Topic:
HEALTH INSURANCE; MENTAL HEALTH; HEALTH FACILITIES; ALCOHOL/DRUG ABUSE;
Location:
DRUGS- REHABILITATION;

OLR Research Report


January 3, 2008

 

2008-R-0006

ADULT DRUG REHABILITATION

By: Saul Spigel, Chief Analyst

You asked a series of questions about drug rehabilitation in Connecticut. Specifically you asked about:

1. the number of public and private in- and outpatient adult drug rehabilitation facilities and beds in Connecticut and how that number compares to other states;

2. the average length of stay in Connecticut facilities;

3. normal insurance coverage for drug rehabilitation;

4. the effect closing Norwich and Fairfield Hills hospitals had on the state's ability to treat substance abusers;

5. the number of judicial referrals for drug rehab over the past 10 years;

6. the number of substance abuse-related incarcerations (i.e., incarcerations for substance-related crimes and of substance abusers); and

7. Connecticut's annual spending on drug rehabilitation, including capital spending, and how this compares to other states.

SUMMARY

The Department of Public Health (DPH) licenses 181 private substance abuse treatment facilities; three mental health hospitals that provide some substance abuse treatment services; and 17 general hospitals that provide in- or outpatient substance abuse treatment. The Department of Mental Health and Addiction Services (DMHAS) directly operates inpatient and outpatient rehab services at four locations, and the Correction Department provides residential and outpatient substance abuse treatment at all prisons and follow-up care after release.

DMHAS reports that these facilities provide 1,245 inpatient beds (4.6 beds/10,000 adults), 7,027 residential treatment slots (26.1/10,000), and 9,746 medication-assisted therapy (e.g., methadone maintenance) slots (35/10,000). Connecticut has more hospital and residential rehabilitation beds per 10,000 people than any other state in an eight-state sample of Northeastern states and others with similar-sized populations.

The length of stay in substance abuse facilities varies by the service provided and type of facility. In 2006, the median stay in residential detoxification was four days and 30 days in ambulatory detox. It was 20 days in hospital and short-term residential rehabilitation and 88 days in long-term rehab. The intensive outpatient treatment median stay was 36 days and 67 in regular outpatient care.

Connecticut law requires most individual and group health insurance policies to cover diagnosis and treatment of substance abuse. Benefits are payable on the same basis as any other medical condition. All but one of Connecticut's managed care organizations cover inpatient and outpatient substance abuse treatment services, including detoxification, at hospitals and treatment facilities, according to a 2007 Insurance Department document.

After DMHAS closed Norwich Hospital, it relocated the detoxification beds to smaller, short-term hospitals and started a telephone access line to screen and refer people to a regional network of providers for evaluation and treatment. After it closed Fairfield Hills, DMHAS increased detox bed capacity at one of its Bridgeport facilities. A 2003 assessment of the closings determined that they did not adversely affect access to medical detoxification services or the likelihood of people entering follow-up rehabilitation in either region.

A court can send someone to substance abuse treatment through four pretrial diversion programs: pretrial drug education, community service labor, treatment of drug and alcohol offenders in lieu of prosecution, and pretrial alcohol diversion. Between 12,000 and 13,000 people have been diverted in each of the past five years.

Narcotics sale and narcotics possession have been among the top four causes of incarceration for the past five years. Incarcerations for these offenses dropped steadily between July 2002 and July 2007 (2,914 to 2,547), according to Correction Department statistics. They fluctuated between 15.6% and 12.6% of all incarcerations during that period.

Six state agencies spent over $200 million in FY 05 on substance abuse treatment; DMHAS accounted for $128,862,295 of that amount. It also awarded $1,575,169 in bond funds to substance abuse treatment agencies for capital improvements. In FY 05, DMHAS spent $24.05 per capita on substance abuse treatment, the fifth highest in the nation.

