Parity, Stigma and Quality Issues at Heart of National Treatment Plan

The Center for Substance Abuse Treatment (CSAT) has released a new report that could serve as the blueprint for a more public-health-oriented approach to dealing with chemical dependency.

The report, “Changing the Conversation: Improving Substance Abuse Treatment,” was prepared by a CSAT-organized consensus group comprised of five expert field panels, representing “the very best thinking in the treatment field,” according to Nelba Chavez, Ph.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA). Participants included researchers, treatment providers and members of the recovery community; input for the report also was gathered through a series of public hearings held in 1999.

Released as the keystone of CSAT's National Treatment Plan initiative, the report made five major recommendations:

  • invest to close the gap between treatment need and availability
  • ensure that treatment can be accessed across all systems, including primary care and criminal justice
  • commit to treatment that is science-based and delivered by trained professionals
  • combat stigma
  • build partnerships between consumers and systems

“The report sets an action agenda to bring the benefits of treatment to a larger segment of patients,” said David Rosenbloom, director of Join Together, who praised the plan for its emphasis on quality and the role of the recovering community.

The consensus report endorses parity coverage for addiction disorders, calling for development of a standard insurance benefits package, and reimbursement mechanisms that are aligned with treatment goals and adequate to cover costs. The report stresses that there must be “no wrong door” for people seeking treatment; in other words, people should be able to access services regardless of where they enter the health-care system.

All systems that deal with people with chemical dependency should be required to make assessments and treatment referrals, the consensus group said. “To be effective, this will require that physicians and other primary-care workers, social workers, teachers and school administrators become more knowledgeable about substance abuse and the importance of timely intervention,” according to a CSAT press release.

Treatment also must be culturally appropriate, and treatment professionals must be well-trained, credentialed and adequately compensated. The consensus group said that a commitment to treatment quality must include better links between research and practice, so that proven and innovative treatment methods are widely adopted. Services research also should be the foundation for developing standards for:

  • rules for delivering and measuring high-quality care
  • educating, training and credentialing treatment professionals
  • program management and operations

The report stresses the need to overcome stigma against people with addictions so that treatment can be delivered properly and adequately. The recovery community must be engaged in all levels of discussion concerning substance abuse and dependence, the consensus group said, and more research is needed on public attitudes toward addiction and treatment and on how stigma affects people who are addicted, in treatment, or in recovery. Finally, the group calls for educational initiatives that “promote the dignity of, and reduce stigma and discrimination against, people in recovery,” according to CSAT.

Jeff Blodgett, coordinator of the Alliance Project, said implementing these three recommendations will be critical to the creation of an effective advocacy movement for people in recovery. “The key now will be finding funding for these key recommendations, to move them forward in a substantial and sustained way,” Blodgett told Join Together.

Fighting stigma is the most important task that the report has laid out for the treatment field, according to H. Westley Clark, M.D., director of CSAT, because it affects everything from attitudes on treating addiction as a public-health problem to reimbursement rates. Clark points out, for example, that research shows that providing parity benefits for addiction would raise health insurance costs by only 0.2 percent. “People realize that to have parity for substance-abuse treatment you're not talking about breaking the bank,” he told Join Together. “The reluctance to do so probably reflects more the effects of stigma than cost.”

Clark said CSAT can play an important role in educating third-party payers about parity treatment. The agency is also funding a project with the Health Research and Services Administration to educate primary-care physicians about addiction, and is teaching physicians about their new ability to dispense buprenorphine to combat heroin addiction. CSAT's Recovery Community Support Program is helping to nurture development of advocacy groups for people in recovery, and the agency plans to take part in a stigma conference organized by its sister agency, the Center for Mental Health Services, next spring.

But despite CSAT's role in creating the National Treatment Plan, both Clark and Join Together's Rosenbloom say that the changes needed to implement the consensus group's recommendations largely will have to be generated at the state and local levels. “CSAT sees this … initiative as the beginning of the end of a fragmented system of substance-abuse treatment,” said Clark, who urged government agencies, providers and consumers of treatment to come together around the plan. “Not all the recommendations in the National Treatment Plan can be put into place by CSAT or our parent, SAMHSA, but CSAT is determined to do what it can to move the process along,” he said.

For example, Clark said, CSAT can work with groups like the National Association of Alcoholism and Drug Abuse Counselors on the issue of credentialing, but he points out that licensing of health-care providers is ultimately a state issue. Similarly, states will have a big say in how and where addiction treatment consumers can have a say in service delivery. Mental-health consumers have long benefitted from federally mandated planning and advocacy councils on the state level, for instance. But no such mechanism yet exists for addiction consumers to monitor state funding and other decision-making, as envisioned in the National Treatment Plan. Clark said CSAT will work with the National Association of State Alcohol and Drug Directors to try to overcome state opposition on the issue of consumer advisory councils.

Clark told Join Together that the recent ballot initiatives in California and Arizona, plus court action in places like New York, demonstrate that people are ready to look at new ways to address the related issues of addiction and crime. A public-health approach provides a cost-effective way to fight both problems, Clark said. “The fact is that treatment reduces the risk of victimization tremendously,” he said, adding that the estimated cost of providing treatment to all who need it — $11.5 billion — pales in comparison to the $283.6 billion that alcohol and other drug abuse costs society each year.

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