We know that substance use disorders cost the nation over $500 billion per year. These include incarceration costs, lost productivity, costs of treatment, and related healthcare costs. The healthcare costs associated with this group are actually staggering and have been estimated to be as high as $366 billion nationwide.[i] We also know that these costs are increasing year over year. The recent attention placed on the opioid crisis also highlights a growing concern around addiction.
Overall, we are becoming more aware and more willing to discuss substance misuse. There appears to be a sense of urgency related to addressing substance use disorders that has not been seen in the past. This is good news.
The question is what do we do about this problem? We believe that a partnership with healthcare is essential to addressing substance use disorders. One obvious area of intervention is the emergency room.
The tendency is to focus on “addiction” or dependency when examining the impact of AOD problems. And this is certainly a significant issue. Approximately 10% of Americans have a diagnosable substance use disorder.[ii] The healthcare costs associated with this group are staggering and have been estimated to be as high as $366 billion nationwide. There are over 70 conditions requiring hospitalization directly attributable to substance use disorders.[iii] However, the problem is even more overwhelming when you take into account non-diagnosable yet risky AOD use. For example, consider the following points:
- For every one person that is dependent on alcohol, six or more are at-risk or have already experienced problems as a result of their use.[iv]
- Approximately 40% of the patients admitted to trauma centers have a positive BAC.[v]
- If drug use is included, approximately 60% of patients seen in trauma centers are under the influence of alcohol or drugs when admitted.[vi]
- Over 20,000 people enter emergency departments every day for alcohol-related injuries and illnesses.[vii]
The traditional response, at a systems level, is to intervene with only the most severe patients. Those with clearly established “problems” are referred to local treatment providers for outpatient AOD care or to inpatient rehabilitation centers. Most do not follow through: only about 10% of those needing treatment actually receive treatment leaving 90% of these most severe cases “unengaged” in any type of recovery process.[viii] This approach has been an exercise in futility.
Essentially, we have come to accept that 9 out of 10 individuals with a diagnosable substance use disorder will not get help. Ostensibly we have come to accept that these individuals will keep showing up at our emergency rooms, physician offices and our intensive care units driving the cost of healthcare through the roof.
If we could engage even 20% more of this group we could dramatically reduce costs. It has been clearly established that healthcare costs drop by as much as 40% when individuals with substance use disorders are receiving some type of specialty AOD “help”. Consider the following:
- A review of over 1,000 patients in a Sacramento chemical dependency program noted a substantial decline in hospital (35%), emergency room (39%), and total medical costs (26%) when compared to a control group.[ix]
- Medical costs for people in treatment were $311 lower per month than for those who needed but did not receive treatment.[x]
- In one federal study, total medical costs were reduced 26 percent among one group of patients that received addiction treatment.[xi]
A second area of great impact would be intervening with the “risky” group described above. Through evidenced-based interventions and a new health coaching model we could identify and engage this population and promote a healthy lifestyle. This could be thought of as tertiary prevention rather than treatment and the return on investment would be substantial. Much can be done with this group through strategic and brief interventions. For example, in a federal study a group of at-risk alcohol users who received brief coaching recorded 20 percent fewer emergency department visits and 37 percent fewer days of hospitalization.[xii]
Based on the above information we have identified the following areas of need:
- Our healthcare system needs a service that can increase the treatment/recovery engagement and retention level for their members with a diagnosable substance use disorder; given the fact that 9 out of 10 do not follow through or access treatment despite clear benefits.
- Our healthcare system needs a service that can assist in identifying and intervening with those individuals that do not meet diagnostic criteria for substance use disorder yet are engaging in destructive/risky AOD use.
Although contemporary medicine has made many breakthroughs and powerful advances, it still remains primarily a disease management system. A focus on acute care and discrete periods of treatment has proven to be insufficient. However, there is a new paradigm emerging with an emphasis on wellness, prevention and ongoing care. The discipline of health coaching is a growing reality within the continuum of care. Duke University describes health coaching in the following ways:
- Health coaching is the missing link in our current health care system.
