National Standards of Care for Substance Abuse Disorders Compared to Actual Practices of Treatment Facilities

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1 National Standards of Care for Substance Abuse Disorders Compared to Actual Practices of Treatment Facilities ~ Frank Norton & Lindsay Harrison Abstract A pilot survey done of 19 inpatient and outpatient substance abuse treatment facilities in several Mid Atlantic states compared their clinical practice to national standards of care as defined by the National Institute on Drug Abuse (NIDA). American Society of Addictive Medicine criteria were also compared to each facility to determine if entrance requirements matched patient acceptance into their program. The researchers examined if each facility accepted co-morbid diagnosed patients and how they defined successful treatment. Gathered also was data on the length of their programs, relapse strategies and follow-up treatment. Results indicated a variation in patterns for staffing of these facilities, 37% used various strategies to protect staff from burnout, and 95% reported co-morbid mental health disorders in their patient populations. Reviewed also were their use of self-help groups, services provided, and roles of mental health professions, such as counselors, social workers, psychologist, nurses, and physicians. Key Words: Co-morbidity, practice guidelines, success rates, staffing, burnout Introduction The National Institute on Drug Abuse (NIDA, 2009) has proposed a standard of care that is optimal for treatment for those with substance abuse disorders. Over the past 10 years, their standard of care has been codified into 13 principles of treatment. Selected NIDA principles that were more objective and measurable were selected for inclusion in this survey. Also, those principles selected for inclusion in this survey were most important to focus on in order to get a better idea on which principles to look at in the next survey. Thus, the following three NIDA principles were reviewed: (1) For treatment to be effective, it must address the multiple needs of the client/patient, and not just look at his or her drug abuse; (2) At minimum, at least 90 days of intensive treatment is needed to start to adequately address the individual s issues, and (3) Many 19

2 Substance Abuse Disorder (SUD) individuals have other mental health disorders which are comorbid with their substance abuse disorders that also need to be assessed and treated including medications as needed (NIDA, 2009, pg. 11). These three NIDA principles advocate for the best care practice of patients. The first principle addresses the multiple needs such as housing, financial assistance, medical issues, child care, legal and other issues. The second principle notes that intensive outpatient and/or inpatient/residential care must, at a minimum, be 90 days or longer depending on the client s issues. The third principle focuses on the large overlap between mental health disorders and SUD which must be addressed to improve successful treatment. A search of the literature was then completed on existing practices for treatment of substance abuse disorders for concurrence with NIDA treatment guidelines. This included changing trends consistent with existing research findings on these three principles and whether treatment of SUD disorders consisted of treatment of co-morbid mental health disorders. What was revealed is that it is the exception to the rule that SUD and mental health disorders are treated simultaneously (Flynn & Brown, 2008; Parsons, Butters, & Nathan, 1987) over the past 20 years. Thus currently, there seems to be only a modest increase in the simultaneous treatment of dual diagnosed individuals. This is contrary to research studies reviewed suggesting that comorbid disorders are far more common than thought in the past (Sterling, Chi, & Hinman, 2011). As noted by NIDA (2007), our current health care delivery system is inefficient in treating SUD and mental illness concurrently. Health care providers such as psychologists and psychiatrists treat mental health disorders, whereas SUD disorders are treated separately by primarily a mixture of various providers such as counselors, social workers, and nurses. Complicating the 20

