Re-Considering Addiction Treatment. Have We Been Thinking Correctly?

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1 Re-Considering Addiction Treatment Have We Been Thinking Correctly?

2 Part I FDA standards of effectiveness Do substance abuse treatments meet those standards?

3 An FDA Perspective A Drug is Approved for An Indication 2 -Randomized Clinical Trials: Often ask for separate investigators Placebo Control: Movement to test vs approved medication Treatment Research Institute

4 Therapies Cognitive Behavioral Therapy Motivational Enhancement Therapy Community Reinforcement and Family Training Behavioral Couples Therapy Multi Systemic Family Therapy 12-Step Facilitation Individual Drug Counseling

5 Medications Alcohol (Disulfiram, Naltrexone, Accamprosate) Opiates (Naltrexone, Methadone, Buprenorphine) Cocaine (Disulfiram, Topiramate) Marijuana (Rimanoban) Methamphetamine Nothing Yet

6 The Specialty Care System A Customer Perspective Patient Survey Care Provided Infrastructure

7 The Alcohol Pyramid In Spec Treatment 1,800,000 Abuse/Dependent 18,000,000 Harmful Users??,000,000

8 13,200 specialty programs in US 31% treat less than 200 patients per year 65% private, not for profit 80% primarily government funded Private insurance <12% Sources NSSATS, 2002; D Aunno, 2004

9 Referral Sources Source Criminal Justice 38% 59% Employers/EAP 10% 6% Welfare/CPS 8% 16% Hosp/Phys 4% 3%

10 Sources: 4 Review Articles Rapp et al. JSAT 2005 Stanton JMFT 2004 Appel et al. AJDA 2004 Tsogia et al. JMH 2001

11 Top Patient Reasons 1) No Problem/Can Handle 58% 2) No Confidence in Trt 51% 3) Bad Trt Experience 36% 4) Abstinence-Only Goal 31%

12 Won t programs deliver quality CAN T care?

13 Four Reasons a. The Infrastructure b. The Acute Care Model c. The Way it is Evaluated d. The State as the Only Market

14 Phone Interviews With National Sample of 175 Programs regarding personnel, management, information McL, Carise & Kleber JSAT, 2003

15 The Treatment System Modality Residential 64% 39% 9% Outpatient 27% 59% 79% Methadone 9% 10% 12%

16 Program Changes In 16 Months: 12% had closed 13% had changed service operation RESULT 25% FEWER PROGRAMS 31% of the rest had been taken over, usually by MH agencies RESULT STAFF CONFUSION

17 STAFF TURNOVER! Counselor turnover 50% per year 50% of directors have been there Less Than 1 year

18 Who Are the Directors? 17% No College Education 58% Had BA Degree 20% Had a MA or MSW 2 Physicians in 175 programs 28% NOT Working Full Time Most had been program

19 Information Systems: Modest Computer Availability Mostly For Administrative Work 80% Had a Computer 50% had Web Access Still very little computer/software availability for CLINICAL STAFF

20 Other Staff 54% Had no physician 34% Had P/T physician 39% Had a Nurse (part of full time) < 25% Had a SW or a Psychologist Major professional group - Counselors

21 Regulations for license & certification All 50 states and Washington, D.C. Both substance abuse and mental health counselors

22 Substance Abuse Mental Health No Degree required 13% 0% < BA min 77% 2% Masters min 10% 98%

23 The Acute Care Model Treatment Models for Other Illnesses

24 A Nice Simple Rehab Model Substance Abusing Patient Medications, Treatment Therapies, NTOMS Sample of 250 Programs JCAHO, CARF, WC Ev. Based Prac. Non- Substance Abusing Patient

25 ASSUMPTIONS Some fixed amount or duration of treatment will resolve the problem Clinical efforts put toward correctly placing patients and getting them to complete treatment Evaluation of effectiveness should occur following completion Poor outcome means failure

26 How Do Other Treatments Work? Chronic Illness & Continuing Care

27 A Continuing Care Model Primary Care Specialty Care Primary Continuing Care

28 In Chronic Illnesses. 1 The effects of treatment do not last very long after care stops 2 Patients who are out of treatment/contact are at elevated risk for relapse

29 So, For Treatment. 1 One goal is to retain patients at an appropriate level of care and monitoring 2 Another goal is to prepare patients to do well in the next level of care 3 - The effects of treatment are evaluated during treatment not post-discharge

30 But Addiction Isn t Like Other Diseases

31 A Comparison With Three Chronic Medical Illnesses Hypertension Diabetes Asthma

32 Why These? No Doubt They Are Illnesses All Chronic Conditions Influenced by Genetic, Metabolic and Behavioral Factors No Cures - But Effective Treatments Are Available

33 Heritability Estimates Twin Studies Eye Color 1.00 ASTHMA (adult only) DIABETES (insulin dep) HYPERTENSION ALCOHOL (dependence) OPIATE (dependence) (males) (males) (males) (males)

34 HYPERTENSION Adherence to medication regime: < 60% Adherence to diet and exercise: < 30% Retreated in 12 months: 50-60% (by Physician, ER, or Hospital) Treatment Research Institute

