Opening New Doors

There are 318 million people in America.

Of those, there are:

• 60-70 million people in some stage of mild or moderate substance use disorder

• 20-23 million people who meet the diagnostic criteria for severe substance use disorder

• 3 million people who receive treatment for their substance use disorder each year

(Based on numbers from a presentation by Dr. A. Thomas McLellan, Chief Scientist and Deputy Director of the White House Office of National Drug Control Policy 2010 [slides] and whitehouse.gov)

70 + 23 + 2.3 = 95.3 million people, or 30% of the total population of the United States.

That also means that 68% of Americans – more than 2/3 – either never use drugs or alcohol, or they do so infrequently and have no adverse effects from their occasional use.

There are 70 million people in mild or moderate substance use disorder at any given time in the United States. They meet two or more of the criteria as outlined in the DSM-V and their use of drugs and/or alcohol has begun to cause measurable issues in their lives. It is impossible to know exactly where the line is between occasional use and harmful use, or how many people may be moving back and forth across it at any given time. We know that there are a lot of them. The people in this area are drinking too much, using too often and it has begun to negatively impact their health, their relationships and their ability to be productive at work. These people typically go completely undiagnosed, and there is very little in the way of education or treatment for someone in this early stage of substance use disorder.

Most of these people will not go on to become addicts or alcoholics. They do not need acute care treatment for their condition and they will eventually either stop drinking and using on their own, or learn to moderate their use so that they can rejoin the two-thirds of the population with no issues around alcohol or drugs.

Once someone crosses into the orange section of the diagram, the frequency, intensity and duration of use has crossed the diagnostic line. The specificity and sensitivity of diagnostic tools in the DSM-V are as accurate for addiction as any other area of medicine, and diagnosis becomes much easier. There are 23-25 million adults in the United States who meet diagnostic criteria for the more severe of the substance use disorders – abuse and dependence.

There is an epidemic of diabetes in the US – 24 million people – about the same number as those with a severe substance use disorder diagnosis. If diabetes were treated like substance use disorders, only people in the most advanced stages of illness would receive treatment – people who had already suffered severe kidney damage, gone blind or had a foot amputated. There is an entire continuum of care for someone who has (or even may have) diabetes, starting with the primary care physician and ending with acute care treatment for the worst cases. We are only beginning to see the development of a similar system aimed at substance use disorders.

Under the Affordable Care act, substance abuse treatment becomes part of primary care. Education and prevention will be the focus. Substance abuse treatment will also be treated as an “essential service,” which means that health plans are now required to provide it. Insurance must now cover all stages of substance use disorder, including people who are in the earliest stages of abuse. Early intervention in other chronic diseases has proven effective at both arresting the development of the disease in many cases as well as reducing costs associated with the treatment of the disease.

Right now, Medicare and Medicaid provide coverage for acute care services for those with drug or alcohol problems (detox programs and in-patient treatment), but don’t cover office visits with a primary care physician for substance use-related issues. By contrast, Medicaid covers 100% of diabetes, asthma, and hypertension-related treatments, including doctors’ appointments, clinic visits and follow-up monitoring, as well as testing, supplies (peak flow monitors, blood pressure cuffs) and medications. These are all primary care prevention and management services, which are the most effective and least expensive ways of managing chronic illness. The new rules set forth by the Affordable Care act will effectively level the playing field for the treatment of substance use disorders, making the same types of early treatment interventions available for drug and alcohol-related health issues.

The impact of these new rules promises to be substantial. Over 100 million Americans are covered by Medicaid or Medicare, and many private insurance companies base their benefits structure on these federal plans. As early intervention programs are put in place and more people have access to these services, there is hope that those people with mild or moderate substance use disorder will be able to get the education and support they need to arrest the development of the disease and avoid the need for costly in-patient treatment. As with diabetes, hypertension and asthma, this approach is the most cost-effective and proactive way of managing the disease.

Figuring out exactly what this early intervention actually consists of is another challenge facing the medical community, especially those in the chemical dependency treatment field. Until now, all treatment models have been based on the needs of those with severe substance use disorders. Programs based on 12-step recovery and complete abstinence may be inappropriate for this new population. According to the DSM-V criteria, these people are not chronic drug or alcohol abusers and, with proper intervention, many will return to the segment of the population that has no ongoing issues with occasional drug or alcohol use. A new model will need to be developed that addresses the specific needs of this early intervention model.

Only 10% of the people who meet the diagnostic criteria for any severity of substance use disorder are actually accessing treatment in any given year, and it’s usually only those who meet the criteria for a severe substance use diagnosis. The other 70 million, who are in a mild to moderate state of substance use disorder, are only now able to access services at the primary care level. These different segments of the population are all important and we will need different policies and approaches for each one. The people who come into treatment are usually the most acute cases, and we will need to develop effective policies to effectively reach and treat the rest of the population.