Crystal Gateway Marriott 1700 Jefferson Davis Highway, Arlington, VA

Joseph G. Liberto, MD

Secretary, American Academy of Addiction Psychiatry

Clinical Manager, Special Programs, VA Maryland Health Care System

Associate Professor, University of Maryland School of Medicine

Thank you for inviting us to participate in these hearings. The American Academy of Addiction Psychiatry is a professional membership organization with approximately 1,000 members in the United States and around the world. It was founded to:

• Promote accessibility to the highest quality treatment for all who need it

• Promote excellence in clinical practice in addiction psychiatry

• Educate the public and influence public policy regarding addictive illness

• Provide continuing education for addiction professionals

• Disseminate new information in the field of addiction psychiatry, and

• Encourage research on the etiology, prevention, identification and treatment of the addictions.

As an organization committed to improving treatment outcome, we support the work that the Commission has already begun in reviewing mental health service delivery in the United States. In particular, we appreciate the Commission’s recognition of the importance of identifying, considering the needs of and treating those with co-occurring disorders. We hope therefore to be an active participant with you in the next stages of the process.

Individuals with co-occurring psychiatric and substance-related disorders experience persistent and recurrent difficulties which can interfere with every aspect of their lives. As elucidated by the Co-occurring Disorders Subcommittee of the President's New Freedom Commission on Mental Health, these individuals are poorly served by systems where treatment is provided in separate settings, with lack of integration and continuity, and insufficient availability of appropriate programs. AAAP wants to acknowledge the growing body of evidence that there are clinical interventions and programs that work for people with co-occurring disorders, and that there are identifiable principles of successful treatment that when applied can lead to the comprehensive, continuous and integrated systems of care necessary for individuals to be treated effectively.

At the last set of hearings on January 8^th, our organization’s president, Dr. Rosenthal, reviewed many areas that AAAP views as important to address if effective treatment for patients with co-occurring disorders is to take hold. Over the time remaining I would like to briefly focus on three additional areas that AAAP feels are of importance to the initiative. These are: 1) improving access to care through parity, 2) supporting the Substance Abuse Prevention and Treatment Performance Partnership put forward by SAMHSA and 3) providing education to addiction specialists.

Psychiatric and substance-related disorders have a biological basis like other medical illnesses. Currently, however, many insurance carriers discriminate against patients with mental illness by charging them higher premiums for psychiatric treatment than for medical/surgical treatment, by imposing limits on mental health treatment that are not applied to other medical care and by setting lower allowable charges for psychiatric services. These discriminatory practices serve as a barrier to treatment for patients with co-occurring disorders, which results not only in continuing human suffering but also places greater economic burden on the public.

AAAP believes the nation needs universal access to a minimal benefits health care package that will provide treatment for mental health and substance-related disorders at all levels of care. This package should include benefits that are on an equal basis with treatment for medical and surgical illnesses. Covered benefits need to include screening, psychiatric and addiction assessment, and detoxification. Pharmacotherapy and follow-up treatment must also be covered to ensure quality care. Treatment at inpatient, outpatient and in other practice settings should be supported.

Concerted efforts to eliminate the stigma associated with the diagnosis and treatment of mental health and substance use problems are essential. Mental health and substance use disorders should be accorded health care coverage equal to that provided for other chronic, relapsing conditions insofar as access to care, treatment benefits, and clinical outcomes are concerned. AAAP opposes lifetime caps, co-payment requirements, and any other mechanisms that discriminate against behavioral health care as compared to the coverage provided for medical-surgical illnesses.

Substance Abuse Prevention and Treatment Performance Partnership

We view the change from the current "Substance Abuse Prevention and Treatment Block Grant" to the "Substance Abuse Prevention and Treatment Performance Partnership" as detailed in the Federal Register as a potentially significant step forward in meeting the goals of the Commission. This change would allow federal funding to be more responsive to the needs of patients in both the mental health and substance abuse systems. Giving states more flexibility to use block grant funds to address their needs should lead to better integrated systems of care that promote best practices for the treatment of patients with co-occurring disorders.

