Substance use disorders: predictions for the 1990s.

Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by Hochschulbibliothek Darmstadt on 11/24/14 For personal use only.

AM. J. DRUG ALCOHOL ABUSE, 18(1), pp. 1-11 (1992)

Substance Use Disorders: Predictions for the 1990s” Joseph Westermeyer, MD, PhD Department of Psychiatry and Behavioral Sciences Oklahoma University Health Sciences Center Oklahoma City, Oklahoma 73190

ABSTRACT Numerous factors will affect the course of alcohol-drug services over the next decade, including technological-scientific advances, legislation, professional training standards, case law, availability and cost of substances, and social policy toward users. Despite some apparent lessening of substance use. high levels of substance abuse are likely to continue due to fetal damage in high-risk offspring, younger onset of substance abuse, and solo-parent families. Care givers must be prepared to treat more youth, elderly, women, minority, and “dual disorder” patients. Federal and local statecraft against substance production and use remains crude and does not show signs of the increasing sophistication observed elsewhere in the world. Although these forces favor continued high levels of substance abuse problems, the funding mechanisms to provide care are under increasing assault by bcth the private and public sectors. Areas in which professional practice are apt to improve include clinical assessment-reassessment, treatment outcome research, monitoring during recovery, and outpatient treatment. Professional groups and treatment organizations will become more proactive in the financial support and management of treatment services.

I. INTRODUCTION Predicting the course of general medical services for the next decade is a risky endeavor. Several factors lend more an aura of guess than estimate to the effort. First, technological advances can affect services for any disorder. Second,

*This paper was presented in part at the annual Betty Ford Center Conference on Clinical Dependency, 1990.

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legislative mandates and third-party-payor policies can and do influence services greatly. Third, the training of professionals and evaluation of professional ethics and standards can set new directions. Further, law suits and the accretion of common law reflect society’s will when untoward consequences result from clinical services. Special factors that do not influence other disorders can produce dramatic changes in substance use disorder. These include sociocultural norms regarding substance use; access, availability, and cost of alcohol and drugs; and social policy regarding the user as victim or criminal. With these caveats in mind, the following predictions are listed with the hope of focusing the dialogue regarding future directions. By anticipating the future, becoming involved with influencing it, and devising alternatives for dealing with it, we will be in a better position to serve our patients.

II. NATURE AND EXTENT OF SUBSTANCE USE DISORDERS IN THE 1990s Some survey data suggest that substance use has gradually decreased in the 1980s, so that (by implication) substance use disorders may be less of a problem

in the 1990s. Sources of these data include college students in California [34] and Louisiana [25] and school children in Canada [23]. However, these survey studies of substance use have employed primarily a sociological method designed to detect normative behavior, e.g., the school survey. It does not obtain data from minors who have died of a substance-related problem (e.g., suicide, accidents), who are not apt to be in school that day (e.g., runaways, pregnant-out-of-wedlock, truant), who have dropped out of school, or who are in a treatment facility or other institution. Since substance use disorders have affected children at younger ages and since schools have become more stringent about drug use and other standards, the cohort effect on these data may render them noncomparable over time. Declining access to mental health care for the young may also stimulate increased drug use in young people with mental-emotional problems [5]. These studies also have demonstrated considerable increases in some drug use, especially cocaine [25]. There has been an increase in hospital admissions for drug abuse during the 1980s [lo]. Until epidemiological studies are developed to study substance disorder (and not just substance use) over time, the issue will remain unclear. Another possibly salutary finding in some areas of North America has been the leveling off or drop in substance-related death: i.e., accidental death and liver cirrhosis in middle-aged men [ l l , 19, 24, 31, 411. Effects on overdose deaths during the last two decades may be due to the better and more available emergency


