ACTING DIRECTOR'S COLUMN
Welcome to the new year and the significant changes that it will bring to our state, our field, and the Department of Alcohol and Drug Programs. With this newsletter, we aim to do what the title asserts—focus attention on issues and concerns that affect our work and our workforce in alcohol, other drug and problem gambling services.
Throughout our 34-year history as the single state authority for substance abuse prevention and treatment, we at ADP have seen significant change. And now we are engaged in four initiatives that, once again, will move us in new directions.
Three of our four initiatives result from the realignment of the fiscal authourity for four ADP programs from the state to local counties:
Initiative A: The transfer of the Drug Medi-Cal Program to the Department of Health Care Services
The State Fiscal Year (SFY) Budget 2011-12 mandated the transfer of the administration of the Drug Medi-Cal program from the Department of Alcohol and Drug Programs to the Department of Health Care Services. That transfer becomes effective July 1, 2012.
Initiative B: The realignment of four state programs and related funding to counties
The State Fiscal Year (SFY) Budget 2011-12 realigned the fiscal authority for four alcohol and other drug programs from the State to local counties. Counties now have both the programmatic and fiscal responsibility for Drug Medi-Cal, Drug Courts, Non-Drug Medi-Cal Perinatal and Non-Drug Medi-Cal Regular State resources.
Initiative C: The elimination of ADP and the transfer of remaining functions and funding to other state departments
As a continuation of the changes in state responsibility described in Initiatives A and B, in May Revise last year the Governor proposed the elimination of the Department of Alcohol and Drug Programs in SFY 2012-13. Accordingly, the Governor’s budget proposal for SFY 2012-13 consolidates and transfers all remaining ADP functions to the departments of Health Care Services, Public Health, and Social Services. These consolidations will improve state efficiency and prepare California and the alcohol and other drug field for health care reform in 2014.
Relative to Initiative C, the existence of ADP as a separate department made sense when alcohol and other drug services were developing and functioned primarily as a separate service delivery system with an emphasis on peer-oriented recovery. Over the years, we significantly expanded our service delivery system to include both clinical and medical care services and now there is a need to establish more formal linkages within those systems of care.
In addition, the treatment needs of our clients and communities have become more complex with increasingly more co-occurring mental and physical health disorders. The prevention needs of both individuals and communities also have changed. The entire substance use disorder healthcare environment has changed dramatically. The state needs to adjust its approach to prevention and treatment to reflect these changes in order to position California to implement health care reform, including efficient management of alcohol and other drug services.
As we work through the steps of each transition initiative, it is our goal—and the goal of the three departments to which we will transfer our functions, funding and personnel—to facilitate an orderly transition without disrupting the programs we administer and the clients we serve. As we progress, we will update our website with the latest information and reference materials as they become available, including comments from the field. You may submit your comments or suggestions through our special mailbox: ADPTransition@adp.ca.gov.
Fourth Initiative: Health Care Reform
The Patient Protection and Affordable Care Act (ACA) of 2010 and other recent health care reforms are changing the way health care services will be determined, provided, and funded in the future. Health care reform calls for the integration of alcohol and other drug services with primary care services. This expansion in coverage—and the Wellstone-Domenici Parity Act of 2008—opens the door for our field to serve a greater portion of those at risk or suffering from substance use disorders.
Our staff at ADP has been working to prepare the alcohol and other drug field for the ACA’s impact on California’s substance use disorder service delivery system. You will find several interesting articles on health care reform in this newsletter, as well as references and links to other resources that will keep you abreast of the changes and challenges. See the ADP Division Updates for more information.
ADP’s State Medical Director
As the issues and concerns that surround health care reform mount—especially as they impact the substance use treatment delivery system—ADP divisional staff have had an increasing need for consultation from our State Medical Director. We are pleased to announce that Dr. Elinore McCance-Katz will be holding office hours at ADP throughout the coming months and will be writing a column for FOCUS aimed at increasing awareness around current issues in the treatment of substance use disorders. Her first article in this issue is an introduction to medication-assisted treatment. Future articles will focus on specific medications and their uses in the treatment of substance use disorders.
There will be challenges ahead, but these challenges will also provide opportunities to make alcohol and other drug services an integral part of the overall health care delivery system. I welcome your comments and look forward to working in your behalf as we meet each challenge this year.
