Post on 11-Jan-2016
transcript
What’s Wrong WithAddiction Treatment?
A. Thomas McLellanNADAAC Presentation
Washington, D.C.September 15, 2003
Three Problems
1) How We Treat It:Acute vs Continuing Care
2) How We Evaluate It:As Though we Have a
Cure
3) Treatment Infrastructure:Can it Support
Expectations
Problem 1
How We Treat It
A Nice Simple Rehab Model
NTOMS Sample of 250 Programs
Treatment
Substance Abusing Patient
Non- Substance Abusing Patient
Meds,Therapies,Services
• Treatment Has Not Met Public’s Expectations – There is No Cure
• Treatments CAN Work But…… Patients Do Not Cooperate
Treatment Compliance Is Low
• 85% of all treatment in US is Outpatient
• About 60% of outpatients drop out of treatment within one month.
• Even court-ordered patients do not complete treatment
Relapse Rates Are High
About 60% use drugs within 6 mos. following treatment discharge
No difference between Brief and Intensive Treatments
No difference between Inpatient and Outpatient Treatments
Maybe We Have the Wrong
Model?
How Are Other Illnesses Treated & Evaluated?
Why Isn’t Addiction More Like Other Illnesses?
Implications for Evaluation and Treatment
Lessons learned from Chronic Illnesses
A Comparison With Three Chronic Medical Illnesses
Hypertension
Diabetes
Asthma
Why These Illnesses?
No Doubt They Are Illnesses All Chronic Conditions Influenced by Genetic, Metabolic
and Behavioral Factors No Cures - But Effective
Treatments Are Available
Adherence to medication regime: < 60%
Adherence to diet and exercise: < 30%
Treatment Research Institute
HYPERTENSION
Retreated in 12 months: 50 - 60%
(by Physician, ER, or Hospital)
Adherence to medication regime: < 50%
Adherence to diet and exercise: < 30%
Treatment Research Institute
DIABETES (Adult Onset)
Retreated in 12 months: 30 - 50%
(by Physician, ER, or Hospital)
Adherence to medication: < 30%
Treatment Research Institute
ASTHMA
Retreated in 12 months: 60 - 80%
(by Physician, ER, or Hospital)
Predictive Factors - All 3 Illnesses
RELAPSE
#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
• Different Goals for Each Stage
• Different Components in Each Stage
• Last Stages Depend on the Success of the First Stages
A Nice Simple Model
NTOMS Sample of 250 Programs
Treatment
Substance Abusing Patient
Non- Substance Abusing Patient
An Ideal Model – No Discharge
Substance Abusing Patient
Regular “Performance” Eval
HospitalDetox
ResidentialRehab
IOPRehab
OutpatientCont Care
AA -TeleMonitoring
TeleMonitoring
A More Typical Model
Detox- Only Admissions
42% of Philadelphia Episodes @ $750 - $1500 each
HospitalDetox
ResidentialRehab
IOPRehab
OutpatientCont Care
AA -TeleMonitoring
TeleMonitoring
A Desirable Model
Continuing Care / MonitoringEarly Detection of Relapse
20% of Philadelphia Episodes
HospitalDetox
ResidentialRehab
IOPRehab
OutpatientCont Care
AA -TeleMonitoring
TeleMonitoring
Problem 2
How We Evaluate It
Why Does Treatment Seem So Ineffective?
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.
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Pre During During During Post
Treatment Research Institute
Outcome In Hypertension
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Pre During During During Post
Treatment Research Institute
Outcome In Addiction
Rehabilitation Model
“.. treatment benefits should be sustained following discharge for addiction treatment to be worth it …”
(McLellan,1998).
Comparing Treatments
Testing Three Treatments in a Rehabilitation Model
Treatment Research Institute
Project MATCH
• RCT - 3 Research-Derived Therapies• $27 Million Dollar NIAAA Study
• Different Mechanisms of Action
• Fixed Interventions – No Changes
• Goal – Achieve Lasting Abstinence or Improved Drinking Post Completion
MET
CBT
12-Step
Project Match Fixed Time - Fixed Content – Rehab Oriented
6 12 18 24 30 39
Treatment Type
Post Treatment Evaluations
45% 38% 27%
Improvement in Project MATCH
81
53
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70
Baseline 6-Mo 39-Mo
% Days Drinking
Maybe We Have the Wrong
Model?
Again….
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Pre During During During Post 1 Post 2 Post 3
Comparing Rehabilitation Treatments
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Pre During During During Post 1 Post 2 Post 3
Treatment
Control
Points
Evaluate during – not after – treatment
We may be missing important effects because of our evaluation model
Comparing Treatments
Testing Three Treatments in a Continuing Care Model
Treatment Research Institute
ALLHAT
The Antihypertensive and Lipid-Lowering Treatment to
Prevent Heart Attack
Treatment Research Institute
ALLHAT
• Groups – Explicitly Different Mechanisms of Action and Cost
• Diuretic - $0.10 /pill• Calcium Channel Blocker - $1.50 /pill• ACE Inhibitor - $4.00 /pill
Goal – to Reach Pre-Specified Criterion DURING TREATMENT
Treatment Research Institute
Diuretic
CCB
ACE
ALLHAT Pre-Specified Criteria – Adjustment Oriented
Step 1 Step 2 Step 3Start
27% Control
DURING Treatment Evaluations
40%
42%
44% 54%
56%
54%
64%
66%
63%
Improvement Comparison
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8053
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64
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Baseline Yr 1 Yr 3
ALLHAT MATCH
An Ideal Model – No Discharge
Substance Abusing Patient
Regular “Performance” Eval
HospitalDetox
ResidentialRehab
IOPRehab
OutpatientCont Care
AA -TeleMonitoring
TeleMonitoring
Considerations for Addiction
• There are Promising, complementary Treatments
• Medications, therapies, services
• Adaptive Strategies are Feasible and Consistent With Care Management
• Switching - Given bad results or no acceptance
• Supplementing - Given sub-optimal results
Problem 3
The National TreatmentInfrastructure
20 Years of Research Shows Treatment Is
Effective*
* When delivered by qualified professionals, using empirically validated medications and
therapies, applied for adequate durations and followed by monitoring and maintenance.
