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    Document Summary
    - Report Published -

    Senate Document No. 5
    PUBLICATION YEAR 2011

    Document Title
    Study of Strategies and Models for the Treatment and Prevention of Substance Abuse (SJR 73, 2010)

    Author
    Division of Legislative Services, Joint Subcommittee to Study Strategies and Models for Substance Abuse Prevention and Treatment

    Enabling Authority
    SJR 73 (Regular Session, 2010)

    Executive Summary
    Meetings

    The Joint Subcommittee Studying Strategies and Models for the Prevention and Treatment of Substance Abuse pursuant to Senate Joint Resolution 73 met four times during 2010.

    Wednesday, August 18th, 2010 - Richmond, Virginia

    The first meeting of the joint subcommittee was held on Wednesday, August 18th at the General Assembly Building in Richmond. At that meeting, the joint subcommittee received information about the Department of Behavioral Health and Developmental Service's "Creating Opportunities" initiative and the Department's efforts to improve services for people with substance use disorders, including efforts related to funding, prevention programs, services and utilization, needs for treatment services, waiting lists and delays experienced by people in need of substance abuse services, information on treatment quality, services for persons with co-occurring mental health and substance use disorders, and new initiatives to improve services quality and access to service.

    The joint subcommittee also received an overview of activities and work plan of the work groups established pursuant to SJR 73. Staff reported that all three work groups (Treatment & Recovery Models, Prevention, and Prescription Drug) met once prior to the first meeting of the joint subcommittee. At that meeting, the work groups voted to combine the three existing work groups into a single work group and that the combined work group planned to:

    • Develop a report on the current system of services in the Commonwealth, including gaps in service and service needs, and to develop recommendations, including recommendations for funding, to address unmet needs,
    • Develop a report on changes in federal policy affecting substance abuse services,
    • Prepare a list of state initiates focused on issues related to substance abuse,
    • Prepare a recommendation on options for continuing the work begun by the Joint Subcommittee, and
    • Develop specific recommendations related to needs for substance abuse prevention, treatment, and recovery support services; expanding the role of and providing support for peer support and recovery support services; expanding the drug court model and supporting drug courts; improve use and effectiveness of the Prescription Monitoring Program; increasing efforts to education prescribers and pharmacists about substance abuse and the prevention of substance abuse, particularly prescription substance abuse; expanding the role of community coalitions in prevention activities, and supporting community coalitions; and the need for data collection and planning around substance abuse prevention and treatment needs.

    At the end of the first meeting, the joint subcommittee discussed its work plan for the 2010 interim and noted that the joint subcommittee would three more times, with meetings to be held in different regions of the Commonwealth.

    September 22nd, 2010 - Blacksburg, Virginia

    The second meeting of the Joint Subcommittee Studying Strategies and Models for the Treatment and Prevention of Substance Abuse was held on Wednesday, September 22, 2010, in the Alumni Assembly Hall at the Inn at Virginia Tech in Blacksburg, Virginia. Following opening remarks by Senator Hanger and introduction of the members of the joint subcommittee, Delegate Nutter introduced Ms. Susan West Marmagas, MPH, Assistant Director of the Public Health Program at Virginia Tech. Ms. Marmagas welcomed the joint subcommittee to Virginia Tech, and described Virginia Tech's Masters of Public Health Program. The joint subcommittee then watched a brief video introducing a documentary developed by the Appalachian Substance Abuse Coalition for Prevention and Treatment. The documentary, produced with grant funds, reveals the nature and impact of substance abuse in the southwestern portion of Virginia and also highlights the potential for recovery and the treatment and recovery activities occurring in the region.

    Next, the joint subcommittee received an update on the activities of the work group. Staff reported that the work group had met for the second time on September 16, 2010. At that meeting, the work group discussed the preliminary report outline, identifying information gaps and needs, and providing input on the direction and scope of the report. Specifically, the work group discussed the need to (i) define key terms used in the report; (ii) note that while issues related to tobacco use often overlapped with issues related to the abuse of alcohol, the report would focus primarily on alcohol and drug use and abuse issues; (iii) provide information about recovery-oriented systems of care, including current activities around development of recovery-oriented systems of care in the Commonwealth, gaps in the Commonwealth's system of recovery support services, and actions that the Commonwealth could take to support development of recovery-oriented systems of care; (iv) develop a full range of treatment services including residential services, particularly residential services for adolescents and pregnant and parenting women; and (v) take steps to ensure ongoing communication and cooperation between school systems and other service providers.

