – the group with an elevated rate of SUDs –
will be covered for prevention services and treatment for
SUDs.
• It will bring coverage to a large number of new enrollees.
• Substance use treatments including medications will be
covered.
30
New organizations bearing
financial and clinical risk,
using integrated EHRs
Medicaid health homes/Integrated care entities will
require access to SUD information in order to provide
patients with improved, coordinated care (2703 of ACA)
Substance use disorders and Addiction is viewed as disease of the brain
treatment integrated into
medical system
Increased role of physicians along with clinicians and peer
support recovery specialists to treat and sustain long term
recovery
31
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11/3/15
Trends in Insurance Status for SUD Admissions Pre/Post
ACA
SAMHSA (2014) Projections of National Expenditures for Treatment of Mental and
Substance Use Disorders, 2010-2020
32
SAMHSA (2014) Projections of National Expenditures for Treatment of Mental and
Substance Use Disorders, 2010-2020
34
.
Saloner, B., Antwi, Y. A., Maclean, J. C., & Lê Cook, B. Access to health insurance and
utilization of public sector substance use treatment: Evidence from the Affordable Care Act 33
dependent coverage provision.
SAMHSA (2014) Projections of National Expenditures for Treatment of Mental and
Substance Use Disorders, 2010-2020
Foreshadowing MHPAEA and ACA Impact:
SUD Treatment Rate by State Parity Status:
Federal Employees Health Benefit Parity Evaluation
Foreshadowing MHPEA and ACA Results?
35
•  No difference in rates of access to substance use treatment between
FEHB and non-FEHB plans.
•  For patients receiving substance use treatment, out-of-pocket
spending declined significantly relative to non-FEHB plans
(difference=−$101.09)
•  Total spending for substance use treatment did not differ
•  10% more patients identified with a new SUD
•  No differences in initiation and engagement in substance use
treatment.
CONCLUSIONS—”parity improves insurance
protection but has little impact on utilization, costs to
plans, or quality of care.”
Azzone, V., Frank, R. G., Normand, S. L. T., & Burnam, M. A.
(2014). Effect of insurance parity on substance abuse treatment.
36
Wen, H., Cummings, J. R., Hockenberry, J. M., Gaydos, L. M., & Druss, B. G. (2013). State parity laws and
access to treatment for substance use disorder in the United States: implications for federal parity
37
legislation. JAMA psychiatry, 70(12), 1355-1362.
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11/3/15
Do Health Insurance Plans in Exchanges Comply with
Parity? Maybe, most of the time (2015 study in 2 states)
Preparedness of Substance Use Providers for
MHPAEA and Parity
•  75% had quantitative treatment limits and prior
authorization requirements equivalent to medical-surgical
benefits
•  Health Reform Readiness Index (HRRI) for specialty SUD
treatment organizations for ACA.
•  427 SUD organizations participated -2010-2012
•  In smaller exchange, about half plans discrepant – mostly
prior authorization
•  Most in the early stages of preparation
•  In larger exchange, more likely to encounter inconsistent
financial requirements
•  Organizations with annual budgets < $5 million (n = 295)
were less likely to be prepared for ACA than organizations
with annual budgets > $5 million
•  Co-pays, co-insurance and deductibles
•  Substance use financial requirements greater than MH
•  Inappropriate matching behavioral health with medical specialists
Berry, K. N., Huskamp, H. A., Goldman, H. H., & Barry, C. L. (2015). A Tale of Two
States: Do Consumers See Mental Health Insurance Parity When Shopping on State
Exchanges?. Psychiatric Services.
38
Molfenter, T. D. (2014). Addiction treatment centers' progress in
preparing for health care reform. Journal of substance abuse
treatment, 46(2), 158-164.