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care that has appeared over that time rather than to a drop in actual cases. The drop in middle-aged male hepatic cirrhosis could also have several causes: death at an earlier age of men vulnerable to cirrhosis at a later age (e.g., from accidents, suicide), increased availability and success of treatment for alcoholism [19,20], moderation of drinking in the general populations [23,28,32,41], and/or greater use of drugs besides alcohol that do not produce alcoholic cirrhosis (e.g., cannabis, cocaine) [25]. Optimistic conclusionsbased on these findings are especially suspect in the face of numerous other data suggesting a high continued prevalence of heavy substance use [14] and of Substance use disorders; i.e., no drop in alcoholiccirrhosis among women and younger men, continued high rates of other substance-relateddeath (e.g., accidents, suicide, homicide), and continued high utilization of treatment for substance use disorders [l, 30, 411. Several factors indicate that the pool of adolescents and young adults at risk to substance use disorders will remain high despite the falling population of young people. Children who have lost a parent during childhood and those raised in “solo parent” households have been increasing in their relative numbers in our society. Both groups are at risk to substanceuse disorder. Even those raised within intact families are more apt to have a substance abuse problem if one or both parents were substance abusers [37]. Another anticipatedchange is an increased number of substanceabusing parents who are learning disordered, mentally retarded, or otherwise impaired with an organic brain disorder. This is apt to occur as a result of maternal abuse of alcohol, tobacco, PCP, cannabis, cocaine, and volatile inhalants during pregnancy [4, 8, 13, 27, 29, 351. Paternal substance abuse for several weeks prior to conception may also affect sperm, resulting in parental damage to the fetus even if the mother is unaffected [29]. Greater numbers of young, unoccupied, and bored chronic mentally ill persons in the community are also contributing to greater numbers of clinically complex substance abusers [6]. Environmental factors also favor a continued high prevalence of substanceuse disorders. The price of alcohol will remain low relative to wage scales, even for the young and unskilled. Dramatic increases in the price of or taxes on alcohol are apt to foster illicit production and distribution. Drugs have remained highly available at about the same cost (or even lower cost) for most illicit drugs in the United States. As federal efforts have shifted to stifle cocaine imports, heroin imports have expanded. Cannabis remains a major cash crop in over a dozen states, with luissez fuire state policies persisting in most locations [38, 391. Social controls over psychoactive consumption are apt to remain weak. Traditional social controls have relied heavily on religious structures, which can be effective in close-knitgroups but do not strongly affect psychoactive use in a largely


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secular society. Continued puddling of certain ethnic minorities at the bottom of the socioeconomic pool fosters ethnic support for illicit drug commerce, and even use (as witnessed by the outpouring of ethnic support recently for the mayor of Washington, D.C., who was caught purchasing and using cocaine). Ethnic groups with traditional constraints against alcohol abuse (e.g., Asian and paraMediterranean groups) have increasingly joined mainstream Americana, adopting American drinking styles (e.g., individual drinking choice at cocktail parties, bars). Mass media efforts to reduce tobacco and alcohol consumption have reduced normative use in the entire society [26, 361 but have not yet had demonstrableeffects in the nonnormative, heavy using, and disorderd groups (e.g., tobacco chewing among youth, increasing lung cancer in women) [38, 391. International economics will support the production of psychoactive substances as a cash crop in the 1990s. Rural-to-urban migration, industrialization, literacy, secularization, social inequity, political unrest, and corruption persist through the third world and favor illicit drug commerce. American efforts to oppose international commerce in drugs will continue to remain ineffective, as it has been, despite the expenditure of over $8 billion dollars in antidrug efforts over the last two decades. The hopelessness of the task is exemplified by the fact that only about 1 % of illicit opiate production is consumed in the United States, yet the other 99% would have to be suppressed to eliminate opiates imported to the United States. Estimates of smuggling interdiction successes fall well below the 10 to 20% needed to suppress drug smuggling successfully. American economic and political forces similarly indicate continued successful production, importation, and distribution of illicit drugs. The economic crisis for farmers favors on-going and possibly expanded cash cropping in cannabis. Absence of job opportunities for unskilled youths makes illicit drug commerce an attractive alternative. Problems with effective police presence in rural cannabis producing areas and in ethnic minority drug commerce areas result in political impotence to control this commerce. Increasingly the professionals and programs must be prepared to assess and treat other patients besides “four M” patients: i.e., middle class, _middle aged, married, and _male. An expanding population of people over age 65 may result in a larger number of elderly patients. More professional and more effective services for addicted and alcoholic youth and their families are needed. Services for women may need to expand. Discussion of mandated services for pregnant women has reached the public media. If the latter does occur, mandated services for mothers of minor children may not be far behind. The damaged children of substance abusers (e.g., mentally retarded, learning disabled, hyperactive) present special problems for treatment programs once these offspring develop their


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own substance use disorders. So-called “familial” substance abusers have earlier onset, more malignant course, and more resistance to treatment; they may benefit from specialized services or treatments. As more effective maintenance medications for AIDS are employed, the need to treat HIV positive patients for their substance use disorders escalates [ 181.

