In the 1950s, the American Medical Association recognized that addiction was a medical condition. Today, a handful of states are implementing programs that are trying to expand the role the medical community plays in reducing the harm associated with drug abuse and addiction.
Since January, Oregon has encouraged doctors to verbally screen their patients for signs of substance abuse indicators. While doctors have used routine physicals and other visits to screen for signs of addictive behaviors for years, it is only this year that Medicaid recognized the need to compensate doctors for their work.
What was once a two minute conversation can now be a 15 to 30 minute evaluation about a patient's drug and alcohol use – a conversation that Ralph Summers says can lead to very positive outcomes.
"A lot of people will stop or drastically reduce their drinking or drug use (after a doctor advises them of the adverse health consequences)," says Summers, DHS Medicaid policy manager for addictions and mental health.
The program, known as screening and brief intervention, aims to reduce substance abuse through medical intervention. This private medical information is not shared with anyone but your doctor, says Summers. Information regarding substance use is guarded under more strict federal regulations than other health information, he said.
The Office of National Drug Control Policy – an office long devoted to notions of law enforcement, propaganda and scare tactics as a means to reduce drug use – has called the program "historic."
"These states have taken an historic step in transforming substance abuse in the United States," said Bertha Madras, ONDCP deputy director for demand reduction. "By 'medicalizing' the detection and intervention of substance abuse, the states recognize the need to de-stigmatize substance abuse and mainstream preventive services into general medical care."
Karen Wheeler, DHS addictions policy manager, said the Medicaid reimbursements could represent a paradigm shift in the way the United States deals with addiction. Currently, the average taxpayer pays $1,000 for law enforcement, $80 for substance abuse treatment and $10 for prevention services, when studies have shown that reversing that spending chart would likely have a much bigger impact on addiction.
"We need to be treating it as a lifelong illness," she said. Many policy makers fail to realize the chronic nature of addiction, she says, instead treating it like something that can be cured with either jail time or one-size-fits-all treatment options – options that are under-funded and overcrowded.
David Fidanque, the executive director of ACLU of Oregon, says he's skeptical of the ONDCP's support of the program.
"It would be a positive shift (in policy) if the screening distinguishes between abuse and use," he said. "If like other (government anti-drug) efforts it assumes any use of marijuana or other drugs is abuse, then it's not going to work."
He also wondered if patients would be inclined to tell the truth about their substance use.
"Given the overall criminal enforcement of the War on Drugs, people don't feel safe talking about any drug use in general," Fidanque said.
According to the new Medicaid program, patients – most are under the Oregon Health Plan — who meet standards for substance abuse may receive a brief talk with their physician or a voluntary referral for treatment – if it is available under their health plan. Only about 25 percent of people who have been diagnosed with a substance abuse problem get treatment – a problem that Wheeler says can be attributed to the nature of how treatment programs are funded.
"Capacity for addiction treatment is not driven by need," Wheeler says. It is driven by the amount of money given by the legislature. While it isn't clear if more money will be allocated because of these new Medicaid referrals – the need for treatment already far exceeding the availability – it could drastically reduce the need for treatment in the future. Wheeler says brief interventions with physicians have shown to reduce substance use before it becomes a problem.
Published 7-9-2008
