Social Change through Legislation

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Regulatory and legislative changes are in store for the Substance Abuse and Mental Health Services Admin- istration (SAMHSA), according to SAMHSA administrator Pam Hyde. The block grant will change “dra- matically” before 2014, said Hyde, speaking at an “Open House” on SAMHSA’s eight strategic initiatives on Oct. 8.

Hyde outlined what some of the current thinking is at the agency about how to transition to health re- form. Medicaid, administered by the Centers for Medicaid and Medicare Services (CMS), will be covering many of the people who otherwise would receive treatment funded by the block grant, according to that current thinking.

“While the block grant is in our house to administer, CMS pays for

over half of the nation’s behavioral health population,” said Hyde. “By 2014, if we get all of the people in, CMS will be paying for more than 75 percent. They see that coming at them and they are asking for our help.”

The field is concerned that in the move to health reform, the block grant as it now exists will be dis- mantled, a concern that increased when a grant solicitation, since pulled, surfaced that indicated this might occur (see ADAW, Sept. 27). Then the strategic initiatives to take SAMHSA from 2011 to 2014 were re- leased, along with a request for comments (see ADAW, Oct. 11). This set the stage for the conversation to move into the public arena, and dur- ing the three-hour “Open House,”

While legislation on the credential- ing of addiction counselors has gen- erated divisiveness among profes- sionals in some states, Kansas is moving toward the effective date of a licensure law that was adopted with minimal fanfare and appears not to be disruptive to most treat- ment operations in the short term.

Addiction field leaders in the state attribute the relative harmony of their process in recent months to several factors, from an agreement to grandfather the state’s current in- frastructure of credentialed coun- selors to the realization that any cost impacts on treatment organiza- tions probably won’t be realized for some time.

Moreover, although they don’t

take credit for predicting the future of healthcare service delivery, Kansas leaders believe that moving to licensure will position addiction counselors much better for the changes to come with health reform.

“In hindsight, we were just right with the timing,” said Sarah Hansen, executive director of the Kansas As- sociation of Addiction Professionals, which represents both counselors and treatment centers in the state. “I can’t say we were savvy, though,” she told ADAW.

In fact, the association had pur- sued licensure legislation for the state’s addiction counselors a full decade ago, but found at the time that there was not sufficient support

See Kansas on page 6

SAMHSA plans dramatic changes as health reform proceeds

Volume 22 Number 40 October 18, 2010 Print ISSN 1042-1394 Online ISSN 1556-7591

In This Issue… NIDA heralds new delivery systems to treat opioid addiction . . . See page 3

Alcoholism & Drug Abuse Weekly wins two Azbee awards . . . See page 4

SAMHSA grant will help Odyssey House develop peer workforce . . . See page 5

Post-disaster alcohol abuse is pre-existing: Study . . . See page 7

D.A.R.E. Minnesota moves beyond drugs . . . See page 7

AAAS offers guide for parents on alcohol . . . See page 8

See SAMHSA on page 2

A Wiley Periodicals, Inc. publication. wileyonlinelibrary.com

Kansas professionals see license law as pivotal to elevating counseling

HEALTH AND MEDICAL WRITING

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It is illegal under federal copyright law to reproduce this publication or any portion of it without the publisher’s permission Alcoholism & Drug Abuse Weekly DOI: 10.1002/adaw

broadcast on the web, Hyde and other SAMHSA officials briefly de- tailed plans and responded to many questions from the audience, both live and on the internet.

There are five goals for the health care reform initiative:

1) Assure behavioral health is in- cluded in all aspects of health care reform implementation.

2) Support federal, state and ter- ritorial efforts to develop and implement new provisions under Medicaid/Medicare.

3) Finalize and implement the parity provisions in the Men- tal Health Parity and Addic- tion Equity Act and the Af- fordable Care Act.

4) Develop changes in SAMHSA block grants to support re- covery and resilience.

5) Foster the integration of pri- mary and behavioral health care.

Not everyone will be covered by Medicaid, Medicare, or private insurance by 2014, so the block grant will still be needed, said Hyde. But how much of it will be used for non-treatment services, and whether CMS would want to take some of it to use to treat its new enrollees, has not been revealed. John O’Brien, who is in charge of SAMHSA’s health reform efforts, was not at the

Open House at all — he was at CMS “working on health reform,” Hyde explained.

Safety net needed The National Association of

State Alcohol and Drug Abuse Di- rectors (NASADAD) is the single biggest stakeholder when it comes to the block grant. It represents each single state authority who controls the block grant in that state. And NASADAD has conducted studies in three states — including Massachu- setts, which implemented its own health care reform two years ago — and found that the block grant was essential because not everyone was covered. “What you thought it would be and what it is, are two dif- ferent things,” said NASADAD exec- utive director Rob Morrison, speak- ing at the Open House.

Morrison stressed the impor- tance of the safety net, so that peo- ple who walk into treatment but have no access to Medicaid or pri- vate insurance can still obtain care. He also noted that 40 percent of the referrals to the block grant come from the criminal justice system. “And health reform does not touch those folks beyond the walls,” he said, referring the people who are still incarcerated but need treatment.