111. SOCIAL FACTORS AFFECTING TREATMENT SERVICES IN THE 1990s The absence of a national alcohol-drug policy with specific goals and focused objectives fosters political rhetoric while undermining the effective exercise of antidrug statecraft. Is the federal government willing to set goals and objectives that others (besides government officials and government purchased contracts) can measure? In the absence of specific statements, such general statements as “zero tolerance for drugs” or “just say no to drugs” become a cruel, federally instigated hoax in drug-affected homes and neighborhoods. Sophisticated political strategies against drugs cannot ignore the moral issues of equal opportunity for all infants and children, of social equity, and of full employment for youth. About two decades ago, the U.S. Department of State adopted the policy that it is easier to get other countries to stop producing and exporting illicit drugs to the United States than it is to stop American citizens from using illicit drugs. One might ask, “Easier for whom?” This policy is not complimentary regarding the national stature of American leaders in our own country, since it explicitly assumes the inability of elected American officials to lead. Further, its very ethnocentricity denigrates the autonomy of other nations by stating that other countries must be manipulated by the United States in order to benefit United States interests. In addition to its flawed morality, it simply has not worked despite massive expenditures of billions of dollars over two decades [38, 401. The alternative to the above policy problems is specific national goals based on realistic policy. To be effective, large sums of money would have to be spent for law enforcement efforts and treatment. Private rights would need to be redefined, with alterations in our current notions regarding civil liberties. The risks of having a substance-abusing family member or of being mugged by an addict must be weighed against searches of property and person. Police pressures in disenfranchised communities require this necessary precondition if civil unrest is to be avoided; i.e., the community must be enfranchised by government and by private enterprise groups. Is the citizenry willing to “bite the bullet” on an expensive and difficult new strategy? Even if willing to do so, can a multiethnic

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nation with numerous disenfranchised minorities accomplish a united and concerted national effort in this area? The answer is not clear. For the next decade, it appears unlikely. The dialogue regarding free treatment for all substance disorderd persons in the United States has been launched by Representative Fortney Stark of California, who introduced a treatment entitlement bill for substance abusers before Congress in 1989. Corporate interests, drained economically through supporting alcohol and drug treatment, may favor this approach. Faced with high costs of detection, treatment, and monitoring, alternatives are being sought by corporate interests, government agencies, third-party payors, and the health care sector. These include the following: Higher insurance fees for coverage Higher copayments for services rendered Higher insurance deductibles (i.e., the amount to be paid initially by the insured before insurance benefits begin) Annual and lifetime ceilings for benefits Reducing costs through reduced inpatient care and increased outpatient care Controlling access, availability, and cost through medical service contracts Exclusion of high-risk persons from the rolls of the insured, so that hospital care is not compensated for more people “7, 91 The future status of these alternative strategies can be appreciated by reviewing today’s governmental acronyms that may affect tomorrow’s medical services for substance use disorders [33]. These reflect governmental thinking and plans to reduce the “fiscal hemorrhage’’ via medical services. A partial list is as follows: DRG (diagnosis related groups): Uniform payment for hospital care for specific diagnoses, initiated by the federal government and adopted by private insurers. DRG’s are still evolving for alcohol- and drug-related diagnoses. RBRVS (resource based relative value scale): A federal fee schedule devised by Harvard researchers and refined by a congressional advisory group to control physician fees, to begin during 1992-1997. RBRVS’s are still being revised for psychiatric disorders, including substance use disorders.


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UCR (“usual, customary and reasonable” fee) will be replaced by MFS (Medicare fee schedule) for professional fees in 1991. ET (expenditure targets) are federal ceilings on health expenditures that, if exceeded, would result in penalties on providers in the subsequent year. ET’s were recently defeated in their first test before Congress [21].

PG (practice guidelines) or “cookbook care” are specified, and presumably mandatory treatment approaches. These are currently in the discussion phase [2, 12, 151. In one form or another, they exist in most countries in which the government pays for medical services. MVPS (Medicare volume performance standards) is a complex means of monitoring federal expenditures for medical services. This will begin in 1991. HCFA (Health Care Financing Administration) is increasingly committed to undertaking treatment effectiveness research. The private sector also utilizes acronyms, titles, and “buzz words” that affect our practices now and will increasingly affect them in the next decade. These include: PTA (pretreatment authorization): Third-party payors do not permit insured care until treatment has been previously authorized, utilizing criteria that are often changing and typically kept secret as “proprietary information. ’* MC (managed care): Although initially touted as a means to enhance compliance, facilitate outreach, and ease service burdens on professionals, MC more often reduces availability of care (by specifying certain clinics or professionals), reduces access to care (by restricting hours of care, delaying appointments, or increasing geographic distance to care), and adding to the professional’s work load (by adding to the time spent in filling out forms and by justifying care to clerks over the phone). MC has lead to the establishment of a powerful new institution that is unlicensed, has no minimal certifying or licensure criteria, wields secret ‘‘proprietary” power over medical services, and holds itself unaccountable to patients as being merely a third-party contractor. JCAHO (Joint Commission on Accreditation of Healthcare Organizations): This old organizationwith a new name and ideal new goals but with old methods (e.g., reviewers unfamiliar with the field) may affect services, but the outcome is unclear so long as nonexpert site reviewers are hired.