STATE MEDICAL DIRECTOR’S COLUMN
Medication-Assisted Treatment: What is it and who needs it?
The term “medication-assisted treatment” can mean different things to different providers, depending on their background and specialization within the healthcare field. For those of us providing treatment to individuals with substance use disorders, the term “medication-assisted treatment” means the inclusion of drugs approved by the U.S. Food and Drug Administration (FDA) for the maintenance treatment or relapse prevention of substance use disorders in addition to any psychosocial treatments offered. For substance use disorders, there are only a few substances for which there are FDA-approved medication treatments—tobacco, alcohol, and opioids. Unfortunately, there are no FDA-approved medication treatments for other substances for which use disorders can develop such as stimulants (cocaine and methamphetamine, MDMA), cannabis, benzodiazepines, or hallucinogens. There are sometimes reports of medications that show some evidence of effectiveness for substance abuse, but often the studies are not controlled or are open-label (i.e., the medication is given to individuals who know that they are receiving it as a treatment for a substance problem). Such interventions are often positive because both the patient and the clinician expect or hope the drug will work, but when such drugs are put in double-blind studies where neither the patient or the clinicians know if the medication is “real” or a placebo (sugar pill), the medication is no more effective than the sugar pill. Individuals with serious diseases such as substance use disorders deserve to receive medications that have been shown to be effective in controlled studies and have been evaluated by the FDA for effectiveness and safety.
Who should be considered for medication-assisted therapy?
In the field of addiction treatment, clients often are referred to medication-free treatment facilities, where relapse prevention medications for substance use disorders are not typically part of the treatment plan. Medication-free treatment can be very effective and helpful to some individuals and this modality has an important role in the field of substance abuse treatment. In particular, drug-free treatment is an important intervention for those whose level of substance problem does not reach the point of physical dependence; for adolescents reluctant to take a medication long term; for those with problems with substances for which there is no approved medication; or for those who wish not to be maintained on a medication, even if it is FDA-approved for their substance problem.
Medication-assisted treatment should be considered, if available, for those who have developed a physical dependence and/or those who were not helped by medication-free treatment. Someone who may suffer serious consequences of relapse (i.e., loss of a job or incarceration) should also be considered for medication-assisted treatment. Medication-assisted treatment can be life-saving for people with medical conditions that place them or others at high risk should they relapse (i.e., pregnant, opioid-dependent women, the seriously mentally ill who may be unable to adhere to treatment for mental illness due to uncontrolled drug use, or injection drug users with HIV or Hepatitis C and addicted to heroin). In the latter example, medication-assisted treatment can reduce the risk of transmission of potentially deadly viruses, thereby improving public health.
How are medications for substance use disorders developed?
In general, when we think about medications developed for substance use disorders, we identify a number of desirable attributes (Table 1).
Table 1: Properties of an Ideal Pharmacotherapy for Substance Use Disorders
- Convenient route of administration - oral, sublingual, intramuscular (depot formulation), or transdermal
- Long acting
- Medically safe with few side effects
- Acceptable to individuals presenting for treatment
- Ideally, little abuse liability
- Useful for more than one class of abused substances
- Useful in conjunction with psychosocial treatments
Several of the currently approved medication therapies for substance use disorders meet a number of these criteria. For example, all FDA-approved medications for treatment of these disorders have a convenient route of administration; several are long-acting (can be dosed as infrequently as once a day to once a month); several have little abuse liability (alcohol and tobacco treatments); some are useful for more than one class of abused substance (for example, naltrexone is FDA approved for treatment of both opioid and alcohol use disorders); and all should be used in conjunction with psychosocial treatments. It is not recommended that any of these medication treatments be offered as a stand alone therapy. Those with substance use disorders often have learned behaviors that are damaging to them and others, and consequently need psychosocial supports to help them learn more adaptive styles of coping with stressors. People with substance use disorders generally will give informed consent to receive medication-assisted therapy if the risks and benefits are clearly explained.
What medications are FDA approved for the maintenance treatment/relapse prevention of substance use disorders?
