More than 20 million people in the United States have a substance use disorder (SUD), yet only about 10% of them receive treatment.1 And although there are about 750,000 licensed counselors specializing in mental health in the United States who could potentially help, few do.
To explore how licensed counselors (LCs) can help more people who have or are at risk of developing SUDs, The Pew Charitable Trusts convened a panel of experts in January 2020 from the fields of social work education and credentialing, psychology, behavioral health, addiction medicine, and psychiatry. (See Appendix 1 for a full list of panelists.)
The panelists agreed that, since millions of people with SUDs already receive treatment for unrelated mental health issues, LCs are well positioned to screen their patients and either treat people with mild and moderate substance misuse to prevent them from developing an addiction or refer those with severe disorders to specialized treatment settings. LCs face several challenges in screening patients for SUDs, however, including insurance coverage and the need for more training.
To encourage and empower LCs to help people address substance misuse and SUD, policymakers can take several steps:
- State lawmakers can require LC graduate and continuing education programs to provide more SUD-related instruction.
- State lawmakers and professional boards can update licensing standards to ensure that LCs have some level of training related to SUDs.
- State lawmakers, Medicaid agencies, and insurers can expand public and private coverage and increase reimbursement rates to incentivize qualified LCs to screen for SUDs and refer people to specialists as needed.
Substance misuse: The use of alcohol or a drug in a manner, situation, amount or frequency that can cause harm to users or to those around them. For some substances or individuals, any use would constitute misuse (e.g., underage drinking, injection drug use).
Substance use disorder (SUD): A medical illness caused by the repeated misuse of a substance or substances … characterized by clinically significant impairments in health, social function, and impaired control over substance use.
In 2019, 20.4 million people had a SUD involving alcohol and/or drugs—14.5 million who had an alcohol use disorder and 8.3 million who had a drug use disorder, including some of whom have both.3
Addiction: The most severe form of substance use disorder, associated with compulsive or uncontrolled use of one or more substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and recovery.4
Licensed counselor (LC): Primarily master’s or higher-level trained social workers, psychologists, psychiatrists, marriage and family therapists, and mental health counselors who provide the bulk of behavioral health services in the U.S.
Licensed substance use disorder specialist: Primarily master’s or higher-level trained providers that include addiction psychiatrists and psychologists, mental health and substance abuse social workers, substance use and behavioral disorder counselors, behavioral health physicians’ assistants and nurse practitioners, and addiction medicine physicians.
Health & Economic Costs of Substance Misuse and Various Chronic Diseases
|Lost productivity and health costs||Costs related to crime|
|Illicit drugs*||$132 billion||$61 billion|
|Alcohol†||$225 billion||$25 billion|
|Heart disease and stroke‡||$352 billion||N/A|
|Obesity‡||$147 billion (health costs only)||N/A|
*U.S. Dept. of Justice, “National Drug Threat Assessment,” 2011, https://www.justice.gov/archive/ndic/pubs44/44849/44849p.pdf
†U.S. Centers for Disease Control and Prevention, “Excessive Drinking is Draining the U.S. Economy,” https://www.cdc.gov/features/costsofdrinking/index.html
‡U.S. Centers for Disease Control and Prevention, “Health and Economic Costs of Chronic Diseases,” https://www.cdc.gov/chronicdisease/about/costs/index.htm
Opportunities Exist to Prevent Substance Misuse and Disorders
Pew’s expert panel discussed the extent to which a range of behavioral health providers—despite not being specialists in substance use—could help identify people who engage in substance misuse, address individuals with mild to moderate SUDs, and refer people with severe disorders for specialty care. The discussion focused on several critical points, which form the basis of this brief and its policy recommendations.
Less severe SUD can be treated without specialty care, so LCs are well positioned to help people with mild to moderate substance misuse
About 750,000 LCs provide most behavioral health services in the U.S., a number that includes some 352,000 licensed social workers and 140,000 mental health counselors as of 2016, as well as 192,300 psychologists and 66,200 marriage and family therapists as of 2019.
