Measurement: The Missing Link to Quality Addiction Treatment

In any given year, an estimated 21.7 million people in the United States aged 12 or older—about 8% of the population—need substance use treatment. In 2016, approximately 2 million individuals received treatment for a substance use disorder (SUD) at a specialty SUD facility. Numerous studies have shown that addiction treatment is effective in helping individuals with SUD reduce substance use and improve functioning.

The National Institute on Drug Abuse has conducted comprehensive research demonstrating the principles of high-quality addiction treatment. However, there are significant opportunities to improve the effectiveness of addiction treatment in actual practice. Take, for example, the following figures:

• Only 50% of addiction programs conduct mental health assessments.
• Only 40% of addiction programs offer medications to treat opioid use disorders (OUDs).
• Only 25% of addiction treatment patients receive addiction treatment within 2 weeks of being discharged.

Why are quality measures important?

As with health care in general, improving SUD treatment requires developing a “learning health care system” in which patient outcomes data are collected as a routine part of clinical practice and fed back to providers to facilitate quality improvement.

A 2006 Institute of Medicine (IOM) report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, concluded that the quality of SUD treatment could be improved if behavioral health service providers increased their use of valid and reliable patient assessments to guide ongoing treatment planning. The report also recommends that outcome measures be summarized by provider to facilitate comparisons among providers and over time. A 2015 IOM report, Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards, also concluded that there is a need to develop quality measures for SUD treatment, particularly outcome-based measures.

Are quality measures currently being used in addiction treatment?

As of May 2019, the Centers for Medicare & Medicaid Services had over 4,000 quality measures in use, but none for addiction treatment programs. There were 53 home health measures, 16 end-stage renal disease measures, 11 hospice measures, 11 measures for long-term care hospitals, 22 for psychiatric hospitals, 25 for nursing homes, but zero measures for addiction programs.

As of May 2019, the Centers for Medicare & Medicaid Services had over 4,000 quality measures in use, but none for addiction treatment programs.

Quality measurement to address the opioid crisis has emphasized identifying and reducing opioid prescriptions through the use of prescription drug monitoring programs and quality measures such as the use the Pharmacy Quality Alliance measure “Use of Opioids at High Dosage in Persons Without Cancer” (National Quality Forum [NQF] #2940). From 2012 through 2017, the United States dramatically reduced opioid prescribing rates. This approach led to unintended consequences of physicians “firing” patients who they found misusing pain medication, which then fueled the shift from misuse of opioid pain medications to misuse of illicit drugs.

Recent research by myself and my colleagues at RTI International finds that most patients who are identified as potentially misusing opioid medications—as defined using the NQF-endorsed Pharmacy Quality Alliance measure of high-dose opioid medication usage—discontinue opioids rapidly. In addition, less than 1% of beneficiaries were transitioned onto an OUD medication, even though 60% of patients in the sample had a diagnosed SUD. Examples of quality measures include (1) the percentage of physicians who treat pain that are buprenorphine-waived and (2) the percentage of patients who clinicians have identified as misusing OUD medications and, as a result, are transitioned to medications to treat OUD; such quality measures could start to address the problematic disconnect between opioid pain medication discontinuation and the treatment and prevention of OUD and SUD.

Such quality measures could start to address the problematic disconnect between opioid pain medication discontinuation and the treatment and prevention of OUD and SUD.

RTI is currently conducting research to improve opioid pain medication practice. For example, Dr. Lauren McCormack is leading a multisite, randomized-controlled trial funded by the Patient-Centered Outcomes Research Institute. This trial assesses evidence-based strategies to reduce or eliminate chronic opioid therapy for patients who are not benefitting from this therapy, while continuing to maintain access for patients who do genuinely benefit. Dr. Barry Blumenfeld and colleagues developed a guide for patient-centered clinical decision support tools to help with pain management and OUD prevention and treatment.

How can we implement quality measures in addiction treatment?

Ensuring individuals with SUD have access to high-quality treatment options is crucial for combating the opioid epidemic. To meet this goal, we need to accomplish the following:

• Develop quality measures for addiction treatment programs that can be used by payers (e.g., Medicaid and private health plans), consumers, and providers to improve the quality of addiction treatment.
• Create addiction program measures from the already endorsed SUD measures at the state and health-plan levels.
• Determine companion measures to the existing measures that focus on reducing opioid pain medication prescribing to ensure that quality measures aimed at reducing opioid medication use are not causing more harm than good.
• Develop outcome measures for addiction treatment to drive measurement-based, feedback-informed care.

The infrastructure already exists to implement these recommendations. Outcome measures are routinely collected from patients in addiction treatment as a requirement of the Substance Abuse and Mental Health Services Administration block grant; additionally, these measures are often integrated into electronic health record systems. Biomarkers of substance use are routinely collected as measures of treatment need and effectiveness. Furthermore, numerous well-validated instruments exist that could measure other symptoms of SUD, such as how well someone is or is not functioning in the major domains of life, qualify of life, and withdrawal/craving.

There is a great need for addiction program quality measures, and the barriers to developing these measures are surmountable.

Learn more about how RTI and Shatterproof are working to create a quality measurement system to help consumers easily find high-quality treatment nearby and to help providers, payers, and policymakers develop benchmarks to improve the quality of addiction treatment services.