In each year between 2007 and 2017, the Pacific division, which includes the State of California has had the largest number of admissions among all Census divisions in the United States, with 403,316 addiction treatment admissions. This number is primarily based upon the data collected for the Treatment Episode Data Set (TEDS), DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration (SAMHSA). The data includes publicly funded treatment providers and does not include private treatment facilities that do not report their treatment episode data. This data set is utilized to describe the picture across the country and in this case the State of California.
According to TEDS in 2007 treatment facilities across the country saw 2,162,877 treatment episodes 844,544 were for Alcohol and 399,853 for Opiates. In 2017 treatment admissions dropped to 2,005,395 with 590,681 for Alcohol and 682,074 for Opiates.
The Role of Opioids in the Country
The Opioid epidemic has run rampant for more than a decade now and has brought with it several substantial issues to our countries health, and legal systems. SAMHSA reports that in 2017 there were 533,394 Heroin treatment episodes and when you include Opioid (Heroin and Opiates other than Heroin) there were an additional 148,680 treatment admissions the highest of primary substances, with the second being alcohol (only) at 333,732.
In 2007, 14 percent of admissions aged 12 years or older were for primary heroin use. In 2017,
27 percent of admissions aged 12 years or older were for primary heroin use. That is nearly double over the course of a decade. These numbers are consistent across the country.
Opiates Other Than Heroin
The proportion of admissions aged 12 years or older for the primary use of opiates other than heroin increased from 5 percent in 2007 to 10 percent in 2011 and 2012, before declining to 7 percent in 2017. This may be indicative of the trend in the country to use Heroin as it is a cheaper alternative, easier to buy now that the Country has put significant legal pressure on the prescribing physicians, and the awareness of the American Medical Association (AMA) pain policy.
Let’s not forget about the Methamphetamine and Amphetamines treatment episodes as they are not small in number and have certainly not gone away!. Often we see trends across the country with California treating a significant rate of individuals for Methamphetamine. The proportion of admissions for primary methamphetamine/amphetamines aged 12 years and older ranged between 8 and 12 percent from 2007 to 2017. The average age at admission was 34 years for primary methamphetamine/amphetamine admissions.
Admissions age factors have shifted between 2007 and 2017.
The proportion of admissions aged 12 to 20 years decreased from 14 percent in 2007 to 7 percent in 2017.
The proportion of admissions aged 25 to 34 years increased from 26 percent in 2007 to 35 percent in 2017.
The proportion of admissions aged 50 years and older increased from 11 percent in 2007 to 18 percent in 2017.
* SOURCES: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS). Data received through 11.21.18. Population: U.S. Census Bureau, NC-EST2017-ALLDATA: Monthly Population Estimates by Age, Sex, Race, and Hispanic Origin for the United States: April 1, 2010, to July 1, 2017.
Are our Treatment Strategies working?
This seems to indicate that on the surface the countries youth strategies may be effective. However, a closer look may point to the increased access to treatment for young adults with the “Mental Health Parity and Addiction Equity Act (MHPAEA)” being passed by Congress in 2008. Then followed up with the 2013 Federal rules to implement the law. Prior to that Insurers, including Medicaid and Medicare policies, limited reimbursement for Behavioral Health including Substance Use Disorder(s).
California Stands above most States for Health Insurance Regulation
California has been vocal as well as action-oriented about its stance on Parity. The Federal guidelines state that the Federal rules are the minimum standard and if a State, like in the case of California, has more stringent rules, the State rules prevail. Fortunately, these Federal rules carry more weight as Insurance has been a near untouchable system throughout the country’s history.
What is Addiction Treatment?
First and foremost, addiction treatment is the treatment of a medical condition classified as a behavioral health condition. As mentioned earlier behavioral health conditions must be treated by health agencies with the same regard as any other medical condition. There must be a diagnosis, treatment-specific protocol, and plan. As with any other medical condition, a patient should seek a consultation by a licensed or credential professional in the field of addiction or addiction medicine.
How a Diagnosis is Formed
A diagnosis is determined by utilizing the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the DSM-5 published by the American Psychiatric Association. If you are wondering, yes, addiction or the medical term, Substance Use Disorder is a psychiatric illness, recognized worldwide by the World Health Organization. The classification process is called the ICD-10, it is the 10th edition (revision) of the International Statistical Classification of Diseases and Related Health Problems (ICD).