Many clients and patients of these practitioners have substance use issues: Nearly 1 of every 5 people with a mental illness also has a SUD, and about half of people with SUDs also have a mental illness.5 But, often, people with mild or moderate SUD do not seek treatment, even when already seeing a mental health professional for other reasons.
In part, this is due to the outdated misperception that SUD is a moral failure. This thinking also makes it “more challenging to marshal the necessary investments in prevention and treatment,” according to the U.S. surgeon general’s 2016 report. Fortunately, the health care system is slowly recognizing that SUDs are chronic health conditions like Type 2 diabetes and high cholesterol.
It is difficult to determine how many people who misuse substances or have mild or moderate SUDs need clinical intervention. Many reduce or eliminate their substance intake on their own or with the help of family and friends. By screening for SUD in places where people routinely seek care for behavioral health issues, LCs could potentially identify millions of people whose substance use could benefit from clinical attention, treat those with substance misuse, and help those with severe SUD acknowledge the need for help and refer them to specialty care.
Early intervention can help prevent substance problems from escalating
When identified and addressed early, through intervention, it’s possible to prevent substance misuse from escalating and becoming more severe.6 “The way we treat alcohol problems is to wait until it’s malignant substance use and someone has addiction. [It would be] as if we didn’t treat high blood pressure until someone had a stroke or a heart attack,” said Larry Gentilello, professor of surgery at the University of Texas Southwestern Medical School and an advocate for physician training in screening for SUD.7 Having LCs address substance misuse and SUDs is in line with recent strides by the U.S. health care delivery system to integrate medical and behavioral health care. Known as “whole-person care,” this new direction acknowledges that substance misuse and SUDs are among the many conditions that can affect a person’s overall health and well-being, and that nonaddiction treatment providers have a role to play in identification and treatment.8 Stakeholders such as the American Medical Association, the surgeon general, the National Association of Social Workers, and the American Psychological Association have called for ending the siloed treatment of substance use and integrating it into primary care as well as behavioral health care settings, reserving specialty settings for patients with the most severe disorders.9
LCs have many of the competencies needed to address mild and moderate substance use disorders, and are likely already treating people with SUDs. But they don’t necessarily recognize their ability to help.
LCs use many of the same competencies to treat individuals with chronic health conditions who need to change their behaviors and/or take medications to maintain healthy functioning—illnesses such as diabetes and hypertension. These competencies can include approaches such as motivational interviewing and cognitive behavioral therapy. LCs are also trained to address the underlying issues that keep people from seeking help, such as denial, shame, and fear.
However, since LCs are not systematically trained to view substance misuse as a behavioral health challenge that they can and should address, few identify it as an issue. Academic programs that train LCs offer scant instruction in substance use treatment. In effect, substance use identification and treatment education has been siloed not only from primary medical education but from the academic programs that prepare most of the behavioral health workforce.10 Relatively few LCs are trained in addressing SUDs, including knowledge of risk factors and protective factors, interventions that target such factors, and the effective methods to deliver SUD interventions.11 For example, a 2014 study found that that only 1 of 58 master of social work programs reviewed required at least one course in SUDs.12 Surveys reveal a similar dearth of SUD training among academic programs that prepare psychologists.13
Calling on LCs to identify and address substance misuse and SUD will require a culture change and some additional education.
The siloed approach that separates mental health and SUD treatment has made other behavioral health specialists believe that addressing substance use is outside of their professional scope. Many also believe that mental health problems cannot be addressed until substance misuse or disorders are resolved by an addiction specialist.14
“There is a false narrative that you need to be a specialist to treat SUD. LCs need to be the general providers of behavioral health, which includes SUD,” said Jennifer Harrison, interim director of the Western Michigan University School of Social Work.
LCs already in the field can be instructed on screening and addressing SUD through continuing education programs. With such training, LCs can more competently screen for substance misuse, provide brief interventions for mild to moderate problems, and refer more severe cases to specialty care.