SUBSTANCE ABUSE TREATMENT FACILITIES

Connecticut

Substance abuse treatment occurs in a variety of locations—specialized substance abuse treatment facilities, general and mental health hospitals, prisons, and clinics and professional offices. DPH licenses 181 private “facilities for the care or treatment of substance abusive or dependent persons.” Fifty-three (53) of these are licensed to provide various categories of residential treatment: intermediate and long-term treatment and rehabilitation, intensive treatment, and residential detoxification and evaluation. The remaining 128 facilities provide only outpatient services, including ambulatory detoxification.

DPH also licenses three mental health hospitals and 30 general hospitals. The mental health hospitals provide inpatient and outpatient treatment for people with substance abuse and co-occurring disorders (i.e., mental illness and substance abuse). They contain 275 licensed treatment beds, but the data do not specify how many beds are solely for substance abuse treatment. The Connecticut Hospital Association (CHA) reports that six general hospitals have inpatient substance abuse treatment units and 16 provide outpatient treatment, but CHA could not determine the specific number of beds or slots they provide.

DMHAS provides inpatient substance abuse treatment at its Connecticut Valley and Blue Hills hospitals and outpatient treatment at its Connecticut and Capital Region Mental Health Centers.

All of these facilities, plus the Correction Department's (DOC) prison-based treatment services, report to DMHAS' Substance Abuse Treatment Information System. Table 1, prepared by DMHAS, shows the number of public and private treatment beds and outpatient slots these facilities reported as of November 5, 2007. (It does not include beds or treatment in general hospitals or Veterans' Administration hospitals (unless DMHAS provides the funds) or private practitioners' offices).

Table 1: Substance Abuse Treatment System Capacity,

Total and Per Capita

Level of Care

Capacity

Rate per 10,000 Adults

 

Beds

 

Detoxification

   

Hospital Inpatient & Residential

205

0.8

Residential Rehabilitation

   

Intensive

303

 

Intermediate/Halfway House

157

 

Long Term Care

785

 

Total Residential Rehabilitation

1,245

4.6

 

Slots

 

Outpatient

   

Standard

5,343

 

Intensive

1,684

 

Total Outpatient

7,027

26.1

Medication Assisted Therapy

   

Ambulatory Detoxification

221

0.8

Methadone Maintenance

9,525

35.4

Source: Residential bed capacity DMHAS Daily Census Report, November 5, 2007.

Many of these facilities offer multiple services. For example, the Rushford Center provides the following services at its 1250 Silver Street, Middletown facility: residential community-based and ambulatory detoxification; community-based intensive, community-based intermediate, and halfway house residential rehabilitation; and standard, partial hospitalization, and intensive outpatient. Attachment 1, prepared by DMHAS, lists substance abuse treatment providers and their programs. (It separately lists programs jointly funded by DMHAS, DOC, and the Judicial Branch, which make for some duplication in the list.)

Interstate Comparisons

The federal Substance Abuse and Mental Health Services Administration (SAMHSA) annually surveys substance abuse treatment facilities. It surveys program-level, clinic-level, and multi-site respondents (which helps explain why the number of facilities it reports exceed the number of facilities DPH licenses, as described above). Table 2 compares the number of facilities in Connecticut with those in (1) three Northeastern states and (2) four states with populations similar to Connecticut.

The table shows that Connecticut and Massachusetts maintain a higher proportion of residential facilities and hospitals than other states relative to outpatient treatment facilities. Consequently, they have more hospital and residential treatment beds per 10,000 people.

Table 2: Comparison of State Substance Abuse Facilities

 

CT

MA

MD

NJ

IA

OK

OR

KY

Facilities

               

Total #

216

309

356

358

128

152

223

314

Private

199

290

283

331

119

116

177

303

Public1

17

19

73

27

9

26

46

11

Type of Care2

               

Outpatient

161

198

296

315

117

129

199

274

Residential

66

124

85

73

31

41

53

52

Hospital Inpatient

17

41

12

22

14

10

3

23

Facility Beds3

               

Residential

1886

2760

2268

2510

558

1234

1285

1105

Hospital

536

697

55

249

17

67

33

359

Population (000s)

3.510

6.399

5.600

8.718

2.966

3.548

3.641

4.173

Beds/10,000 pop.