3 picture is that most SUD treatment facilities are not equipped or prepared to deal with co-morbid disorders (NIDA, 2007). Still prevalent is the belief that those who suffer from a dual diagnosed disorder should be treated separately although existing empirical data (NIDA, 2009) indicate both disorders should be treated simultaneously. The National Institute on Drug Abuse (NIDA, 2007) metaanalysis of studies suggests that 60% of substance abusers also have an existing mental health disorder. One study by Dingle & King (2009) found that 92% of 104 adults admitted to a substance abuse inpatient unit had a co-occurring psychiatric disorder, with the majority having a Major Depressive Disorder (57%). Other studies have found overlapping disorders such as Bipolar Disorder, Post Traumatic Stress Disorder (PTSD), and a history of sexual abuse overlapping with SUD disorders (Jones, Knutson, & Haines, 2003). What is needed for best treatment practices is to simultaneously treat co-morbid conditions for best treatment practices to improve patient care (Langas, Malt, & Opjordsmoen, 2011). A frequently found dual diagnosis (Baschnagel, Coffey, & Rash, 2006) with the SUD is Post Traumatic Stress Disorder. Thus, complicating treatment for substance abuse disorders is they frequently have multiple issues on-going at the same time (Parsons et al., 1987). Disorders also affecting treatment may include cognitive deficits due to drug abuse (Taper, Ozyurt, Myers, & Brown; 2004), history of trauma/sexual abuse, nutritional needs, legal problems, child care issues especially if they are women, and job and housing needs (Emerson, Amaro, & Nieves, 2009; Greenfield & Wolf-Branigin, 2009; Virmani, Binienda, Ali, & Gaetani, 2006). Method A list of over 400 SUD treatment facilities was given to graduate students in a drug and alcohol class. They were told to choose any site they wished and make an appointment to 21

4 interview a staff member at a SUD agency. Two mid Atlantic states and the District of Columbia were then visited to gather demographic data on the SUD treatment site. Data gathered included whether the SUD agency was either an inpatient, residential, and/or outpatient one and if they were classified as a non-profit or privately owned for profit agency. Also asked were the length of their program, how many clinical staff they employed, and the types of mental health professionals employed part-time/full-time such as psychologist, social workers, physicians/psychiatrists, counselors, nutritionists and nurses. Reviewed with the site was the number of SUD patients/clients the facility treated, whether they had co-morbid disorders such as depression, Post Traumatic Stress Disorder (PTSD), anxiety, bipolar, schizophrenia, and if they treated both SUD and co-morbid disorders at their agency. Other key demographic data collected were if they provided family counseling, self-help groups such as Alcoholics Anonymous/Narcotics Anonymous (AA/NA), and their estimated number of staff who may have experienced burn out. The demographic data collected was gleaned from the NIDA principles and ASAM admission criteria considered to be critical in successful treatment of SUD individuals. The demographic questionnaire had a total 35 questions. A total of 26 sites were visited by graduate students. One site refused to be interviewed for research and another 5 sites were discarded due to incomplete data collection leaving 19 sites with complete data sets. Graduate students gathered data by on-site interviews of staff at basically three types of facilities; that is, outpatient, inpatient and/or residential treatment facilities which were identified as treatment agencies for substance abusers. A sheet provided to the site in writing explained the purpose of the interview and that the researcher was available to clarify any questions regarding the research/interview. A structured interview was used by the graduate students to collect data. Each site was asked to provide literature, pamphlets, and/or 22

5 brochures which describe the services they provided, staffing, and the patient population they served such as adolescents, adults, females only, and/or dual diagnosed individuals. Data were then reviewed and collated by the second author of this paper. Results Of the total of 19 agencies visited with usable data, seventeen facilities (17) were nonprofit agencies and two (2) others were state owned and operated. Six (32%) were classified as outpatient treatment facilities, and thirteen (68%) were inpatient/residential facilities. Ten (53%) of the 19 substance abuse agencies had programs that meet NIDA criteria of being over 90 days in length with 5 of those being over 180 days in length. Awareness of having dual diagnosed patients/clients in their programs existed in 18 of the 19 programs; that is, 95% were acknowledging they had individuals with co-morbid mental health disorders in their respective patient population. Sixteen of the programs followed ASAM criteria for admission into their programs, 84% of the agencies visited. Of interest is that 49 of their counselors were in recovery themselves out of the approximately 146 part time and full time personnel working at their sites. The pilot survey found few of the facilities had any psychologists or psychiatrists on their staff. In fact, master s level counselors and/or social workers comprised the majority of the staffing for substance abuse agencies, while nurses were often available for medical issues. Burnout of staff was an issue acknowledged by 15 (79%) of the 19 agencies, although few had any programs in place to treat staff burnout. Reported means to deal with staff burnout included taking time off from work, long weekends off, team support of each other, and advising staff to take care of themselves. We found seven of the 19 agencies (37%) visited provided their mental health professionals with active training and/or counseling services to deal with burnout issues. Nutritionists were also found to be working in nine agencies (47%), thus recognizing the need to 23