    Dr. J. Randy Koch, Ph.D., Executive Director of the Institute for Drug and Alcohol Studies and Associate Professor of Epidemiology and Community Health, Virginia Commonwealth University, presented information on the potential impacts of ABC privatization on alcohol consumption and alcohol-related harms developed by representatives of the SJR 73 work group. Dr. Koch provided an overview of scholarship on the issue and summarized the findings of the research, noting that privatization of the sale of alcoholic beverages may result in increased accessibility of alcohol, leading to an increase in consumption and associated harms, including accidents, illness, and crime. Dr. Koch noted that some evidence indicates that harms can be reduced by limiting the number, density, and days and hours of operation of outlets, restricting marketing activities, increasing taxes, or increasing prevention efforts.

    Dr. Sarah Melton, PharmD, BCCP, CGP, Director of Addiction Outreach & Associate Professor of Pharmacy Practice, Appalachian College of Pharmacy, described Appalachian College of Pharmacy's Addiction Outreach program. The program begins with 12 hours of mandatory didactic education for every student in the students' second year of the Doctor of Pharmacy program. After completing the 12 hours of mandatory education, pharmacy students may participate in an elective course that provides additional training and education related to substance abuse and the role of pharmacists in identifying substance abuse and assisting clients in need of services or who are in recovery. Students enrolled in this elective are placed in "front line" positions and work directly with people receiving substance abuse treatment services. Dr. Melton stated that Appalachian College of Pharmacy developed this program in order to serve its mission of improving the general health and well-being of residents of rural or underserved populations, particularly vulnerable populations within Central Appalachia through education, service, and scholarship that prepares pharmacists to optimize patient care and health outcomes. Program development was supported by grant funds, which allowed the College to fund 20 places. Due to significant demand, however, the College expanded the program to allow 30 students to participate. Appalachian College of Pharmacy was also able to provide eight hours of free Continuing Medical Education for 110 prescribers and pharmacists in the area, and is working with those participants to collect information about interventions in order to demonstrate the effectiveness of the program. In closing, Dr. Melton noted that the program was inexpensive to implement, and that feedback indicates the program has been very successful in increasing awareness of substance abuse issues. She suggested that the program be expanded to all pharmacy programs in the Commonwealth.

    Ms. Laurie Peery, Doctor of Pharmacy Candidate and participant in the Addiction Outreach program, spoke about the benefits she sees from the program and the role the program has played in informing her practice. Ms. Peery also noted the lack of access to the Prescription Monitoring Program in most chain pharmacies in the Commonwealth, and suggested that requiring these pharmacies to provide access to the Prescription Monitoring Program would greatly improve the ability of pharmacists to identify and address substance abuse among clients.

    At the end of the meeting, the joint subcommittee received public comment.

    • Dr. Harvey Barker provided some statistics illustrating the impact of substance abuse in the southwestern portion of Virginia. He stated that prevention and treatment services are necessary to combat the problem, but that a lack of funding for public service providers severely limits their ability to respond. Dr. Barker emphasized the need for sufficient funding to provide a full continuum of substance abuse services, including prevention, assessment, screening, identification, treatment, and aftercare. He noted the important role of drug courts in addressing substance abuse problems, and also the need to ensure that services are provided to individuals who are incarcerated.

    • James Pritchett described New River Valley CSB's prevention activities, and stated that while services were provided, additional funding was needed to support prevention services. Lee Spiegel spoke about the important role of community coalitions in preventing substance abuse. She stated that while these programs are able to provide services at little or no cost, a small amount of funding to support development would make a significant impact. Kat McClinton described the important role of residential treatment facilities, noting that the greatest barrier to accessing this key service was money. Despite New River Valley CSB's efforts to provide funding and reduce the cost to the client, many who need this service still cannot pay for it. The limited number of persons that can be served in the facility, the limited scope of residential services generally, and long waiting lists also keep people from accessing this service. Cheryl Humes reiterated the importance of residential treatment, and noted a need for additional outpatient services and for a fully funded continuum of services generally. Chris Alderman spoke about the recovery process, and noted the importance of prevention first, and also treatment and recovery support services.