6.90

5.40

4.15

3.16

1.94

3.66

3.62

3.51

Source: SAMHSA, National Survey of Substance Abuse Treatment Services, 2005

1 Includes facilities operated by tribal governments

2 Facilities may be included in more than one category

3 Excludes some facilities

AVERAGE LENGTH OF STAY

Table 3 displays the average and median length of stay by all clients discharged from various forms of substance abuse treatment situations. The average stay is greater than the median because of small numbers of people who stay in treatment for unusually extended periods (“outliers”).

Table 3: Mean and Median Length of Stay by Level of Care, 2006

Level of Care

Average Stay

(days)

Median Stay

(days)

Detoxification

   

Hospital Inpatient

5

4

Free-standing Residential

4

4

Ambulatory

66

30

Residential Rehabilitation

   

Hospital Inpatient

22

20

Short-term (up to 30 days)1

19

20

Long-term (over 30 days) 2

97

88

Outpatient

   

Regular

94

67

Intensive

54

36

Opioid Replacement Therapy

   

Methadone Maintenance

360

223

Source: DMHAS, Connecticut Treatment Episode Data Set (TEDS) discharges, calendar Year 2006

1. Short-term programs are comprised of intensive residential programs

2. Long-term programs are comprised of intermediate, halfway, and long-term care and rehabilitation programs

INSURANCE COVERAGE

Connecticut law requires most individual and group health insurance policies to provide benefits for the diagnosis and treatment of mental disorders, as defined in the most recent edition of the American Psychiatric Association'Diagnostic and Statistical Manual of Mental Disorders (DSM) (CGS 38a-488a and 38a-514). DSM-IV, the most recent edition of the DSM, classifies substance abuse and substance dependence as substance-related mental disorders.  Therefore, insurance policies must cover their diagnosis and treatment.  All Connecticut managed care organizations (except for Celtic Insurance) cover inpatient and outpatient substance abuse treatment services, including detoxification, at hospitals and treatment facilities, according to the Insurance Department's 2007 Comparison of Managed Care Organizations in Connecticut.

By law, benefits are payable on the same basis as any other medical condition. Benefits payable for a physician's services are payable for the same services provided by a psychologist, social worker, marital and family therapist, alcohol and drug counselor, or professional counselor (CGS 38a-514(d)).

 

Group health insurance policies must cover the treatment of medical complications from alcoholism (e.g., cirrhosis of the liver, gastrointestinal bleeding, pneumonia, and delirium tremens; CGS 38a-533).

EFFECT OF CLOSING NORWICH AND FAIRFIELD HILLS HOSPITALS

The Boneski Chemical Dependence Treatment Center at Norwich Hospital closed in 1995; the Berkshire Woods Center at Fairfield Hills Hospital closed in 1996. In 1994, Boneski reported 1,446 detox admissions and 203 admissions to residential treatment; Berkshire Woods reported 1,138 detox and 171 residential treatment admissions in its final year.

To compensate for the closures, DMHAS implemented different service models in the two affected regions. In the Eastern region (which Norwich served), it (1) relocated Norwich's detoxification beds to smaller, short-term hospital programs and (2) started a telephone service to screen and refer people to a regional network of providers for further evaluation and treatment. In contrast, DMHAS replaced few of the beds Fairfield Hills provided for Northwest region residents. Instead, it increased the bed capacity at a single facility in Bridgeport to accommodate those residents as well as meet the growing demand for detoxification services in the Southwest region.

In 2003, the UConn Health Center School of Medicine assessed the hospital closures' effect on the two regions. The assessment focused on access to medical detoxification services and continuity of care after detoxification. Its authors hypothesized that (1) Northwest and Eastern region residents would have lower detox usage rates than those in regions that did not experience facility closures and (2) people in the Northwest region who had to use detox services outside their region would be less likely to enter follow-up services.