However, it may be easier to prepare LCs for a new way of practicing through initial coursework or training, rather than trying to change established patterns. That said, some LCs may view an added focus on substance use as crowding out other clinical priorities, and potentially leading to an unmanageable workload. Another perceived barrier is the need for operational changes—scheduling, supervision, and other changes to daily routines.
State lawmakers, licensing boards, professional bodies, Medicaid officials, and insurers can take a variety of steps to transform how LCs can help prevent and treat substance misuse.
Changing Academic Curricula for Students Preparing to Become LCs
State lawmakers have several ways to increase SUD-related instruction in LC graduate programs. For example, they can pass legislation requiring substance use-related instruction in LC academic preparatory programs. In 2018, the Arizona Legislature passed legislation requiring public and private medical programs to offer at least three hours of instruction related to opioid use disorder for anyone whose degree would make them eligible to dispense drugs regulated by the Drug Enforcement Administration.15
Legislators can also amend state practice acts to require behavioral health professionals to undergo SUD training in order to obtain their license. This requirement would not only ensure that LCs are prepared to screen for SUD, but it would also influence the courses of medical and other graduate programs training LCs in the state. If states make such licensing changes, it would also likely influence changes to the variety of accrediting boards that determine standards for academic curricula to train the various LC disciplines.
Additionally, state boards of education, which typically comprise political appointees by the governor, can exert pressure to augment academic curricula. “It’s a rare public university that, if confronted by a governor or state legislature that was anxious to ensure that substance [use] be added to the academic programs for behavioral health counselors, wouldn’t try to show that they were sensitive to that concern,” said Terry Hartle, senior vice president of government relations at the American Council on Education. “Especially if it was clear that there was consumer—i.e., student—demand for [it].”
Expanding Continuing Education for Practicing LCs
Although state licensing boards oversee the various LC disciplines and set the amount and content of continuing education required for maintaining licensure, many do not require continuing education related to substance use.
“It would greatly advance this work if state licensing boards would require all behavioral health professionals to obtain continuing education on the topic of substance misuse and SUDs,” said Darla Coffey, president of the Council on Social Work Education and a panel member. In addition, states could also ease provider training burdens by sponsoring the instruction and/or subsidizing its cost.
Challenges to Requiring Additional Training
“State licensing boards are under intense scrutiny to reduce licensing and relicensing barriers. Adding another course/topic mandate will be seen as burdensome by licensees and policymakers,” said Jennifer Henkel, senior director of member engagement and regulatory services at the Association of Social Work Boards.
The key to persuading licensing boards to amend their rules is to appeal to their mandate to protect the public, Henkel said. Advocates will need to make a strong case that primary and secondary prevention of substance misuse will save lives and dollars.
In general, state policymakers can take two routes to require additional substance use-related training for LCs as a condition of licensure (either via school curricula or continuing education): changing state practice acts through legislation or having state regulatory boards amend regulations without a legislative mandate. Going the legislative route is often more difficult than working directly with regulatory boards, said Henkel, as the scope of practice legislative debates are frequently contentious and long. For instance, amending state practice acts governing behavioral health professions can trigger scope-of-practice clashes between professions as well as concerns that practice acts could be vulnerable to other unrelated changes introduced during legislative debate.
A Tool Frequently Used for Screening and Intervention
States seeking to be more prescriptive in defining competencies for academic curricula as well as continuing education could consider requiring mastery of a tested tool such as the Screening, Brief Intervention, and Referral to Treatment (SBIRT), which was developed to guide nonspecialists in screening patients for SUD, providing brief intervention, and referring to specialty care as needed. Requirements can be set through rule-making or legislation. (See text box.)
A Model for Screening and Intervention
The Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool was developed to guide nonspecialist providers (primary care medical providers and nonspecialist behavioral health counselors) in screening patients for substance misuse/disorders, addressing nonsevere problems through brief interventions, and referring people with severe disorders to specialty care.