    • Karen Smith presented information on Project REMOTE, a rural enhanced model for opioid treatment expansion program designed to address prescription drug abuse in the Southwestern Virginia. She noted the impact of prescription drug abuse in the region, including a significant number of deaths from overdose. She described the program, which combines a range of treatment services, including abstinence counseling, peer support programs, and medication assisted treatment. Ms. Smith described the elements of a successful medication assisted treatment program, including the training and certification requirements for providers, and emphasized the need for counseling and other wrap-around services. Project REMOTE has worked with local physicians to increase awareness and availability of these services and to increase the availability of other treatment services in the area. Overall, the program has resulted in reduced rates of drug use, fewer overdose deaths, and improved functioning among persons receiving medication assisted treatment. Ms. Smith did state, however, that the project is supported by grant funds, which will run out soon.

    • Lisa Moore, Executive Director of the Mt. Rogers Community Services Board, reiterated the importance of treatment and prevention programs, grass roots coalitions and faith-based organizations, and recovery support organizations.

    • Derek Burton provided an overview of OneCare of Southwest Virginia, a 501(c)(3) organization composed of 16 coalitions representing 22 counties that are committed to decreasing substance abuse and misuse, and related social, economic, and health factors through planning, policy, data, and advocacy. Mr. Burton stated that OneCare has conducted extensive research and developed a BluePrint for Health for the region, which identifies substance abuse issues, sets measurable goals for reducing substance abuse, and includes plans for achieving those goals.

    • David Moore of Virginia Cares, a statewide network of ex-offender reentry programs focused on providing transitional, financial and employment assistance and ongoing support services to prisoners, ex-offenders, and their families, spoke about the need to remember the challenges faced by persons with substance abuse issues who are reentering society from jails and prisons. Mr. Moore stated that one major problem is the inability of ex-offenders to obtain driver's licenses, often because they are unable to pay fines. He noted that without driver's licenses, many ex-offenders cannot get jobs, which would otherwise help them pay their fines and meet other financial obligations. Mr. Moore encouraged the joint subcommittee to consider options that would allow ex-offenders and others to obtain licenses so that they may get to work and access treatment services.

    October 18th, 2010 - Norfolk, Virginia

    The third meeting of the SJR 73 Joint Subcommittee Studying Strategies and Models for the Prevention and Treatment of Substance Abuse was held on Monday, October 18, 2010, at Old Dominion University in Norfolk, Virginia.

    Ms. Carol McDaid, Co- Founder and Principal, Capitol Decisions, provided an overview of implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. Ms. McDaid reported that regulations implementing the act became effective July 1, 2010, and will apply to all plans beginning plan years after that date. Regulations establishing additional requirements, including requirements related to the scope of services covered, may be promulgated in the future. Ms. McDaid also identified several issues that may affect the effectiveness of the MHPAEA, including the fact that currently mental health and substance abuse services are not mandated benefits, so that plans may opt not to provide any services rather than comply with parity requirements; certain practices like medical necessity criteria, utilization review, and provider authorization requirements may still limit parity in practice; and a lack of clarity in the test applied to determine compliance may allow some providers to avoid compliance. Also, the fact that many providers remain unaware of the requirements of the new law may result in noncompliance. Despite these issues, Ms. McDaid noted that while early research findings from other states indicate that the quality of mental health and substance abuse services remains unchanged despite implementation of the MHPAEA, implementation does appear to have eased pressures on state budgets as more people are covered by private insurance rather than public services. Additional education of providers and consumers, and continued state attention to implementation and compliance may increase compliance with the requirements of the MHPAEA and benefits to the Commonwealth.

    Following her discussion of the MHPAEA, Ms. McDaid also provided additional information about the impacts of federal health care reform on Medicaid, highlighting the expansion of Medicaid to newly eligible populations, increased federal match for these populations, new service requirements including requirements for substance abuse and mental health services, and the potential benefits of increased coverage for public health.