The study found that closing the two state-operated hospitals did not adversely affect access to medical detoxification services or the likelihood of people entering follow-up rehabilitative treatment in either region. The analysis of treatment utilization data also showed the following.

1. As anticipated, the proportion of substance abusers who went outside their area for medical detoxification increased in both regions, but the continuity of care rates were unaffected. Clients who received detoxification out of their region were significantly more likely to enter treatment within 30 days after inpatient stabilization than those who were detoxed in their own region.

2. Continuity of care rates improved over time, but only a minority of clients discharged from inpatient medical detoxification programs entered treatment.

3. Referral rates following detoxification more than doubled between 1993 and 2000. Referral after completing detoxification was found to be the strongest predictor of continuity of care.

4. The treatment system's capacity grew over time in all regions, as reflected in greater numbers of admissions to treatment and treatment programs available.

5. Lengths of stay in medical detoxification, residential rehabilitation, and outpatient programs decreased, which may explain the treatment system's growing ability to serve more people.

DMHAS also acted to address residential rehabilitation, the other level of substance abuse care the closures affected, by establishing links between stable living environments (i.e., recovery houses) and community-based outpatient care. Recovery houses located in each service region have reduced time to treatment engagement, according to DMHAS. This has benefited both those moving from residential care back into the community and those needing immediate care.

JUDICIAL REFERRALS

State law establishes four pretrial diversion programs through which a court can send someone to substance abuse treatment: separate pretrial drug and alcohol education programs, community service labor, and treatment in lieu of prosecution. The Judicial Branch also operates a special drug intervention session in three courts—Bridgeport, New Haven, and Danielson—where judges, attorneys, and other court officers can refer nonviolent, drug-dependent defendants to treatment.

The pretrial drug education and community service labor programs are for people charged with possession of drugs or drug paraphernalia. The latter program can be a pretrial diversion, part of a sentence of conditional discharge, or a condition of probation. The pretrial alcohol education system is for people charged with driving while under the influence. Courts can also commit drug-or-alcohol-dependent offenders into treatment in lieu of prosecution or incarceration. The pretrial diversion aspect of the program covers all drug sale and possession crimes. A Judicial Branch publication, A Guide to Special Sessions and Diversionary Programs in Connecticut (available at http://www.jud.ct.gov/Publications/CR137P.pdf), provides more information on each alternative.

The Judicial Branch's Biennial Report provides data on participation in some of these programs. The available data show that the pre-trial alcohol education program is consistently the most heavily used and its use has grown over the past decade. Participation in the pre-trial drug education program has increased nearly five-fold over in the past five years while participation in the community service labor program has dropped by over 50% over the same period. Table 4 displays the available data.

Table 4: Pretrial Drug and Alcohol Diversion Program Participation, FY 1997-06

Program

FY 97

FY 98

FY 99

FY 00

FY 01

FY 02

FY 03

FY 04

FY 05

FY 06

Pre-Trial Alcohol Education

6,812

6,076

5,882

6,204

7,312

7,673

7,667

8,357

7,964

7,627

Pre-Trial Drug Education

NA

NA

NA

NA

693

1,328

1,275

1,919

2,396

2,941

Community Service Labor

1,431 (# participating on 7/1/97)

1,580 (# participating on 7/1/98)

NA

NA

3,922

3,680

3,060

2,387

1,970

1,595

Alcohol Commitment

NA

NA

NA

NA

6

7

8

3

2

5

Drug Commitment

NA

NA

NA

NA

17

5

21

27

3

0

Source: Judicial Branch, Biennial Reports, 1996-97 to 2005-06; Judicial Branch communication

SUBSTANCE ABUSE-RELATED INCARCERATIONS

The Correction Department reports biannually on the 10 top offenses for which people are incarcerated. For the past five years sale of hallucinogens and narcotics has been either the first or second highest on the list (alternating with parole or conditional discharge violation), with narcotics possession third or fourth. The department reports that it identified substance abuse or dependence in 77% of the 24,463 offenders it assessed for these conditions between June 30, 2006 and October 30, 2007.

