Policy Brief

To: Department of Health and Human Services

Date: July 18, 2021

Re: Substance use disorder prevention and intervention

Statement of Issue:

According to the National Institute of Drug Abuse, the national cost burden of substance abuse such as alcohol, tobacco and illicit drugs is $740 billion annually in costs related to crime, lost work productivity and health care [1]. The most recent National Survey on Drug Use and Health showed in 2019 that 61.2 million Americans have a mental illness and/or substance use disorder which increased by 5.9% from the previous year due to the rise in mental illness [2]. The increase in co-occurring substance use disorder and mental illness was seen in ages 18-49. In addition, a survey conducted on June 2020, assessing the effects of COVID on mental health and substance, showed that 40.9% of the respondents age 18 or over reported at least one adverse mental or behavior health condition and 13.3% reported increased substance use to cope with COVID related stress [3]. Likewise, the National Center for Health Statistics reported 81,230 drug overdose death in the year ending May 2020, the largest number ever recorded representing an overall 18% increase from the previous year [4]. These findings highlight an important link between substance use and mental health which has been worsened by the COVID pandemic. As a nation also in the midst of an opioid epidemic, how can we increase access to evidence-based care for substance users?

Policy Options
  • Federal mandate for every hospital to establish an integrated substance use treatment and mental health services program. Individuals admitted for overdose or other illicit drug related health problems would have access to an integrated health system that provides long term treatment, prevention and recovery services on site or coordinated with local facilities.
    • Advantages: Patients admitted for illicit drug use related problems in the ER are stabilized and then discharged without addressing the underlying cause. In an integrated system, the patient would be provided counseling and therapy options before discharge with evidence-based treatments initiated on site and then continued at the hospital or at an affiliated facility which practices evidence-based recovery and rehabilitation practices.
    • Disadvantages: Initiation and implementation of this program would put an additional cost burden on hospitals on top of the already existing costs of substance use admission. A hospital in Indiana reported that substance abuse admission makes up almost one quarter of the resources used by their ICU department [4].
  • Mobile Health Clinics in communities of high substance use which focus on mental health and substance use prevention, treatment and recovery.
    • Advantages: Mobile health clinics (MHC)can provide community targeted therapy by providing services that specifically address the communities needs and provide services in the language used by the population. MHC can also provide cost savings to the healthcare system with earlier intervention which can improve patient management and potentially decrease hospital admission or emergency room visits [5].
    • Disadvantages: Mobile health clinics do not provide continuity of care which is important for successful substance use recovery especially during the first phases of treatment when the patient is most likely to relapse. In addition, MHC have spatial and structural constraints being able to provide services to a limited number of patients. In addition, the structural limitations can compromise patient confidentiality as conversations can be more easily overhead.
  • Federal mandate that would require all insurances, private or public, to cover telehealth substance use and mental health services indefinitely, beyond the duration of the COVID pandemic. In the midst of the COVID pandemic, Medicaid has approved medication-assisted treatment for the duration of the State Disaster Emergency, Executive Order 202 [6] but there is no indication of this change being permanent. Private health plans are not mandated to cover mental health and substance use services which further limits access to substance use treatment.
    • Advantages: Telehealth increased use during COVID has shown to increase access to care. This can be especially beneficial in rural location where substance use services aren’t readily available. Telehealth allows the provider to monitor clinical signs, symptoms and check in with the patient more frequently by eliminating the need to travel.
    • Disadvantages: Telehealth limits the providers ability to do an adequate physical exam which can be crucial in patients with withdrawal symptoms. Virtual mental health counseling lacks may hinder the development of a quality patient-provider relationship and can result in poorer patient compliance.  Limited access to technology devices, internet services and connectivity issues may limit the number of individuals that can make use of telehealth services.
Policy Recommendation

The rise in fatal drug overdoses and the continuous rise in co-occurring substance use disorder and mental health illness in adults over the last four year emphasize a need for a policy to help individuals with additions. My ultimate recommendation is a Federal mandate for every hospital to establish an integrated substance use treatment and mental health services program. Many substance users end up in the hospital emergency department due to overdose or accidents related to substance use. Although the patient’s acute medical needs are addressed, substance users would benefit greatly from a system designed to facilitate transition to long term care. Creating a streamlined system that integrates behavioral and physiological dependence can help facilitate the medical symptoms faced during withdrawal and can increase success in patient recovery.

References

[1] Costs of Substance Abuse. NIDA Archives. (n.d.). https://archives.drugabuse.gov/trends-statistics/costs-substance-abuse.

[2] National Survey on Drug Use and Health: CBHSQ Data. SAMHSA.gov. (n.d.). https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health.

[3] Centers for Disease Control and Prevention. (2020, August 13). Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic – United States, June 24–30, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm.

[4] Westerhausen, D., Perkins, A. J., Conley, J., Khan, B. A., & Farber, M. (n.d.). Burden of Substance Abuse-Related Admissions to the Medical ICU. Chest Journal . https://journal.chestnet.org/article/S0012-3692(19)33736-5/fulltext.

[5] Yu, S. W. Y., Hill, C., Ricks, M. L., Bennet, J., & Oriol, N. E. (2017, October 5). The scope and impact of mobile health clinics in the United States: a literature review. International journal for equity in health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629787/.

[6] Department of Health. COVID-19 Guidance for Medicaid Providers. (n.d.). https://health.ny.gov/health_care/medicaid/covid19/faqs.htm.

[7] Centers for Disease Control and Prevention. (n.d.). Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html.