* When delivered by qualified professionals, using proven medications and therapies, applied for adequate durations and followed by monitoring.
So, Is Contemporary
Treatment Structured
to Be Effective ?
• Results of Initial Work on the National Treatment Outcomes Monitoring System (NTOMS)
• Leadership Management
• Staffing Information
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
Program Survey - 1
• 50-60% of directors have been there Less Than 1 year
• Counselor turnover is 50% per year
Program Survey - 2
STAFF TURNOVER!
Program Survey - 4Who Are the Directors ?
• 17% No College Education 58% Had BA Degree20% Had a MA or MSW
• 28% NOT Working Full Time
• Most had been clinicians @ program
Program Survey - 5Other Staff :
• 54% Had no physician 34% Had P/T physician39% Had a Nurse (part of full time)
• < 25% Had a SW or a Psychologist
• Major professional group - Counselors
Admission Process:
• No Standard Procedure or Instrument
–Total process often 3 hours–15 – 20% Don’t Do Assessment
• No Use of/for Assessment
–“Simply Paperwork”
Program Survey - 6
Information Systems:
• Improved Computer Availability– Mostly For Administrative/Fiscal Work
– 80% Had a Computer
– 50% had Web Access
• Still very little computer/software availability for CLINICAL STAFF
Program Survey - 7
Thank You For Sharing!
Can Research Help?
• Using Technology to Improve Retention & Participation
Background
The JCAH-O wants to see customized treatment plans and “wrap-around” services:
BUT this can be time-consuming and costly
Counselors need help to efficiently locate necessary services.
DENS-Resource Guide
Site & Counselor Characteristics
• 10 Community Treatment Programs– All Required to Learn the ASI – by the state
• 5 Counselors per program– No experience with ASI previously
• 5 Admissions per counselor– Essentially random selection
Site & Counselor Characteristics
No significant differences to start:Among Programs – Very similar on the ATIAmong Counselors -
in ASI training, education, recovery status, tenure on jobAmong Patients – Demographics and ASI scores
SPLIT INTO TWO GROUPS ALL GET:A Computer With ASI Software InstalledTraining in Admission Interviewing (8 Hrs CEU)
HALF GET:Training on the United Way First Call for
Help to link ASI data to service availability
Problem-Services Linkage
Treatment Research Institute
•Alcohol
•Drugs
•Medical
•Employment
•Family
•Psychiatric
•Legal
GED training
Resume Development
Job Finding
Mentoring Sessions
Training Loans
(e.g. Employ - related services
Counselor Turnover• 50 Counselors
from 10 Programs
• Within 5 months, 19 counselors had been promoted, fired or just quit (38%)
28%
62%
Quit Study
Completed
Findings
Hypothesis 1Patients of Extra Training counselorswill receive more and better-matched services.
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101214
D/A Med Emp Legal Family Psych
Enhanced Group Standard Group
Mean Number of Services Received
Hypothesis 2
Patients of Extra Training counselors:will remain in treatment longer.
Percent Retained at 30 Days
68%
39%
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40
60
80
Extra Standard
Percent Retained at 60 Days
49%
12%10
30
50
70
Extra Standard
Unexpected Finding
Counselors who received the Extra Training:
Remained on the job longer.
Percent Who Quit by 6 Months
20%
60%
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30
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70Extra Standard
Lessons
Addiction Can Learn from Chronic Care
What Continuing Care Does NOT Imply
• Not Every Case of Substance Abuse Needs a Continuing Care Strategy
– Not Clear When to Shift from Acute– Also Not Clear in Other Illnesses
• A Continuing Care Strategy Does Not Imply Lack of Responsibility
– Just the Opposite – One Purpose is to Teach Self Management
What Continuing Care Does Imply• Need for Pre-Specified Treatment Goals
– Agreeable to the Patient, Measurable
• Need for Continuing Contact/Monitoring– Tailored to the severity and needs of the patient – Telephone and Internet Options
• Need for Multiple Options– Most First Efforts Will Fail – Hard to Predict– Sensible Switching or Adding Time Frames
• Most Patients Do NOT Respond to Their First Treatment/Medication
• Need for more alternatives
• Improves retention
• Monitoring is Part of Health Care
• Monitoring is Part of Health Care
• Telephone and IVR Useful
• Saves Physician Time, Reduces Number and Severity of Relapses
• Not Currently Reimbursed
• Evaluations of Continuing Care Should Occur DURING Treatment
•Need for interim performance markers (retention, linkage, urines, pro-social behaviors, etc.)
Lessons
Chronic Care Can Learn from Addiction Treatment
• Symptom Improvement Does Not Continue Without Behavioral Change
• Social Support and Counseling Alone Can Improve Symptoms and Function
• Poor, Psychiatrically Ill Patients CAN & DO Improve