39
Screening and Brief Interventions in Hospital
Emergency Departments
Opportunities for SBIRT
Cochrane Collaboration review (McQueen et al, 2011)
14 RCTs, adults and adolescents
Hotspot 1:
Hospitals
Outcomes favor BI over non-treatment controls
• 
• 
• 
• 
Systematic review of ED SBI
12 RCTs with pre- and post-BI results
11 or 12 observed significant effects on
alcohol intake, risky drinking practices,
alcohol related negative consequences,
injury frequency
Significant drop in 6 month alcohol consumption
Significant drop in alcohol
consumption at 9 months
Self Report at 1 year favor BI
Significantly fewer deaths at
6 months and 1 year
Nilsen et al, J Sub Ab Treat. 2008
40
Gundersen Lutheran Hospital, La Crosse, WI:
Inpatient SBIRT Program Cost
Hospital SBIRT for Acutely Medically Ill, Traumatically
Injured and ED Patients
• Hospital-wide screening for high risk and
dependent substance use implemented with no
additional FTE – extension from Trauma Center
• Falmouth Hospital (MA)
• Denver General Hospital (CO)
• Gunderson Lutheran Hospital (WI)
• Oregon Health Sciences University (OR)
• Christiana Hospital (DE)
• Salina Regional Hospital (KS)
• Boston Medical Center (MA)
• Yale-New Haven (CT)
• Assessment responsibility of nursing admission
Built into Gunderson’s
process
Electronic Health Record
• All hospital inpatients 365 days per year to
includes smoking, alcohol, and psychotherapeutic
medication misuse and illicit drug use
42
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11/3/15
Hospital SBIRT Reimbursement
Integrating SBI reimbursement into the EHR
http://www.sbirtoregon.org/
Payer
Code
Commercial
Insurance,
Medicaid
Commercial
Insurance,
Medicaid
SBIRT a Profit Center for Health System –
Inpatient, Emergency Department, Ambulatory
Clinics
99408
99409
Medicare
G0396
Medicare
G0397
Medicaid
H0049
Medicaid
H0050
ED Fee
Schedule
Description
Alcohol and/or substance abuse structured
screening and brief intervention services; 15
to 30min
Alcohol and/or substance abuse structured
screening and brief intervention services;
greater than 30min
Alcohol and/or substance abuse structured
screening and brief intervention services; 15
to 30min
Alcohol and/or substance abuse structured
screening and brief intervention services;
greater than 30min
Alcohol and/or drug screening (code not
widely used)
Alcohol and/or drug service, brief
intervention, per 15 min (code not widely
used)
$85
$185
$32
$65
$24
$48
45
Kaiser-Permanente Northern California’s Early Start:
A transformational program that is cost beneficial
Hotspot 2:
Prenatal Screening and Case Management
• Universal Screening of ALL
pregnant women
•  Screening questionnaire
•  Urine toxicology (with consent)
• Place a licensed mental health
provider in the department of OB/
GYN
• Link the Early Start appointments
with routine prenatal care
appointments
• Educate all women and providers
46
RATE OF INTRAUTERINE FETAL DEMISE (stillborn)
Maternal and Infant Mean Costs Comparison
$30,000
7.1%
7.0%
$25,000
6.0%
5.0%
$20,000
4.0%
$15,000
3.0%
2.0%
0.5%
0.8%
0.6%
1.0%
$10,000
$5,000
0.0%
Screen +,
Followup
Screen+,
Assess
Screen +
Controls
Stillborns (IUFDs) were 14.2 times more likely in the S group
than the SAF or C groups
$0
Screen +,
Followup
Maternal Total Costs
Screen +,
Assess
Infant Total Costs
Screen +
Controls
Maternal and Infant Costs Combined
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11/3/15
Hotspot 3:
Ambulatory Primary Care SBIRT
www.sbirteducation.com
But most important – it’s about people
50
51
NORC Analysis of Key Elements to Successful Integration of
Key Elements to Successful SBIRT Integration in Primary
SBIRT into Primary Care
Care
•  Inner setting
• • Intervention
characteristics
Consolidated
Framework for Implementation Research
•  Organizational development consultation
•  Competency-based training of BH clinicians in SA
•  SA records integrated as part of EHRs
•  Support must come from leaders
•  Standardized, brief BH screener
•  Adapt substance risk assessment and intervention to setting
•  Characteristics of Individuals
•  Outer setting
•  Continuing SA education for PC and BH personnel
•  SA training in pre-professional workforce development
•  Standardize SBI metrics for electronic records
•  SBI as an essential element of PCMHs
•  Remove provider communication restrictions – 42 CFR Part 2
•  Remove reimbursement barriers
•  Integrate SA services throughout PC-BH integration efforts
•  Implementation
•  Create SUD quality enhancement center for primary care
ASPE Briefing: SBIRT in FQHCs 3-25-15
ASPE Briefing: SBIRT in FQHCs 3-25-15, NORC
Average Number of Community Health Center
Staff, Visits and Patients
SBIRT Reimbursement in Primary Care
2009
2010
2011
2012
Total Medical FTEs
38.4
41.4
43.6
44.4
Substance Use FTEs
0.7
0.8
1.1
1.1
Total
Medical
July 27,
2015
Encounters/Visits
53298
51198
50080
HRSA $100 million in new funding to51401
300 FQHCss
to expand SUD
Substance
Use to 11 states to expand medication assisted treatment
SAMHSA $11 million
services
Encounters/Visits
1003
1005
1336
1278
CMS isMedical
releasing guidance
to help states
implement
comprehensive,
Total
Patients
