Considering Health Insurance Parity: The Federal Experience

The APA offers commentary on parity:

The parity policy in the Federal Employees Health Benefits program began on Jan. 1, 2001, and offers comprehensive insurance coverage for mental disorders, including substance use disorders, on terms that are identical to the coverage of general medical conditions when the treatment is provided by in-network providers.

We compared seven Federal Employees Health Benefits plans with a matched set of plans that did not change benefits or management and did not have parity. We compared use and spending by enrollees in these plans for the 2 years before parity (1999 and 2000) and for the 2 years after parity began (2001 and 2002)....

We concluded that "parity of coverage of mental health and substance abuse services, when coupled with management of care, is feasible and can accomplish its objectives of greater fairness and improved insurance protection without adverse consequences for health care costs" (1, p. 1386).

The parity policy performed just as insurance should: it reduced costs from out-of-pocket payments with a small increase in plan payments (3). This could result in very small increases in insurance premiums without leading to an increase in the use of services. The Congressional Budget Office estimates a premium impact for group plans of a 0.4 percentage point increase (4), a figure that is identical to our estimate based on the Federal Employees Health Benefits experience.

We also looked at indirect measures of quality of behavioral health care in the Federal Employees Health Benefits plans during this same period. Parity was accomplished without increases in the hospitalization of patients and without a decline in the measures of quality of care that we studied, such as the likelihood of receiving follow-up care for depression or being referred for substance abuse treatment.

There was no use of or spending for (oft-parodied) trivial behavioral conditions under managed care plans. It is worth noting that the ICD contains a wide range of general medical conditions, such as scrapes and bruises, rashes, sprains, and the common cold, just as it includes sleep disorders, mild phobias, and mild learning problems. Managed care arrangements and "medical necessity" criteria control unnecessary use and spending for trivial cases of general medical conditions and mental disorders alike.

Governor unveils program to help combat meth addiction

Utah has a new public education campaign that avoid hype and treats drug users has human beings in need of, and deserving of, our help. Let's hope that this approach catches on.

A statewide methamphetamine public-awareness campaign — one without scare tactics and stereotypes — was unveiled today by Gov. Jon Huntsman Jr.

The campaign's newspaper ads and a series of television and radio commercials urge family members and friends to recognize the signs and help addicts, rather than judging people who use meth.

...

Contrary to awareness campaigns in other states — particularly Montana's time-lapse video of people emaciated by drug use — the Utah campaign focuses on debunking stereotypes of so-called drug users and urges loved ones to realize that a meth addict is "not a lost cause."

Defining Recovery

The latest issue of the Journal of Substance Abuse Treatment has a special section of defining recovery. I'll have more on it later. Any DF staff who want the articles can contact me.

Rep. Ramstad, Recovery Advocate, to Resign

Congress is losing its most dedicated parity advocate:

Rep. Jim Ramstad (R-Minn.), a nine-term member of Congress and longtime supporter of addiction treatment and recovery issues, has announced that he will retire at the end of his current two-year term in office

Family History Of Alcoholism Affects Response To Drug Used To Treat Heavy Drinking

As we learn more about genetic factors and brain science there is growing interest in developing typologies that might help in treatment decisions. Past attempts at this have been pretty shaky, so I'll believe it when I see a good evidence-base. Keep in mind that this looks very preliminary:

Naltrexone is one of four oral medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of alcoholism. A recent large multicenter research study of alcohol dependence supported by the National Institute of Alcoholism and Alcohol Abuse (NIAAA), the COMBINE Study, suggested that naltrexone produced a modest but significant benefit but another FDA-approved medication, acamprosate, was ineffective.

Perhaps consistent with its modest effects in COMBINE, naltrexone is not widely prescribed in the treatment of alcoholism. Yet, clinicians report that naltrexone may have significant benefits for individual patients.

John H. Krystal, M.D., one of the authors, notes that "When studied in large groups, naltrexone appears to have a rather small effect upon the ability to reduce drinking or remain abstinent from alcohol. However, there is growing evidence that there are subgroups of patients who show substantial benefit from naltrexone, even when naltrexone fails to work in the overall trial.*

"According to Suchitra Krishnan-Sarin, Ph.D., the lead author, "The results suggest that family history of alcoholism may be an important predictor of clinical response to naltrexone and could potentially be used to guide clinical practice." Dr. Krystal agrees, "These data suggest that family history might influence the optimal dosing of naltrexone and the nature of the clinical response."