In upcoming columns, the classes of medication-assisted treatments will be considered, as well as when and how to use these medications; the risks and benefits; considerations in the development of treatment plans; and assessment of response to treatment.
There are FDA-approved medications for tobacco, alcohol, and opioid use disorders. For tobacco, these medications include nicotine replacement therapies (most frequently administered as gum or transdermal patch), bupropion (Zyban), and varenicline (Chantix). For alcohol, there are currently three FDA-approved medications: disulfiram (Antabuse), naltrexone (tablets or the monthly injectable medication, Vivitrol), and acamprosate (Campral). For opioid dependence, the approved medication treatments are naltrexone (tablets or the monthly injectable, Vivitrol), buprenorphine products (buprenorphine/naloxone is the recommended formulation for treatment of opioid dependence, Suboxone), and methadone. When it is determined that medication-assisted treatment is appropriate, there are a variety of things to consider before deciding which medication is best suited for a particular individual.
Meet Elinore F. McCance-Katz, MD, PhD
State Medical Director for Alcohol and Drug Programs
Dr. Elinore McCance-Katz is professor of psychiatry at the University of California, San Francisco. She is board-certified in general psychiatry with added qualifications in addiction psychiatry and is a Distinguished Fellow of the American Academy of Addiction Psychiatry.
Dr. McCance-Katz has been working in the field of addiction medicine for 20 years as a clinician, teacher, and clinical researcher. Her specialty areas include pharmacotherapy for substance use disorders, clinical pharmacology of drugs of abuse, drug interactions, cocaine/alcohol/opioid medications development, and co-occurring HIV disease and addiction. She is the State Medical Director of the California Department of Alcohol and Drug Programs. She is also Medical Director of the Physicians’ Clinical Support System for Buprenorphine and Prescribers’ Clinical Support System for Opioids, which are Center for Substance Abuse Treatment/SAMHSA-sponsored national training and peer support programs for physicians and clinicians treating patients with clinical need for opioid medications.
Dr. McCance-Katz is developing educational curriculum to assist with the integration of substance use screening, brief intervention and treatment referral through an SBIRT grant to UCSF for which she is the co-principal investigator. Internationally, she has been part of a World Health Organization (WHO) committee to develop guidelines on the treatment of drug users living with HIV/AIDS and has reviewed and contributed to WHO white papers on methadone and buprenorphine treatment of opiate addiction. Most recently, Dr. McCance-Katz has been conducting studies of drug-drug interactions between opioids or alcohol and HIV therapeutics through research studies funded by NIAAA/NIH. She also is conducting studies on drug interactions between disulfiram and HIV therapeutics, funded by NIDA/NIH.
Highlights of the Governor’s Proposed Budget 2012-2013
The budget proposed by Governor Brown for the coming state fiscal year includes the elimination of the Department of Alcohol and Drug Programs (ADP) as a separate department and the transfer of all functions and funding to three other state departments.
The proposed 2012-13 Governor’s Budget includes the transfer of $330.357 million ($37.582 million General Fund) from ADP to various departments within the California Health and Human Services Agency. Of the total transfer, $8.254 million ($3.513 million GF) is for the administrative functions associated with the Drug Medi-Cal (DMC) Program that is transferring to the Department of Health Care Services (DHCS) pursuant to the Governor’s 2011 Realignment. In addition, the Governor’s Budget reflects the elimination of ADP and the shift of $322.103 million ($34.069 million GF) for the remaining Non-Drug Medi-Cal functions transferring to DHCS, the Department of Social Services (DSS), and the Department of Public Health (DPH).
The following is a summary of the ADP functions and associated resources being transferred to other departments:
Department of Health Care Services
- DMC - $8.254 million and 59.0 positions for the administrative support associated with the DMC Program which includes program oversight, certification, and complaints.
- Non-DMC - $305.572 million and 161.5 positions for administering and supporting the Substance Abuse Prevention and Treatment (SAPT) Block Grant, various federal discretionary grants, parolee services programs, and drug court technical assistance.
Department of Social Services
- Licensing - $4.529 million and 36.0 positions supporting alcohol and other drug licensing functions.
Department of Public Health
For further description of the programs, functions and funding to be transferred to DHCS, DSS, and DPH, visit the following link: http://www.adp.ca.gov/Admin/pdf/FY_2012-13_Governor's_Budget_Highlights.pdf.