We applaud the Subcommittee's policy recommendation that all health training programs receiving DHHS funding must include co-occurring substance abuse and mental disorders in curriculum design. We believe there is a need to increase the focus on substance use disorders and their associated psychiatric and medical comorbidities. Clearly, we support the need for proper psychiatric assessment among addicted patients and the need for education about the epidemiology, identification and treatment of dual disorders among all mental health providers. 

While we recognize the importance for generalists to be trained in the identification and treatment of addictive disorders, we feel strongly that recommendations also have to be made to enhance funding for the training of addiction specialists (possibly through augmentation of the Performance Partnership grants). With the subcommittee’s report highlighting the dramatic under-diagnosis and under-treatment of persons with co-occurring disorders, it is clear that more addiction specialists than currently exist will be necessary. These addiction specialists will be needed to provide direct care, and to serve as trainers and expert consultants to other health care providers.

What can we do to help?

We are looking for opportunities to access and utilize the expertise of the membership of the American Academy of Addiction Psychiatry in achieving the goals of this Commission and to assure that those with substance use disorders are included. We are pleased to learn that our views and those of the Co-Occurring Disorders Subcommittee are convergent.

Because we are mental-health professionals trained in addiction, areas where AAAP could be of specific service to the mission of this Committee are:

1. Assisting in reaching consensus definitions of "co-occurring disorders" and "integrated co-occurring disorder treatment," and developing specific, measurable performance standards.

2. Using our experience in training and access to the highest-level evidence-based research and practice to assist in curriculum development for and training of clinicians, especially at the state level, where AAAP has an excellent track record.

3. Using our unique qualifications to pursue in greater depth the psychopharmacologic aspects of treating co-occurring disorders -- an area that is under-addressed in the current report.

Becky Stein, MPA, Executive Director

7301 Mission Road, Suite 252

Prairie Village, KS 66208

(913) 262-6161

(913) 262-4311(fax)

E-Mail: bstein@aaap.org

Web site: www.aaap.org

Co-Occurring Psychiatric and Substance Use Disorder Treatment Policy

Introduction:

Individuals with co-occurring psychiatric and substance-related disorders experience persistent and recurrent difficulties, which can interfere with every aspect of their lives. These individuals also have a high incidence of medical comorbidity and their clinical course is associated with higher costs and poorer outcomes. In almost all psychiatric and addiction settings, people with co-occurring disorders appear with sufficient frequency that their presence must be anticipated at every of level of care. Settings that serve people with severe mental illness are likely to have a majority of the people seeking care with co-occurring disorders. These individuals are poorly served by systems where treatment for co-occurring disorders is provided in separate settings, with a lack of integration and continuity, and insufficient availability of appropriate programs.

Policy Statement:

AAAP recommends that in every system of care the following core principles form the basis of a comprehensive, continuous, integrated system for individuals with co-occurring psychiatric and substance-related disorders:

Welcoming: The goal is to insure that each clinical contact is welcoming, empathic, hopeful, culturally sensitive, and makes an effort to engage individuals who may be unwilling to accept or participate in recommended services, or who do not fit into available program models.

Accessibility: Twenty-four hour crisis intervention services should be available to provide assessment and intervention for both psychiatric and substance-use disorders. Barriers to immediate evaluation that are based upon drug or alcohol levels rather than clinical presentation should be eliminated. At each level of care (acute, outpatient, residential, or inpatient) there should be programs available to accept patients without barriers or waiting lists. Patients should not be required to self-define as "psychiatric", "substance abuse" or "dual diagnosis" in order to be accepted for evaluation and treatment.

