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Sound power, usually measured in watts, is the amount of energy per unit of time that radiates from a source in the form of an acoustic wave. Generally, sound power cannot be measured directly, but modern instruments make it possible to measure the output at a point that is a known distance from the source. Understanding the relationship between sound pressure and sound power is essential to predicting what noise problems will be created when particular sound sources are placed in working environments. An important consideration might be how close workers will be working to the source of sound.

As a general rule, doubling the sound power increases the noise level by 3 dB. As sound power radiates from a point source in free space, it is distributed over a spherical surface so that at any given point, there exists a certain sound power per unit area. This is designated as intensity, I, and is expressed in units of watts per square meter.

Sound intensity is heard as loudness, which can be perceived differently depending on the individual and his or her distance from the source and the characteristics of the surrounding space. As the distance from the sound source increases, the sound intensity decreases. The sound power coming from the source remains constant, but the spherical surface over which the power is spread increases--so the power is less intense. In other words, the sound power level of a source is independent of the environment.

Most noise is not a pure tone, but rather consists of many frequencies simultaneously emitted from the source. To properly represent the total noise of a source, it is usually necessary to break it down into its frequency components. One reason for this is that people react differently to low-frequency and high-frequency sounds. Additionally, for the same sound pressure level, high-frequency noise is much more disturbing and more capable of producing hearing loss than low-frequency noise. Engineering solutions to reduce or control noise are different for low-frequency and high-frequency noise.

As a general guideline, low-frequency noise is more difficult to control. Certain instruments that measure sound level can determine the frequency distribution of a sound by passing that sound successively through several different electronic filters that separate the sound into nine octaves on a frequency scale.

Two of the most common reasons for filtering a sound include 1 determining its most prevalent frequencies or octaves to help engineers better know how to control the sound and 2 adjusting the sound level reading using one of several available weighting methods. These weighting methods e. The following paragraphs provide more detailed information. Octave bands, a type of frequency band, are a convenient way to measure and describe the various frequencies that are part of a sound.

The center, lower, and upper frequencies for the commonly used octave bands are listed in Table II The width of a full octave band its bandwidth is equal to the upper band limit minus the lower band limit. For more detailed frequency analysis, the octaves can be divided into one-third octave bands; however, this level of detail is not typically required for evaluation and control of workplace noise. Electronic instruments called octave band analyzers filter sound to measure the sound pressure as dB contributed by each octave band.

These analyzers either attach to a type 1 sound level meter or are integral to the meter. Both the analyzers and sound level meters are discussed further in Section III. Loudness is the subjective human response to sound. It depends primarily on sound pressure but is also influenced by frequency. Three different internationally standardized characteristics are used for sound measurement: weighting networks A, C, and Z or "zero" weighting. The A and C weighting networks are the sound level meter's means of responding to some frequencies more than others.

The very low frequencies are discriminated against attenuated quite severely by the A-network and hardly attenuated at all by the C-network. Sound levels dB measured using these weighting scales are designated by the appropriate letter i. In contrast, the Z-weighted measurement is an unweighted scale introduced as an international standard in , which provides a flat response across the entire frequency spectrum from 10 Hz to 20, Hz. The C-weighted scale is used as an alternative to the Z-weighted measurement on older sound level meters on which Z-weighting is not an option , particularly for characterizing low-frequency sounds capable of inducing vibrations in buildings or other structures.

A previous B-weighted scale is no longer used. The networks evolved from experiments designed to determine the response of the human ear to sound, reported in by a pair of investigators named Fletcher and Munson. Their study presented a 1,Hz reference tone and a test tone alternately to the test subjects young men , who were asked to adjust the level of the test tone until it sounded as loud as the reference tone.

The results of these experiments yielded the frequently cited Fletcher-Munson, or "equal-loudness," contours, which are displayed in Figure 6. These contours represent the sound pressure level necessary at each frequency to produce the same loudness response in the average listener.

The nonlinearity of the ear's response is represented by the changing contour shapes as the sound pressure level is increased a phenomenon that is particularly noticeable at low frequencies. The lower, dashed curve indicates the threshold of hearing and represents the sound-pressure level necessary to trigger the sensation of hearing in the average listener. Among healthy individuals, the actual threshold may vary by as much as 10 decibels in either direction.

Ultrasound is not listed in Figure 6 because it has a frequency that is too high to be audible to the human ear. See Appendix C for more information about ultrasound and its potential health effects and threshold limit values. The ear is the organ that makes hearing possible. It can be divided into three sections: the external or outer ear, the middle ear, and the inner ear.

Figure 7 shows the parts of the ear. The function of the ear is to gather, transmit, and perceive sounds from the environment. This involves three stages:. To categorize different types of hearing loss, the impairment is often described as either conductive or sensorineural, or a combination of the two. Conductive hearing loss results from any condition in the outer or middle ear that interferes with sound passing to the inner ear. Excessive wax in the auditory canal, a ruptured eardrum, and other conditions of the outer or middle ear can produce conductive hearing loss.

Although work-related conductive hearing loss is not common, it can occur when an accident results in a head injury or penetration of the eardrum by a sharp object, or by any event that ruptures the eardrum or breaks the ossicular chain formed by the small bones in the middle ear e. Conductive hearing loss may be reversible through medical or surgical treatment. It is characterized by relatively uniformly reduced hearing across all frequencies in tests of the ear, with no reduction during hearing tests that transmit sound through bone conduction.

Sensorineural hearing loss is a permanent condition that usually cannot be treated medically or surgically and is associated with irreversible damage to the inner ear. The normal aging process and excessive noise exposure are both notable causes of sensorineural hearing loss.

Studies show that exposure to noise damages the sensory hair cells that line the cochlea. Even moderate noise can cause twisting and swelling of hair cells and biochemical changes that reduce the hair cell sensitivity to mechanical motion, resulting in auditory fatigue. As the severity of the noise exposure increases, hair cells and supporting cells disintegrate and the associated nerve fibers eventually disappear. Occupational noise exposure is a significant cause of sensorineural hearing loss, which appears on sequential audiograms as declining sensitivity to sound, typically first at high frequencies above 2, Hz , and then lower frequencies as damage continues.

Often the audiogram of a person with sensorineural hearing loss will show a "Notch" at 4, Hz. This is a dip in the person's hearing level at 4, Hz and is an early indicator of sensorineural hearing loss. Results are the same for hearing tests of the ear and bone conduction testing. Sensorineural hearing loss can also result from other causes, such as viruses e. Figure 8 shows the typical audiogram patterns for people with conductive and sensorineural hearing loss. It is important to note that some hearing loss occurs over time as a normal condition of aging. Termed presbycusis, this gradual sensorineural loss decreases a person's ability to hear high frequencies.

Presbycusis can make it difficult to diagnose noise-related hearing loss in older people because both affect the upper range of an audiogram. An 8,Hz "Notch" in an audiogram often indicates that the hearing loss is aged-related as opposed to noise-induced. As humans begin losing their hearing, they often first lose the ability to detect quiet sounds in this pitch range. Workplace noise affects the human body in various ways.

The most well-known is hearing loss, but work in a noisy environment also can have other effects. Although noise-induced hearing loss is one of the most common occupational illnesses, it is often ignored because there are no visible effects. It usually develops over a long period of time, and, except in very rare cases, there is no pain. What does occur is a progressive loss of communication, socialization, and responsiveness to the environment.

In its early stages when hearing loss is above 2, Hz , it affects the ability to understand or discriminate speech. As it progresses to the lower frequencies, it begins to affect the ability to hear sounds in general. The primary effects of workplace noise exposure include noise-induced temporary threshold shift, noise-induced permanent threshold shift, acoustic trauma, and tinnitus. A noise-induced temporary threshold shift is a short-term decrease in hearing sensitivity that displays as a downward shift in the audiogram output.

It returns to the pre-exposed level in a matter of hours or days, assuming there is not continued exposure to excessive noise. If noise exposure continues, the shift can become a noise-induced permanent threshold shift, which is a decrease in hearing sensitivity that is not expected to improve over time. A standard threshold shift is a change in hearing thresholds of an average of 10 dB or more at 2,, 3,, and 4, Hz in either ear when compared to a baseline audiogram. Employers can conduct a follow-up audiogram within 30 days to confirm whether the standard threshold shift is permanent.

Under 29 CFR Recording criteria for cases involving occupational hearing loss can be found in 29 CFR The effects of excessive noise exposure are made worse when workers have extended shifts longer than 8 hours. With extended shifts, the duration of the noise exposure is longer and the amount of time between shifts is shorter. This means that the ears have less time to recover between noisy shifts. As a result, short-term effects, such as temporary threshold shifts, can become permanent more quickly than would occur with standard 8-hour workdays.

Tinnitus, or "ringing in the ears," can occur after long-term exposure to high sound levels, or sometimes from short-term exposure to very high sound levels, such as gunshots. Many other physical and physiological conditions also cause tinnitus. Regardless of the cause, this condition is actually a disturbance produced by the inner ear and interpreted by the brain as sound. Individuals with tinnitus describe it as a hum, buzz, roar, ring, or whistle, which can be short term or permanent. Acoustic trauma refers to a temporary or permanent hearing loss due to a sudden, intense acoustic or noise event, such as an explosion.

The U. Bureau of Labor Statistics BLS publishes annual statistics for occupational injuries including hearing loss reported by employers as part of required recordkeeping. This represents more than 18, workers who experienced significant loss of hearing due to workplace noise exposure. Nonfatal occupational injuries accounted for the overwhelming majority of cases reported for the SOII in Most illness cases fall into the "All other illnesses" category, which includes such things as repetitive motion cases and systemic diseases and disorders.

