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Key Results: Substance Abuse and Healthcare Costs
Citations Listed in Key Results
- Alcohol and drug abuse consistently increases the cost of healthcare.
The United States spent less than 2% of its $1.6 trillion in total health care outlays in 2003 for substance abuse treatment. Direct spending for alcohol and drug treatment represents approximately 2% of Medicaid spending and a slightly lower percentage for private insurers (Mark, et al., 2007). However, healthcare spending caused by substance abuse is almost certainly many times higher than these figures.
Substance abuse contributes to higher healthcare costs in private and public insurance programs by raising the cost of treating both mental and physical health conditions (Clark, Samnaliev, & McGovern, 2009; Garnick, Hendricks, Comstock, & Horgan, 1997). Among Medicaid beneficiaries with behavioral health disorders in 6 states during 1999, co-occurring substance abuse or dependence often doubled the cost of mental health treatment and raised expenditures for other medical conditions anywhere from 7% in one state to more than 100% in another (Clark, Samnaliev, et al., 2009). Although costs are higher in almost every category of service use, the largest impact flows from a greater risk of hospitalization and emergency room use (Clark, Samnaliev, & McGovern, 2007; McGeary & French, 2000; Owens, Myers, Elixhauser, & Brach, 2007; White, et al., 2005). One study argued that one in five Medicaid hospitalizations during the early 1990s was caused by substance abuse (Fox, Merrill, Chang, & Califano Jr, 1995).
Substance abuse increases use of emergency department and inpatient care directly through higher rates of motor vehicle accidents, other injuries, and drug overdoses. Another cause of high cost emergency and inpatient care arises from complications in the care for chronic illnesses, such as asthma (Baxter, Samnaliev, & Clark, 2008). For example, substance abuse may directly exacerbate asthma symptoms or cause individuals to neglect care such as taking recommended controller medications. In both cases, the result may be a trip to the local emergency department to treat a life threatening breathing difficulty. Addiction often co-occurs with other psychiatric disorders, such as depression, bipolar disorder or schizophrenia, raising the cost of treating those conditions as well (Bartels, et al., 1993; Dickey & Azeni, 1996; Kessler, 2004).
Because people who abuse drugs often abuse alcohol, and vice versa, and both groups are more likely to use tobacco than the general population, it is difficult to precisely estimate the cost of healthcare attributable to a specific type of substance abuse. A report prepared by Harwood and colleagues for the Office of National Drug Control Policy estimated total societal health care spending related to drug abuse at $15.8 billion in 2002 and a report prepared by the same group estimated alcohol-related healthcare spending in 1998 at $26.3 billion(Harwood, 2000; Office of National Drug Control Policy, 2004). The Centers for Disease Control estimated health care costs related to smoking at $96 billion per year during the period between 2000 and 2004 (Centers for Disease Control, 2008). More recently, a report issued in 2009 by the National Center on Addiction and Substance Abuse (CASA) estimated that federal and state governments alone spent more than $200 billion on all three substances (National Center on Addiction and Substance Abuse at Columbia University, 2009). These widely discrepant estimates reflect different methods for cost estimation as well as different data sources, with the CASA report having access to more recent data from a broader spectrum of federal, state and local government sources and using an epidemiologically-based approach for estimating the cost of medical consequences. The acknowledged difficulty in distinguishing the impact of specific substances when polysubstance abuse is common also contributes to discrepancies in cost estimates. As the quality and accessibility of health care data improves and greater consensus in methods develops, it is likely that cost estimates will become more consistent.
Widely varying estimates notwithstanding, there is little doubt that substance abuse has a substantial impact on overall healthcare spending.
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- A variety of approaches to substance abuse treatment have been shown to lower healthcare costs, particularly for expensive services such as emergency room visits and inpatient care.
A number of studies show that treated individuals have lower rates of emergency room use and hospitalization, which usually results in lower overall healthcare costs (Ettner, et al., 2006; Holder, 1998; McGeary & French, 2000; Parthasarathy, Weisner, Hu, & Moore, 2001; Turner, Laine, Yang, & Hauck, 2003; Wickizer, Krupski, Stark, Mancuso, & Campbell, 2006). Lower use of expensive health care is found consistently across individuals using different substance abuse treatment modalities, such as outpatient drug free, residential and medication assisted treatment, and for both alcohol and drug addiction (Ettner, et al., 2006; Wickizer, et al., 2006). Of course, cost and effectiveness vary by site and type of treatment (Cisler, Holder, Longabaugh, Stout, & Zweben, 1998; Ettner, et al., 2006; Finney & Monahan, 1996).
Some treatment interventions , such as Screening Brief Intervention Referral and Treatment (SBIRT), based in primary, emergency or other medical care settings or brief physician advice for problem drinkers, also show promising results for healthcare savings (Washington State Screening, Brief Intervention, Referral and Treatment Project, 2008). However, treatment does not always completely eliminate cost differences between those whose substance abuse is treated and others without a substance use disorder (Goodman, Tilford, Hankin, Holder, & Nishiura, 2000; Harwood, 2008; Parthasarathy, et al., 2001). In the short term, the cost of substance abuse treatment can be higher than healthcare savings (Ettner, et al., 2006). Actual healthcare savings from treatment, also called healthcare cost offsets, may vary widely depending on age, gender and the presence of co-occurring psychiatric conditions (Zywiak, et al., 1999).