15232
15939
15385evidence15091
based SUD treatment
Substance Use
Patients
123
108
137
147
HHS Launches Multi-pronged
Effort to Combat Opioid Abuse ASPE Briefing: SBIRT in FQHCs 3-25-15
54
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11/3/15
Impact of SBI on Utilization in an
Employment-Based Health Plan
Hotspot 4: Treatment of SUDs with
Medications
•  BH inpatient days decreased
63%
•  Medical inpatient days decreased
51%
•  ER visits decreased
20%
•  Partial Hospital and IOP visits increased
81%
•  Psychiatrist visits increased
31%
•  Therapist visits increased
22%
•  Net total medical cost savings
15%
(N = 247, 12 month continuous enrollment prior and post SBI)
Total Cost/Opiate Dependent Pa,ent in 6 months post 18000 57
Comparison of Massachusetts Medicaid
Treatment Alternatives: 2003-2007
16000 Buprenorphine Methadone Drug Free No Tx 12000 10000 8000 6000 Medicaid expenditures/
person/month in 6
months post-index date
(average $1,220/month) $0.00 $28.70 Relapse Odds Ratio in 6
months post-index date 1.0 0.72*** 1.25*** 2.97*** Deaths Odds Ratio in 6
months post-index date 1.0 0.91 1.75*** 2.25*** $50** $148.5*** 4000 2000 0 Depot NTX 8582 Oral NTX 8903 Bupe 10049 Meth 16752 Drug-­‐free 14353 Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioiddependence treatments. Am J Managed Care, 2011:17(6);S235-248.
6 Months Post-­‐index Total Cost/Alcohol Dependent Pa,ent $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 Depot NTX Oral NTX Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state
Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs.
2011:30(8);1425-1433.
Associated Challenges under the ACA
—  MH/SUD treatment will need to
$14,000 Cost per pa,ent in 6 months Cost per pa,ent $ 14000 $6,757 $6,595 Disulfiram $7,107 Acamprosate $10,345 Drug-­‐free $11,677 integrate with physical medicine/
primary health care despite conflicts
in the ways that each handles
confidential patient information
—  Medicaid health homes/Integrated
care entities will require access to
SUD information in order to provide
patients with improved, coordinated
care (2703 of ACA)
—  Addiction is viewed as disease of
the brain
—  Increased role of physicians along
with clinicians and peer support
recovery specialists to treat and
sustain long term recovery
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare
costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
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11/3/15
Revising 42 CFR Part 2?
•  Federal regulations at 42 CFR Part 2 are over
40 years old
Integrated Care: How important do you think care
integration of substance use is to improved outcomes?
3.70%
1.20%
•  Is it time for change? Are we ready? What do
patients want and need when it comes to privacy?
•  ACA emphasizes preventive holistic care and
wellness, such that individuals are being
treated by their primary and specialty care
providers in a coordinated way
16.80%
Very Important
Important
•  These aims appear to directly conflict with the
restrictions of 42 CFR Part 2
78.30%
Somewhat
Important
Unimportant
August 13, 2013 Popovits/Vendome Webinar Poll Results
Outlook with MHPAEA and ACA:
Transforming Substance Use Screening and Treatment
Change Happens:
• SUD screening and treatment will be widely
dispersed
•  Less prominent federally-assisted, grant-funded, stand alone SUD facilities
•  More integrated programs/care systems where both general medical and
SUD screening & treatment is delivered (ACOs, medical homes, health
homes)
•  Health care industry standard of freely exchanged health information
•  Hotspots will be early adopters of integrated SU care
•  Passage of laws does not immediately result in improved
access, improved quality or reduced costs – vigilance,
advocacy and planning are needed
References and a website
Smyth, Hoffman, Fan, Hser, Years of potential life lost among heroin addicts 33 years after treatment. Prev. Med, 2007; 44(4) 132-140.
Jones, Moore, Sindelar, O’Connor, Schottenfeld, Fiellin. Cost analysis of clinic and office-based treatment of opioid dependence. Drug Alcohol
Depend. 2009;99(1-3): 132-140
Knudsen HK, Abraham AJ. Perceptions of state policy environment and adoption of medications in treatment of substance use disorders.
Psych Services. 2012:63(1);19-25.
Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care,
2011:17(6);S235-248.
Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction
treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433.
Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008 MMWR, November 4, 2011 / 60(43);1487-1492
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and
pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC:
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Susan L Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash, Mary Hardy, Mickel Jourabchi, and Yih-Ing Hser The economic costs of
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• Information www.sbirteducation.com “Nothing is permanent, but change”
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survive, nor the most intelligent, but the
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