Other consequences of excessive workplace noise exposure include interference with communications and performance. Workers might find it difficult to understand speech or auditory signals in areas with high noise levels. Noisy environments also lead to a sense of isolation, annoyance, difficulty concentrating, lowered morale, reduced efficiency, absenteeism, and accidents.

In some individuals, excessive noise exposure can contribute to other physical effects. These can include muscle tension and increased blood pressure hypertension. Noise exposure can also cause a stress reaction, interfere with sleep, and cause fatigue. Ultrasound is high-frequency sound that is inaudible i. However, it still might affect hearing and produce other health effects. For more information, see Appendix C. Animal experiments have indicated that combined exposure to noise and solvents induces synergistic adverse effects on hearing. Experimental studies have explored specific substances, including toluene, styrene, ethylbenzene, and trichloroethylene.

In reviewing IMIS data, note that the exposure levels are not necessarily typical of all worksites and occupations within an industry. Typically, OSHA identified those jobs as having some potential for noise exposure. A number of epidemiological studies have investigated the noise-solvent relationship in humans. Overall, the evidence strongly suggests that combined exposure to noise and organic solvents can have interactive effects either additive or synergistic , in which solvents exacerbate noise-induced impairments even though the noise intensity is below the permissible limit value.

In addition to the synergistic effects with solvents, noise may also have additive, potentiating, or synergistic ototoxicity with asphyxiants such as carbon monoxide and metals such as lead. See Appendix D for additional information and additional sources of information on this topic. Workplace noise exposure is widespread. Although this time span covers many years, the recent decade is well represented: 58, 27 of the personal noise exposure levels in IMIS were measured in or later. These tables also present the median noise levels and the percentage of noise measurements over either the action level AL , 85 dBA, or the permissible exposure limit PEL , 90 dBA 2.

In addition, 47 of the samples taken in the construction industry exceeded the PEL. In addition to median decibels and percent over the PEL, Table II-5 shows the distribution of manufacturing industry dosimetry measurements at the PEL and higher by decibel level. Noise is a potential hazard for most jobs that involve abrasive or high-power machinery, impact of rapidly moving parts product or machinery , or power tools. According to IMIS noise measurements, workers in certain occupations within specific industries are exposed to excessive noise more frequently than others.

While many jobs have noise exposure, historically, some of the occupations with the most extreme exposures listed by Standard Industrial Classification, or SIC have included:. Source: Adapted from Seixas and Neitzel, This effort to reduce occupational noise hazards was not far-reaching but was a first attempt to regulate noise hazards. Even though noise energy exposure doubles every 3 dB, OSHA thought it important to account for the time during the workday that a worker was not exposed to noise hazards.

At the time, using a 5-dB exchange rate was viewed as a sufficient way to account for this. In , OSHA published a proposed occupational noise standard, which included a requirement for employers to provide a hearing conservation program for workers exposed to an 8-hour TWA of 85 dBA or more.

This provision was adopted as part of the amendments of and While OSHA provided requirements for hearing conservation programs in general industry, the construction industry standard remained less specific in that regard. More recently, in the recordkeeping standard 29 CFR Part , OSHA clarified the criteria for reporting cases involving occupational hearing loss. In , the U. Environmental Protection Agency EPA developed labeling requirements for hearing protectors, which required hearing protector manufacturers to measure the ability of their products to reduce noise exposure--called the noise reduction rating NRR.

OSHA adopted the NRR but later recognized that the NRR listed on hearing protectors often did not reflect the actual level of protection, which likely was lower than indicated on the label because most workers were not provided with fit-testing, and donning methods in a controlled laboratory setting were not representative of the donning methods that workers used in the field. EPA is considering options for updating this rule.

In special cases, noise exposure originates from noise-generating headsets. See Appendix F for a discussion of the techniques used to evaluate the noise exposure levels of these workers. General Industry: 29 CFR The General Industry standard establishes permissible noise exposures, requires the use of engineering and administrative controls, and sets out the requirements of a hearing conservation program. Paragraphs c through n of the General Industry standard do not apply to the oil and gas well-drilling and servicing operations; however, paragraphs a and b do apply.

The general industry noise standard contains two noise exposure limit tables. Each table serves a different purpose:. The requirements for permissible noise exposures and controls under the Construction standard are the same as those under the general industry standard Continuing effective hearing conservation programs are required in all cases where the sound levels exceed the values shown in Table D-2 Agricultural Worksites: Although there is no standard for occupational noise exposure in agriculture, the evaluation and control methods discussed in this chapter are still valid. Maritime Worksites: Marine terminals and longshoring operations fall under the requirements of the general industry noise standard; therefore, employers in such operations must meet the elements of the general industry Hearing Conservation Amendment, 29 CFR Noise controls should minimize or eliminate sources of noise; prevent the propagation, amplification, and reverberation of noise; and protect workers from excessive noise exposure.

Ideally, the use of engineering controls should reduce noise exposure to the point where the risk to hearing is significantly reduced or eliminated. Engineering and administrative controls are essential to an effective hearing loss prevention program. They are technologically feasible for most noise sources, but their economic feasibility must be determined on an individual basis.

In some instances the application of a relatively simple noise-control solution reduces the hazard to the extent that the other elements of the program, such as audiometric testing and the use of hearing protection devices, are no longer necessary. In other cases, the noise reduction process may be more complex and must be accomplished in stages over a period of time. Even so, with each reduction of a few decibels, the risk of hearing loss is reduced, communication is improved, and noise-related annoyance is reduced.

The first step in noise control is to identify the noise sources and their relative importance. This can be difficult in an industrial setting with many noise sources.

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It can be accomplished through several methods used together: obtain a frequency spectrum from an octave band analyzer, turn various components in the factory on and off or use temporary mufflers or enclosures to isolate noise sources, and probe areas close to equipment with a sound level meter to pinpoint areas where sound is dominant. These measures will aid in identifying the sound sources that affect workers the most and should be prioritized when implementing noise controls.

Once the noise sources have been identified, it is possible to proceed in choosing an engineering control, administrative control, or a form of personal protective equipment to reduce the noise level if noise exposure is too high Driscoll, Principles of Noise Control. The hierarchy of controls for noise can be summarized as: 1 prevent or contain the escape of the hazardous workplace agent at its source engineering controls , 2 control exposure by changing work schedules to reduce the amount of time any one worker spends in the hazard area administrative controls , and 3 control the exposure with barriers between the worker and the hazard personal protective equipment.

This hierarchy highlights the principle that the best prevention strategy is to eliminate exposure to hazards that can lead to hearing loss. Corporations that have started buy-quiet programs are moving toward workplaces where no harmful noise will exist. Many companies are automating equipment or setting up procedures that can be managed by workers from a quiet control room free from harmful noise.

When it is not possible to eliminate the noise hazard or relocate the worker to a safe area, the worker must be protected with personal protective equipment. The rest of this section, until the discussion of administrative controls, presents information adapted from material developed under contract for the Noise eTool by Dennis Driscoll in Much industrial noise can be controlled through simple solutions.

It is important, however, that all individuals administering abatement projects have a good understanding of the principles of noise control and proper use of acoustical materials. Reducing excessive equipment noise can be accomplished by treating the source, the sound transmission path, the receiver, or any combination of these options.

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Descriptions of these control measures follow. The best long-term solution to noise control is to treat the root cause of the noise problem. For source treatment to be effective, however, a comprehensive noise-control survey usually needs to be conducted to clearly identify the source and determine its relative contribution to the area noise level and worker noise exposure. At least four methods exist for treating the source: modification, retrofit, substitution, and relocation. For the most part, industrial noise is caused by mechanical impacts, high-velocity fluid flow, high-velocity air flow, vibrating surface areas of a machine, and vibrations of the product being manufactured.

To reduce noise caused by mechanical impacts, the modifications outlined below should be considered.

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For any of these options to be practical, however, they must not adversely affect production:. High-velocity fluid flow can often create excessive noise as the transported medium passes through control valves or simply passes through the piping. A comprehensive acoustical survey can isolate the actual noise source so that the appropriate noise-control measures can be identified. When deemed practical, some effective modifications for high-velocity fluid-flow noise include:.

One of the most common noise sources within manufacturing equipment is pneumatic- or compressed-air-driven devices such as air valves, cylinders, and solenoid valves. High-velocity air is also a major contributor to worker noise exposure where hand-held air wands or guns are used to remove debris from work areas. Finally, compressed air nozzles are often used to eject parts from a machine or conveyor line. All these forms of pneumatic systems generate undesirable noise as the high-velocity air mixes with the atmospheric air, creating excessive turbulence and particle separation.

It is important to note that the intensity of sound is proportional to the air flow velocity raised to the 8th power. Therefore, as a source modification, it is recommended that the air-pressure setting for all pneumatic devices be reduced or optimized to as low a value as practical. As a general guideline, the sound level can be reduced by approximately 6 dBA for each 30 reduction in air velocity.

Additional noise controls for high-velocity air are presented in the retrofit and relocation sections below. Machine casings or panels can be a source of noise when sufficient vibratory energy is transferred into the metal structure and the panel is an efficient radiator of sound. Typically, machine casings or large metal surface areas have the potential to radiate sound when at least one dimension of the panel is longer than one-quarter of the sound's wavelength. Conducting a thorough noise-control survey will help in identifying the source of vibration and in determining the existence of any surface-radiated sound.

When a machine casing or panel is a primary noise source, the most effective modification is to reduce its radiation efficiency. The following noise-control measures should be considered:. A variety of commercially available acoustical products and applications can be applied on or relatively close to noise sources to minimize noise. The Noise and Vibration Control Product Manufacturer Guide should be consulted for a partial list of the manufacturers of these products and applications.