“We know there will be gaps in coverage after health reform,” re-

SAMHSA from page 1 sponded Hyde. Currently, about 61 percent of patients in publicly fund- ed treatment for substance abuse are uninsured, and 39 percent of pa- tients in publicly funded mental health treatment are uninsured, she said. “We expect a lot of those peo- ple to have access to Medicaid and health insurance exchanges,” said Hyde. But there will still be about 15 million uninsured people, and one-fifth to one-third of them will have “major substance abuse is- sues,” she said. The block grant will have to provide services for them.

The block grant will also be used to provide services that will not be covered by Medicaid or pri- vate insurance – non-treatment serv- ices – said Hyde. Exactly what these will be is still to be determined, al- though the basics are outlined in O’Brien’s “good and modern” treat- ment systems paper, released this summer (see ADAW, June 14) and on the web.

New demands in 2014 One issue the federal govern-

ment is working on is how to pro- vide services for the people who will be newly covered by Medicaid or insurance in 2014. “Those num- bers are staggering,” said Hyde. Out of the 32 million people who will be newly covered, six to 10 million are expected to have “major behavioral

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health issues,” she said. “Medicaid is working with us on how to manage that,” she said. “What should be covered by Medicaid, what is likely to be covered by insurance, and what should we be trying to cover with the block grant?”

Hyde noted that there are “lim- ited dollars,” and that by 2014 there will have to be “coordination of benefits” between SAMHSA, the states, and Medicaid. This is where the block grant, worth about $1.8 billion, comes in. In fact, O’Brien, who is in charge of health reform at SAMHSA, is the one working on de- veloping a regulation for the block grant, said Hyde.

SAMHSA is also working with

stakeholders, including some states, to look at what the block grant should be used for, said Hyde. “We understand that the block grant is going to have to change pretty dra- matically. We don’t want to just let that happen. We want to guide it.”

SBI There is also a concern is that the

role of primary care in screening and brief intervention (SBI), which is a lynchpin of the administration’s sub- stance abuse strategy, will usurp the role of the specialty treatment provider. To paraphrase one ques-

tioner: What can be done to ensure that referral to qualified substance abuse treatment is part of the SBI equation? “We recognize that linkages need to be established where they don’t exist, and maintained when they do,” responded H. Westley Clark, M.D., director of SAMHSA’s Center for Substance Abuse Treat- ment. “SBIRT is not a panacea,” he said, going on to explain that SBI is for the people who do have a sub- stance abuse problem but don’t rec- ognize it.

“Ninety-five percent of the peo- ple who meet criteria for abuse and dependence perceive no need for treatment,” said Clark. “The intent is to intervene early, assist the individ- ual to understand that there may be a problem, and make a determina- tion.” In the federal SBIRT grant program, there was only a 3 percent referral rate, he said. “But that means out of 1 million people, that’s 30,000 who would not have been seen.” •

October 18, 2010 Alcoholism & Drug Abuse Weekly 3

Continues on next page

A Wiley Periodicals, Inc. publication. wileyonlinelibrary.comAlcoholism & Drug Abuse Weekly DOI: 10.1002/adaw

Skolnick, Ph.D., director of NIDA's Division of Pharmacotherapies and Medical Consequences of Drug Abuse. “For medications that are used to treat substance abuse disor- ders in general, the biggest issue is compliance,” Skolnick told ADAW last week. “You can take naltrexone pills to prevent relapse, but if you decide you want to get high this weekend, all you have to do is not take the pill.” And every day, the patient must decide to take the pill, or not. With Vivitrol, that decision only needs to be made once a month, noted Skolnick. Naltrexone completely blocks the effects of opi- oids. Even if a patient “experiments” and tries to get high while on nal- trexone, it won’t work, said Skol- nick. “You will not be able to over-

and there was a sense at NIDA that this heralded a new day in the treat- ment of opioid addiction.

Methadone, the traditional treat- ment for opioid addiction, can only be provided through specialized clinics, and, like sublingual bupre- norphine, requires daily dosing. Long-term treatments mean that there are fewer compliance prob- lems with the medication, according to NIDA. In addition, Vivitrol is not an agonist, and it would offer an al- ternative to patients who would prefer not to take an opioid med- ication like methadone or buprenor- phine, according to NIDA.

Compliance and daily dosing Buprenorphine and naltrexone

are not new medications, but the delivery systems are, explained Phil

NIDA heralds new delivery systems to treat opioid addiction Last week the Food and Drug

Administration (FDA) approved Viv- itrol (naltrexone), a month-long nal- trexone depot injection, for the treatment of opioid dependence. Also last week, results of a clinical trial of a 6-month buprenorphine implant (Probuphine) were pub- lished showing it had better results than the sublingual form of the medication. Vivitrol has already been approved, and is being used, for the treatment of alcoholism.

Both developments were ap- plauded by the National Institute on Drug Abuse (NIDA), which issued a special advisory about them from director Nora Volkow, M.D. Both happened to take place at about the same time (the FDA approved Vivit- rol on Oct. 12, and the Probuphine study was published on Oct. 13),

‘What should be covered by Medicaid, what is likely to be covered by insurance,

and what should we be trying to cover with the block grant?’

Pam Hyde

To read the Strategic Initiatives Paper, leave comments, read the com- ments others have provided, and vote, go to http://feedback.samhsa.gov.

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