1 Treatment Delivery Systems as a Public Health Approach to the Population Management of Substance Use Disorders Thomas F. Babor, Ph.D., MPH Dept of Community Medicine & Health Care University of Connecticut School of Medicine Farmington, CT USA
2 McLean Asylum for the Insane
3 WHO Global Strategy (2010) (a) leadership, awareness and commitment (b) health services response (c) community action (d) drink driving policies and countermeasures (e) availability of alcohol (f) marketing of alcoholic beverages (g) pricing policies (h) reducing the negative consequences of drinking and alcohol intoxication (i) reducing the public health impact of illicit alcohol and informally produced alcohol (j) monitoring and surveillance
4 First most commonly used treatment settings for alcohol use disorders in the world World N= % 1.5% Specialized treatment services General health services Mental health services Primary health care 34.6% Other 39.8% 14.3%
5 QUESTIONS and CHALLENGES Arising from the Global Strategy Can systems concepts contribute to reduce the gap between population needs and the current availability of substance abuse services? How can treatment services be made more accessible to those in need? How best to utilize primary health care to provide more appropriate services and linkage to specialized care? What can be done to build stronger community support networks (e.g., AA, family social clubs)? To what extent can mental health and general medical services be better integrated with formal treatment?
6 Service System An arrangement of facilities, programs, and personnel designed to function in a coordinated way Includes linkages between specialized care and other types of services, such as mental health, general medicine, social welfare, criminal justice and mutual help organizations
7 Why a systems perspective? Services for substance use disorders expanded dramatically in developed countries in the 1960 s but often in a fragmented and arbitrary way. Resource allocation decisions and treatment policies have a major effect on the development of SUD services, but there is little knowledge to guide service planning Or to indicate whether services achieve their public health objectives Low and middle income countries are investing in services as prevalence rates increase, so system-level analysis may be helpful as a planning tool.
8 Conceptual Model of Population Impact Treatment Policies Planning Financing Monitoring Workforce development Criminal justice Mental health Social welfare Structural Resources Facilities Programs Personnel System Qualities Equity Efficiency Economy Effectiveness Population Health Moderating Factors Case Mix Social Capital Drinking/drug use cultures Policies System Characteristics Effectiveness Population Impact
9 Functions of SUD Service System Care Cure Control Secondary prevention Primary prevention
10 Common Problems in Organization of Services: Can a Systems Perspective Solve Them? Inadequate Services Inaccessible Services Unaffordable Services Underutilized Services Fragmented Services Discontinuous Services
11 Service System Qualities Equity acceptability, appropriateness, accessibility to population subgroups Efficiency coordination of services to meet population needs: referral, diagnosis, detox, rehab, after-care, mutual help Economy organization of available services to minimize cost and maximize effectiveness
12 Equity In South Africa, a study found inequitable access to substance abuse treatment services among poor, with non-need factors mainly determining utilization (Myers et al., 2010)
13 Efficiency: Findings from Largescale Treatment Matching Studies Project MATCH The Dept. of Veterans Affairs Effectiveness study UKATT
14 Clinical Implications of Large Scale Matching Research Trials The decision to enter treatment is associated with considerable reductions in drinking The value of different types of treatment may be to convince clients that treatment is going to help them A key ingredient of the success of any therapy may be its ability to attract clients and generate enthusiasm among therapists Access to treatment may be as important as the type of treatment
15 Implications for treatment systems The Technology Model of (psychotherapy) treatment effectiveness may be flawed Instead of distinct, non-overlapping elements, therapy may work through common mechanisms, such as empathy, an effective therapist-client alliance, a desire to change, inner resources, a supportive social network, and the provision of a culturally appropriate solution to a socially defined problem.
16 Implications for Finding the Holy Grail Look for matching in larger populations at the level of communities or treatment systems, where a wider range of settings and therapeutic interventions can be evaluated Study how formal treatment and mutual help societies alter the long-term drinking career and accelerate the natural recovery process Consider the population-level impact of treatment as well as individual effects Investigate ways to increase access to treatment through resource allocation as well as individual marketing
17 Efficiency: focus on treatment process elements like waiting time Are improvement collaboratives capable of improving efficiency? Improvement collaborative methods, especially coaching, can decrease waiting time, improve treatment retention, and increase recruitment of new patients (Gustafson et al., in press).
18 Efficiency of treatment process Humphreys and McLellan (2011, Addiction) found that process improvements can change the efficiency of treatment programs, but the link to better outcomes is weak, in part because outcomes are mainly influenced by environmental factors and life events outside of formal treatment.