Vibration damping materials are an effective retrofit for controlling resonant tones radiated by vibrating metal panels or surface areas. In addition, this application can minimize the transfer of high-frequency sound energy through a panel. The two basic damping applications are free-layer and constrained-layer damping. Free-layer damping, also known as extensional damping, consists of attaching an energy-dissipating material on one or both sides of a relatively thin metal panel.

For thicker machine casings or structures, the best application is constrained-layer damping, which consists of damping material bonded to the metal surface covered by an outer metal constraining layer, forming a laminated construction. Each application can provide up to 30 dB of noise reduction. It is important to note that the noise reduction capabilities of the damping application are essentially equal, regardless of which side it is applied to on a panel or structure. Also, for practical purposes, it is not necessary to cover of a panel to achieve a significant noise reduction.

For example, 50 coverage of a surface area will provide a noise reduction that is roughly 3 dB less than coverage. In other words, assuming that coverage results in 26 dB of attenuation, 50 coverage would provide approximately 23 dB of reduction, 25 coverage would produce a dB decrease, and so on. Next, for free-layer damping treatments, it is recommended that the application material be at least as thick as the panel or base layer to which it is applied. For constrained-layer damping, the damping material again should be the same thickness as the panel; however, the outer metal constraining layer may be half the thickness of the base layer.

Finally, just because a surface area vibrates, it is not safe to assume it is radiating significant noise. If fact, probably less than 5 of all vibrating panels produce sufficient airborne noise to be of concern in an occupational setting. For damping materials to be successful, at a minimum, the two following conditions must be satisfied determine by a comprehensive noise-control survey :. When selecting the right type of damping material, it is recommended that the person making the decision refer to the expertise of the product manufacturer or their designated representative s.

Typically, the supplier will need to obtain specific information from the buyer, such as the temperature and size of the surface area to be treated and the substrate thickness. The supplier will then use the input data to select the most effective product for the particular application.

The vendor can also provide the buyer with estimates of noise reduction and costs for procuring the material. Most industrial equipment vibrates to some extent. As machines operate, they produce either harmonic forces associated with unbalanced rotating components or impulsive forces attributed to impacts such as punch presses, forging hammers, and shearing actions. Quite often, vibration problems are clearly identified by predictive-maintenance programs that exist within most industrial plants. Assuming that the root cause or source cannot be effectively modified, the next option for controlling undesirable vibration is to install vibration isolation.

Isolators come in the form of metal springs, elastomeric mounts, and resilient pads. These devices serve to decouple the relatively "solid" connection between the source and the recipient of the vibration. As a result, instead of the vibratory forces being transmitted to other machine components or the building, they are readily absorbed and dissipated by the isolators. When selecting the appropriate isolation device s , the person making the decision should consider the expertise of trained professionals.

It is critical to note that improper selection and installation of isolators can actually make a noise and vibration problem worse. Many manufacturers of vibration isolation equipment have useful websites for troubleshooting problems and finding solutions see the Noise and Vibration Control Product Manufacturer Guide for a partial list of manufacturers. Silencers are devices inserted in the path of a flowing medium, such as a pipeline or duct, to reduce the downstream sound level.

For industrial applications, the medium typically is air. There are basically four types of silencers: dissipative absorptive , reactive reflective , combination of dissipative and reactive, and pneumatic or compressed air devices. This section will address the absorptive and reflective type; a separate section will discuss the pneumatic or compressed air silencers. The type of silencer required will depend on the spectral content of the noise source and operational conditions of the source itself. Dissipative silencers use sound-absorbing materials to surround or encompass the primary airflow passage.

These silencers' principal method of sound attenuation is by absorption. The advantages and disadvantages of dissipative silencers include:. Reactive silencers use sound reflections and large impedance changes area variations to reduce noise in the airflow. The principal method of attenuation is through sound reflection, which cancels and interferes with the oncoming sound waves.

The advantages and disadvantages of reactive silencers include:. The combination dissipative and reactive silencer is essentially a reactive silencer with sound-absorption added to provide high-frequency attenuation capabilities. The advantages and disadvantages are similar to those listed for each type. To determine which type of silencer is best for a particular application, a trained professional should be consulted. The manufacturer or a designated representative will need to work closely with the facility engineering representative s to clearly identify all operational and physical constraints.

The Noise and Vibration Control Product Manufacturer Guide contains a partial list of silencer manufacturers and their websites. In the earlier High-Velocity Air Flow section, it was mentioned that pneumatic or compressed air is a very common noise source in manufacturing plants. Assuming sufficient noise reduction cannot be achieved by optimizing the air-pressure setting, the second step for controlling this class of noise source is to use commercially available silencers. For retrofitting pneumatic devices, selecting the appropriate silencer type is critical for this control measure to succeed over time.

If the source is a solenoid valve, air cylinder, air motor, or some other device that simply exhausts compressed air to the atmosphere, then a simple diffuser-type silencer will suffice. The disadvantage of these types of devices is that they can cause unacceptable back pressure. Therefore, when selecting a diffuser silencer, it is important that the pressure-loss constraints for the particular application be satisfied. All diffuser silencers can provide 15 to 30 dB of noise reduction. For compressed air systems that perform a service or specific task, such as ejecting parts or blowing off debris, a number of devices are available for retrofit at the point of discharge.

Another typical application for compressed air is in blow-off guns or air wands. These tools come in a variety of sizes and shapes and can generate noise levels of 90 dBA to dBA, depending on the velocity of the air and the surface area they contact. It is recommended that the Noise and Vibration Control Product Manufacturer Guide be consulted for a list of available suppliers. Usually, the manufacturer websites provide sufficient information and self-help guidance to enable selection of the most appropriate device for retrofit.

If these devices are kept in good working order, however, excessive high-velocity air noise in manufacturing facilities technically should not be an issue. The major problem with air guns is that, like other pneumatic or compressed air systems used to drive and motivate machinery, equipment operators will often increase the air pressure in an attempt to create more blow-off power. Earlier, in the High-Velocity Air Flow section, it was noted that the intensity of noise is proportional to the 8th power of the air velocity. Consequently, a higher pressure setting will significantly increase the noise level.

In addition, when a compressed air silencer is installed on machines, many operators will remove or suppress this device to maintain the perception of having the higher level of power to which they are accustomed, which is based on their subjective assessment of the sound level. To prevent unnecessary or unauthorized air adjustments by the process or equipment operators, air-pressure regulators should be set and locked to ensure that they cannot be modified without a supervisor's consent, and operators should be educated and trained in determining whether the power is adequate.

Another source treatment involves using alternative equipment or materials that are inherently quieter yet still meet the production needs. This option is called substitution for the source. Often, equipment manufacturers have alternative devices that perform the same function at lower noise levels. These quieter devices typically cost more, however, as they require tighter tolerances and more precision as they are manufactured. Therefore, when applicable, it will be necessary for the user to determine if the noise reduction benefit justifies the additional cost.

The supplier's or the manufacturer's website should be consulted to learn if quieter equipment is available and at what additional cost. Examples where alternative and quieter equipment may exist include:. There might also be opportunities to replace equipment with different devices or materials. Here, the user should investigate whether alternative and quieter ways exist to accomplish the task or intended service. Where practical, examples of source substitution include:. Controlling noise by locating or relocating the source should be considered for the design and equipment layout of new plant areas and for reconfiguring existing production areas.

A simple rule to follow is to keep machines, processes, and work areas of approximately equal noise level together, and separate particularly noisy and quiet areas by buffer zones having intermediate noise levels. In addition, a single noisy machine should not be placed in a relatively quiet, populated area. Reasonable attention to equipment layout from an acoustical standpoint will not eliminate all noise problems, but it will help minimize the overall background noise level and provide more favorable working conditions.

Assuming that all available options for controlling noise at the source have been exhausted, the next step in the noise-control hierarchy is to determine ways to treat the sound transmission path. Typical path treatments include adding sound-absorption materials to the room or equipment surfaces, installing sound transmission loss materials between the source and receiver s , using acoustical enclosures or barriers, or any combination of these treatments. A description of each treatment option follows. Sound-absorption materials are used to reduce the buildup of sound in the reverberant field.

The reverberant field exists at all locations where sound waves reflect off relatively hard surfaces, such as walls, ceilings, or inside enclosures, and then combine with the sound waves propagating directly from the noise source. The added effect produces a higher noise level than the level that would have existed in the absence of any reflecting surfaces. A user must understand and apply the principles of room acoustics when adding sound-absorbing materials to the walls and ceiling to reduce the noise levels throughout the room.

If a user installs sound absorption in a room without putting any science behind the decision, then the likelihood of success will be tenuous at best. Keep in mind that adding sound absorption to decrease the reflected or reverberant noise in a room will do nothing to reduce the acoustical energy propagating by direct line of sight from the source. Therefore, it is helpful for the user to estimate what portion of a worker's noise exposure comes from the direct sound field and what percentage results from reverberant sound.

When reverberant noise is a major contributor to a worker's daily noise exposure, then adding sound-absorbing materials may be beneficial. Sound TL materials are used to block or attenuate noise propagating through a structure, such as the walls of an enclosure or room. These materials are typically heavy and dense, with poor sound transmission properties.

Common applications include barriers, enclosure panels, windows, doors, and building materials for room construction. It is important to note that TL rating varies with frequency. TL values generally range from 20 to 60 dB, with the higher number indicating superior attenuation properties. For TL values of common building materials, consult Table 9. The acoustical enclosure is probably the most common path of treatment.

Quite often enclosures are used to address multiple noise sources all at once or when there are no feasible control measures for the source. However, there are a number of advantages and disadvantages associated with solid enclosures no acoustical leaks that must be considered by the user. Enclosures, both off-the-shelf and custom-design, are available from a number of manufacturers listed in the Noise and Vibration Control Product Manufacturer Guide.