    Ms. Ilana Cohen, Senior Health Policy Associate with the National Association of State Medicaid Directors/American Public Human Services Association provided an overview of health care reform resulting from the Patient Protection and Affordable Care Act. She highlighted the expansion of Medicaid, private insurance reforms including prohibitions on exclusion of pre-existing conditions and annual or lifetime limits on care, the requirement of guaranteed issue/renewal, and new required benefits, which include behavioral health and substance abuse services. Ms. Cohen noted that Medicaid is currently the largest payer for behavioral health services in the country, and that Medicaid expansion will increase the number of people eligible for publicly funded behavioral health and substance abuse services. She also stated that the new federal health policy emphasizes integration and coordination of behavioral health and primary care systems, and will focus on ensuring that behavioral health and substance use conditions are treated as chronic health care conditions similar to other health care problems. Finally, Ms. Cohen identified several opportunities for states resulting from federal health policy changes in the area of behavioral health and substance abuse services, including the opportunity to establish chronic health care homes to integrate health care services, grants to fund service development, and increased federal match for newly eligible Medicaid populations.

    Ms. Lynne Cramer, Chair, Virginia Association of Community Services Boards, provided an overview of Recovery-Oriented Systems of Care (ROSC), the philosophy of this approach to substance abuse services, and potential opportunities for the Commonwealth in this area. Ms. Cramer began by noting that ROSC is about delivering both professionally directed and peer-based recovery support services and other necessary supports in a combined and sequenced manner to enhance long-term recovery outcomes. She stated that the ROSC model is based on principles of recovery management using peer-based support services. ROSC systems are networks of formal and informal services developed and mobilized to support and sustain long-term recovery for individuals and families impacted by substance use disorders. ROSC systems should include pre-recovery identification and engagement, recovery initialization and stabilization, long-term recovery maintenance, and quality of life enhancements for individuals and families. These systems include primary medical and psychiatric care, addiction treatment, peer-based recovery support services and recovery coaches, and other ancillary services including case management, transportation, day care, housing, financial counseling, educational services, vocational services, and legal counseling. Post-treatment monitoring and support including saturated support during the first 90 days and "recovery check-ups" thereafter help individuals maintain recovery. Ms. Cramer noted that research on ROSC shows that over half of people completing specialized addiction treatment in the U.S. resume use within one year of finishing treatment, 50% of people who complete substance abuse treatment will reenter treatment within two years, the effects of treatment diminish over time so that the likelihood of relapse increases as more time passes after a person leaves treatment, and stability of recovery is not reached for four or five years. Research also shows that post-treatment monitoring and support can improve outcomes for adults and adolescents, the length of service contact is the single best indicator of post-treatment addiction recovery, and ROSC systems can provide the support and assistance necessary to address many problems that lead people to relapse.

    At the end of the meeting, the joint subcommittee received public comment.

    • Ms. Jennifer Faison with the Virginia Association of Community Services Boards stressed the need to remain aware of the changes in services that would result from federal health care reform. She noted the need to focus on prevention, treatment and recovery services, and to take steps to implement recovery-oriented systems of care in the Commonwealth. She recommended investing in local capacity to reduce waiting times for services, improve access for services, and make sure services are available to all persons in need of substance abuse services at the time they are ready to access services. Ms. Faison noted the impact of substance abuse on the criminal justice system, and the high costs of substance abuse and use in the area of corrections. She suggested that the Commonwealth might consider the sequential intercept model as a strategy for addressing substance use and abuse and the model's impact on the criminal justice system. Finally, Ms. Faison stressed the need to treat substance abuse like the chronic health issue that it is, and to integrate primary care and substance abuse services.

    • Mr. Vince Sawyer with The Haven in Lynchburg spoke about the need for community-based services for persons with substance abuse disorders, particularly the need for a model like that of the Healing Place. He described The Haven as a service based on the Healing Place model, which addresses the housing and treatment needs of people with substance abuse problems and is effective in terms of both costs and outcomes. This model, which has been implemented in many other states, has been shown to reduce incidences of substance abuse, with approximately 70% of participants avoiding relapse, at a cost of approximately $30 per day. Mr. Sawyer recommended that the Commonwealth provide funds to establish services based on the Healing Place model in the Commonwealth. He also recommended that the Commonwealth dedicate funding for prevention services through community services boards.