19 Other system characteristics System density: The number of services available for those in need System Integration: The amount of interconnectedness among the organizations in a network
20 System Integration Drug courts SBIRT (Screening, Brief Intervention, Referral to Treatment) Integrated treatment programs for pregnant drug users Managed care
21 Drug Courts Increase social controls and duration of treatment Reduce crimminal behavior Lower rates of recidivism
22 Screening, Brief Intervention, and Referral to Treatment Raise the Issue Conduct Screening No/Low Risk Negative Screen Positive Screen High-Risk or Risky Substance Use Individual screening scores determined to assess level of risk Brief Intervention Brief Treatment Risk Continues Referral to Treatment Risk Continues Risk Continues Motivational Counseling Specialist Treatment Risk Reduced Risk Reduced Risk Reduced Follow-up Follow-up Follow-up
23 Growth of SBIRT Worldwide Finland: 2 nation-wide projects ongoing (Seppä & Kuokkanen, 2008) Norway/ Denmark: SBI not working with doctors (Aasland & Johannesen, 2008; Barfod, 2008) Catalonia: Extensive training and support (Funk et al., 2005) South Africa: Difficult to implement in PHC (Peltzer et al., 2008) Brazil: Some success in PHC (Souza-Formigoni et al., 2008) USA: Demonstration programs in 20+ states
24 Integrated treatment programs Integrated women s programs providing pregnancy and parenting services associated with improvements in child development (Niccols et al., 2012)
25 FROM EFFECTIVENESS TO POPULATION EFFECTS Research on efficacy and effectiveness suggests: Treatment and early intervention can: a) improve psychiatric, medical and employment outcomes, b) reduce alcohol and drug use Treatment of drug abuse may have supply side effects Treatment may affect the social ecology of families and communities Can the additive effects of prevention, early intervention and treatment services reduce population rates of alcohol and drug problems? Can the integrative effects of prevention, early intervention and treatment systems reduce population rates of alcohol and drug problems?
26 Conceptual Model of Population Impact Treatment Policies Planning Financing Monitoring Workforce development Criminal justice Mental health Social welfare Structural Resources Facilities Programs Personnel System Qualities Equity Efficiency Economy Effectiveness Population Health Moderating Factors Case Mix Social Capital Drinking/drug use cultures Policies System Characteristics Effectiveness Population Impact
27 Population Impact: Drug Treatment Growth in availability of Opioid Mainenance Treatment is associated with reductions in illicit opiate use, crime and HIV risk behaviors in UK, France, Norway, USA (Bukten et al. 2011; Marsch, 1998)
28 Research on population effects of alcohol treatment Mann et al (1992) increases in the proportion of alcoholics in treatment linked to decreases in liver cirrhosis morbidity Holder and Parker (1992) - increases in treatment linked to declines in cirrhosis mortality Smart and Mann (2003) increases in AA membership and amount of treatment linked to decreased alcohol problems
29 System Planning Needs There are currently no objective, validated methods for measuring the extent, quality and integration of services for substance use disorders No way to determine whether current services are meeting population needs No methods to demonstrate accountability Planning often based on ideology, fads, personal and professional preferences rather than public health considerations
30 Functions of the WHO SAIMS (Substance Abuse Instrument for Mapping Services) Assessment/description of syste)m Evaluation of system fit with population needs for substance abuse services, including gaps in services Planning of new services, re-allocation of resources Monitoring of changes as system develops Comparative analysis within and across national boundaries
31 Treatment System Development Levels Level I. Minimal/fragmentary Level II. Rudimentary: Some specialised services in medical and psychiatric settings and some delivered in primary care settings Level III Modest. A variety of services delivered in most settings and some regional coordination and planning Level IV Mature. A variety of integrated services in a range of settings
32 Configuration of the SAIMS field test instrument 1. Core instrument 2. Optional supplements, such as population planning module, qualitative module
33 SAIMS Domains Policy and legislative framework, inc. cost Existing alcohol and drug services Management in primary care Human resources and workforce training Linkages with other services Monitoring and research capabilities
34 Toward a Public Health Approach TRADITIONAL Acute care Treat disorder Accountable for individual patients Fill treatment slots Separate programs Case management PUBLIC HEALTH Continuum of care Health promotion/ disease prevention Accountable for defined populations Provide care at most appropriate level Integrated delivery systems
35 Population Health Care Management Defined by geographic boundaries as well as age, sex and other characteristics Allocation of resources to preventive, curative, restorative and rehabilitative services Design interventions and monitor services for entire population Organize providers into networks Shift utilization to lower cost settings or most appropriate level of care
36 Benefits of a systems approach Improve access, efficiency, economy, effectiveness, continuity of care, thereby improving the population impact of treatment services. Focus attention on components having greatest impact on morbidity and mortality Draw attention to cost implications Guide allocation of scarce resources
37 The Hartford Retreat established 1822
38 Conceptual Model of Alcohol/Drug Specialist Treatment and Its Connections With Other Sectors Mental Health Drinking Driving Work Place Programs Primary Care Harm Reduction Self -Change Alcohol/Drug Specialty Treatment Mutual Help Organizations Criminal Justice Social Service General Medicine Chronic Disease Treatment Emergency Trauma Services