It can also be more cost-effective to build enclosures in-house by following the Guidelines for Building Enclosures. An acoustical barrier is a partial partition inserted between the noise source and receiver, which helps block or shield the receiver from the direct sound transmission path. For a partial barrier to be effective, it is critical that the receiver be in the direct field, not the reverberant field.

Should the worker's location be primarily in the reverberant field, then the benefit of the barrier will be negligible. The noise reduction provided by a barrier is a direct function of its relative location to the source and receiver, its effective dimensions, and the frequency spectrum of the noise source. The practical limits of barrier attenuation will range from 15 to 20 dB. For additional details on calculating barrier insertion loss or attenuation, the user should review some of the references, particularly The Noise Manual AIHA, ; or latest edition. Recommendations for acoustical barrier design and location to maximize noise reduction capabilities include:.

The final control option involves reducing noise at the receiver. When deemed practical, personnel shelters can be installed or the receiver can be relocated to a relatively quiet area. It is important to keep in mind that worker noise exposure is a function of both the magnitude of noise and duration of exposure.

Therefore, receiver treatment works best in areas with high noise for those job activities that are fairly stationary or confined to a relatively small area, and where significant time is spent throughout the workday. Enclosures, or personnel shelters, can provide a cost-effective means for lowering worker noise exposure instead of lowering equipment noise levels. Any of the vendors listed in the manufacturer's guide can provide a cost estimate upon request. As a minimum requirement, all control rooms should maintain an interior sound level lower than 80 dBA, which will minimize worker noise exposure.

Should there be a need to communicate with workers inside a control room, however, then a better design criterion would be to limit sound levels to 60 dBA or less. As mentioned above, for a personnel enclosure to work well, it is critical that worker s spend a significant portion of their workshift in the shelter. The amount of time needed inside the enclosure will depend on the magnitude of the existing noise exposure. Finally, if it is not essential for the worker to spend significant time in the immediate vicinity of noisy equipment, then another option for reducing noise exposure would be to relocate the worker to a quieter area, when practical.

Quite often, equipment operators will spend most of their time up close to the production or process equipment, when in fact, they could stand back 5 to 7 feet, where the sound level might be a few decibels less. For relocation to work, however, it is critical that the worker still be able to perform the same job function. To help identify areas or zones where lower noise levels exist, a comprehensive sound survey of the production area is recommended.

It is also valuable to plot the sound level data on an equipment layout or floor plan, then add or draw contour lines of equal sound levels. This results in a noise contour map, which is often useful because it provides a simple representation of the sound field over a large area. Besides identifying regions of lower noise levels, these maps may also be used to visually educate and train workers regarding where hearing protection is mandatory, and as a tool for identifying hot spots for potential noise controls.

Administrative controls, defined as "management involvement, training of workers, and changes in the work schedule or operations that reduce noise exposure," may also effectively reduce noise exposure for workers. Examples include operating a noisy machine on the second or third shift when fewer people are exposed, or shifting a worker to a less noisy job once a hazardous daily noise dose has been reached.

Generally, administrative controls have limited use in industry because workers are rarely permitted to shift from one job to another. Be aware that if noise levels are high enough, rotation could increase the chances of hearing loss in more workers. If there is a regular noise level of 90 dB, for example, a healthy worker in the area can rotate into an area with a dB noise level without a substantial increase in risk of hearing loss.

Another administrative control involves redesigning workers' work schedules to reduce the amount of time that any one worker is located in the hazard area. To increase the effectiveness of this control, employers can also ensure that noise exposure is kept to a minimum in nonproduction areas frequented by workers. Select quiet areas to use as lunch rooms and work break rooms. If these areas must be near the production line, they should be acoustically treated as describe elsewhere in this section to minimize background noise levels. Employers can also increase the distance between workers and the noise source.

This can be accomplished in many ways. For example, television monitors allow the worker to monitor a job or process at a safe distance from the noise-producing area; a boom-mounted drill increases the distance from the noise source to the worker. Additionally, noisy jobs on construction sites might be scheduled when other trades will not be affected.

Another administrative control involves creating policies that result in regularly scheduled equipment maintenance. Maintenance should be scheduled frequently enough to minimize the noise produced by equipment with parts that are loose or not lubricated. Regular maintenance should allow a piece of equipment to operate within 2 dBA of its lowest potential operating noise level. Maintenance workers can also be trained to observe and listen for noise sources in equipment. This might involve providing training on using sound level meters to perform surveys in work areas to identify areas with high noise levels.

Hearing protection devices HPDs are considered the last option for controlling noise exposures. HPDs are generally used during the time it takes to implement engineering or administrative controls, or when such controls are not feasible. Unless great care is taken in establishing a hearing conservation program, workers will often receive very little benefit from HPDs. The best hearing protector, when fitted correctly, is one that is accepted by the worker and worn properly. If the worker exposure is above 85 dBA 8-hour TWA , hearing protection must be made available, along with the other requirements in the hearing protection program.

Earplugs are designed to occlude the ear canal when worn. All hearing protectors are provided with an NRR. Although earplugs can offer protection against the harmful effects of impulse noise, and some earplugs are designed specifically to reduce this type of noise, the NRR is based on the attenuation of continuous noise and may not be an accurate indicator of the protection attainable against impulse noise. Earmuffs are another type of hearing protector Figure They come in a variety of sizes, shapes, and materials and are relatively easy to dispense, as they are one-size devices designed to fit nearly all adult users.

Earmuffs are designed to cover the external ear and thus reduce the amount of sound reaching the inner ear. Care must be taken to ensure that the seal of the earmuff is not broken by safety glasses, facial hair, respirators, or other equipment, as even a very small leak in the seal can destroy the effectiveness of the earmuff. Earmuffs should be chosen based on the frequency that needs to be reduced.

Refer to the EPA label on the manufacturer's product. Earmuffs are a good choice for intermittent exposure, given how easy they are to put on and take off. Hearing bands are a third type of HPD Figure 11 and are similar to earplugs, but with a stiff band that connects the portions that insert into a worker's ears. The band typically wraps around the back of the wearer's neck, though variations are available. Hearing bands come in a variety of sizes, shapes, and materials and are popular for their convenience.

Hearing bands may not provide the same noise attenuation as properly fitting earplugs, as the portions that fit into the ears are stationary and cannot be twisted into place like earplugs. Earplugs, earmuffs, or hearing bands alone might not provide sufficient protection from significantly high noise levels. In this case, workers should wear double hearing protection-earmuffs with earplugs. Avoid corded earplugs, as the cord would interfere with the muff seal. Additionally, hearing bands cannot be worn with earplugs or earmuffs, as the connected band would interfere with the muff seal, and there is no room to insert earplugs at the same time.

HPDs are rated to indicate the extent to which they reduce worker noise exposure. New technologies are being developed to test the effectiveness of earplugs and could eventually change the way hearing protection is rated. Several sound-measuring instruments are available to CSHOs. These include sound level meters, noise dosimeters, and octave band analyzers. This section describes general equipment care, followed by the uses and limitations of each kind of instrument.

Instruments that measure noise contain delicate electronics and require practical care. Store and transport the equipment in its custom case. Be aware of the instrument manufacturer's recommendations for proper storage for example, some manufacturers recommend removing all batteries from stored equipment, while others require a primary battery to remain in the instrument.

Make sure batteries will last the anticipated sampling period. A battery tester can be useful. CSHOs may need to install fresh batteries or recharge reusable batteries with a battery charger. Both pre- and post-inspection calibrations are required for any noise instruments used by CSHOs. It is important to understand the difference between these two types of calibrations.

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Calibrators must also be calibrated on an annual basis. Equipment manufacturers typically recommend periodic calibration on an annual basis. These rigorous testing protocols ensure that the electronic components are in good working order and detect shifts in performance that indicate gradual deterioration. Periodic calibration results in a calibration certificate documenting the standard of performance.

Typically, the instrument will also receive a sticker indicating its last calibration date and when the next periodic calibration is due Figure Do not continue to use it past the calibration date. CTC also coordinates periodic factory calibration of any OSHA-owned noise-monitoring instruments that it does not service directly.

Employers that lease or own Type I or Type II noise-measuring instruments can arrange annual calibration of the equipment through the equipment supplier or manufacturer. During periodic calibration, the CTC also performs preventive maintenance to ensure that the equipment remains fully functional over its life expectancy. If the calibration team detects a problem, it services the instrument as necessary. When returning equipment to CTC for periodic calibration, be sure to include a note about any problems or concerns with equipment function so they can be evaluated as part of the maintenance process.

If equipment is not functioning well, CTC requests that the instrument be returned for inspection, even if it is not yet due for calibration. Octave band analyzers that are integrated into a sound level meter will be calibrated as part of the sound level meter. However, detachable octave band analyzers must be returned to CTC for periodic calibration with the meter with which they are intended to be used. Pre- and post-calibration procedures confirm that the instrument is functioning properly on the day that it is used and prove that it is still registering sound levels correctly at the end of the day.

Pre- and post-calibrations also confirm that changes in temperature or humidity have not affected the instrument's accuracy. If practical, spot check the instrument with a calibrator after the stabilization period. Each instrument model is calibrated in a slightly different manner, but the general process follows basic standard steps. Typical daily pre-use calibration involves 1 setting up the instrument for use, 2 turning on both the electronic "calibrator" and the noise-measuring instruments to allow them to "warm up," 3 checking the calibrator and instrument battery charge, 4 testing the instruments with a standard tone of known pitch and intensity produced by the calibrator e.