Screening involves using one of a range of validated instruments (e.g., the Drug Abuse Screening Test or the Alcohol, Smoking and Substance Involvement Screening Test) to assess the severity of substance use. Brief interventions are used to increase awareness of the dangers of substance use, gauge a patient’s motivation to change, and provide self-help materials.16 Providers usually conduct one to five brief sessions, and are directed to link patients to treatment if their screening scores indicate high levels of severity.
SBIRT was originally developed for alcohol use, and its effectiveness—both in terms of reduced drinking and cost savings—has been widely documented in health care settings nationally and abroad.17 Randomized control trial studies have found that after brief SBIRT interventions, participants reduced the average number of weekly drinks by up to 34%, and the rate of moderate (safe-level) drinking by up to 19% compared with controls.18 Cost-benefit analyses suggest that SBIRT for alcohol use yields $43,000 in future health care cost savings for every $10,000 invested in early intervention.19
SBIRT was expanded to address drug use including opioids, but the research base showing its impact with illicit drugs is smaller than that for alcohol. Although some findings have been promising in terms of reduced use and cost savings, the overall results have been mixed. The U.S. Preventive Services Task Force recommends the full SBIRT tool for use with alcohol, but only recommends the screening portion of SBIRT for drugs due to limited evidence.20 Still, the use of SBIRT for alcohol as well as drug use is reimbursed by Medicaid, Medicare, and many private insurers. SBIRT training for LCs already in the field can be done in a single day and is offered for free through the federal government’s 10 regional Addiction Training Technology Center Networks throughout the country. In addition, several state health agencies and schools that educate the behavioral health workforce offer this training, as do behavioral health professional associations.
The federal government—through the Substance Abuse and Mental Health Services Administration (SAMHSA)—has accelerated SBIRT’s adoption for alcohol and drug use by funding implementation grants throughout the country. Since 2003, SAMHSA has funded cooperative agreements with 29 states, launched 17 medical residency programs, and initiated 12 programs for students at colleges and universities.21
Ensure LCs Payment for Addressing Substance Misuse/Disorders
Reimbursement policies—particularly among Medicaid and private payers—can play a critical role in encouraging LCs to address substance use. In 2015, private insurers covered 29% of expenditures for substance use disorder services, Medicaid 25%.22
A 2018 report found that 44 states allowed Medicaid to reimburse for “assessment and education for at-risk individuals who do not meet diagnostic criteria for a substance use disorder.”23 States, however, determine the types of providers eligible to bill for such services, and may not allow all disciplines of licensed counselors to provide these services.24
If LCs are to play a larger role in linking clients with addiction to specialty treatment, they should be reimbursed for their time spent making these connections. In 2018, 41 states allowed their Medicaid programs to reimburse for targeted case management, a service that helps providers connect patients to a range of needed services. Again, not all categories of LCs are eligible to bill for this service in states that cover this benefit through Medicaid.25 Policymakers should review whether their state Medicaid programs reimburse for connecting patients to services and whether they allow a variety of LCs to bill for care.
A number of large commercial insurers reimburse specifically for screening and counseling sessions for alcohol and illicit drug use, although they vary in the types of providers who can bill.26 State lawmakers could pass legislation requiring commercial insurers to allow LCs to bill and be reimbursed for these services.
Using Substance Use-Specific Codes
Public and private payers have billing codes for reimbursement for general categories of behavioral health screening and counseling, and LCs may be able to use these for services related to substance misuse. As an example, CPT code 96127 (brief emotional/behavioral assessment) is a general screening code designed to uncover mental health conditions used by most major insurers.27 That said, using other, specific codes for screening and counseling related to substance use (CPT 99408—Alcohol and/or substance use structured screening and brief intervention)28 would enable larger health systems, provider organizations, and researchers to more precisely track the extent to which LCs and other general health care providers are conducting primary and secondary substance misuse prevention. States have the authority to use such specific codes in Medicaid.
