Re-Considering Addiction Treatment Have We Been Thinking Correctly?
Part I FDA standards of effectiveness Do substance abuse treatments meet those standards?
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
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
Medications Alcohol (Disulfiram, Naltrexone, Accamprosate) Opiates (Naltrexone, Methadone, Buprenorphine) Cocaine (Disulfiram, Topiramate) Marijuana (Rimanoban) Methamphetamine Nothing Yet
The Specialty Care System A Customer Perspective Patient Survey Care Provided Infrastructure
The Alcohol Pyramid In Spec Treatment 1,800,000 Abuse/Dependent 18,000,000 Harmful Users??,000,000
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
Referral Sources Source 1990 2004 Criminal Justice 38% 59% Employers/EAP 10% 6% Welfare/CPS 8% 16% Hosp/Phys 4% 3%
Sources: 4 Review Articles Rapp et al. JSAT 2005 Stanton JMFT 2004 Appel et al. AJDA 2004 Tsogia et al. JMH 2001
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%
Won t programs deliver quality CAN T care?
Four Reasons a. The Infrastructure b. The Acute Care Model c. The Way it is Evaluated d. The State as the Only Market
Phone Interviews With National Sample of 175 Programs regarding personnel, management, information McL, Carise & Kleber JSAT, 2003
The Treatment System Modality 1975 1990 2005 Residential 64% 39% 9% Outpatient 27% 59% 79% Methadone 9% 10% 12%
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
STAFF TURNOVER! Counselor turnover 50% per year 50% of directors have been there Less Than 1 year
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 clinicians @ program
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
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
Regulations for license & certification All 50 states and Washington, D.C. Both substance abuse and mental health counselors
Substance Abuse Mental Health No Degree required 13% 0% < BA min 77% 2% Masters min 10% 98%
The Acute Care Model Treatment Models for Other Illnesses
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
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
How Do Other Treatments Work? Chronic Illness & Continuing Care
A Continuing Care Model Primary Care Specialty Care Primary Continuing Care
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
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
But Addiction Isn t Like Other Diseases
A Comparison With Three Chronic Medical Illnesses Hypertension Diabetes Asthma
Why These? No Doubt They Are Illnesses All Chronic Conditions Influenced by Genetic, Metabolic and Behavioral Factors No Cures - But Effective Treatments Are Available
Heritability Estimates Twin Studies Eye Color 1.00 ASTHMA (adult only).35 -.70 DIABETES (insulin dep) HYPERTENSION ALCOHOL (dependence) OPIATE (dependence).70 -.95 (males).25 -.50 (males).55 -.65 (males).35 -.50 (males)
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
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
ASTHMA Adherence to medication: < 30% Retreated in 12 months: 60-80% (by Physician, ER, or Hospital) Treatment Research Institute
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
Implications of How We Evaluate I Differences in Outcome Expectations
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.
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.
Outcome In Hypertension 10 8 6 4 2 0 Pre During During During Post Treatment Research Institute
Outcome In Addiction 10 8 6 4 2 0 Pre During During During Post Treatment Research Institute
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.
Serving the Customer Helping the Counselor
Demands on Counselor Do Comprehensive Assessement Develop Individual Treatment Plan Provide Services to Meet Needs of Patient Be Culturally and Gender Sensitive
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
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
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
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
Mean Number of Services Received 14 12 10 8 6 4 2 0 Standard Group Enhanced Group D/A Med Emp Legal Family Psych
Percent Retained at 30 Days 80 60 40 Extra 68% 39% Standard 20
Percent Retained at 60 Days 70 50 Extra 49% Standard 30 10 12%
Average Percent Positive 20 15 10 5 0 Extra 9% 16% * trend Standard
Regulating Treatment Process Vs Purchasing Results
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
State of Delaware Performance Contracting
Delaware Situation 2002 11 Outpatient Providers Limited Budget No success with outcome evaluation Providers won t/can t use EBPs
Delaware s Performance Based Contracting 2002 Budget 90% of 2001 Budget Opportunity to Make 106% One Criterion: Active Participation Audit for accuracy and access
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
Utilization 6500 6000 Average Daily Census 5500 5000 4500 4000 3500 3000 2001 2002 2003 2004 2005
% Attending 80 70 >30 days >60 days 60 50 40 30 20 2001 2002 2003 2004 2005
Philadelphia Contracting for Public Health Value Eliminating Detox-Only
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
Inpatient Detoxification: 1-year Follow-Up Davison et al., J. Add. Dis. 25, 2006 Treatment Research Institute
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
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
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
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
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