For the post-use calibration check, the process is repeated, without step 5, after the instrument has been used. Both the pre- and post-use calibration must be documented If it isn't properly documented, it didn't happen. See Figures 13 and 14 for illustrations of this process for dosimeters and sound level meters, respectively. Confirm that you understand the procedures for calibrating each of the instruments you use. If in doubt, review instructions in each instrument's user's manual and consult CTC if questions arise. In general, as long as the sound level readout is within 0.

If large fluctuations greater than 1 dB in the level occur, then either the calibrator or the instrument may have a problem. Additionally, confirm that you know how to change the battery in both the calibrator and the instruments. If in doubt, review instructions in each instrument's user's manual. As described elsewhere in this Report , a substance use disorder is a substantial risk factor for committing a criminal offense. Reduced crime is thus a key component of the net benefits associated with prevention and treatment interventions.

Overall, within the criminal justice system, more than two thirds of jail detainees and half of prison inmates experience substance use disorders. Substance use-related costs are also prominent within child welfare and related services. The estimated prevalence of substance use disorders among parents involved in the child welfare system varies across service populations, time, and place. One widely cited estimate is that between one-third and two-thirds of parents involved with the child welfare system experience some form of substance use problem.

The National Survey of Child and Adolescent Weil-Being found that caseworkers perceived substance misuse problems in 23 percent of cases, which was correlated with significantly higher probabilities of severe harm to children 24 percent , compared with parents with no such indication 5 percent. Children of parents with substance use problems were more likely than others to require child protective services at younger ages, to experience repeated neglect and abuse from parents, and to otherwise require more intensive and intrusive services. Substance use disorders appear to account for a large proportion of child welfare, foster care, and related expenditures in the United States.

It is one of the largest health care systems in the United States. The IOM conducted a comprehensive study of military prevention and treatment services for substance use disorders. Further, service members and veterans suffer from high rates of co-occurring health problems that pose significant treatment challenges, including traumatic brain injury, post-traumatic stress disorder, depression, and anxiety. Along with other recommendations, the IOM report recommended conducting routine screening, integrating substance use treatment with other health care, and implementing evidence-based treatments.

These illustrative examples underscore that the costs associated with substance use disorders are incurred across diverse service systems that serve vulnerable populations. These expenditures might be reduced through more aggressive measures to address substance misuse problems and accompanying disorders. Moreover, many substance use-related services provided through criminal justice, child welfare, or other systems seek to ameliorate serious harms that have already occurred, and that might have been prevented with greater impact or cost-effectiveness through the delivery of evidence-based prevention or early treatment interventions.

Different kinds of economic analyses can be particularly useful in helping health care systems, community leaders, and policymakers identify programs or policies that will bring the greatest value for addressing their needs. Two commonly used types of analyses are cost-effectiveness analysis and cost-benefit analysis. Both types of studies have been used to examine substance use disorder treatment and prevention programs. Studies have found a number of substance use disorder treatments, including outpatient methadone, alcohol use disorder medications, and buprenorphine, to be cost-effective compared with no treatment.

Treatment Settings and Approaches. A study estimating the cost-effectiveness of four different treatment modalities—inpatient, residential, outpatient methadone, and outpatient without MAT—found that the treatment of substance use disorders is cost-effective compared to other health interventions, with outpatient programs without MAT being the most cost-effective.

Methadone Maintenance versus Methadone Detoxification. Cost-effectiveness study. A comparative analysis of two or more interventions against their health and economic outcomes. These outcomes could be lives saved, illnesses prevented, or years of life gained. Cost-benefit study. A study that determines the economic worth of an intervention by quantifying its costs in monetary terms and comparing them with the benefits, also expressed in monetary terms.

Total benefits divided by total costs is called a cost-benefit ratio. If the ratio is greater than 1, the benefits outweigh the costs. Methadone Maintenance versus Maintenance with Other Medications. However, extended-release naltrexone is not off-patent, and therefore these cost findings will likely change when it becomes generic. A measure of the burden of disease used in economic evaluations of the value of health care interventions that accounts for both the years of life lived and the quality of life experienced during those years, relative to quality associated with perfect health.

Buprenorphine-Naloxone versus No Treatment. A study examined individuals with opioid use disorders who had completed 6 months of buprenorphine-naloxone treatment within a primary care setting. A review of cost-effectiveness studies for alcohol SBI in a primary care setting found considerable variability in the estimated cost-effectiveness ratios and cost savings across studies. Using that comparison, alcohol misuse screening achieved a combined score similar to screening for colorectal cancer, hypertension, or vision for adults older than age 64 , and to influenza or pneumococcal immunization.

Because current levels of SBI delivery are much lower than desired, this service deserves special attention by health care professionals and care delivery systems. Interventions that prevent substance use disorders can yield an even greater economic return than the services that treat them. The Washington State Institute for Public Policy has used a standardized model to estimate the cost-benefit of diverse prevention, early intervention, and treatment programs.

In a literature review of the economics of substance use disorder treatment, one study highlighted the variability in cost estimates for substance use disorder treatment delivered in specialty settings. Costs were typically lower when activity-based costing assigning the cost and amount of each activity that is part of the intervention was employed and when the SBI occurred in a primary care setting or was performed by a provider who was not a physician. Additionally, variation was attributed to the wage of the person conducting the screening and the amount of time the screening took.

In recent years, use of MAT has increased. Recent studies have examined extended-release naltrexone, buprenorphine, and methadone for opioid use disorder treatment. While other treatments may be less costly, they are also somewhat less effective. In , about three-quarters of all general health care purchased in the United States was paid for by private insurance, Medicare, or Medicaid.

The rest was covered by consumers paying out-of-pocket, by other federal health grants, and by programs and other insurance provided by the DoD, Department of Veterans Affairs, and other state and local programs. In , the largest share of substance use disorder treatment financing was from state non-Medicaid and local governments 29 percent.

Coverage of substance use disorder services under private insurance has waxed and waned over the past 30 years. During the s, insurance benefits and specialty addiction providers expanded, , and from to , substance use disorder spending grew by 6. This expansion was followed by managed care restrictions on reimbursement for substance use disorder treatment in inpatient settings, such as limitations on length of residential rehabilitation stays a common treatment regimen.

Further, the share of substance use disorder financing from private insurance dropped dramatically between and , from 32 percent in to 13 percent in ; this was followed by an increase to 18 percent in , likely due to MHPAEA and qualified health plan coverage now being available through the Affordable Care Act. Approximately 20 percent of people in the United States have health coverage through Medicaid, a joint federal and state health coverage program that provides medical assistance for children, families, and individuals with low income and limited resources; an estimated 12 percent of adult Medicaid beneficiaries have a substance use disorder.

The federal government establishes basic requirements that states must follow in designing their Medicaid programs, including some mandated services that must be covered and guidance regarding payment rate-setting and contractual arrangements, eligibility and quality standards, and provision of optional services. States can choose to cover or not cover specific treatments or to place restrictions on covered services. In the past, some states have not included certain critical substance use disorder treatment options in their benefit packages e.

In many states, Medicaid also does not cover residential treatment, especially for adults. For those who are eligible and have substance use disorders, Medicaid is an extremely important program, as it can cover many services that such individuals may need, such as crisis services and many preventive services. In addition, while Medicaid does not provide payments for housing e. In states that did not expand Medicaid, racial and ethnic minorities are disproportionately affected.

In addition, in these states, young adult single males—a group with high rates of substance use disorders-are ineligible for Medicaid benefits. An estimated 14 to 15 percent of uninsured individuals nationwide who could be newly eligible for Medicaid coverage under the Affordable Care Act have a substance use disorder. Medicare covers almost all individuals aged 65 or over as well as those eligible because of disabilities. Approximately Prescription drug treatment is generally covered for beneficiaries enrolled in Medicare Part D or a Medicare Advantage plan that includes drug coverage.

Medicare does not cover outpatient use of oral methadone for substance use disorders, but Part D can include coverage for medications, such as disulfiram, naltrexone, acamprosate, and buprenorphine. Although insurance coverage is critical to improving access to and integration of services for individuals with substance use disorders, it is unlikely to cover all the services that such individuals may need, such as crisis services e. Research has shown that uninsured individuals have higher unmet medical needs than do insured individuals, and those without insurance also have higher rates of substance use disorders than do individuals with insurance.

Funds from federal block grants to states for substance use disorder treatment services such as the SABG, which is often used for prevention activities and for maternal, child, and adolescent health services Title V of the Maternal and Child Health Services Block Grant may be used to fill the gaps in treatment services not covered by insurance. These funds also finance treatment for people without insurance and support community prevention activities. In addition, federal funding for certain community prevention programs encourages public-private partnerships and community collaboration to improve health outcomes.

Grants are used to increase screening, counseling, workplace wellness programs, and community prevention. Although investments in prevention have repeatedly demonstrated favorable economic returns, primary prevention for all health conditions still accounts for less than 5 percent of overall health spending in the United States.

Prevention should be seen as an appropriate health cost to be covered by insurance. Current funding options for community prevention, described below, include grants from hospital and health system foundations, hospital-based community benefit programs, tax earmarks, and targeted state programs. Foundations formed from the conversion of tax-exempt non-profit hospitals and health systems into for-profit entities are required by federal law to invest in health-related activities within the community area served by that hospital.

Beginning in , tax-exempt hospitals have been required to provide benefits to the community in return for not paying taxes. Tax-exempt hospitals must: 1 conduct a community health needs assessment at least once every 3 years; 2 involve public health experts and representatives of the community served by the facility in the needs assessment; 3 make the results of the assessment available to the public; 4 develop an implementation strategy to address each of the community health needs identified through the assessment; and 5 report yearly to the Internal Revenue Service.