6 also provide physical nutritional health care needs of their clientele in an effort to provide more comprehensive services. As noted in national trends, the number of counselors in recovery working in substance abuse facilities is decreasing. The number of master s level counselor staff is increasing over the years. A study of 547 substance abuse counselors in one state found that 42.2% of them had completed a graduate degree and another 8% had some doctoral work or and completed a doctorate (Culbreth & Borders, 1999). Therefore, it appears that SUD treatment is becoming more of a professional staffing field of master s level counselor as opposed to volunteers helping and/or bachelor s level individuals who are themselves in recovery being the primary care givers for substance abuser. Staffing is an issue at many SUD facilities. Physician/psychiatrist/psychologist staffing was found to be minimal in outpatient facilities, but who are often found in inpatient facilities for the treatment of mental health disorders. Most SUD facilities visited here were staffed by master s level personnel, primarily counselors and social workers who are trained to work with substance abuse issues and not deal with the mental health issues of their clients. SUD facilities visited seem to lack the resources to treat significant issues in their clients mental health. This is consistent with national trends. For example, one study found that PTSD may be as high as 60-80% in SUD individuals (Donovan & Padin-Rivera, 1999) yet resources are not available often to treat the co-morbid disorders together at the same time. Further, often found with PTSD are significant rates of childhood physical and/or sexual abuse (Najavits, Weiss, & Shaw, (1997). Specialized training is needed to deal with these co-morbid conditions. Few facilities offer the full range of NIDA services from screening, detoxification, treatment to include services such as nutrition, legal, child care, group, family, individual counseling, and wrap around services needed such as shelter, housing, job guidance and 24

7 connection. For many of those individuals, it is often difficult to stay in recovery if one does not have a means of obtaining an income. There is a trend towards more recognition that they are basically treating dual diagnosed with minimal resources or training in place to treat both comorbid conditions. It was also found that few programs had data on success rates, after care plans, relapse strategies, and/or follow up of program graduates which will be expanded in a future article. Discussion Multiple reasons exist for the lack of dual diagnosed care. Many are tied to lack of funding due to minimal medical insurance coverage for treatment or no insurance. This forces agencies to scramble for resources to provide the care needed by their clients (Sterling et al., 2011). One large scale study by the U.S. Department of Health and Human Services (2007) found that private insurance payments for substance abuse treatment have decreased over the ten year period of The end result is that the public sector is financing most of SUD treatment as private insurance levels drop over the years. Though addictions impact all segments of society, lack of health coverage for treatment places enormous demands on the publicly funded system and its workforce (U.S. Dept. of Health & Human Services, pg. 16). Integrated treatment care continues to be the exception and not the rule. Overlap between actual treatment practices and national standards of care in this study were found to be acknowledged by SUD treatment facilities who also stated they do not have the resources to implement comorbid treatment programs. Substance abusers tend to have complex issues that require comprehensive treatment (Tsai, Saylers, Rollins, McKasson, & Litmer, 2009). Optimal treatment guidelines that are empirically derived improve success rates. By combining treatment that looks at multiple needs of patients, such as a past history of abuse, co-occurring disorders 25

8 along with the substance abuse disorder, outcome success is improved (Greenfield & Wolf- Branigin, 2009). For SUD best practice, simultaneous treatment of all issues is needed (Langas et al., 2011). Better screening needs to be done to improve treatment (Perron, Bunger, Bender, Vaughn, & Howard, 2010). It is beyond the scope of this short research article to review each of the 13 principles of NIDA that were found. A follow up research article will expand on other principles not discussed in this Results Section. However, what can be said is that few facilities were found to follow most of the 13 principles of treatment as outlined by NIDA. There were many reasons why this is so. For one, medical insurance for substance abuse treatment is minimal compared to other medical conditions or even for mental health patient s coverage (U.S. Department of Health and Human Services, 2007). Reliance on grants and/or donations to keep their doors open is another problem agencies face. There seems to be difficulty in seasoned staff staying on due to burn out, low pay, long hours, and small staff support systems (Bride & Kintzle, 2011; Knudsen, Ducharme, & Roman, 2006). In order to be more comprehensive, most facilities visited used self-help groups such as AA/NA to provide services to their population. It is a low cost or no cost option for supplemental treatment. Limitations of this survey include few facilities visited, that is, 26 out of 400 SUD agencies, in a small geographical area of the Mid- Atlantic region of the United States. Therefore, generalizability of findings is limited. Also, the sample size was small. Future surveys will need to include larger samples that have a more equal distribution of inpatient, residential, and/or outpatient programs. 26