    • Ms. Claudia Gooch of the Hampton Roads Planning Council spoke about the need for services that address both homelessness and substance abuse, which are often linked. She seconded the recommendation for adoption of a model based on the Healing Place model, and recommended that the Commonwealth provide funding for this purpose.

    • Ms. Angela Kellam, Vice President of Resource Development and Community Solutions with the United Way of South Hampton Roads, also spoke about the benefits of a model based on the Healing Place model, and reiterated support for funding for this model in the Commonwealth. She noted that a number of agencies in the Hampton Roads area had studied the issue of homelessness and substance abuse, and concluded that the Healing Place model provided the best opportunity for addressing these two related problems. She stated that a system that linked programs based on the Healing Place model with other treatment and recovery services would provide significant benefit for the Commonwealth.

    November 16th, 2010 - Bristow, Virginia

    The fourth and final meeting of the SJR 73 Joint Subcommittee Studying Strategies and Models for the Prevention and Treatment of Substance Abuse was held on Tuesday, November 16, 2010, at Youth for Tomorrow in Bristow, Virginia.

    Ms. Keith Shuster, LPC, described the Prince William County Community Services Board's Suboxone program for people with opioid dependence. She stated that the program provided 90 days of Suboxone-assisted residential treatment for people with opioid dependence, including residential treatment for individuals in need of stabilization. The program has served 89 clients since 2008. Early results based on the first 16 months of program operations show that retention rates for program participants were significantly higher than retention rates for clients with opiate dependence who did not receive Suboxone as part of their treatment program (73% as compared to 34%). Recent data shows that program participants are involved with treatment for an average of 343 days, which is close to the recommended 365 days. Studies show that longer treatment involvement correlates with higher rates of success and lower rates of criminal activity. Ms. Shuster reported that the annual cost of the program has been $120,000.

    Mr. Ralph Orr, Program Director, Virginia Prescription Monitoring Program, reported on the Virginia Department of Health Professions' study of Prescription Monitoring Program Utilization, as required by Senate Joint Resolution 73 (2010). Mr. Orr stated that the Prescription Monitoring Program was established in 2003, and in October of 2009 underwent several programmatic changes, making the service available 24 hours a day through an automated service. This change has made the program more user-friendly. At the same time, the Department of Health Professions has increased public awareness and education activities around the Prescription Monitoring Program, providing educational conferences and materials to health care professionals. The Department and Prescription Monitoring Program staff also continues to work together with Virginia Commonwealth University's School of Medicine to offer an online chronic pain management course that licensed health professionals may take at no cost to satisfy continuing education requirements. As a result, the number of registered users has doubled since October 1, 2009. Additionally, the number of requests processed between January 1 and September 30 of 2010 was four times the number of requests processed in all of 2009. As of the end of September, 2010, the Prescription Monitoring Program had 7,906 registered users. Between January 1 and September 30 of 2010, the Program had processed over 300,000 requests for information. Approximately one million prescriptions are reported to the Program each month. One hundred forty of the 1,707 pharmacies registered in the Commonwealth are exempt from reporting requirements. During the first six months of 2010, an average of 83 patients met thresholds for potential misuse of prescription medications, and an average of seven prescribers and three pharmacies met thresholds for notification of potential concerns per month. Between January 1 and September 30, 2010, the Department contacted 91 pharmacies regarding failure to report required information during two or more reporting periods.