Once diagnosed, an individual would be assessed for appropriateness for a specific level of care. The American Society of Addiction Medicine (ASAM) has a set of criterion for Substance Use Disorder Treatment. Contrary to popular belief, addiction treatment or “rehab” is not a 30, 60 or 90-day process. Addiction treatment or recovery is an as-needed process. An individual must fit the criteria for a specific level of care in order to be treated at that level of care. For instance, if a patient is seen by a cardiologist for a 50% arterial blockage the treatment would not be a radical quadruple bypass surgical procedure. Correspondingly, addiction treatment is the same. Of course, it is trickier than a cardiac issue, it is clear to see a physical arterial blockage whereas, Substance Use Disorder relies on self-reporting of symptoms. Often, the individual minimizes their use, thus a poor diagnosis.
What is a Level of Care?
The ASAM Criteria is broken down into six dimensions.
- Dimension 1: Acute Intoxication and/or Withdrawal Potential
- Dimension 2: Biomedical Conditions and Complications
- Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications
- Dimension 4: Readiness to Change
- Dimension 5: Relapse, Continued Use, or Continued Problem Potential
- Dimension 6: Recovery and Living Environment
The level of severity from lowest to highest for each dimension is utilized to recommend an appropriate level of care.
ASAM lists the levels of care as:
- 0.5 Early Intervention
- 1 Outpatient Services
- 1 Opioid Treatment Program (OTP Level 1)
- 2.1 Intensive Outpatient Services
- 2.5 Partial Hospitalization Services
- 3.1 Clinically Managed Low-Intensity Residential Services
- 3.3 Clinically Managed, Population Specific High-Intensity Residential Services
- 3.5 Clinically Managed High-Intensity Residential Services
- 3.7 Medically Monitored Intensive Inpatient Services
- 4 Medically Managed Intensive Inpatient Services
For simplicity the categories would be ambulatory, rehabilitation/residential, detoxification, and medication-assisted opioid therapy.
A skilled, licensed or credentialed clinician assesses the patient via a set of questions, gathering of clinical data and history and then recommends a level of care for treatment. Furthermore, the patient will move through a continuum of care from one level to another, and at times back due to the regressive nature of the manifestation of the illness. In simple terms, Detox, (withdrawal management), then residential followed by outpatient care. In response to a physical or emotional relapse, an individual could be recommended a higher level of care in the process of the treatment episode.
The Impact in California, Drug Overdose deaths
The Centers for Disease Control and Prevention (CDC) reports that during the year 2017 there were 70,237 drug overdose deaths, with 47,600 (67.8%) involving opioids. That is over 130 Opioid overdose deaths a day and over 192 of all drug-related overdose deaths per day! In California, there were 2,196 opioid-related overdose deaths reported, that’s over 6 Opioid overdose deaths per day and a total of in the State. There are limitations to these numbers to be aware of. First, toxicological tests have improved over the years so autopsies are now more drug-specific. Additionally, often in the past Medical Examiners would not list all contributing substances on the death certificate. However, the numbers have grown and are clearly impacting our Country and the State of California significantly.
Impact to the Community at Large
On Oct. 26, 2017, President Trump Declared the Opioid Epidemic a Public Health Emergency. He was quoted as saying, “As Americans, we cannot allow this to continue.” It is clear we face a major issue in the country and California is not exempt. The State faces significant budget issues as the economy slowly rebounds. Not since the 1980’s HIV/AIDS crisis has the Country faced an issue with greater ramifications.
What is the financial impact?
A 2018 report by Altarum, a nonprofit health research institute, indicates the economic impact exceeds $1 Trillion dollars between 2001 and 2017 and expects an additional half a trillion by 2020. These numbers take into consideration; lost wages, low productivity in the private sector, health care costs, government spending on and in response to the crisis via health care, social services, and criminal justice expenditures. Besides the loss of life, quality of life for the individual and families of the affected, and the overall spiritual and emotional damage to the country, Opioids and Substance Use Disorder(s) are ravaging California and the Country.
Over more than a decade, the Country has been engulfed in an epidemic of grand proportion. Opioids have taken the country by storm. The effects on California and its population has been devastating. On average six people die every day in California due to Opioid overdose. When you add to that number overdoses from other drugs, motor vehicle casualties due to alcohol and other drug consumption, the health issues associated with drug use, and death by suicide there is no doubt that addiction is playing a huge role in our communities.
Finding solutions to these issues is high on the list for action steps. Substance use disorder treatment is more important today than ever. Addressing prevention and harm reduction are necessary for a full-scale assault on this public health issue. Politics aside representatives from both sides of the aisle and in between must recognize the dilemma we face and come together to find keep our communities, states, and country safe and on a healthy path.