The number of substance abuse-related incarcerations dropped steadily between July 2002 and July 2007 (2,914 to 2,547), according to DOC statistics. Substance abuse-related incarcerations as a percentage of all incarcerations fluctuated during that period, ranging from a high of 15.6% of the total population in January 2003 to a low of 12.6% in July 2006. Table 5 shows the number of people incarcerated for sale and possession and the percentage of total incarcerations attributable to those offenses.

Table 5: Substance Abuse-Related Incarcerations, 2002 to 2007

 

Sale

Possession

Date

# Incarcerated

% All Incarcerations

# Incarcerated

% All Incarcerations

7/1/02

2,138

11.3

776

4.1

1/1/03

2,207

11.4

804

4.2

7/1/03

2,161

11.3

806

4.2

1/1/04

1,960

10.6

765

4.1

7/1/04

1,870

10.0

723

3.9

1/1/05

1,828

10.1

702

3.9

7/1/05

1,664

9.2

661

3.6

1/1/06

1,668

9.3

853

4.9

7/1/06

1,613

8.7

720

3.9

1/1/07

1,685

8.9

1,112

5.9

7/1/07

1,776

10.3

771

4.0

Source: Department of Correction Population Statistics

STATE EXPENDITURES

Connecticut

A 2007 DMHAS report states that six state agencies spent over $200 million in FY 05 on substance abuse treatment. Table 6 displays each agency's expenditures.

Table 6: Substance Abuse Treatment Expenditures by Agency,

FY 05

AGENCY

EXPENDITURE

DMHAS

$128,862,295

JUDICIAL-CSSD

10,856,107

DCF

14,128,612

DOC1

10,616,883

DSS2

37,175,576

DVA

397,873

TOTAL

$202,037,346

Source: DMHAS, Collection and Evaluation of Data Related to Substance Use, Abuse and Addiction Programs, June 2007

1 Treatment expenditures include services provided to offenders in Parole & Community Services.

2 Medicaid expenditures for substance abuse treatment exclude pharmacy, transportation, and Medicare crossover claims, none of which has a diagnosis on the claim.

In addition, in FY 05 DMHAS awarded $1,575,169 in bond funds to nonprofit substance abuse treatment agencies for capital improvements to their facilities.

Interstate Comparison

In FY 05, Connecticut ranked fifth nationally in per capita spending by state substance abuse service agencies, even without including Medicaid and State Administered General Assistance (SAGA) behavioral health expenditures. Table 7 compares states' FY 05 substance abuse treatment and prevention spending.

The table is derived from the federal Substance Abuse Prevention and Treatment Block Grant (SAPTBG) application for FY 07. States whose drug and alcohol agency has purview over Medicaid funds include that money in their spending report, but since DSS, not DMHAS, is responsible for Connecticut's Medicaid spending, the table does not show this $37,175,576 expenditure. Nor does it show the $39,954,902 DMHAS spent on its SAGA behavioral health program.

