Commentary: Affordable Care Act Does Little to Increase Addiction Care Access

By Dr. Stuart Gitlow | July 13, 2012 | 1 Comment | Filed in Government,Healthcare, Insurance, Legislation & Treatment


The demand for addiction treatment is high. The supply of addiction specialists is comparatively low. Yet unlike traditional economic models where money is the obstacle, in our field, the obstacle is time.

There are two factors involved: the time required to provide reasonable quality of care, and the time required to produce a specialist who has the ability to provide that care. These limitations restrict the number of patients that can be seen per day by all available addiction specialists. While increasing pay for care would result in an increased interest in the field, development of appropriate training and the years of training necessary would result in only slow growth of available treatment.

Because addiction specialists are not currently sitting idly at their desks surfing the Internet, access to treatment is not limited by financial factors but rather by availability factors. There simply isn’t a great enough supply of specialists to meet the demand of patients.

In 20 years of practice, I have worked in an academic setting as a staff physician in an addiction specialty unit, as a medical director of a community mental health center (CMHC) and as a private practice physician specializing in addiction. In each setting, I have turned no patient away. At the private practice, as is the common practice here, we do not take insurance but always work out a fee arrangement that is compatible with a patient’s needs. The CMHC also utilized a sliding scale for patients, and in the academic center, patients who could not pay were seen by a fellow with oversight from faculty. Patients have roughly equal access to at least one part, if not all parts, of the system. But availability of service, not fiscal issues, always proved the greatest constraint. “We’re happy to see you, Miss Smith, but our next opening is in 2015.”

That’s not to say there is no fiscal issue: my CMHC lost money on physician-provided care for nearly 20 years. Expenses were more than my hourly wage, and included collection costs, billing, insurance reviews and audits, with the revenues limited to copays and insurance payments. Things got much worse a few years ago. Collections dropped, audit rates increased and ultimately the CMHC could no longer afford my services. Did I mention that the CMHC I worked for is in Massachusetts? The community no longer has an addiction specialist and was recently featured in the news due to increased problems associated with substance use.

But the fiscal issue does not represent an access constraint because we clinicians can easily practice outside the employed environment. Looking at my case above, I left the CMHC and took most of my existing patients with me into my private practice in an adjoining state. Because I do not take insurance yet charge a reasonable rate, my expenses are quite low and patients do not have a significant financial burden in comparison to the CMHC model. Thus payment again did not end up being a significant limitation to access.

Now let’s come to the headline of the hour: the recent Supreme Court ruling. In many ways, the ruling was a non-event in that it simply supports, largely, what had already passed in Congress. The Affordable Care Act does very little to increase access to addiction care because it does not solve the primary obstacle we’ve discussed. It promises to increase the number of those who have insurance coverage, but as I’ve pointed out, coverage has not represented a significant obstacle in long-term outpatient addiction treatment. And long-term outpatient treatment is the key to avoiding higher levels of care. Outpatient care is where addiction treatment truly takes place since the higher levels of care are limited to the acute manifestations of substance use (e.g. detox, rehabilitation, and medical/psychiatric sequelae) and not the chronic issues related to addictive illness.

The Act promises that substance use disorders will be covered at parity as part of the essential health benefit. But any expectation that this will lead to coverage of long-term outpatient treatment is misguided. Because the primary limiting factors – time – is not being addressed, we will see no significant improvements. Given my experience in Massachusetts, however, we may see a significant alteration in how services are provided, with greater numbers of independent clinicians moving away from an employed model and into private practice and fewer clinicians accepting insurance. Too, there may be higher charges because of the higher taxes in place now due to the very Act that is supposed to increase access. This is a good thing as costs are much lower in private practice due to the reduced administrative burden and overhead. The overall cost of health care will drop.

Remember pendulums swing both ways. Just as the past decade saw a decline in private practice, the Affordable Care Act, should it not be repealed, will likely prove an economic force in the other direction insofar as bio-psycho-social-spiritual treatment of addiction is concerned.

Stuart Gitlow MD MPH MBA is a member of the American Medical Association’s Council on Science & Public Health, and Acting President of the American Society of Addiction Medicine. This Op-Ed represents his personal opinion and does not imply any position or policy taken by either the AMA

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Simulation Program Teaches Teens About Drunk and Distracted Driving

By Join Together Staff | June 21, 2012 | Leave a comment | Filed in Alcohol,Prevention, Young Adults & Youth

A new simulation program is teaching young drivers about the risks of drunk and distracted driving. The program is designed to demonstrate what can happen if they have an accident while they are driving under the influence or texting while driving.