Many states also have community benefit programs that must be synchronized with the requirements of the Affordable Care Act. In certain jurisdictions, direct funds from a local or state tax can be earmarked for substance misuse prevention in the same way as tobacco taxes are currently used for public health and health programming in many states. Jackson County, Missouri, first introduced a dedicated sales tax in to tackle drug use and drug-related crime. The funds are used for a variety of prevention, treatment, and anti-drug and drug-related crime prevention programs.

In addition, Florida and Indiana, among other states, earmark alcohol taxes for child and adolescent substance use-related services. The Massachusetts Legislature passed the first state-based prevention fund, called the Prevention and Wellness Trust Fund, in as part of a health cost control bill. Grantees have a strong focus on extending care beyond clinical sites into the community.

It is clear that integrating substance use disorder services with mainstream health care is beneficial for individuals and communities and that health reform is encouraging this trend.

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However, several key challenges must be addressed if integration is to be fully successful. The Congressional Budget Office currently estimates that by , 24 million Americans who would otherwise be uninsured will obtain health insurance coverage as a result of the Affordable Care Act. However, the specialty care substance use disorder treatment system faces challenges along with these new opportunities. Nationally representative data from the National Drug Abuse Treatment System Survey underscore the importance but also the difficulty of integrated care efforts.

Fifty-five percent of addiction treatment patients in expansion states are receiving care in organizations that at least have contractual linkages to some medical or health home arrangement. Substance use disorder treatment organizations currently face significant challenges in engaging in care coordination with other types of providers.

Because these organizations have traditionally been organized and financed separately from general health care systems, the two systems have not routinely exchanged clinical information. In a survey of treatment programs to assess their readiness for health reform, 63 percent described their organizations' adoption of EHRs as having not yet begun, or only in the early stages.

For example, private, for-profit treatment facilities were significantly more likely to be early adopters of buprenorphine therapies than were their public or private non-profit peers. This offers promise for increasing adoption and use of health IT by behavioral health providers.

Another challenge for effectively coordinating care relates to the need for specialty substance use disorder treatment programs to comply with substance abuse confidentiality regulations 42 CFR Part 2 and state privacy laws when implementing health IT systems. In addition, substance use disorder treatment organizations face the challenge of communicating with non-health care personnel including those in social service, criminal justice, and educational facilities and even when EHRs are in place these systems lack interoperability the ability to effectively exchange digital health information from an EHR in a common format with the information systems used by social service organizations, hindering communication.

Medical homes are most likely to pursue contractual arrangements with large and technologically sophisticated organizations that are best equipped to meet their needs for timely clinical and administrative information. The move toward integrated care is therefore likely to accelerate consolidation of substance use disorder treatment programs, which may hasten the adoption of new technologies and processes among sophisticated providers. Particularly in combination with expanded insurance coverage, this trend may attract new partnerships, for example between ACOs, which are integrated delivery systems, and more sophisticated specialty addiction providers.

Yet, the same patterns may harm smaller providers, some of whom offer the only culturally competent services for particular patient groups, such as services tailored for specific racial and ethnic populations, sexual and gender minorities, or women in need of trauma-related residential services. One key challenge for integrating substance use treatment and health care is that implementation of pharmacotherapies i. Research suggests that whether treatment programs offer MAT is influenced by a number of organizational and state-level factors, including differences in organizational size, whether the treatment program is in a hospital setting, whether psychiatric medications are prescribed, whether the program has access to prescribing staff, and whether state Medicaid policies support the use of generic drugs.

Another medication, extended-release injectable naltrexone, approved by the FDA for use in treating individuals with opioid use disorders, is underutilized by programs. For example, one study found that only three percent of United States treatment programs used it for opioid use disorders. One study found that between and , its use for detoxification in specialty opioid treatment programs OTPs increased from 36 percent of programs in the sample to 46 percent; its use for maintenance increased from 37 percent of programs in the sample to 53 percent.

A recent study found that raising this limit further, rather than increasing the number of specialty addiction programs or waivered physicians, may be the most effective way to increase buprenorphine use. Another key challenge is that primary care settings have not yet routinely implemented recommended preventive health and intervention services related to substance misuse. Currently, the Affordable Care Act requires that all non-grandfathered health plans must cover, without cost-sharing, certain preventive health services recommended by the USPSTF, and women's preventive services and preventive services for infants, children, and adolescents in guidelines supported by HRSA As discussed earlier, the USPSTF recommends alcohol screening and counseling for adults.

The USPSTF currently considers the evidence to be insufficient to support screening or behavioral interventions for substance misuse problems in pediatrics. Hilton Foundation, are currently underway that could add to the evidence base. Major pediatric medical organizations, including the American Academy of Pediatrics, strongly recommend addressing these issues regularly at each well-adolescent visit and appropriate urgent care visits.

The Affordable Care Act requires health plans to cover, at no out-of-pocket cost to families, the preventive care services outlined in this schedule. Bright Futures discusses how to incorporate screening into the preventive services visit for these age groups. Screening and brief intervention for substance misuse is also consistent with the prevention activities recommended in the IOM report Preventing Mental, Emotional, and Behavioral Disorders Among Youth: Progress and Possibilities.

The Joint Commission Requirements mandate that hospitals offer inpatients brief counseling for alcohol misuse and follow-up, and measure the provision of counseling as one of the core measures for hospital accreditation. Primary care teams that include non-physician providers e.

Several large health systems, such as the Veterans Health Administration and Kaiser Permanente, have successfully implemented primary care-based alcohol SBI in a sustainable manner. These approaches can also be implemented in emergency departments and in obstetrics and gynecology departments. Data on the substance use workforce are incomplete. Nevertheless, it is clear that the workforce is inadequate, as evidenced by its uneven geographic distribution with rural areas underserved , access barriers for adolescents and children, and recruitment challenges across the treatment field.

Moreover, the workforce is aging. For example, 46 percent of psychiatrists are older than age Recent reforms may strain the current workforce in an already overstretched health care system working to address treatment and prevention strategies. A recent study documented staffing models in primary care practices and determined that, even among those designated as patient-centered medical homes, fewer than 23 percent employed health educators, pharmacists, social workers, nutritionists, or community service coordinators, and fewer than half employed care coordinators.

The IOM's report Improving the Quality of Health Care for Mental and Substance Use Conditions , 32 which adapted Crossing the Quality Chasm to address mental and substance use conditions, noted that a critical concern in attracting a skilled workforce is the low salary structure of the substance use disorder treatment workforce. In practice, the Block Grant is used broadly, and Medicaid less and only with a subset of providers. It is not yet clear whether the integration of substance use disorder treatments in general health care will help to address salary structure.

An integrated health and substance use disorder treatment system requires a diverse workforce that includes substance use disorder specialists, physicians, nurses, mental health treatment providers, care managers, and recovery specialists. This workforce also includes peer recovery coaches a reimbursable service under some state Medicaid programs , health educators, social workers, and other staff who are trained to deliver timely mental health and substance use-related health interventions, such as SBI.

As substance use disorder treatment and general health care become more integrated, clinical staff in both systems will need to expand their scope of work, operate in an integrated manner with a variety of populations, and shift their treatment focus as needed. Health care professionals moving from the specialty workforce into integrated settings will require specific training on treatment planning and care coordination and an ability and willingness to work under the leadership of medical staff.

Working in teams with the broad mandate of improved health is not currently commonplace and will require collaboration among professional and certification bodies. Incorporating peer workers, who bring specific knowledge of patients' experiences and needs and can encourage informed patient decision making, into teams will also require further adjustment. Improving the Quality of Health Care for Mental and Substance Use Conditions also discussed the shortage of skills both in specialty substance use disorder programs and in the general health care system. Currently, 66 organizations license and credential addiction counselors, , and although a consensus on national core competencies for these counselors exists, they have not been universally adopted.

Without a comprehensive, coordinated, and focused effort, workforce expansion and training will continue to fall short of the challenge of meeting the needs of individuals across the continuum of service settings. HRSA has taken a number of steps to address these workforce challenges as part of its mission to prepare a diverse workforce and improve the workforce distribution to increase access for underserved communities. Among its many programs, HRSA awards health professional and graduate medical education training grants and operates scholarship and loan repayment programs.

Of particular note is the National Health Service Corps, where, as of September , roughly 30 percent of its field strength of 9, was composed of behavioral health providers, meeting service obligations by providing care in areas of high need. The development of the workforce qualified to deliver these services and services to address co-occurring medical and mental disorders will have significant implications for the national workforce's ability to reach the full potential of integration.

Effectively integrating substance use disorder treatment and general health care requires the timely exchange of patient health care information. These privacy protections were motivated by the understanding that discrimination attached to a substance use disorder might dissuade people from seeking treatment, and were enacted in the context of patient methadone records being used in criminal cases. HIPAA does not require patient authorization to share health information for purposes of treatment, payment, or health care operations. With 42 CFR Part 2, patient consent is required to share and use patient identifying information and any information that could be used to identify someone as having, or having had, a substance use disorder, such as payment data.

Given the long and continuing history of discrimination against people with substance use disorders, safeguards against inappropriate or inadvertent disclosures are important. Disclosures to legal authorities can lead to arrest, loss of child custody, or relinquished parental rights. Disclosures to insurers or to employers can render patients unable to obtain disability or life insurance and can cost patients their jobs. Currently, persons with substance use disorders involving illicit drugs are not protected under anti-discrimination laws, such as the ADA.

However, exchanging treatment records among health care providers has the potential to improve treatment and patient safety. For example, in the case of opioid prescribing, a study in health systems of long-term opioid users found those with a prior substance use disorder diagnosis received higher dosages and were co-prescribed sedative-hypnotic medications—which can increase the risk for overdose—more often. Because of privacy regulations, it is likely that physicians were not aware of their patients' substance use disorders.