- Specialized Services - $12.002 million and 34.0 positions supporting the Narcotic Treatment Program, Driving-Under-the-Influence Program, the Office of Problem Gambling, and Counselor Certification activities.
REPORTS FROM THE FIELD
Prescription Drug Overdoses—a U.S. Epidemic
In a recent Morbidity and Mortality Weekly Report entitled, “CDC Grand Rounds: Prescription Drug Overdoses—a U.S. Epidemic,” the Centers for Disease Control and Prevention (CDC) presented some startling data. The January 13, 2012, report gives facts and figures on the extent of prescription drug abuse and unintentional drug overdose deaths from licit drugs in the United States. The report also suggests prevention strategies and the response to the issue from the White House Office of National Drug Control Policy.
Essential Health Benefits and the ACA
A significant mandate in the Patient Protection and Affordable Care Act (ACA) of 2010 is the provision of “essential health benefits” to consumers of health care services. The U.S. Department of Health and Human Services (HHS) recently released a bulletin outlining proposed policies that will allow states to specify their essential health benefits (EHB) package within broad categories for Affordable Insurance Exchanges (Exchanges). Under the ACA, consumers participating in an Exchange must receive coverage that meets their state’s EHB package. The Exchanges are charged with creating a new insurance marketplace in which individuals and small businesses will be able to purchase competitively priced health insurance plans using federal tax subsidies and credits beginning in 2014.
Under the ACA, health insurance offered in the individual and small group markets must provide ten categories of services to meet the EHB requirements:
- Ambulatory patient services (medical care that is provided on an outpatient basis to persons who are able to walk)
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
The HHS bulletin indicates flexibility and freedom in the benefits provided by states, similar to the variations found in each state’s Medicaid Program. HHS proposes that EHB will be defined by states using a benchmark approach. Under this approach, states select an existing health insurance plan’s benefit package as the benchmark. The benefits and services included in the benchmark health insurance plan would become the EHB package. Plans could adjust coverage within the ten benefit categories, so long as the coverage is not reduced.
States would choose one of the following benchmark health insurance plans:
- One of the three largest small-group plans in the state by enrollment
- One of the three largest state employee health plans by enrollment
- One of the three largest federal employee health plan options by enrollment
- The largest HMO plan offered in the state’s commercial market by enrollment
By taking this approach, HHS is allowing states to determine what services and benefits must be provided within each category for their Exchanges. If a state selects a benchmark plan that does not cover all ten categories of care, they may examine other health insurance plans, including the Federal Employee Health Benefits Plan, to form the required complete package of EHB.
The deadline to propose a federal final rule on the EHB was extended to an unspecified date in 2012. In the interim, the HHS bulletin provides states with guidance on establishing their own EHB packages for health insurance plans in their Exchanges. At a later date, the federal government will issue separate guidance on EHB requirements for the Medicaid expansion population.
The Transformation of Substance Abuse Treatment Services
Public substance abuse treatment services have largely operated as an independent part of the overall health care system, with unique methods of administration, funding, and service delivery. The Patient Protection and Affordable Care Act of 2010 and other recent health care reforms, coupled with declines in state general revenue spending, will change this.
Overall funding for substance abuse services should increase, and they should be better integrated into the mainstream of general health care. Reform provisions also are likely to expand the variety of substance abuse treatment providers and shift services away from residential and stand-alone programs toward outpatient programs and more integrated programs or care systems. As a result, patients should have better access to care that is more medically based and person-centered.
Jeffery A. Buck, senior adviser for behavioral health at the Centers for Medicare and Medicaid Services, offers a thoughtful look at the changing environment in his article entitled, “The Looming Expansion and Transformation of Public Substance Abuse Treatment under the Affordable Care Act.”
Problem Gambling Summit
The Office of Problem Gambling is again partnering with the UCLA Gambling Studies Program to present the 2012 Problem Gambling Training Summit, “Building a Foundation for Multi-Cultural Problem Gambling Prevention and Treatment Services,” March 5-6, 2012, in San Diego. The goals of the summit are to:
- Expand the knowledge of gambling prevention and treatment service providers
- Provide information related to cultural and linguistic appropriate services
- Provide a better understanding of California’s unique gambling industry
- Deliver California Problem Gambling Treatment Services Program outreach tools
Continuing education units will be offered to eligible attendees. As the details are confirmed, more information will be available at www.problemgambling.ca.gov or by calling the OPG office at (916) 327-8611.