Panelists noted that relatively low reimbursement rates may be among the barriers preventing more widespread screening and treatment of substance misuse.29 Increasing Medicaid reimbursement could be an important incentive for LCs to provide such services. The mechanisms to accomplish this vary by state and can include passing legislation or changing Medicaid regulations.
Expanding the list of providers eligible to bill for particular services, creating new billing codes, and raising reimbursement rates may affect state spending if the changes result in more people receiving care, which is the intended result. As such, advocates for change will compete with other interests within and outside of health care for state resources and would need legislative and executive branch leaders to champion their cause.30
The health care system is addressing the need to better identify and address substance misuse and SUDs, and given their strong co-occurrence with mental health disorders, LCs are poised to contribute to their early identification, treatment, and referral. Getting the LC community to view substance misuse as part of its professional scope will require not only a paradigm shift in the way these professionals conduct their work, but also in the action of state lawmakers, professional bodies, licensing boards, and insurers. Such investments, however, could yield enormous benefits in terms of reduced health care costs, improved quality of life, and number of deaths prevented.
- Substance Abuse and Mental Health Services Administration, “Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP 20-07-01-001, NSDUH Series H-55)” (2020), https://www.samhsa.gov/data/report/2019-nsduh-annual-national-report.
- U.S. Department of Health & Human Services, “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health” (2016), https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf.
- Substance Abuse and Mental Health Services Administration, “Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP 20-07-01-001, NSDUH Series H-55).”
- D.S. Hasin et al., “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale,” The American Journal of Psychiatry 170, no. 8 (2013): 834-51, https://pubmed.ncbi.nlm.nih.gov/23903334 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767415/; U.S. Department of Health & Human Services, “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health.”
- Substance Abuse and Mental Health Services Administration, “Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP 19-5068, NSDUH Series H-54)” (2019), https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report.
- R.E. Adkins et al., “Missouri Screening, Brief Intervention, Referral, and Treatment: An Analysis of National Funding Trends for SBI Services” (March 2014), https://www.mimh.edu/content/uploads/2015/03/FundingSBIRTCodes_2014_0318-_FINAL.pdf
- Agency for Healthcare Research and Quality, “What Is Integrated Behavioral Health?,” https://integrationacademy.ahrq.gov/about/integrated-behavioral-health.
- E. Goplerud, H. Hagle, and T. McPherson, “Preparing Students to Work in Integrated Health Care Systems,” Addiction Technology Transfer Center Network (2017), https://attcnetwork.org/centers/network-coordinating-office/product/attc-white-paper-preparing-students-work-integrated; M.S. Fisher Sr., J. Holton, and K. van Wormer, “NASW Standards for Social Work Practice with Clients with Substance Abuse Disorders,” National Association of Social Workers (2013), https://www.socialworkers.org/LinkClick.aspx?fileticket=ICxAggMy9CU%3D&portalid=0; Adopted by Council of Representatives, “Resolution on Psychologists in Integrated Primary Care and Specialty Health Settings,” American Psychological Association (2016), https://www.apa.org/about/policy/integrated-primary-care.
- Goplerud, Hagle, and McPherson, “Preparing Students to Work in Integrated Health Care Systems.”
- National Research Council and Institute of Medicine, “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities,” National Academies Press (2009).
- J.L. Russett and A. Williams, “An Exploration of Substance Abuse Course Offerings for Students in Counseling and Social Work Programs,” Substance Abuse 36, no. 1 (2015): 51-58, https://doi.org/10.1080/08897077.2014.933153.
- Goplerud, Hagle, and McPherson, “Preparing Students to Work in Integrated Health Care Systems.”
- R.E. Drake and K.T. Mueser, “Psychosocial Approaches to Dual Diagnosis,” Schizophrenia Bulletin 26, no. 1 (2000): 105-18, https://doi.org/10.1093/oxfordjournals.schbul.a033429.