Placing these results in context, it is important to understand that healthcare cost savings are only one type of economic benefit from treatment. Substance abuse treatment often increases employment and reduces criminal activity (Holloway, Bennett, & Farrington, 2006; Hser & Evans, 2008; Hubbard, Craddock, & Anderson, 2003; Metsch, Pereyra, Miles, & McCoy, 2003; Wickizer, Campbell, Krupski, & Stark, 2000). Many effective substance abuse treatments produce net savings when lower criminal justice costs and increased earnings from employment are included in calculations (Doran, 2008; McCollister & French, 2003). Even when only healthcare costs are considered, the cost effectiveness of substance abuse treatment compares very favorably with other effective healthcare interventions, most of which improve health outcomes but do not produce cost savings (Cohen, Neumann, & Weinstein, 2008). Substance abuse treatment is among the most cost-effective healthcare interventions available.
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- Individuals with alcohol or drug addiction have higher rates of chronic physical illness than others.
Physical illnesses are more prevalent among individuals with addictions, in part, as a result of the direct negative impact of excess alcohol and drugs on physical health, and often risky behaviors associated with substance abuse. Higher prevalence of asthma, arthritis, acid-related disorders, hypertension, lower back pain, headache, injuries, overdose, and chronic obstructive pulmonary disease were observed among adults with substance abuse or dependence entering a Chemical Dependency Recovery Program in one HMO, compared to adults without substance use disorders (Mertens, Lu, Parthasarathy, Moore, & Weisner, 2003). In a later study, Mertens and colleagues (Mertens, Flisher, Fleming, & Weisner, 2007) report higher rates of acid-related disorders, asthma, benign conditions of the uterus, injuries and poisoning, sexually transmitted diseases, sleep disorders, and sinusitis among adolescents (13 to 18 years old) entering the same treatment program compared to adolescents without substance use disorders. Higher rates of infectious and chronic diseases were observed among privately insured opioid abusers compared to non-abusers (White, et al., 2005). And rates of diabetes, heart disease, asthma, gastrointestinal disorders, skin infections, cancer, and acute respiratory disorders were higher among Medicaid beneficiaries with substance use disorders compared to those without them (Dickey, Normand, Weiss, Drake, & Azeni, 2002). Higher co-occurring disease prevalence is a key driver of healthcare costs for individuals who abuse alcohol or other drugs.
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- Psychiatric disorders are more prevalent among people with addictions.
Mental health disorders are much more prevalent among individuals with alcohol or drug substance use disorders. And, for many people, a psychiatric disorder precedes substance abuse or dependence (Kessler, 2004).
In the National Comorbidity Survey of non-institutionalized English-speaking adults in the US (Kessler, 2004), lifetime prevalence of mental health disorders was significantly associated with alcohol abuse or dependence , and with drug abuse or dependence. Individuals with psychiatric disorders had more severe forms of substance use disorders. The mental health conditions that were most strongly correlated with addiction included mania, conduct disorders, and adult antisocial personality disorder.
The 2006 National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration (SAMHSA), 2007) reported higher rates of past year major depressive episodes among adults with (15.4%) than without (7.0%) past year substance abuse or dependence. Psychiatric disorders contribute a significant proportion of the overall higher costs associated with substance abuse populations.
High quality studies consistently show high rates of mental illness in substance abuse populations, thus, effective treatment for mental illness may require substance abuse treatment and addressing psychiatric disorders may assist with substance abuse recovery.
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- Rates of infectious disease, such as human immunodeficiency virus (HIV), hepatitis b, and hepatitis c are significantly higher.
The relationship between infectious disease and addiction has been well-documented, particularly with regard to HIV/AIDs, hepatitis C (HCV), sexually transmitted infections (STI), and tuberculosis (TB) (Amon, et al., 2008; Brown, et al., 2007; Edlin & Carden, 2006; Friedman, Pross, & Klein, 2006; National Institute on Drug Abuse, 2008; Oeltmann, Kammerer, Pevzner, & Moonan, 2009). People with substance use disorders are disproportionately affected by these diseases; as many as 30 to 40% of injection drug users in the US are estimated to be infected with HIV, 60 to 90% with HCV, and 90% with at least one previous or current STI (Brown, et al., 2006; Substance Abuse and Mental Health Services Administration, 2007). In addition, although the rate of TB is declining in the US, the rate of decline is slower among those with substance use disorders (Oeltmann, et al., 2009).