One Simple Decision, made by Virtual Driver Interactive (VDI), combines simulated driving with video footage of interactions with law enforcement, judges and emergency medical personnel, USA Today reports.

The Ohio Department of Transportation bought four VDI simulators, at a cost of $42,000. It uses them at schools, football games and county fairs, the article notes. “We recognized that there is an issue, especially among young drivers, with paying attention to the road,” spokeswoman Melissa Ayers told the newspaper. “We started using it last year. We’ve gotten really good feedback. The kids realize after they’ve used it, ‘I really can’t do two things at once (while driving).’”

A government report issued in December found an estimated 31 percent of driving deaths were linked to alcohol in 2010, compared with nine percent of deaths caused by distracted driving. The National Highway Traffic Safety Administration’s report found that overall, highway deaths fell last year to the lowest level in six decades, even though Americans are driving more

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“Drug Tourists” Increase States’ Challenges in Fighting Prescription Drug Abuse

By Join Together Staff | July 13, 2012 | Leave a comment | Filed in Community Related, Legal, Prescription Drugs & Prevention


States’ efforts to crack down on prescription drug abuse are being made more difficult by people who travel to states such as Florida and Georgia to obtain painkillers, the Associated Press reports. These so-called “drug” or “prescription” tourists are transporting huge amounts of drugs across state lines, according to the AP.

Trying to stop drug tourists involves complicated prosecutions that cross a number of state lines, the article notes. Drug tourists travel to states with many “pill mills,” where they obtain a large amount of painkillers and then return home to sell them for as much as $100 per pill.

Florida was long known as a prime destination for drug tourists. Now that the state is cracking down on pill mills, Georgia is becoming a more popular destination for those who want to find easy access to painkillers. They come from adjacent states, and from more distant states such as Nebraska and Arizona.

“They’re like a swarm of locusts,” said Richard Allen, Director of the Georgia Drugs and Narcotics Agency. “Once they have a script, they’ll hit every pharmacy in the state trying to get them filled.”

Earlier this year, the Drug Enforcement Administration announcedsales of oxycodone fell 20 percent last year in Florida. Officials said the drop was mainly due to the closure of some of the state’s biggest pill mills and the arrest of some of the clinics’ operators and doctors. Florida pharmacies and doctors sold about 498 million doses of oxycodone in 2011, compared with a record 622 million doses the previous year.

In June 2011, Florida Governor Rick Scott signed into law a bill designed to cut down on prescription drug abuse by controlling pill mills in the state. The law authorized the creation of a prescription-drug monitoring database to reduce doctor-shopping by people looking to collect multiple painkiller prescriptions. The legislation also imposed new penalties for physicians who overprescribe medication and imposes stricter rules for operating pharmacies.

Bill Aims to Reduce Teen Abuse of Cough Syrup

By Join Together Staff | July 12, 2012 | 3 Comments | Filed in Drugs, Legal,Prevention & Youth


Two senators introduced a bill this week designed to prevent the abuse of cough syrup by teenagers. The bill restricts the sale of products containing the cough syrup ingredient dextromethorphan (DXM) to those older than 18, Drug Store News reports.

Senator Bob Casey of Pennsylvania and Senator Lisa Murkowski of Alaska sponsored the measure, known as the Preventing Abuse of Cough Treatments (PACT) Act of 2012. The PACT Act also places limits on the purchase of bulk (unfinished) DXM, so that only manufacturers registered with the Food and Drug Administration or relevant state agencies have access to DXM in its raw form. Currently, there are no national restrictions on sales or purchase of DXM in this form.

The 2011 Monitoring the Future survey found that 5 percent of teens report abusing cough medicine. Abuse of DXM can cause hallucinations, confusion, blurred vision and loss of motor control.

The Consumer Healthcare Products Association (CHPA) notes that DXM is a safe and effective cough suppressant found in more than 100 cough and cold medicines. The legislation “will give parents an additional tool to prevent abuse, while ensuring access for the millions of adults and families who responsibly use products containing DXM to relieve cough symptoms,” CHPA President and CEO Scott M. Melville said in a news release.

“By addressing easy access to purchasing cough syrup for teens, the main cause of the harmful trend of its abuse, my bill will help keep our children safe and lessen the strain cough syrup abuse has put on families, hospitals and law enforcement,” Senator Casey said in astatement. “My common-sense legislation will prevent kids from purchasing a drug that has dangerous consequences when abused to get high, while also ensuring it is available to those with a legitimate need for it.”