Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported.

a. Percentage of patients who initiated treatment including either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis 
b. Percentage of patients who engaged in ongoing treatment including two additional interventions or a medication for the treatment of AOD abuse or dependence within 34 days of the initiation visit. For patients who initiated treatment with a medication, at least one of the two engagement events must be a treatment intervention.

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Report a total score, and each of the following strata:
Stratum 1: Patients age 13-17 at the start of the Measurement Period
Stratum 2: Patients age >=18 at the start of the Measurement Period

None

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There are more deaths, illnesses and disabilities from substance abuse than from any other preventable health condition. In 2018, 20.3 million individuals in the U.S. age 12 or older (approximately 8 percent of the population) were classified as having an SUD within the past year (SAMHSA, 2019). Despite the high prevalence of SUD in the U.S., fewer than 20 percent of individuals with SUD receive any substance use treatment and only 12 percent receive treatment in a specialty SUD program (SAMHSA, 2019).

American Society of Addiction Medicine (2020) 
* All FDA approved medications for the treatment of opioid use disorder should be available to all patients. Clinicians should consider the patient’s preferences, past treatment history, current state of illness, and treatment setting when deciding between the use of methadone, buprenorphine, and naltrexone.
* There is no recommended time limit for pharmacological treatment
* Patients’ psychosocial needs should be assessed, and patients should be offered or referred to psychosocial treatment based on their individual needs. However, a patient’s decision to decline psychosocial treatment or the absence of available psychosocial treatment should not preclude or delay pharmacotherapy, with appropriate medication management. Motivational interviewing or enhancement can be used to  encourage patients to engage in psychosocial treatment services appropriate for addressing individual needs.

American Psychiatric Association (2018)
* Patients with alcohol use disorder should have a documented comprehensive and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments. [1C]
* Naltrexone or acamprosate be offered to patients with moderate to severe alcohol use disorder who have a goal of reducing alcohol consumption or achieving abstinence, prefer pharmacotherapy or have not responded to nonpharmacological treatments alone, and have no contraindications to the use of these medications. [1B]
* Disulfiram should be offered to patients with moderate to severe alcohol use disorder who have a goal of achieving abstinence, prefer disulfiram or are intolerant to or have not responded to naltrexone and acamprosate, are capable of understanding the risks of alcohol consumption while taking disulfiram, and have no contraindications to the use of this medication. [2C]
* Topiramate or gabapentin be offered to patients with moderate to severe alcohol use disorder who have a goal of reducing alcohol consumption or achieving abstinence, prefer topiramate or gabapentin or are intolerant to or have not responded to naltrexone and acamprosate, and have no contraindications to the use of these medications. [2C]

American Psychiatric Association (2006)
* Because many substance use disorders are chronic, patients usually require long-term treatment, although the intensity and specific components of treatment may vary over time [I rating]. 
* It is important to intensify the monitoring for substance use during periods when the patient is at a high risk of relapsing, including during the early stages of treatment, times of transition to less intensive levels of care, and the first year after active treatment has ceased [I rating].
* Outpatient treatment of substance use disorders is appropriate for patients whose clinical condition or environmental circumstances do not require a more intensive level of care [I rating]. As in other treatment settings, a comprehensive approach is optimal, using, where indicated, a variety of psychotherapeutic and pharmacological interventions along with behavioral monitoring [I rating ].
* Disulfiram is also recommended for patients with alcohol dependence [II rating].  
* Naltrexone, injectable naltrexone, acamprosate, a y-aminobutyric acid (GABA) are recommended for patients with alcohol dependence [I rating]. Disulfiram is also recommended for patients with alcohol dependence [II rating]. 
* Methadone and buprenorphine are recommended for patients with opioid dependence [I rating]. 
* Naltrexone is an alternative strategy [I rating].

American Society of Addiction Medicine (2015) 
* Methadone and buprenorphine are recommended for opioid use disorder treatment and withdrawal management.
* Naltrexone (oral; extended-release injectable) is recommended for relapse prevention.

Michigan Quality Improvement Consortium (2017)
*Patients with substance use disorder or risky substance use: Patient Education and Brief Intervention by PCP or Trained Staff (e.g. RN, MSW)
*If diagnosed with substance use disorder or risky substance use, initiate an intervention within 14 days.
*Frequent follow-up is helpful to support behavior change; preferably 2 visits within 30 days.
*Refer to a substance abuse health specialist, an addiction physician specialist, or a physician experienced in pharmacologic management of addiction.