Getting Better Numbers on Drugs

Time looks at the process of estimating drug use in the U.S.:

At least, that's what the numbers say. Though it's been more than 30 years since Richard Nixon famously announced America's "War on Drugs," it's hard to know exactly how far we are from victory, partly because the facts are so elusive: Who uses illegal drugs? Which drugs? How often? The answers come mainly from SAMHSA's national survey, a complex and carefully worded questionnaire administered continually throughout the year. It is one of the government's primary sources of statistical information on the use of illegal drugs by the U.S. population, but its data are far from perfect.

"The bottom line is, we learn about drug use by asking people about their behaviors," says Dr. Wilson Compton, director of the Division of Epidemiology Services and Prevention Research at the National Institute on Drug Abuse. "But because it's survey research, there are multiple ways it can be improved."

From FAVOR

CALL HOUSE SPEAKER NANCY PELOSI TUESDAY, September 18th

Help pass the Paul Wellstone Mental Health and Addiction Equity Act
(H.R. 1424) this year!

There are important new developments in our efforts to take the first step to end insurance discrimination faced by people with mental illness and addiction.

Help us end practices like higher co-pays and deductibles, restrictive day and visit limits and lower and annual lifetime caps on people seeking mental illness and addiction treatment and recovery services! Take Action next Tuesday!

1). The House Ways and Means Committee's Health Subcommittee will be considering or “marking-up” H.R. 1424 next Wednesday, September 19th. After this mark-up, the only remaining hurdle before the House can vote on the bill is for the House Committee on Energy and Commerce to act.

2). According to Congressional Quarterly magazine, “the Congressional Budget Office released a surprisingly low estimate late last week of the cost impact of House legislation to put mental health care benefits on par with those for treatments of other kinds of illnesses. The estimate of the cost of the bill (HR 1424) could stiffen the resolve of the House bill's backers to stick with the more sweeping provisions of the House measure, which is expected to see floor action this fall.”

ACT SEPTEMBER 18th
—TIME IS RUNNING OUT IN CONGRESS TO PASS HR 1424!

NATIONAL CALL-IN DAY TO
END INSURANCE DISCRIMINATION

Tuesday, September 18th
9:00 am – 6:00 pm Eastern

Call House Speaker Nancy Pelosi Toll-Free

at 877.978.9996*

Our Message:

“Please schedule a vote on H.R. 1424, the Paul Wellstone Mental Health and Addiction Equity Act of 2007, by mid-October. The time has come for mental illness and addiction to be treated the same as other illnesses. Thank you for your help in making this long overdue action a reality.”

* When you dial 877.978.9996 an operator will be standing by to assist you.

Thanks for all of your advocacy that has helped continue to build momentum for passage of The Paul Wellstone Mental Health and Addiction Equity Act this year!

This Is Your (Father’s) Brain on Drugs

I never really get what this guy is saying.

Is he saying that adolescence is not "a time of heightened vulnerability for risky behavior"? That there is no such process as brain maturation or plasticity?

I can accept an argument that there's hype around adolescents and risky behaviors, but does it not have some basis in fact?

I can accept an argument that adults 35 to 54 should be of much greater concern. Does this mean that we shouldn't be concerned about adolescents?

What exactly does he suggest?

Free cocaine for addiction study subjects

Clearly, a case can be made for this kind of research if it is highly likely to lead to effective treatments for addiction. What troubles me is that there was no mention of treatment in this article. I would hope that and IRB would require a study of this type to try to engage participants into treatment--really try to engage them into treatment of adequate duration and intensity that addresses all of their barriers to recovery.

Drug Tests Part of the Curriculum at Recovery High

NPR profiles a recovery high school.

More on the subject here.

Crystal mess

"People have a low threshold for BS." I couldn't have said it better.

Disturbing Facts about Sexual Abuse

Much less surprising to professional helpers, but interesting because I've never seen these kinds of numbers:

From research by economists J.J. Prescott and Jonah Rockoff, here are a few current statistics on sex offenses reported to the police:

1. 25 percent of victims are 10-14 years old; 23 percent are nine or younger.
2. 22.5 percent of the offenders are family members. Only 8 percent are strangers.
3. 25 percent of sex offenses reported to the police lead to an arrest.

And these are only the offenses reported to the police. Stranger sex offenses must be much more likely to be reported to the police than family abuse.

Using this data, I estimate that six out of every 1,000 10- to 14-year-old girls are victims of sex offenses which are reported to the police each year. The actual victimization rate is surely much higher.

Can In Utero Exposure to Alcohol Lead to Alcohol Disorders During Early Adulthood?

Another argument for not drinking during pregnancy. I'd caution that correlation does not equal causation.