35 DIABETES (Adult Onset) Adherence to medication regime: < 50% Adherence to diet and exercise: < 30% Retreated in 12 months: 30-50% (by Physician, ER, or Hospital) Treatment Research Institute

36 ASTHMA Adherence to medication: < 30% Retreated in 12 months: 60-80% (by Physician, ER, or Hospital) Treatment Research Institute

37 RELAPSE Predictive Factors - All 3 Illnesses #1 - Lack of Adherence to diet, medications, or behavior change #2 - Low Socioeconomic status #3 - Low Family Supports #4 - Psychiatric Co-Morbidity Sources: Natl Ctr Health Stats; Harrison, 13th Ed.; 30+ studies

38 Implications of How We Evaluate I Differences in Outcome Expectations

39 If many or most cases of addiction are really chronic then: 1) We may be evaluating the effectiveness of addiction treatments in the wrong way.

40 Studies show few differences between Brief and Intensive Treatments Inpatient and Outpatient Treatments Conceptually Different Treatments Matched and Mismatched Trt. Gender or Culturally Oriented Trt.

41 Outcome In Hypertension Pre During During During Post Treatment Research Institute

42 Outcome In Addiction Pre During During During Post Treatment Research Institute

43

44 Studies show few differences between Brief and Intensive Treatments Inpatient and Outpatient Treatments Conceptually Different Treatments Matched and Mismatched Trt. Gender or Culturally Oriented Trt.

45 Serving the Customer Helping the Counselor

46 Demands on Counselor Do Comprehensive Assessement Develop Individual Treatment Plan Provide Services to Meet Needs of Patient Be Culturally and Gender Sensitive

47 Computer Assisted System for Patient Assessment and Referral CASPAR Start with Computer Assisted ASI Reduced training & administration time Generates, state forms, JCAHO narrative and treatment plan Add Free or Low Cost Service Referral From United Way s First Call for Help Easy match of services to problems

48 Problem-Services Linkage Alcohol Drugs Medical Employment Family Psychiatric Legal Treatment Research Institute From United Way GED training Resume Development Job Finding Mentoring Sessions Training Loans

49 Problem-Services Linkage Alcohol Drugs Medical Employment Family Psychiatric Legal Treatment Research Institute From United Way Domestic Violence Parenting Skills Specialized Babysitting Safe Housing Legal Aid

50 Results of CASPAR Training Counselors now get ASI Now seen as part of engagement They love United Way services Most counselors use it for most patients Many counselors use it themselves Patients who get more services stay longer

51 Mean Number of Services Received Standard Group Enhanced Group D/A Med Emp Legal Family Psych

52 Percent Retained at 30 Days Extra 68% 39% Standard 20

53 Percent Retained at 60 Days Extra 49% Standard %

54 Average Percent Positive Extra 9% 16% * trend Standard

55 Regulating Treatment Process Vs Purchasing Results

56 13,200 programs in US 65% private, not for profit 80% primarily government funded Private insurance <12% 31% treat less than 200 patients per year Sources NSSATS, 2002; D Aunno, 2004

57 State of Delaware Performance Contracting

58 Delaware Situation Outpatient Providers Limited Budget No success with outcome evaluation Providers won t/can t use EBPs

59 Delaware s Performance Based Contracting 2002 Budget 90% of 2001 Budget Opportunity to Make 106% One Criterion: Active Participation Audit for accuracy and access

60 Delaware s Results Years 1 & 2 One program lost contract Two new providers entered, did well Mental Health and Employment Programs Programs worked together First, common sense business practices Second, incentives for teams or counselors 5 programs learned MI and MET

61 Utilization Average Daily Census

62 % Attending >30 days >60 days

63 Philadelphia Contracting for Public Health Value Eliminating Detox-Only

64 40 70% of all Addiction Treatment Episodes are Detox-Only Cost $1,750 - $2,400 per episode Re-Detox only tracked by 7 states Average = 40% (23 78% range) 28% admitted 3+ times/yr 2000 Inspector Gen Report

65 Inpatient Detoxification: 1-year Follow-Up Davison et al., J. Add. Dis. 25, 2006 Treatment Research Institute

66 Inpatient Detoxification Short Term Results 92 completed All prescribed Opt. Care & Naltrex. 20 left AMA 73 Attended 1 or more sessions 65% 25 Still Attending at 60 Days 22% 5 Opiate free at 90 days 3% John Davison et al., J. Add Dis. 25(4), 2006

67 Inpatient Detoxification 1-Year Results 92 Completed Detoxification 23 Readmitted for Detox 21% 21 Admitted to ER 19% 5 Died 5% John Davison et al., J. Add Dis. 25(4), 2006

68 State is the market for D-O State could make market for continuity 85% Detox-only reimbursement 115% Detox+5 sessions of OPT 100% Detox + 5 days Residential

69 Specialty care system is in trouble Customers Do Not Want the Product Ruled by Gov, Not Market Forces System Change is Necessary Public Health Value thru Patient Value Purchasers CAN Treatment Programs MUST Change Meet Customer Needs Offer New Options

70 Specialty care system is in trouble Customers Do Not Want the Product Ruled by Gov, Not Market Forces System Change is Necessary Public Health Value thru Patient Value Purchasers CAN Treatment Programs MUST Change Meet Customer Needs Offer New Options

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