There is increasing evidence that abuse of drugs compromises the immune system and impairs the bodys ability to fight infectious diseases (Friedman, et al., 2006). In addition, people with alcohol and, especially, drug abuse are more likely than others to engage in behaviors that increase the risk of acquiring and transmitting these diseases. For example, sharing of drug paraphernalia increases exposure to HIV and HCV, and impaired judgment increases the likelihood of unprotected sexual encounters and exposure to sexually transmitted diseases (Amon, et al., 2008; Brown, et al., 2007; Edlin & Carden, 2006; Santibanez, et al., 2006; Substance Abuse and Mental Health Services Administration, 2007). Once infected, substance abusers are more likely to postpone seeking treatment, less likely to adhere to treatment regimens, and more likely to acquire multiple infectious diseases that are difficult to treat when they co-occur (Brown, et al., 2007; Khalsa, Treisman, McCance-Katz, & Tedaldi, 2008; National Institute on Drug Abuse, 2008; Oeltmann, et al., 2009).
Infectious disease and drug abuse are tightly linked. Integrated, or closely coordinated, substance abuse and medical treatment is critically important for treating and preventing the spread of HIV, hepatitis and other deadly diseases.
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- The impact of substance abuse on general healthcare costs may increase with age.
Although rates of substance abuse are higher among younger adults, there is some evidence that alcohol and drug dependence take a greater medical toll as people age. Health declines faster for individuals with substance use disorders than for those without these disorders. In a cohort of individuals with self reported good health in a baseline year who were then reassessed after 13 years (Kertesz, et al., 2007), rates of decline in general self-rated health (from good to fair or poor) were greater among past year hard drug users (12.6%) compared to individuals who never used drugs (7.2%). Consequently, the gap in demand for medical care between those with substance use disorders and others may widen with age. In a study of Medicaid beneficiaries with psychiatric disorders, expenditures for general medical care were greater among those with substance use disorders than among those without and this difference increased by age group from $636 (ages 21 to 30), to $652 (ages 30 to 40), $985 (ages 40 to 50), $2,725 (ages 50 to 60) and $3,277 (ages 60 to 65), measured in annual 1999 dollars (Clark, Samnaliev, et al., 2009). Among individuals with drug or alcohol abuse entering the outpatient Chemical Dependency Recovery Program in one HMO (Parthasarathy, et al., 2001), the difference in average medical costs (1998 dollars per person including inpatient, emergency department and outpatient visit costs) compared to a matched group of non-abusers was higher in the 40-49 ($207) compared to the 18-29 ($131) and the 30-39 age groups ( $77), although this difference decreased to $102 for patients over 50. There is some evidence that substance abuse treatment at an early age has a greater impact on long-term health care costs than intervention for older adults (Holder, 1998; Holder & Blose, 1986.)
Overall, the impact of substance abuse on health and healthcare costs seems to increase with age. Growing rates of abuse in older age groups, coupled with high rates of physical illness, will likely increase the importance of integrated physical and behavioral healthcare in coming years.
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- Patients who abuse drugs or alcohol receive lower quality care for their physical health problems than others without addictions.
Substance abuse has long been associated with restricted access to quality health care (Brown, et al., 2007; McCoy, Metsch, Chitwood, & Miles, 2001; Narevic, et al., 2006; Savage, Gillespie, & Lindsell, 2008; Tobias, et al., 2007). Even though those with substance use disorders have many unmet health care needs, they are less likely to receive non-emergency medical services than non-users who have similar sociodemographic characteristics and health needs (McCoy, et al., 2001; Narevic, et al., 2006). Substance abusers are also less likely to use primary care for health maintenance and disease management (Baxter, et al., 2008; Cavazos-Rehg, et al., 2009; Kang & Deren, 2009; Savage, et al., 2008; Wilkinson, et al., 2007) and are less likely to seek treatment at early stages of progressive diseases. When they receive primary care, they are less likely than others to receive treatment that complies with generally accepted standards (Baxter, Samnaliev, & Clark, 2009; Clark, Weir, Ouellette, Zhang, & Baxter, 2009). Poor self care and provider oversight both contribute to the problem (Ahmed, Karter, & Liu, 2006; Jackson & Kroenke, 2001). Conversely, substance abusers are more likely than others to use costly emergency department and inpatient health services because of health emergencies such as overdose, drug toxicity, and other acute health problems (McCoy, et al., 2001; Narevic, et al., 2006).
Although there are financial and structural barriers such as cost and availability of services that restrict access to care, research has shown that, for individuals with substance use disorders, personal barriers such as lack of motivation to seek care, poor adherence to self care regimens, and fear of discrimination also contribute to poor health (Ahmed, et al., 2006; McCoy, et al., 2001; Mehta, et al., 2005; Tobias, et al., 2007). As addiction becomes the driving force in a persons life, health maintenance and disease management receive lower priority (Kuehn, 2008; McCoy, et al., 2001; Mehta, et al., 2005; Starrels, Barg, & Metlay, 2009). In addition, individuals with addictions often need basic social services such as housing, which impacts their ability to manage non-urgent health care needs. Longer and more frequent alcohol and drug use has also been found to increase the likelihood and severity of unmet health needs (Narevic, et al., 2006; Savage, et al., 2008).
Healthcare financing and systems, provider practices and individual patient behavior all contribute to poorer quality care. Changes at all levels may be needed to achieve lasting improvement.
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