Drug Recovery Program Honors San Quentin Inmates

There are a lot of things I like about the idea of of training inmates to to provide recovery support and basic treatment in prison. (Although it shouldn't be a replacement for experienced professionals.) I feel a little queasy about prisons being a workforce recruitment and development center:

Nine inmates in the Addiction Counselors Training (ACT) program, which began training inmates to become certified drug and alcohol counselors in 2005, were honored at the event. Working under clinical supervision by experienced addiction treatment professionals, the inmate counselors provide peer counseling, case management and education services to other inmates in the Addiction Recovery Counseling (ARC) program while in custody and will receive job placement counseling and referrals for employment in the addictions treatment field when they are paroled, prison officials reported.

"Are you suicidal?"

Troubling findings about suicide crisis lines:

Two of the unprecedented studies involved eavesdropping on suicide hot-line calls - in which the researchers heard things like that terrifying rifle shot - and two main conclusions came out of the work: One, many crisis-line callers are indeed in suicidal distress (and not just lonely or sad) and they are helped by talking to an empathetic fellow human being. And two, the call centers fail, with alarming regularity, to ask some very basic questions: Are you suicidal? Do you have a plan? Do you have the tools at hand to carry it off? Are you alone and drinking?

Is bipolar disorder overdiagnosed among patients with substance abuse?

A new study found a 57% false positive rate:

The study was performed at a residential treatment facility for patients with known substance abuse or dependence. All consecutive patients who presented to the psychiatrist affiliated with the facility with a request for ongoing psychiatric care for a previous diagnosis of BD were asked to participate. To qualify for the study, patients had to have either a history of treatment for BD by a psychiatrist or be in current treatment for BD as an outpatient. In other words, all subjects had to have been diagnosed or treated for bipolar illness by a psychiatrist.

...

All potential subjects participated. A total of 21 patients were interviewed....Only 9 of the 21 (42.9%) participants met DSM-IV criteria for BD.

They hate us

From a local research center:

Heroin-dependent volunteers who also use cocaine are needed for an eight-week research study.

The purpose is to study how certain factors, including drug dose, the amount of work effort and medication dose affect opiate and cocaine drug choice. Short-term maintenance on buprenorphine (an alternate to methadone) is included but this is not a treatment study. This requires reporting ... every day to receive the medication.

Volunteers must be willing to live for at least 22 and up to 26 consecutive nights on a residential unit, during which time they will participate in 12 experimental sessions that involve different doses of a medication (sustained release amphetamine) and choices between different drug does and money. Candidates will be thoroughly medically and psychiatrically screened. Only volunteers who are in good health, from 18 to 55 years old, and not seeking treatment will be accepted.

Volunteers can earn up to $50 for screening and from $880 to $1,328 for completing the study.

I wonder what will happen when you take a group of heroin addicts, give the bupe to help keep them off heroin during the study, give them stimulants for 3 weeks, give them a large sum of money, and then send them on their way?

At best, it's a set-up for a self-destructive binge. At worst, it's a set-up for an overdose.

This made it through a human subjects committee. They hate us.

UPDATE: Someone questioned whether "they" really hate us. I believe that this could only happen in a climate of contempt and dehumanization. If it's not hatred, it's depraved indifference.

Parolees can't be forced into Alcoholics Anonymous, court rules

More here. Just stupid, given all of the recovery support options available in California.

Michigan treatment and prevention cuts

As the Michigan legislature tries to hammer out final budget agreements, there is ongoing concern that there will be PA2 fund cuts to the Substance Abuse Coordinating Agencies (SACA). The SACAs have not had a funding increase in 17 years and the proposed cuts may amount to as much as 20%.

If this is an issue you care about, contact your State Representative and State Senator.

Here's what I might write:

Dear [Legislator]:

As you consider additional cuts to the state budget, please do not cut the PA2 funds currently allocated to the Regional Substance Abuse Coordinating Agencies. Cuts in addiction treatment and drug prevention will actually lead to increased costs to the state. Medicaid healthcare costs will increase. Emergency departments will be flooded. Jails and prisons costs will rise. These cuts would not be fiscally responsible.

More than 600 scientific papers have concluded that treatment for drug addiction works. Relapse rates for addiction treatment are lower than treatment for asthma and hypertension, and equivalent to relapse rates in type 2 diabetes. Patient compliance rates for addiction treatment are better than patient compliance rates in the treatment of asthma and hypertension. Treatment is also cost effective. Studies by the RAND Corporation and UCLA have both found that every $1 spent on addiction treatment saves $7 in other costs like medical, human service and criminal justice system costs.

Unfortunately, treatment remains out of reach for most people. More than 1.2 million Americans wanted treatment but did not receive it; nearly 38% tried to enter treatment but were unable due to costs.