ADP Training Conference (Watch for upcoming name change)
In the next few years, health care reform will affect alcohol, drug and problem gambling services and practitioners across the state. With the coming reform in mind, ADP’s 2012 statewide training conference will focus on ideas for integrating addiction prevention, treatment and recovery services with primary care and mental health services—the current direction of reform initiatives. This year’s conference, “Journey to Integration: Opportunities and Challenges,” will bring together people and ideas that will help shape the future of the field, and promote universal understanding and use of the prevention, public health, chronic care and recovery support frameworks.
Join your peers August 21-23, 2012, at the Woodlake Hotel Sacramento (formerly known as the Radisson Hotel Sacramento) for powerful presentations and compelling speakers.
The four conference goals focus on the continuum of services with the coming changes associated with health care reform. The goals are to:
- Share the Best to Promote Change. Attendees will share new technologies, promising practices, proven approaches and successes for instituting systemic, programmatic and individual change to improve services.
- View the Landscape. Participants will discuss California’s current environment of diverse service needs, interdependency and trends and the affect on the substance use disorder field.
- Promote Gender and Cultural Responsiveness. The conference will offer perspective on current knowledge, skills and resources to address disparities, build alliances, and promote culturally responsive services and systems for California’s diverse population.
- Explore Alternative Resources. Attendees and speakers will share knowledge and skills to enlighten others on ways to develop new—and leverage existing—funding and other resources.
For more information, description of conference emphasis areas, and submission forms for presenters, follow this link ADP Training Conference 2012.
Editor’s Note: This section of FOCUS will highlight recent ADP Bulletins to the field that contain important messages on specific programs and service issues. To read the full text of the bulletin, click on the bulletin number.
Bulletin 12-03 Change in Billing Procedures for Methadone Maintenance Treatment Services
Issue date: January 13, 2012 - Expiration Date: None
This bulletin informs the field that Drug Medi-Cal methadone maintenance treatment services (MMTS) claims can be submitted to the Short Doyle/Medi-Cal system without proof of billing Other Health Coverage insurers. This bulletin provides instructions and deadlines to counties and direct contract service providers for submission and resubmission of claims for MMTS provided from November 1, 2009, forward. Of major importance is the February 29, 2012, due date on Page 3 for submitting/resubmitting claims for service dates from November 1, 2009, to June 30, 2010, to ensure the prompt payment of claims.
Bulletin 12-02 - Revised Drug Medi-Cal Program Aid Codes Master Chart
Issue Date: January 12, 2012 - Expiration Date: Not applicable (Supersedes Bulletin 11-04)
This bulletin communicates revisions to the Department of Alcohol and Drug Programs (ADP), Drug Medi-Cal (DMC) Program, Aid Codes Master Chart. The following six codes were added effective January 1, 2012: 4N, 4S, 4W, 07, 43, and 49. The revised Aid Codes Master Chart can be accessed using the following link on ADP’s website: http://www.adp.ca.gov/Library/index.shtml. The Aid Codes Master Chart identifies aid codes that are authorized for use in the DMC Program. Certified DMC programs can receive reimbursement for providing medically-necessary substance use treatment services to Medi-Cal eligible beneficiaries whose aid codes are identified on the Aid Codes Master Chart.
Bulletin 12-01 Substance Abuse Prevention and Treatment Block Grant New Reporting Requirements for HIV Early Intervention Services Funds
Issue Date: January 4, 2012 - Expiration Date: Not applicable
This bulletin contains information on new annual reporting requirements for the Substance Abuse Prevention and Treatment Block Grant (SAPT BG) HIV Early Intervention Services (EIS) funds. The Substance Abuse and Mental Health Services Administration’s (SAMHSA) new requirements for the SAPT BG can be found under Section 1924 of the Public Health Service Act. California’s SAPT BG funding is contingent upon meeting all reporting requirements; therefore, compliance with this bulletin is critical.