Table 7: Interstate Substance Abuse Treatment Expenditures Comparison, FY 05

State

SAPTBG

Medicaid

Other Federal

State Funds

Total

Per Capita

DC

4,670,259

$ -

231,966

$ -

$ 22,364,378

$ 40.62

WY

2,482,086

537,249

698,719

7,713,183

20,329,445

39.92

AK

3,476,650

153,267

884,549

19,100,569

23,615,035

35.58

VT

3,855,311

10,234,087

343,452

6,578,671

21,011,521

33.72

CT

12,607,702

-

6,316,308

53,581,004

84,417,287

24.05

ND

4,159,234

2,576,709

48,802

6,994,394

14,428,248

22.66

Table 7: -Continued-

State

SAPTBG

Medicaid

Other Federal

State Funds

Total

Per Capita

MN

14,404,480

5,367,799

-

62,094,200

100,338,101

19.55

NY

80,476,707

-

23,308,077

259,261,709

363,046,493

18.86

WA

24,932,735

36,590,270

3,993,563

50,031,238

116,074,465

18.46

MD

22,579,369

915,432

-

66,695,346

102,998,487

18.39

RI

4,847,893

5,524,430

115,694

8,393,409

18,881,426

17.54

DE

4,533,986

-

-

10,132,491

14,666,477

17.39

IL

49,236,711

52,163,828

5,185,835

111,530,032

218,549,980

17.12

AZ

23,233,922

57,559,319

19,360

14,617,875

100,275,433

16.88

ME

4,831,039

9,233,376

513,690

7,022,341

21,600,446

16.35

NM

5,602,179

-

5,335,230

16,216,020

27,153,429

14.08

CA

182,488,282

117,728,987

1,522,502

190,134,279

491,874,050

13.61

NJ

33,519,984

-

1,229,032

79,658,274

116,632,656

13.38

HI

4,479,328

-

-

12,302,228

16,781,556

13.16

IA

9,543,545

12,459,958

984,787

14,173,390

37,161,680

12.53

MT

4,985,358

913,690

-

3,830,356

10,857,491

11.60

MO

19,989,944

23,313,287

3,253,982

24,699,454

71,256,667

12.28

OH

46,797,835

38,452,960

1,348,663

52,558,131

140,285,676

12.24

MA

25,112,067

-

2,797,432

49,415,783

77,325,282

12.08

OR

12,609,549

14,810,099

3,031,804

12,583,447

43,034,899

11.82

LA

18,251,834

-

4,964,907

21,413,019

52,382,831

11.58

KS

9,571,956

14,178,621

1,408,000

6,494,544

31,653,121

11.53

OK

13,400,415

362,294

2,052,626

23,771,964

39,587,299

11.16

SD

3,319,343

-

1,102,432

3,595,000

8,016,775

10.33

NE

5,539,689

2,109,870

-

9,217,059

16,866,618

9.59

UT

13,257,985

-

-

9,993,664

23,251,649

9.42

VA

30,733,177

-

-

40,460,119

71,193,296

9.41

FL

62,815,181

7,490,130

14,984,567

76,115,463

161,405,341

9.07

GA

37,984,909

-

-

41,592,456

79,577,365

8.77

WV

6,747,822

-

-

8,731,737

15,479,559

8.52

MI

42,480,312

30,131,483

4,550,210

7,736,127

84,898,132

8.39

NC

25,903,946

-

142,244

39,715,395

65,761,585

7.57

NH

5,005,918

-

4,398

4,701,416

9,711,732

7.41

ID

4,722,690

-

1,156,298

4,517,768

10,396,756

7.28

KY

16,573,513

-

1,015,722

12,326,067

29,915,302

7.17

CO

18,875,720

469,550

127,117

10,525,170

29,997,557

6.43

SC

15,116,291

782,392

2,078,085

8,479,878

27,118,037

6.37

PA

41,767,165

-

2,553,350

27,553,438

74,462,544

5.99

AR

9,594,972

-

1,606,194

4,407,296

15,927,666

5.73

AL

17,432,798

2,752,944

-

5,591,042

25,776,784

5.66

NV

9,275,384

-

253,897

3,490,583

13,037,190

5.40

IN

24,422,281

-

-

9,344,139

33,766,420

5.38

TX

91,869,513

-

1,392,379

20,661,049

114,130,598

4.99

MS

10,066,971

-

373,178

4,088,372

14,528,521

4.97

TE

19,709,163

-

25,762

6,377,934

29,433,189

4.94

WI

20,544,961

-

-

2,599,385

23,144,346

4.18

TOTAL

$1,180,440,064

$ 446,812,031

$ 100,954,813

$1,552,817,908

$3,376,380,821

$ 11.39

SS:ts