PDMPs are state-run databases that collect prescribed and dispensed controlled prescription drug information and give prescribers and pharmacists access to a person's controlled substance prescription history. Authorized providers can check the database before prescribing or dispensing. However, PDMPs have many limitations. They do not include information about methadone used for opioid use disorders, which is exclusively dispensed at OTPs, or from programs covered by 42 CFR Part 2.

While disclosure of patient-identifying information that is subject to 42 CFR Part 2 is allowable, it would require written patient consent, and re-disclosures of this information would not be permitted unless the patient consents. In addition, PDMPs only collect prescription information as allowed by their state laws, in most cases controlled substances Scheduled II through IV or V, and thus health care professionals may not be aware of other prescriptions their patients are receiving.

As EHR interoperability and the exchange of health information increases, best practices must be developed for handling substance use disorder treatment data, consistent with state and federal privacy laws. Clearly, integrating health care and substance use disorder treatment within health care systems, as well as integrating the substance use disorder treatment system with the overall health care system, are complex undertakings. The good news, however, is that a range of promising health care structures, technologies, and innovations are emerging, or are being refined and strengthened, under health reform.

These developments are helping to address challenges and facilitate integration. In so doing, they are broadening the focus of interventions beyond just the treatment of severe substance use disorders to encompass the entire spectrum of prevention, treatment, and recovery. These promising developments include:. Medicaid is not only an increasing source of financing for substance use disorder treatment services, it has become an important incubator for innovative substance use disorder financing and delivery models that can help integrate substance use disorder treatment and mainstream health care systems.

Within the substance use disorder treatment benefit, and in addition to providing the federally required set of services, states also may offer a wide range of recovery-oriented services under Medicaid's rehabilitative services option. These services include therapy, counseling, training in communication and independent living skills, recovery support and relapse prevention training, skills training to return to employment, and relationship skills.

Nearly all states offer some rehabilitative mental health services, and most states offer the rehabilitation option for substance use disorder services. CMS provides various authorities by which states can structure their Medicaid programs, thus providing mechanisms for states to expand and improve their substance use disorder treatment delivery system: This includes authorities to: - Recently, CMS gave states new opportunities to design service delivery systems for substance use disorders through demonstration projects under section This initiative is designed to support states to provide coverage for the full continuum of care; ensure that care is delivered consistent with the ASAM Treatment Criteria; design strategies to coordinate and integrate care; and support quality improvement programs.

The agency is providing technical and program support to states to introduce policy, program, and payment reforms to identify individuals with substance use disorders, expand coverage for effective treatment, expand access to services, and develop data collection, measurement, and payment mechanisms that promote better outcomes. Medicaid is also encouraging the trend to integration in other ways, including supporting new models for delivering primary care, expanding the role of existing community-based care delivery systems, enacting mental health and substance use disorder parity for Medicaid and Children's Health Insurance Program CHIP as included in the final rule that CMS finalized in March Health homes are grounded in the principles of the primary care medical home, which focuses on primary care-based coordination of diverse health care services, and patient and provider engagement.

The Affordable Care Act created an optional Medicaid State Plan benefit allowing states to establish health homes to coordinate care for participants who have chronic health conditions. Beneficiaries with chronic conditions are eligible to enroll in health homes if they experience or are at risk for a second chronic condition, including substance use disorders, or are experiencing serious and persistent mental health conditions. These arrangements emphasize integration of care, targeting of health home services to high-risk populations with substance use and mental health concerns, and integration of social and community supports with general health services.

As of January , 19 states and the District of Columbia had established Medicaid health home programs — covering nearly one million individuals — and nearly a dozen additional states had plans for establishing them. States that implement Medicaid health homes receive substantial federal subsidies, including 90 percent federal matching rates for health home services during the first eight quarters after the effective date of health home coverage under the Medicaid state plan, covering comprehensive case management, coordinating services and health promotion, comprehensive transitional care from inpatient to other settings, individual and family support services, linkage and referrals to community-based services, and health IT.

In some settings, these integrated care models are associated with reduced cost and improved cost-effectiveness, and research is underway to test new models. Recognizing the important role that these kinds of integrated care arrangements can play, the American Academy of Family Physicians and SAMHSA have issued reports promoting the inclusion of substance use and mental health services in patient-centered medical homes and related efforts. Another Affordable Care Act provision created opportunities to encourage the integration of primary and specialty care, as well as community and public health systems, by establishing integrated delivery systems known as ACOs.

ACCs are an important variation on the ACO model because, by focusing on the larger community, they can address the social determinants of health and health disparities that have such a profound impact on community members' health and well-being, including their risks for substance misuse, substance use disorders, and related health consequences. Initially developed as a model under Medicare, ACOs have now also been encouraged under Medicaid for its covered populations.

An underlying assumption of the new service delivery and payment models funded in the SIM states is that they will be more effective and produce better outcomes when implemented as part of a broad-based, statewide initiative that brings together multiple payors and stakeholders, and when they use the levers of state government to effect change. The SIM states are leading the implementation of accountable care systems for Medicaid populations that embrace population health for SIM states, this is defined as health of the community in a geographic area as opposed to the population of patients in the health delivery system.

Several states have adopted ACC models that support integration of medical health care services with public health and community-based programs. Oregon's CCOs are a network of all types of health care professionals physical health care, addiction and mental health care, and dental care providers who have agreed to work together to serve people who receive health care coverage under Oregon's Medicaid plan, which is called Oregon Health Plan.

The Oregon Health Authority publishes regular reports on quality, access, and progress toward benchmarks in both prevention and treatment. Increased insurance coverage and other provisions of the Affordable Care Act have sparked important changes that are facilitating comprehensive, high-quality care for people with substance use disorders. For example, the Affordable Care Act provided mandatory funding for Federally Qualified Health Centers FQHCs receiving grants under section of the public health service act, including community health centers, migrant health centers, health care for the homeless health centers, and public housing primary care centers that is supporting the expansion of their activities and numbers of patients served.

These community health centers emphasize coordinated primary and preventive services that promote reductions in health disparities for low-income individuals, racial and ethnic minorities, rural communities, and other underserved populations. Two-thirds of health centers have been designated as PCMHs. Community health centers provide primary and preventive health services to medically underserved areas and populations and may offer behavioral and mental health and substance use services as appropriate to meet the health needs of the population served by the health center.

As such, they are well-equipped to address co-occurring physical, mental, and substance use disorders, and provide substance misuse prevention, treatment, and RSS to patients. Because they provide services regardless of ability to pay and are required to offer services on a sliding scale fee, they are well-positioned to serve low-income and economically vulnerable patients.

An example of the important role FQHCs can play in improving access to treatment for substance use disorders is their efforts in providing buprenorphine maintenance treatment for opioid-dependent patients within primary care. FQHCs have access to B drug pricing, making the purchase of substance use disorder medications less costly and thus more accessible than for providers who cannot take advantage of this pricing.

EHRs and health IT have the potential to support better coordination of services across primary care and specialty substance use disorder treatment, greater safety by reducing harmful drug-drug interactions, and improved monitoring of treatment outcomes and relapse risk in general health care. Strong health IT systems improve the organization and usability of clinical data, thereby helping patients, health care professionals, and health system leaders coordinate care, promote shared decision-making, and engage in quality improvement efforts.

These systems have the capacity to easily provide information in multiple languages and to put patients in touch with culturally appropriate providers through telehealth. Meaningful Use. Using certified EHR technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and family; improve care coordination and population and public health; and maintain privacy and security of patient health information. Health IT has shown benefits in improving care for patients with chronic conditions, and use is expected to greatly increase because of the Affordable Care Act and related incentives, such as grants supporting health center networks with the implementation and adoption of health IT.

Health IT also holds great potential for improving services for individuals with substance misuse problems because they can provide up-to-date medical histories of patients to providers, and they can support care coordination by facilitating communications between primary and specialty care providers across health systems. For example, educational and training materials including clinical guidelines for physicians e.

Many health systems have additional information on wikis for patients and providers. Most have or will have patient portal websites, which can provide patients access to health, mental health, and substance use self-assessments; computerized interventions for reducing alcohol or drug use, anger management, dealing with depression, and other problems; referral sources for smoking quit-lines and self-help groups; information on medications for substance use disorders; and general health information.

Clinical Decision Support. A system that provides health care professionals, staff, patients, or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. Although research suggests that patients with substance use disorders are not using patient portals as much as individuals with other conditions, they have great potential for reaching patients.

To foster systems change, efforts are needed to increase adoption of EHR technology in substance use disorder and mental health treatment organizations. These programs currently lag and are likely to continue to lag behind the rest of medicine. It will be critical to facilitate the uptake of EHRs within the specialty substance use disorder treatment system, to implement common data standards to support interoperability across specialty substance use disorder treatment and mainstream health care, and to coordinate care across systems.

The federal interagency Behavioral Health Coordinating Council recently created a quality metrics subcommittee tasked with ensuring that substance use and mental health performance and quality measures are consistently and appropriately included across payment systems of HHS, including diverse programs within CMS. PDMPs are becoming an increasingly important health IT tool for preventing substance misuse and identifying patients with substance use disorders.

As discussed above, PDMPs are state-run databases that collect prescribed and dispensed controlled prescriptions drug information and give providers and pharmacists access to information about a person's controlled substance prescription history. They are designed to help identify patients as well as providers who are misusing or diverting i. This technology represents a promising state-level intervention for improving opioid prescribing, informing clinical practice, and protecting patients at risk in the midst of the ongoing opioid overdose epidemic.

A number of states have passed legislation requiring prescribers to check their PDMP before prescribing controlled substances. Additional research is needed to identify best practices and policies to maximize the efficacy of these programs. Now these disease registries are being developed for substance use disorders, such as opioid use disorder.