9 References Baschnagel, J., Coffey, S., & Rash, C. (2006). The treatment of co-occurring PTSD and substance use disorders using trauma-focused exposure therapy. International Journal of Behavioral Consultation and Therapy, 2 (4), Bride, B., & Kintzle, S. (2011). Secondary traumatic stress, job satisfaction, and occupational commitment in substance abuse counselors. Traumatology, 17(1), Culbreth, J., & Borders, D. (1999). Perceptions of the supervisory relationship: Recovering and nonrecovering substance abuse counselors. Journal of Counseling & Development, 77, Dingle, G., & King, P. (2009). Prevalence and impact of co-occurring psychiatric disorders on outcomes from a private hospital drug and alcohol treatment program. Mental Health and Substance Use: Dual diagnosis, 2 (1), Donova, B., & Padin-Rivera, E. (1999). Transcend: A program for treating PTSD and substance abuse in Vietnam combat veterans. NC-PTSD Clinical Quarterly, 8 (3), Emerson, G., Amaro, H., & Nieves, R. (2009). Unhealthy weight gain during treatment for alcohol and drug use in four residential programs for Latina and African American women. Substance Use & Misuse, 44, Flynn, B., & Brown, B. (2008). Co-occurring disorders in substance abuse treatment: Issues and prospects. Journal of Substance Abuse Treatment, 34, Greenfield, L., & Wolf-Branigin, M. (2009). Mental health indicator interaction in predicting substance abuse treatment outcomes in Nevada. The American Journal of Drug and Alcohol Abuse, 35, Jones, E., Knutson, D., & Haines, D. (2003). Common problems in patients recovering from chemical dependency. American Family Physician. 68 (10), Knudsen, H., Ducharme, L., & Roman, P. (2006). Counselor emotional exhaustion and turnover intention in therapeutic communities. Journal of Substance Abuse Treatment, 31, Langas, A., Malt, U., & Opjordsmoen, S., (2011). Comorbid mental disorders in substance users from a single catchment area a clinical study. BMC Psychiatry. 1 (25),

10 Najavits, L.M., Weiss, R.D., & Shaw, S.R. (1997). The link between substance abuse and posttraumatic stress disorder in women: A research review. The American Journal on Addictions, 6, National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research guide, 2 nd Ed., National Institute of Health, U.S. Dept. of Health & Human Services,1-80, NIH Publication No National Institute on Drug Abuse. (2007). Comorbid drug abuse and mental illness. Topics in Brief, October. Parsons, O., Butters, N., & Nathan, P. (1987): Neuropsychology of alcoholism: Implications for diagnosis and treatment. New York: The Guilford Press. Perron, B., Bunger, A., Bender, K., Vaughn, M., & Howard, M. (2010). Treatment guidelines for substance use disorders and serious mental illnesses: Do they address co-occurring disorders. Substance Use & Misuse, 45, Sterling, S., Chi, F., & Hinman, A. (2011). Integrating care for people with co-occurring alcohol and other drug, medical, and mental health conditions. Alcohol Research and Health, 33 (4), Taper, S., Ozyurt, S., Myers, M., & Brown, S. (2004). Neuropsychological ability in adults coping with alcohol and drug relapse temptations. American Journal of Drug and Alcohol Abuse, 30, Tsai, J., Saylers, M., Rollins, A., McKasson, M., & Litmer, M. (2009). Integrated dual-disorders treatment. Journal of community psychology, 37 (6), U.S. Department of Health and Human Services (2007). Substance Abuse and Mentla Health Services Administration, Report to Congress, Addictions Treatment Workforce Development, Virmani, A., Binienda, Z., Ali, S., & Gaetani, F. (2006). Links between nutrition, drug abuse, and the metabolic syndrome. Annals New York Academy of Sciences, 1074,

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