Department of Veterans Affairs/Department of Defense (2015)
* Offer referral to specialty SUD care for addiction treatment if based on willingness to engage. [B]
* For patients with moderate-severe alcohol use disorder, we recommend: Acamprosate, Disulfiram, Naltrexone- oral or extended release, or Topiramate. [A]
* Medications should be offered in combined with addiction-focused counseling. offering one or more of the following interventions considering patient preference and provider training/competence: Behavioral Couples Therapy for alcohol use disorder, Cognitive Behavioral Therapy for substance use disorders, Community Reinforcement Approach, Motivational Enhancement Therapy, 12-Step Facilitation. [A]
* For patients with opioid use disorder we recommend buprenorphine/naloxone or methadone in an Opioid Treatment Program. For patients for whom agonist treatment is contraindicated, unacceptable, unavailable, or discontinued, we recommend extended-release injectable naltrexone. [A]
* For patients initiated in an intensive phase of outpatient or residential treatment, recommend ongoing systematic relapse prevention efforts or recovery support, individualized on the basis of treatment response. [A]

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'American Psychiatric Association, Kleber, H. D., & McIntyre, J. S. (2006). Practice Guideline for Treatment of Patients with Substance Use Disorders (pp. 1-276). Arlington, VA: American Psychiatric Association.'

Reference Type: CITATION

Reference Text: 'Michigan Quality Improvement Consortium. (2017). Screening, diagnosis, and referral for substance use disorders. Southfield, (MI): Michigan Quality Improvement Consortium. Retrieved from http://www.mqic.org/pdf/mqic_screening_diagnosis_and_referral_for_substance_use_disorders_cpg.pdf'

Reference Type: CITATION

Reference Text: 'Schneider Institute for Health Policy. (2001). Substance abuse: The nation's number one health problem. Robert Wood Johnson Foundation.'

Reference Type: CITATION

Reference Text: 'Department of Veteran Affairs, Department of Defense. (2015). VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Washington DC: Department of Veterans Affairs, Department of Defense.'

Reference Type: CITATION

Reference Text: 'Kampman, K., Jarvis, M. (2015). American Society of Addiction Medicine (ASAM) National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Journal of Addiction Medicine; 9(5): 358–367. DOI: 10.1097/ADM.0000000000000166.'

Reference Type: CITATION

Reference Text: 'Pietras, S., Azur, M., & Brown, J. (2015). Review of medication assisted treatment guidelines and measures for opioid and alcohol use. Washington, DC: Assistant Secretary for Planning and Evaluation.'

Reference Type: CITATION

Reference Text: 'Reus, V. et al. (2018). Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder. American Journal of Psychiatry, 175(1), 86-90. doi:10.1176/appi.ajp.2017.1750101'

Reference Type: CITATION

Reference Text: 'Substance Abuse and Mental Health Services Administration (SAMHSA). (2019). Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Retrieved from: https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.htm#mhisudSubstance'

Reference Type: CITATION

Reference Text: 'Cunningham, C., Edlund, F. M. J., Fishman, M., Gordon, D. A. J., Jones, D. H. E., Langleben, D., ... & Freedman, D. K. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update.'

The initiation visit is the first visit for alcohol or other drug dependence treatment within 14 days after a diagnosis of alcohol or other drug dependence.

Treatment includes inpatient AOD admissions, outpatient visits, intensive outpatient encounters or partial hospitalization.

The Intake Period: January 1-November 14 of the measurement year. The Intake Period is used to capture new episodes of Alcohol or Drug Dependence. The November 14 cut-off date ensures that all services can occur before the measurement period ends.

The new episode of alcohol and other drug dependence should be the first episode of the measurement period that is not preceded in the 60 days prior by another episode of alcohol or other drug dependence.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Patients age 13 years of age and older who were diagnosed with a new episode of alcohol, opioid, or other drug abuse or dependency during a visit between January 1 and November 14 of the measurement period

Equals Initial Population

Exclude patients with a negative diagnosis history, defined as an encounter or medication treatment for a diagnosis of alcohol, opioid or other drug abuse or dependence in the 60 days prior to the first episode of alcohol or drug dependence.

Exclude patients who are in hospice care for any part of the measurement period.

Numerator 1: Initiation of treatment includes either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis. 

Numerator 2: Engagement in ongoing treatment within 34 days of initiation includes:

1. Patients that initiated treatment with a psychosocial visit, and whose engagement criteria was fulfilled by a dispensed medication.

2. Patients that initiated treatment with a psychosocial visit, and whose engagement criteria was fulfilled by two further psychosocial visits.

3. Patients that initiated treatment with a dispensed medication, and whose engagement criteria was fulfilled by both a further medication dispense and a psychosocial visit.

4. Patients that initiated treatment with a dispensed medication, and whose engagement criteria was fulfilled by two psychosocial visits.

Not Applicable

None

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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