Please do not cut PA2 funding to the Regional Substance Abuse Coordinating Agencies. Lives and families depend on access to addiction treatment.

Sincerely,

Jason Schwartz

One tip. If you plan to email your legislators and you work for a treatment program, you may not want to use your work email account.

Michigan addiction professional requirements

The Michigan Office of Drug Control Policy (ODCP) recently announce new requirements for all treatment agencies receiving funding through the Regional Substance Abuse Coordinating Agencies.

All treatment specialists (Basically, any counselor.) must obtain a CAC-M, CAAC-M, CAC-R, CAAC, or CCJP credential from MCBAP. In addition, all treatment supervisors must obtain a CCS (Certified Clinical Supervisor) credential from MCBAP. These requirements apply regardless of professional licensure. (With the exception of ASAM and APA certifications specializing in addiction.)

These changes are to be effective October 1, 2008.

I plan to contact the ODCP to share my opinion on this requirement. If you have an opinion, you should too.

Here's their email address: MDCH-ODCP@michigan.gov

Michigan Co-occurring Numbers

Don Allen, Michigan's Director of the Office of Drug Control Policy, reported today that 33% of people served in Michigan's public substance abuse treatment system have a co-occurring psychiatric disorder.

Hardly an expectation.

It's worth noting that this number is not too far from the 27% identified in the NSDUH.

Pain relievers surpass marijuana

From the 2006 National Survey on Drug Use & Health:
I've also posted on this before, but this graph shows that marijuana has been replaced by pain relievers (non medical use) as the drug most often tried for the first time.

Tsk, tsk, tsk, baby boomers

From the 2006 National Survey on Drug Use & Health:
I've posted on this before. This graph shows that young baby boomers are the demographic with the fastest growing rates of drug use.

Dual diagnosis is an expectation?

From the 2006 National Survey on Drug Use & Health:

Meeting the criteria for SPD indicates that the respondent endorsed having symptoms at a level known to be indicative of having a mental disorder (i.e., any disorder such as an anxiety or mood disorder).

Am I missing something? It's also worth noting that this makes no attempt to distinguish between primary and secondary problems.

A two question asessment?

From Alcohol, Other Drugs, and Health: Current Evidence:

• Among subjects in the developmental sample, 2 criteria*—recurrent drinking in physically hazardous situations and drinking more or for longer than intended—had a sensitivity of 96% and a specificity of 85% for current alcohol use disorders.
• Among all subjects in the 3 validation samples, the criteria had a sensitivity of 72% to 94% and a specificity of 80% to 95%.

Risk factors for non-fatal overdose

From Alcohol, Other Drugs, and Health: Current Evidence:

an overdose more than 6 months before study entry (odds ratio [OR], 28.6)

younger age (e.g., OR, 7.2 for subjects 18–24 versus those 45 and older)

cocaine use in the last 6 months (OR, 2.1)

serious withdrawal symptoms in the last 2 months (OR, 2.7)

alcohol use in the last 6 months (OR, 1.9)

Alcohol Use Disorders: Chronic or Not?

From Alcohol, Other Drugs, and Health: Current Evidence:

Alcohol Use Disorders: Chronic or Not?
Interviews of a representative sample of 43,093 U.S. adults provide new information on the usual course of alcohol use disorders (abuse or dependence).

• Approximately 5% of adults had past-year abuse while 4% had past-year dependence. Lifetime prevalences were 18% and 13%, respectively.
• Of those with lifetime alcohol dependence, only 24% reported ever having received alcohol treatment, even though treatment was defined broadly and included (but was not limited to) participation in 12-step programs, care in an emergency department, and assistance by clergy or other professionals.
• The mean age of onset of an alcohol use disorder was 22 years.
• Most patients with lifetime abuse or dependence had only 1 episode (72%). Those with more than 1 episode had a mean of 5 episodes. The mean duration of the longest episode was about 3 years for abuse and 4 years for dependence.

Comments:
This nationally representative survey tells us that alcohol use disorders begin in young adulthood and usually go untreated. They are characterized by recurrence for relatively few patients (though patients with recurring episodes are the ones that physicians are most likely to encounter and remember). More commonly, alcohol use disorders consist of 1 symptomatic episode, even when not treated, lasting up to several years.

Richard Saitz, MD, MPH

So, alcohol use disorders are generally not chronic. What would be nice to know is what the breakdown looks like for abuse versus dependence.

Study: Romantic love affects brain like drug addiction

A very interesting look at the neurobiology of love. Surprise! There are some striking similarities to addiction:

Her front brain is telling her he's trouble. Look at the facts, it says. He's never made a commitment, he can't keep a job.

