Treating Substance Use Disorders in the Same Way We Treat Other Chronic Diseases
According to the U.S. Surgeon General’s Report, Facing Addiction in America, illicit drug use, risky alcohol use, and substance use disorders (SUDs) cost over $400 billion in the United States annually in the form of health care costs, lost productivity, associated crime, and premature death; these costs significantly outpace those associated with other chronic illnesses like diabetes, which is estimated to cost $245 billion annually.1 In 2017 alone, over 70,000 individuals died from a drug overdose. Substance use and associated mental health and medical problems are the primary drivers of the recent decrease in life expectancy in the United States. Evidence-based SUD prevention and treatment, including medications, improve health and save lives yet are rarely integrated into healthcare settings.
In the Veterans Health Administration (VHA), the nation’s largest integrated healthcare system, SUD care is included in the uniform medical benefits for each enrolled Veteran– making VHA the largest SUD provider in the United States. Among the 6 million Veterans treated in fiscal year (FY) 2019, more than 550,000 were treated for SUDs, with 170,000 receiving care in SUD specialty care settings.
Pathophysiology of SUDs
SUDs are caused by repeated exposure of the brain to addictive substances. The requisite exposure to induce SUD varies according to the characteristics of the substance (e.g., higher potency substances and frequent use confer higher risk) and the individual (e.g., posttraumatic stress disorder or younger age at first use confer higher risk). Addictive substances are able to activate primitive brain pathways that mediate split-second decisions necessary for survival.2 This circuit activation can impair decision-making, falsely conveying that the substance is more important for survival than food or water. Repeated substance exposure induces enduring changes in neural circuits that disrupt emotion regulation and motivation, and manifest as signs and symptoms of SUD. Limiting exposure to addictive substances can prevent negative personal and public health impacts of SUDs. For those who have developed SUDs, treatment reduces symptoms such as craving, withdrawal, and impaired decision-making regarding continued drug use. However, vulnerability to relapse persists. The Surgeon General recommends a continuum of care for SUD, including primary prevention, early intervention, treatment, and long-term recovery support.
VHA’s Public Health Approach VHA’s public health approach to SUD care is guided by the VA and Department of Defense Clinical Practice Guideline for the Management of Substance Use Disorders (SUD CPG) and facilitated by the integration of SUD care throughout the VA healthcare system.3 The SUD CPG contains evidence- based recommendations for prevention, stabilization of withdrawal, and treatment of specific SUDs. The National SUD Program within the Office of Mental Health and Suicide Prevention develops policy to promote access to guideline-recommended care and partners with the Center of Excellence in Substance Addiction Treatment and Education (CESATE), the Program Evaluation and Resource Center, Pharmacy Benefits Management, Primary Care, the VHA Enterprise Opioid Strategy Team, and others to facilitate national policy implementation and address emerging challenges in SUD treatment.
Primary Prevention. In parallel with a rise in opioid analgesic sales, overdose deaths have risen dramatically in the United States, from 5,990 in 1999 to 47,600 in 2017. Many patients exposed to opioids for pain management have developed opioid use disorder (OUD) and many others have developed OUD through misuse and diversion of prescribed medications. Prescription drug use often precedes illicit use. For example, 45 percent of those using heroin began with prescription opioid use. Reducing population exposure to opioid analgesics remains a top priority to prevent opioid overdose deaths and OUD.
The VHA Opioid Safety Initiative has reduced opioid prescribing for Veterans who receive care in VHA by more than 56 percent over the past five years. Seventy-five percent of this reduction is attributed to not starting Veterans with chronic, non-cancer pain on long-term opioid therapy, and instead utilizing multimodal strategies that manage pain more effectively long-term. The Whole Health system of care, including complementary and integrative treatments (such as massage therapy, yoga, Tai Chi, etc.), is an important component of primary OUD prevention in VHA. In the first two years of implementing Whole Health, Veterans with chronic pain who used VHA’s Whole Health services realized a three- fold reduction in pain compared to those who did not.
Early Intervention. VHA provides universal annual screening, brief intervention, and treatment for at-risk alcohol use and alcohol use disorder (AUD). Risky alcohol use claims over 88,000 lives each year in the United States. Many of the lives lost are individuals without a diagnosis of AUD. For such individuals, screening and brief intervention involving feedback and advice by a health care professional reduces alcohol consumption and its negative health impacts. The Surgeon General’s Report indicates that only about one in six adults reports being asked about alcohol use, and less than 10 percent of health plans verify that screening is performed. VA Health Services Research & Development (HSR&D)- supported research demonstrates that the consumption questions of the Alcohol Use Disorders Identification Test (AUDIT-C) are an effective alcohol screening tool. VA policy and clinical reminders in the electronic health record support annual AUDIT-C screening and brief intervention, and in contrast to the broader population, in FY 2019, 96 percent of VHA-treated Veterans were screened for at-risk alcohol use, and 84 percent of those with a positive screen received brief counseling.
Treatment. SUD treatment reduces healthcare costs and saves lives. Every VA facility provides SUD CPG-concordant care including medication and psychosocial treatments for alcohol, cannabis, opioid, stimulant, and tobacco use disorders. VA offers a continuum of care, from screening, brief counseling, and medications in primary care to outpatient, intensive outpatient, and residential SUD specialty care. SUD specialty care includes mental health evaluation and treatment of co-occurring medical and mental health concerns as well as co-occurring psychosocial needs as indicated to sustain recovery. In 2018, VHA took initial steps through the Stepped Care for Opioid Use Disorder Train the Trainer initiative to increase availability of medications for OUD in settings outside of SUD specialty care. In collaboration with multiple complementary initiatives including the Medication Addiction Treatment in VA, the Psychotropic Drug Safety Initiative, and Academic Detailing, VHA has seen a steady increase in access to life-saving medications, with over 26,000 Veterans receiving medication for OUD in FY 2019. While this reflects a three- fold increase from FY 2004, only about 40 percent of those clinically diagnosed with OUD received medication; this gap reflects a need to continue efforts to increase access to these life- saving medications.
Ongoing and Emerging Challenges
Despite the recent progress in SUD prevention and treatment, multiple challenges remain. HSR&D’s State of the Art Conference on opioid safety and OUD in September 2019 highlighted the need for more research to define essential elements of chronic OUD management and to overcome barriers to its implementation outside of SUD specialty care settings; research needs to directly address the stigma that remains a significant barrier to care. Methamphetamine overdose deaths and demand for stimulant and cannabis use disorder treatment are rising. Improving access to evidence-based psychosocial interventions such as Contingency Management and Cognitive Behavioral Therapy for SUD will be important to reduce the public health impact of these emerging threats.
We have provided select examples of VHA’s comprehensive approach to management of substance use disorders that encompasses primary and secondary prevention, early intervention, and treatment. Ongoing and emerging challenges will require that VHA continue efforts to identify evidence-based practices in SUD treatment that 1) go beyond specialty SUD settings; 2) are responsive to emerging and evolving threats; and 3) integrate directly with prevention and early intervention efforts that often occur in settings such as primary care, general mental health, emergency departments, and pain management clinics.