Care Management

Connecting the Dots

July 19, 2017 12:06 pm

The opioid epidemic is garnering many headlines these days. But amid all the attention to the many negative impacts of addiction on people’s lives, one aspect is often overlooked.

Having a substance use disorder—whether it involves prescription opioids, heroin, alcohol, or another drug—often doubles the odds that a person will develop another chronic and costly medical illness, such as arthritis, chronic pain, heart disease, stroke, hypertension, diabetes, or asthma, according to the Surgeon General’s comprehensive 2016 report, Facing Addiction in America. a Yet the link between addiction and chronic conditions seemingly flies under the radar.

Missing Opportunities for Early Intervention

The Surgeon General’s report states that providing services to people with mild and moderate substance use disorders in general healthcare settings is likely to reduce the need for intensive and costly treatment services later. This is not a radical idea. Early intervention is the principle that underlies contemporary approaches to managing a wide range of chronic health conditions. So why have we missed the boat when it comes to addiction treatment?

In part, it’s because addiction treatment has been separated from general health care. It’s compartmentalized. While there are valid reasons for this separation, it “has also created unintended and enduring impediments” to care, according to the Surgeon General. For example, separation reinforces the idea that substance use disorders are different from other medical conditions. Although many patients in emergency departments, hospitals, and general medical settings have substance use disorders, mainstream health care generally has failed to recognize or address them.

Medical education in this area is inadequate, which perpetuates the problem. Training in substance use disorders at medical schools is focused on transmitting scientific facts rather than developing the attitudes and skills that would help physicians have difficult but crucial conversations with their patients. b

Tracing the Trajectory

According to the not-for-profit Facing Addiction organization (for which I am a board member), 20.8 million people suffer from a substance use disorder today, with another 23 million in recovery. That is similar to the number of people who live with diabetes and more than 1.5 times the number who have cancer.

The number of people living with—and dying from—addiction is growing rapidly. Fatal heroin overdoses were more than five times higher in 2014 than in 2004. The admission rate for substance use disorder treatment in 2009 was six times the 1999 rate. In certain segments of the U.S. population, there has been a dramatic increase in mortality from chronic liver disease and cirrhosis—both conditions that are linked to alcohol abuse—since the year 2000, reversing decades of progress. c Alcoholism is currently overshadowed by the opioid epidemic, but it has most definitely not gone away.

The downstream effects of these trends on healthcare utilization by addiction survivors will be significant.

Connecting the Dots

As I wrote about previously in this space, 93 percent of Medicare fee-for-service spending is for patients who have multiple chronic conditions. We must improve management of these patients to curtail the growth of healthcare spending, which is projected to reach 20 percent of GDP by 2025.

Managing chronic conditions is generally not a priority for those who work in hospital and health system settings. Chronic conditions are managed primarily in physicians’ offices and patients’ homes, whereas hospitals typically treat the complications of chronic conditions—complications that could be prevented if the conditions were better managed early on.

As an industry, we need to do a better job of coordinating care so that people with chronic conditions—including addiction—receive the care they need in the appropriate setting. As the Surgeon General put it, it’s time to face addiction in America.

Joseph J. Fifer, FHFMA, CPA, is president and CEO, HFMA. Follow Joe Fifer on Twitter @HFMAfifer.


a. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, D.C.: HHS, November 2016.

b. Ram, A., and Chisolm, M.S., “The Time Is Now: Improving Substance Abuse Training in Medical Schools,” Academic Psychiatry, June 2016.

c. Case, A., and Deaton, A., “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of the United States of America, Dec. 8, 2015.


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