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CQH (Center for Quality Healthcare): In an effort to relate expenditures to outcome and “quality, ” the private third-party-payor industry has established the free-standing CQH, giving it an initial $2.5 million per year for operating expenses. RMS (Rand Medicare study): The Rand Corporation, a private “think tank” that supports itself on government contracts, has expanded from political and military studies to health studies in recent years. A recent Rand study detailed what its staff considered “unnecessary medicare services.” Problems with Rand health studies are familiar to professionals in the substance abuse field. COMS (computerizedoutcomes management system): Paul Ellinwood has now denigrated the HMO movement, which he fostered, and promised the COMS will link expenditures to outcome, thereby refurbishing his tarnished image. Professional subspecialization will have an increasing influence during the 1990s. The newly renamed American Society of Addiction Medicine (ASAM)

now has over 3,000 physician members. Although not a certifying board, ASAM does have a “qualifying” examination. Some members refer to themselves as “addictionologists,” although others aver that the skills and knowledge of members differ greatly by basic specialty training (e.g., psychiatry, medicine, family practice). Some members wish to be designated as a new specialty. Within psychiatry, the Amsrican Association of Psychiatrists in Alcoholism and the Addictions (AAPAA) has had increasing influence. Now close to 1,OOO members, the AAPAA has succeeded in its pursuit of subspecialty status and representation in the governing body of the American Psychiatric Association. One- and twoyear fellowship programs in substance use disorders now number over 30 and are located from New York to Hawaii and from Minnesota to Texas.

IV. CHANGES IN CLINICAL PRACTICE FOR THE 1990s During the 1980s some programs advertised “free assessment” as an inducement to enter a particular program. Growing awareness regarding the importance, complexity, and cost of assessment has relegated such ads to quackery status. The high prevalence of associated psychiatric disorders among substance disordered persons, revealed by the Epidemiological Catchment Area (ECA) study of the early 1980s, helped to focus the field and various clinical studies [6, 161 on so-called “dual disorder.” The need for a phased assessment, reassessment over time, and special assessment in certain cases is being better defined with



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time [ 171. Appropriate assessment at the proper time, although not inexpensive, may enhance treatment efficacy and increase cost benefit. Treatment research has not received adequate funding up to this point in time. This has changed dramatically in 1990, as tens and perhaps hundreds of millions of dollars are now being earmarked at NIAAA and NIDA for treatment outcome research. Although research in this field is complex, expensive, and requires replication in diverse settings, still we should obtain considerable information on treatment by the mid-1990s. New approaches will be sought to assess “severity” in terms of treatment outcome and prognosis. Treatment programs will be changing, modified by new research data, changing patient characteristics [22], subspecialization,and efforts by the federal government [33] and corporations to reduce treatment costs. Greater use of intensive outpatient programs and less inpatient care are likely. Greater public awareness regarding the early signs of substance use disorders and screening to detect cases will result in earlier identificationof cases, even during “pathogenic” but “preaddictive” phases of use. Although offering the potential for less morbidity and better treatment outcomes, treatment of earlier cases requires greater emphasis on psychological and interpersonal issues and less reliance on abstinence alone as a key to recovery. Recovery will be monitored by more methods and by more resources or agents. The traditional “professional opinion” regarding recovery status will be supplemented by numerous other sources: family, employer, third-party payor, licensing agencies, union or professional associations, and others. Sources of data will include self-report, collateral informants, scales rated by professionals over time, social functioning, and body fluids [38]. Computers will prove useful in the route monitoring of patients. As research reveals more of nature’s secrets regarding recovery, tradition will give way to scientific bases for clinical decision making.

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SUMMARY

The need for substance abuse services will not drop appreciably in the 1990s. Moreover, the need for services to new subgroups of patients will expand. Federal, corporate, and third-party-payor pressures to reduce costs will be felt with greater emphasis on outpatient services, treatment efficacy, and cost benefit of treatment. If assessment and reassessment support treatment efficacy, they will expand. Federal, state, and local governments are unlikely to commit the resources or to undertake the sociocultural changes that would effectively reduce the national prevalence of substance use disorders in the 1990s. Treatment programs will

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develop “step down” plans to deal with financial cut-backs, and “phase out” plans if services become financially unsupportable. Treatment programs and professional associations will press for public publication of so-called “proprietary criteria” employed by managed care groups. These so-called criteria will be challenged when and where appropriate, perhaps in court. Efforts will begin to regulate managed care groups and to hold them responsible for their influences over medical services. Professionals and programs in the alcohol-drug field will show greater unity as external financial pressures mount and as knowledge increases. “Bundled” (i.e., one fee per visit or per treatment day) in lieu of “procedure” billing will increase, especially in outpatient settings.

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