Integration: Psychiatric disorders and substance-related disorders are both examples of primary mental illnesses and the recommended treatment approach is integrated dual primary treatment that utilizes a disease and recovery model in a single setting or service system. Individuals should have a primary treatment relationship that coordinates ongoing treatment interventions for all disorders. Each disorder should receive specific and individualized treatment, which takes into account complications resulting from co-occurring disorders, clinical variables such as the phase of recovery, the extent of disability, and the presence of external supports (e.g. supportive family) or stressors (e.g. no family, criminal justice involvement).

Continuity: Since integrated treatment is significantly associated with better outcome and reduction of more expensive service utilization, a comprehensive service system must develop mechanisms for identifying patients with co-occurring disorders and establish a collaborative system of care management. The service system must be proactive to ensure continuity and prevent patients from "falling through the cracks". It should also seek out patients who are most disengaged and hardest to serve (e.g. individuals who are homeless). Services should be available regardless of initial motivation or adherence, and should include outreach and engagement. The system must be responsive to the needs of the patient, instead of patients needing to meet the specifications of the program or system.

Comprehensiveness: Due to the high prevalence, high cost, and poor outcomes of this population, AAAP recommends that all programs meet at least the standard of "dual diagnosis capability" (ASAM PPC 2R), with each program having defined responsibility for a cohort of individuals with co-occurring disorder, matched according to diagnosis, disability, phase of recovery, stage of change, and level of care.

Background:

AAAP members are primary providers of treatment for individuals with co-occurring disorders and were participants in a 1998 SAMHSA funded a national consensus panel project on co-occurring disorders. Recommendations of that panel were utilized in the development of this AAAP policy on the treatment of individuals with co-occurring psychiatric and substance use disorders.

Approved by AAAP Board of Directors: December 2002

Treatment Parity

Introduction:

Abuse of tobacco, alcohol, and other psychoactive substances is a major national problem that causes mental and physical illness and contributes to the social problems of violence, crime, homelessness, family disruption, decreased occupational performance, and legal difficulties. Addressing substance abuse should be a top priority in health care reform.

Policy Statement:

1. The nation needs universal access to a minimal benefits health care package that will provide treatment for alcoholism and substance-related disorders at all levels of care. Substance use disorder treatment benefits should be part of a basic package that also includes treatment for other psychiatric illnesses on an equal basis with treatment for medical and surgical illnesses in an organized system of care. Covered benefits must include screening, psychiatric assessment, and detoxification. Pharmacotherapy and follow-up treatment with psychiatric input must also be covered to ensure quality care. Treatment at inpatient, outpatient and in other practice settings should be supported.

2. Concerted efforts to eliminate the stigma associated with the diagnosis and treatment of substance use problems are essential. Substance abuse should be accorded health care coverage equal to that provided for other chronic, relapsing conditions insofar as access to care, treatment benefits, and clinical outcomes are concerned. AAAP opposes lifetime caps, co-payment requirements, and any other mechanisms that discriminate against behavioral health care as compared to the coverage provided for medical-surgical illnesses.

3. AAAP supports increased funding for clinical education and research on alcoholism and drug abuse, including new treatment development and treatment outcome research.

Background:

Substance-related disorders have a biological basis like other medical illnesses and require physician’s care. The most effective current treatments require careful diagnosis and targeting of the right treatment to the right patient. Relapsing patients frequently fail because of lack of treatment for an additional psychiatric diagnosis and because of inadequate treatment targeting. A large number of patients with addictions also have additional psychiatric diagnoses that must be taken into account. Furthermore, substance use disorders are commonly co-morbid conditions in patients with primary psychiatric disorders. Physicians with specialty training and credentials in caring for patients with substance related disorders are best able to screen, diagnose and effectively integrate medications as part of treatments that address complex biological and psychosocial issues. AAAP supports the American Psychiatric Association’s practice guidelines for the Treatment of Substance-Use Disorders as a guide to the minimal standards for quality treatment that should be accessed and supported by basic health care benefits.

Approved by AAAP Board of Directors: October 2002

Revises Previous Policy Endorsed: September 1999

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