- Arizona S.B. 1001 (2018), https://www.azleg.gov/legtext/53leg/1S/laws/0001.htm.
- U.S. Department of Health and Human Services - SAMHSA Technical Assistance Paper 33, “Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment” (2013), https://store.samhsa.gov/product/TAP-33-Systems-Level-Implementation-of-Screening-Brief-Intervention-and-Referral-to-Treatment-SBIRT/SMA13-4741.
- Screening Brief Intervention and Referral to Treatment, “SBIRT Information,” https://www.masbirt.org/sbirt-information.
- E.P. Whitlock et al., "Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive Services Task Force." Annals of internal medicine 140, no. 7 (2004): 557-568.
- M.F. Fleming et al., “Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Benefit-Cost Analysis,” Alcoholism: Clinical and Experimental Research 26, no. 1 (2002): 36-43.
- U.S. Preventative Health Services Task Force, “Unhealthy Drug Use: Screening—Final Recommendation Statement” (June 9, 2020), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening.
- Substance Abuse and Mental Health Services Administration, “Screening, Brief Intervention, and Referral to Treatment (SBIRT) Grantees,” last modified Dec. 2, 2020, https://www.samhsa.gov/sbirt/grantees#Colleges%20&%20Universities%20SBIRT%20Programs.
- Substance Abuse and Mental Health Services Administration, “Behavioral Health Spending & Use Accounts, 2006-2015” (2019), https://store.samhsa.gov/product/Behavioral-Health-Spending-and-Use-Accounts-2006-2015/SMA19-5095.
- Medicaid and CHIP Payment and Access Commission (MACPAC), “June 2018 Report to Congress on Medicaid and CHIP” (2018), https://www.macpac.gov/publication/june-2018-report-to-congress-on-medicaid-and-chip/.
- Office of the Assistant Secretary For Planning and Evaluation, “Credentialing, Licensing, and Reimbursement of the SUD Workforce: A Review of Policies and Practices Across the Nation, Billing Eligibility and Reimbursement” (2019), https://aspe.hhs.gov/report/credentialing-licensing-and-reimbursement-sud-workforce-review-policies-and-practices-across-nation/billing-eligibility-and-reimbursement.
- Medicaid and CHIP Payment and Access Commission (MACPAC), “Recovery Support Services for Medicaid Beneficiaries With a Substance Use Disorder” (2019), https://urldefense.proofpoint.com/v2/url?u=https-3A__www.macpac.gov_wp-2Dcontent_uploads_2019_07_Recovery-2DSupport-2DServices-2Dfor-2DMedicaid-2DBeneficiaries-2Dwith-2Da-2DSubstance-2DUse-2DDisorder.pdf&d=DwMFaQ&c=2qwu4RrWzdlNOcmb_drAcw&r=z6i2EXDNdptOIly2TcXvWFNuWZxkmAUejT95bcXLaxI&m=BH-X-H-u38moKs7egjBphP9AitlrKcdbOd8oEXNa6Kg&s=FFTcCCKexBmKVawGR0TZ_0BQbamYGX7eN-ev5ZM84sc&e=.
- E. Goplerud, “Screening, Brief Intervention, Treatment and Recover Support: Getting Paid,” The George Washington University Medical Center, https://studylib.net/doc/5600022/screening--brief-intervention-and-referral-to-treatment-s.
- University of Washington, “Basic Coding for Integrated Behavioral Health Care” (2019), https://aims.uw.edu/sites/default/files/Basic_BHI_Coding_0.pdf.
- Goplerud, “Screening, Brief Intervention, Treatment and Recover Support: Getting Paid.”
- C. Fullerton et al., “Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Primary Care Settings” (presentation, Medicaid Innovation Accelerator Program, June 8, 2015), https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/20150608tlo4sbirt.pdf.
- J. Hinde et al., “The Influence of State-Level Policy Environments on the Activation of the Medicaid SBIRT Reimbursement Codes,” Addiction 112 Suppl 2 (2017): 82-91.
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