    While changes made to the Program have resulted in increased use of the Prescription Monitoring Program, the Department of Health Professions did recommend several enhancements to the Program, including recommendations to:

    • Add tramadol and carisoprodol to Schedule IV in the Drug Control Act
    • Add authority to add additional drugs of concern as covered substances utilizing the regulatory process of the Virginia Board of Pharmacy
    • Expand access to include additional federal law enforcement to include authorized agents of FBI, FDA, and HHS with the requirement of having an open investigation. (Based on NASPER)
    • Expand access to include authority for medical reviewers for worker's compensation programs (Reviewer would be a prescriber)
    • Add authority to provide unsolicited reports to law enforcement and regulatory agencies
    • Change reporting requirement to “within 7 days of dispensing”
    • Change reporting format to ASAP version 2007, provide mechanism for Director to change reporting format by providing timeframe to come into compliance
    • Add requirement of notarized application for prescribers, dispensers, and delegates
    • Add requirement of notarized application for law enforcement and regulatory personnel
    • Add method of payment to reporting requirements (Cash, Medicaid, other)
    • Require dispensers to report the DEA registration of the dispenser (Note: change from NCPDP#, cost savings for program, align with other state programs)
    • Require dispensers to report the number of refills ordered
    • Require dispensers to report whether the prescription was a new or refill
    • Require the dispenser to report the date the prescription was written
    • Require estimated number of days for which prescription should last (Days Supply)

    Ms. Althelia Battle, Chief Insurance Market Examiner, Bureau of Insurance, Virginia State Corporation Commission, presented the Bureau's report on Data Collection and Information on Substance Abuse Treatment Services. Ms. Battle reported that the Bureau mailed requests for information to 798 health insurers, health service plans, and health maintenance organizations licensed to sell accident and sickness insurance in Virginia as of August 16, 2010, and received responses from 468 companies. Of these companies, 34 companies reported issuing policies that included coverage for substance abuse services. These 34 companies reported a total of 30 complaints, with a total of $23,991,007 paid to settle those claims. During 2009, the Bureau received three complaints related to substance abuse services. One complaint involved a policy issued in another state. The other two complaints were investigated and found to have been handled by the insurers in accordance with their contract and in compliance with applicable laws. The Bureau did not report any recommendations for change.

    Dr. Randy Koch, Ph.D., Executive Director, Institute for Drug and Alcohol Studies, Virginia Commonwealth University, presented information on alcoholic energy drinks. Dr. Koch reported that alcoholic energy drinks include alcohol (usually malt liquor) mixed with caffeine and other stimulants. Premixed alcoholic energy drinks are frequently sold in large cans containing up to 23.5 ounces of beverage, and may contain up to 12% alcohol by volume. A study of consumption of alcoholic energy drinks in North Carolina found that 68% of college students reported drinking alcohol in the previous month, and that 24% of college students reported drinking alcoholic energy drinks on at least one day in the past month. Studies of consumption of alcoholic energy drinks indicate that those who drink alcoholic energy drinks are likely to consume more alcohol per episode of drinking, possibly because stimulants in alcoholic energy drinks counteract the depressant effects of alcohol and interfere with drinkers' perceptions of intoxication. Studies also show that individuals who drink alcoholic energy drinks are more likely to engage in risky behavior, are twice as likely to binge drink, are nearly twice as likely to be sexually assaulted (females), more than twice as likely to sexually assault someone (males), twice as likely to get hurt or injured, more than twice as likely to require medical treatment, and four times as likely to drive than individuals who consume alcohol that has not been mixed with stimulants. In response to these risks, Dr. Koch reported that several states have banned the sale of alcoholic energy drinks. Others have reclassified alcoholic energy drinks as distilled spirits. Dr. Koch and the SJR 73 work group recommended that the General Assembly ban the sale of alcoholic energy drinks in the Commonwealth. Alternately, the General Assembly should:

    1. Provide funding to the Governor's Office of Substance Abuse Prevention to conduct a public awareness campaign about alcoholic energy drinks, their effects, and the associated dangers.
    2. Provide additional funding to the Department of Alcoholic Beverage Control to conduct compliance checks on sales of alcoholic energy drinks.
    3. Consider re-classifying alcoholic energy drinks in a manner that would provide for sale of these beverages through package stores only.
    4. Increase the tax on alcoholic energy drinks to reduce consumption; funds received as a result of this tax should be allocated to substance abuse prevention and treatment services.
    5. Require warning labels on premixed alcoholic energy drinks sold in the Commonwealth (California considered legislation (AB 1598) that would have required labeling, but the bill failed to report from committee).
    6. Prohibit the mixing of alcohol and energy drinks in restaurants and other establishments that serve alcohol.