Even low levels of alcohol and drug use are important factors in this population. Because substance use disorders often first come to light in the context of school, law enforcement, and employment, communities have many opportunities to expand the delivery of prevention and treatment services to include schools and school-based health care clinics, jails and prisons, and places of employment. Services provided in these settings can range from prevention education to SBIRT to treatment for substance use disorders. For example, law enforcement and emergency medical services in many communities are already collaborating in the distribution and administration of naloxone to prevent opioid overdose deaths.

These efforts require a public health approach and the development of a comprehensive community infrastructure, which in turn requires coordination across federal, state, local, and tribal agencies. A number of states are developing promising approaches to address substance use in their communities. One recent example is Minnesota's State Substance Abuse Strategy, which includes a comprehensive strategy focused on strengthening prevention; creating more opportunities for intervening before problems become severe; integrating the identification and treatment of substance use disorders into health care reform efforts; expanding support for recovery; interrupting the cycle of substance use, crime, and incarceration; reducing trafficking, production, and sale of illegal drugs; and measuring the impact of various interventions.

In , the group developed its first opioid prescribing guideline in collaboration with practicing physicians, with the latest update released in States' and localities' efforts to expand naloxone distribution provide another example of building a comprehensive, multipronged, community infrastructure. Many communities have recognized the need to make this potentially lifesaving medication more widely available.

For example, community leaders in Wilkes County, North Carolina, implemented Project Lazarus , a model that expands access to naloxone for law enforcement, emergency services, education, and health services, and reduced the county overdose rate by half within a year. North Carolina also passed a law in that implemented standing orders, allowing naloxone to be dispensed from a pharmacy without a prescription. States have also expanded training on naloxone use for opioid users and their families and friends, as well as for a wide range of social service agency personnel. Federal partners have been instrumental in expanding access to naloxone training.

A few states have passed legislation to make naloxone more readily available without a prescription if certain procedures are followed. This program was expanded to all interested pharmacies in and formalized in regulation in States have also expanded naloxone coverage under Medicaid. The CDC reported more than 26, overdose reversals by lay people between and , all using naloxone. The need to engage individuals in services to address their opioid use is a critical next step following an overdose reversal. This becomes increasingly challenging as naloxone kits are distributed widely, rather than when distribution is limited to health care and substance use disorder treatment providers.

In , the State of Vermont implemented an innovative treatment system with the goal of increasing access to opioid treatment throughout the state. The result has been: , A key finding from this chapter is that the traditional separation of specialty addiction treatment from mainstream health care has created obstacles to successful care coordination.

Research is needed in three main areas:. In each of these areas, research is needed on the development of interventions and strategies for successfully implementing them. Outcomes for each model should include feasibility, substance use and other health outcomes, and cost. Although a great deal of research has shown that integrating health care services has potential value both in terms of outcomes and cost, only a few models of integration have been empirically tested. Mechanisms through the Affordable Care Act make it possible to provide and test innovative structural and financing models for integration within mainstream health care.

This research should cover the continuum of care, from prevention and early intervention to treatment and recovery, and will help health systems move forward with integration. This research should explore innovative delivery models including telemedicine and other health IT, as well as health or wellness coaching. Studies should focus on patient-centered approaches and should address appropriate interventions for individuals across race and ethnicity, culture, language, sex, sexual orientation, gender identity, disability, health literacy, and for those living in rural areas.

So as not to limit health care systems to services for those with mild or moderate substance misuse problems and to offer support for individuals with severe problems who are not motivated to go to specialty substance use disorder treatment, it is also important to study how to implement medication and other evidence-based treatments across diverse health care systems. This chapter pointed out that when substance use problems become severe, providing ongoing, chronic care is required, as is the case for many other diseases.

Little research has studied chronic care models for the treatment of substance use disorders. Research is needed to develop and test innovative models of care coordination and their implementation. This research should use a more broadly defined workforce in both health care and substance use disorder treatment, develop models to share information electronically, and support coordination of care between health systems using health IT.

Finally, the chapter pointed out the gap in our understanding of how to implement models of care coordination between specialty addiction treatment organizations and social service systems, which provide important wrap-around services to substance use disorder patients. Many models are in existence, but have not been empirically tested. This area of research should involve institutions that provide services to individuals with serious co-occurring problems specialty mental health agencies , individuals with legal problems criminal justice agencies and drug courts , individuals with employment or other social issues, as well as the larger community, determining how to most effectively link each of these subpopulations with a recovery-oriented systems of care.

They can be run by private, government, non-profit, or for-profit agencies and organizations. Turn recording back on. National Center for Biotechnology Information , U. Search term. Chapter 6 Preview Services for the prevention and treatment of substance misuse and substance use disorders have traditionally been delivered separately from other mental health and general health care services. Efforts are needed to support integrating screening, assessments, interventions, use of medications, and care coordination between general health systems and specialty substance use disorder treatment programs or services.

Supported scientific evidence indicates that closer integration of substance use-related services in mainstream health care systems will have value to both systems. Substance use disorders are medical conditions and their treatment has impacts on and is impacted by other mental and physical health conditions. Integration can help address health disparities, reduce health care costs for both patients and family members, and improve general health outcomes. Supported scientific evidence indicates that individuals with substance use disorders often access the health care system for reasons other than their substance use disorder.

Many do not seek specialty treatment but they are over-represented in many general health care settings. Promising scientific evidence suggests that integrating care for substance use disorders into mainstream health care can increase the quality, effectiveness, and efficiency of health care. Many of the health home and chronic care model practices now used by mainstream health care to manage other diseases could be extended to include the management of substance use disorders.

The Affordable Care Act also requires non-grandfathered individual and small group market plans to cover services to prevent and treat substance use disorders. Health care delivery organizations, such as health homes and accountable care organizations ACOs , are being developed to better integrate care.

The roles of existing care delivery organizations, such as community health centers, are also being expanded to meet the demands of integrated care for substance use disorder prevention, treatment, and recovery. Use of Health IT is expanding to support greater communication and collaboration among providers, fostering better integrated and collaborative care, while at the same time protecting patient privacy. It also has the potential for expanding access to care, extending the workforce, improving care coordination, reaching individuals who are resistant to engaging in traditional treatment settings, and providing outcomes and recovery monitoring.

Supported evidence indicates that one fundamental way to address racial and ethnic disparities in health care is to increase the number of people who have health insurance coverage. Well-supported evidence shows that the current substance use disorder workforce does not have the capacity to meet the existing need for integrated health care, and the current general health care workforce is undertrained to deal with substance use-related problems.

Diverse health care systems have many roles to play in addressing our nation's substance misuse and substance use disorder problems, including: Screening for substance misuse and substance use disorders;. Delivering prevention interventions to prevent substance misuse and related health consequences;. Coordinating care across both health care systems and social services systems including criminal justice, housing and employment support, and child welfare;.

Health Care Settings Health care systems are made up of diverse health care organizations ranging from primary care, specialty substance use disorder treatment including residential and outpatient settings , mental health care, infectious disease clinics, school clinics, community health centers, hospitals, emergency departments, and others. Workforce Just as a diversity of health care settings is needed to meet the needs of patients, a diversity of health care professionals is also critical.

Structural and Financing Models A range of promising health care structures and financing models are currently being explored for integrating general health care and substance use disorder treatment within health care systems, as well as integrating the substance use disorder treatment system with the overall health care system. Technology Integration Technology can play a key role in supporting these integrated care models. The Promise of Integration When health care is not well integrated and coordinated across systems, too many patients fall through the cracks, leading to missed opportunities for prevention or early intervention, ineffective referrals, incomplete treatment, high rates of hospital and emergency department readmissions, and individual tragedies that could have been prevented.

Intensive, hour-a-day services delivered in a hospital setting. A Growing Impetus for Integration An integrated system of prevention, early intervention, treatment, and recovery that can address the full spectrum of substance use-related health problems is a logical and necessary shift that our society must make to prevent substance misuse and its consequences and meet the needs of individuals with substance use disorders. Medicaid Expansion under the Affordable Care Act To more broadly cover uninsured individuals, the Affordable Care Act includes a provision that allows states to expand Medicaid coverage.

Reasons Why Integrating Substance Use Disorder Services and Mainstream Health Care Is Necessary A number of strong arguments underpin the growing momentum to integrate substance use disorder services and mainstream health care. A number of other realities support the need for integration: 63 Substance use, mental disorders, and other general medical conditions are often interconnected;. Integration has the potential to reduce health disparities;. Integration can lead to improved health outcomes through better care coordination.

Health Systems and Opioids Physician prescribing patterns, patient drug diversion selling, sharing, or using medications prescribed for another person , and doctor shopping behaviors have all contributed to the ongoing opioid overdose epidemic. Substance Use Disorders, Mental Disorders, and Other Medical Conditions Are Interconnected Many individuals who come to mainstream health care settings, such as primary care, obstetrics and gynecology, emergency departments, and hospitals, also have a substance use disorder.

Integration Can Lead to Improved Health Outcomes through Better Care Coordination Treatment of substance use disorders has historically been provided episodically, when a person experiences a crisis or a relapse occurs. Quality and Performance Measurement and Accountability Publicly available quality measurement information helps consumers, health care purchasers, and other groups make informed decisions when choosing services, providers, and care settings. An evidence-based prevention intervention focused on women who are at risk for an alcohol-exposed pregnancy because of risky drinking and not using contraception consistently and correctly.

A study of a computerized screening and brief intervention in both Spanish and English used in a public health center's obstetrics-gynecology department was shown to be feasible and accepted by patients. A small trial of Latino heavy drinkers compared culturally adapted motivational interviewing to motivational interviewing that was not culturally adapted. The trial suggested stronger results for the culturally adapted program. A study comparing rural and urban differences in screening for substance use disorders in mental health clinics did not find significant differences in screening outcomes.