But her middle brain won't listen. Man, it swoons, he looks great in those jeans, his black hair curls onto his forehead so adorably. His front brain is lecturing, too: She's flirting with every guy, and she can drink you under the table, it says. His mid-brain is unresponsive, distracted by her come-hither stare.

"What could you be thinking?" their front brains demand.

Their middle brains, each on a quest for reward, pay no heed.

Alas, when it comes to choosing mates, smart neurons can make dumb choices.

...

That initial spark can flash and fade. Or it can become a flame and then a fire, a rush of exhilaration and sense of union that scientists know as passionate love.

Key to this state of seeing a person as a soul mate instead of a one-night stand is the limbic system, nestled deep within the brain between the neocortex (the region responsible for reason and intellect) and the reptilian brain (responsible for primitive instincts). Altered levels of dopamine, norepinephrine and serotonin – neurotransmitters also associated with arousal – wield influence.

But passionate love is also "a drive to win life's greatest prize, the right mating partner," Dr. Fisher says. It is, she says, an addiction.

People in the early throes of passionate love, she says, can think of little else. They describe sleeplessness, loss of appetite and feelings of euphoria, and they're willing to take exceptional risks. Brain areas governing reward, obsession, recklessness and habit all play their part in the trickery.

In an experiment published in the 2006 book Evolutionary Cognitive Neuroscience, Dr. Fisher found 17 people who were in relationships for an average of seven months. All said they'd feel deep despair if their lover left, and they yearned to know all there was to know about the loved one.

She put them in an FMRI to see what areas of their brains got active when they saw a photograph of their beloved ones.

"We saw activity in the ventral tegmental area and other regions of the brain's reward system associated with motivation, elation and focused attention," she said. It's the same part of the brain that presumably is active when gamblers think they're going to win.

...

Lucy Brown, professor of neuroscience at the Albert Einstein College of Medicine, has also taken FMRI images of people in the early days of a new love. In a study reported in the July 2005 Journal of Neurophysiology, she too found key activity in the ventral tegmental area. "That's the area that's also active when a cocaine addict gets an IV injection of cocaine," Dr. Brown says. "It's not a craving. It's a high."

Biologically, the cravings and pleasures unleashed are as strong as any drug. Certain brain regions, scientists have found, are being deactivated, such as within the amygdala, associated with fear. Excited brain messages reach the caudate nucleus, a dopamine-rich area where unconscious habits and skills, such as the ability to ride a bike, are stored.

A 40-fold increase in bipolar?

This is a little outside my usual areas of focus, but Michelle Cottle from The New Republic does a great job summarizing a very troubling story from the New York Times:

There's a disturbing front-pager in today's New York Times about the sharp increase in the diagnosis of bipolar disorder among U.S. children.

According to a study in this month's Archives of General Psychiatry, between 1994 and 2003, the number of bipolar diagnoses for Americans under the age of 20 rose from 20,000 to 800,000. As the Times calculates it, the disorder now affects about 1 percent of the under-20 population, making it more common than garden-variety depression.

These findings strike me as deeply troubling, not because I think today's kids are dramatically more disordered than they were a decade ago, but because--this being America--the rise in diagnoses is naturally being accompanied by a rise in the prescription of powerful drugs.

Whatever your views on America's psychopharmaceutical habit, you have to admit we have an unfortunate (and accelerating) tendency to respond to any unpleasant behavior with medication. So be it. But ostensibly well-informed, responsible adults dosing themselves willy-nilly is one thing. Dosing their kids is another matter entirely.

For starters, as psychiatric experts told the Times, diagnosing biploar disorder in kids is an iffy business, in part because it tends to manifest itself differently in children than in adults. Worse still, the meds used to treat the disorder apparently have few proven benefits in children and can prompt some pretty nasty side effects (including tremors and rapid weight gain). As we saw with certain antidepressants' tendency to raise the risk of suicide in kids, assuming that what's good for Mom and Dad is also good for Junior can be flat-out dangerous.

One might argue that no parent would dose their beloved offspring with a brain-altering drug unless the kid's behavior was so terrible that there was no doubt but that he was seriously ill. (And yes, more often than not, the child in question is a he: two-thirds of bipolar patients are boys.) But I think exactly the opposite is true: Parents understandably cannot bear to sit helplessly by and watch their children suffer--Why is he so angry? Why is he so sad? Why does he get into so much trouble at school? We want answers. We want a plan of action. We want desperately to be told by some nice doctor that the nightmare will end with the proper combination of pills. (Besides, who has the time, energy, and comprehensive insurance coverage for longer-term treatment options?)