- Health coaching is a new paradigm of care that defines success not as more procedures and tests, but as better patient engagement and outcomes
- Health coaching empowers clients to make lasting health behavior changes that are the cornerstones of lifelong well-being
- Health coaching bridges the gap between medical recommendations and patients’ abilities to successfully implement those recommendations into their complex lives.[xiii]
Consistent with the philosophy and model of health coaching we suggest a sub-specialty that is specifically designed to meet the needs of healthcare patients with co-occurring AOD issues. Peer-Based Recovery Coaching provides targeted interventions and support delivered by a professionally trained and supervised recovery expert. Guided by the general principles of shared experience, practical problem-solving, and true empathy Recovery Coaches are able to walk individuals through the labyrinth of available supports. Recovery Coaches can also ensure follow through on treatment recommendations in the face of patient resistance. Through the use of evidenced-based approaches (Motivational Interviewing) Recovery Coaches are able to engage even the most oppositional patient. In addition, it is possible to imbed a case-management philosophy that is guided by the principles of assertive community treatment. Coaches can employ a strong outreach component visiting people in their homes, using technology to reach out, making strategic phone calls and embracing non-traditional engagement methods (for example: connecting with individuals through recreational activities).
Recovery Coaches are cost effective in terms of personnel costs and incredibly dedicated individuals. The current system is desperately in need of such an addition to the continuum of care. The use of coaches to increase recovery engagement and retention among AOD patients will help to eliminate the revolving door of medical care that seems to accompany these problems. The opportunity exists for progressive healthcare organizations to lead the way in solving this seemingly insurmountable problem. Through a partnership with recovery community organizations these organizations will be part of a very unique and innovative community health initiative.
[i] National Institute on Drug Abuse (NIDA). http://www.drugabuse.gov/publications/addiction-science-molecules-to-managed-care/introduction/drug-abuse-costs-united-states-economy-hundreds-billions-dollars-in-increased-health. Retrieved 10/7/14.
[ii] Substance Abuse Mental Health Services Administration (SAMHSA). (September 4, 2014). National Household Survey on Drug Use and Health (NHSDUH). Rockville, MD.
[iii] Columbia University CASA. (1993). Cost of Substance Abuse to Americas Healthcare System. http://www.casacolumbia.org/addiction-research/reports/cost-substance-abuse-americas-health-care-system-report-1-medicaid. Retrieved 9/14/13.
[iv] Grant, B.F., Dawson, D.A., Stinson, F.S. et al. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 2001-2002. Drug and Alcohol Dependence, 2004; 72; 223-234.
[v] Rivara, F.P., Jurkovich, G.J., Gurney, J.G., et al. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg 1993; 128: 907-913.
[vi] Dinh-Zarr, T., Goss, C., Heitmann, E., Roberts, I., DiGuiseppi, C. Interventions for preventing injuries in problem drinkers. In the Cochrane Library. Chinchester, UK. John Wiley and Sons Ltd, 2004: Issue 4.
[viii] Substance Abuse Mental Health Services Administration (SAMHSA). (September 4, 2014). National Household Survey on Drug Use and Health (NHSDUH). Rockville, MD.
[ix] Parthasarathy, S., C. Weisner, et al. (2001). “Association of outpatient alcohol and drug treatment utilization and cost: revisiting the offset hypothesis.” Journal of Studies on Alcohol and Drugs, 62(1): 89-97.
[x] Estee, S. and Norlund, D. (2003). Washington State Supplemental Security Income (SSI) Cost Offset Pilot Project: 2002 Progress Report. R.a.D.A. Division and W.S.Do.S.a.H. Services, Washington State.
[xi] Fleming, Michael, and Marlon Mundt, Michael French, Linda Manwell, Ellyn Stauffacher, and Kristen Barry. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Benefit-Cost Analysis.” Alcoholism: Clinical and Experimental Research 26, no. 1 (January 2002) 36-43.
[xii] Fleming, Michael, and Marlon Mundt, Michael French, Linda Manwell, Ellyn Stauffacher, and Kristen Barry. “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Benefit-Cost Analysis.” Alcoholism: Clinical and Experimental Research 26, no. 1 (January 2002) 36-43.
[xiii] Duke University, Center for Integrative Health Coaching. http://www.dukeintegrativemedicine.org/professional-training/integrative-health-coach-professional-training. Retrieved 9/14/14