Bulletin 11-18 Non-medical Residential Alcoholism or Drug Abuse Recovery or Treatment Facilities
Issue Date: December 9, 2011 - Expiration Date: Not applicable
This Bulletin informs the field that pursuant to Health and Safety Code (HSC) section 11834.02, a residential alcoholism or drug abuse recovery or treatment facility licensed by the Department of Alcohol and Drug Programs (ADP) may provide only non-medical services under the terms of its license.
ADP DIVISION UPDATES
Program Services Division—Treatment
ADP’s Program Services staff has pulled together a noteworthy set of Web pages on health care reform to help the alcohol and other drug field prepare for changes that will come with implementation of the federal Patient Protection and Affordable Care Act of 2010 (ACA). The ACA will affect California’s substance use disorder (SUD) services in a number of significant ways. For example, the ACA's public and private insurance expansion presents several opportunities for SUD service providers to serve new clients, increase prevention efforts, improve service quality and health outcomes, and reduce overall health care costs. But with change comes challenges. The ADP Health Care Reform website provides valuable resources from federal, state and credible private organizations. If you are looking for answers to your questions, browse through Health Care Reform Relating to Substance Use Disorder Services.
Program Services Division – Prevention Branch
The PSD-Prevention Branch is looking for comments from the field on courses being developed for the Professional Competencies in Substance Abuse Prevention Training Series, which is part of the Community Prevention Initiative (CPI). The Center for Applied Research Solutions (CARS), ADP’s technical assistance contractor for CPI, sent a course entitled Needs Assessment—the first in a long line of trainings—to a group of reviewers for input. CARS is looking for more reviewers in the field, so if you have not already signed up to be a reviewer, but are interested in doing so, simply complete a short questionnaire. It is our goal to gather input from a variety of volunteers who bring diverse backgrounds in culture, experience, professional aptitude, education, and skill sets.
The CPI training series will offer courses that fall into three main categories of competency: Core, Foundational and Specialized. The development schedule starts with Core Competencies, which includes a set of five courses—one for each of the five stages of the Strategic Prevention Framework (SPF). These courses will be web-based as well as in-person, small group training opportunities. The training series is designed to support and complement the California Certification Board of Alcohol & Drug Counselors (CCBADC) Prevention Specialist professional classification. The organization defines a Prevention Specialist as “a professional who uses a specialized set of knowledge, experience, training and skills to encourage healthy attitudes and behaviors which prevent the abuse of alcohol and other drugs. The role of the prevention specialist…is to empower individuals and communities to assess needs and to develop and implement strategies that effectively meet those needs.”
Once the series is launched, participation in the CPI training courses will be voluntary. Counties, organizations, and individuals may choose which training opportunities they want and which staff to include. If you would like to apply courses toward attaining a CCBADC Prevention Specialist certificate, you should consult the CCBADC manual available at www.caadac.org.
Office of Problem Gambling
The Office of Problem Gambling has good news to report about the latest addition to its services—the California Problem Gambling Treatment Services Program (CPGTSP). This pilot program for gamblers was launched, but only partially operational, in 2010 and served a total of 212 clients that year. With the addition of an outpatient services component in March 2011, the program was able to offer a multi-modal, stepped-care approach including interventions, telephone counseling, outpatient, intensive outpatient, and residential care. Another component of the program is the training of licensed mental health providers in evidence-based practices that focus on changing behaviors that lead to gambling addiction. The Problem Gambling Telephone Intervention (PGTI) Program and outpatient therapy consist of blocks of eight counseling sessions per individual. Intensive outpatient services offer clients more intensive therapy several times a week, integrating services with residential clients for group sessions. Inpatient treatment is provided at a residential care facility and includes daily care, recovery activities and 24-hour support. The residential treatment program is conducted within an existing, licensed substance abuse treatment program with experience in treating pathological gamblers. Additionally, the UCLA Gambling Studies Program, OPG’s partner, continues to serve clients through its clinical innovations program, offering the latest treatment options for problem gamblers and their families.
In 2011, OPG served 1,288 clients through the CPGTSP bringing the cumulative total to 1,500 clients served since the inception of this program. Now that it is fully operational, OPG anticipates serving the maximum number of clients with treatment services in 2012.