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Re-Considering Addiction Treatment Have We Been Thinking Correctly?
Re-ConsideringAddiction Treatment
Have We Been ThinkingCorrectly?
• FDA standards of effectiveness
• Do substance abuse treatmentsmeet those standards?
Part I
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 SystemA “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 ArticlesRapp 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 qualitycare?
CAN’T
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 NationalSample of 175 Programs regardingpersonnel, 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%
• 12% had closed
• 13% had changed service operationRESULT – 25% FEWER PROGRAMS
• 31% of the rest had been taken over,usually by MH agenciesRESULT – STAFF CONFUSION
Program Changes In 16 Months:
• Counselor turnover
50% per year
• 50% of directorshave been thereLess Than 1 year
STAFF TURNOVER!
17% No College Education
58% Had BA Degree20% Had a MA or MSW
2 Physicians in 175 programs
28% NOT Working Full Time
• Most had been clinicians @ program
Who Are the Directors ?
• Modest Computer Availability
– Mostly For Administrative Work
– 80% Had a Computer
– 50% had Web Access
• Still very little computer/softwareavailability for CLINICAL STAFF
Information Systems:
Other 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
Regulations for license & certification
All 50 states and Washington, D.C.
Both substance abuse and mentalhealth counselors
Substance Mental
Abuse Health
No Degree required 13% 0%
< BA min 77% 2%
Masters min 10% 98%
• The Acute Care Model
• Treatment Models for OtherIllnesses
A Nice Simple Rehab Model
NTOMS Sample of250 Programs
Treatment
Substance Abusing Patient
Non- Substance Abusing Patient
Medications,Therapies,JCAHO, CARF, WC
Ev. Based Prac.
ASSUMPTIONS• Some fixed amount or duration of
treatment will resolve the problem
• Clinical efforts put toward correctlyplacing patients and getting them tocomplete treatment
• Evaluation of effectiveness shouldoccur following completion
– Poor outcome means failure
How Do Other
Treatments Work?
Chronic Illness &Continuing Care
A Continuing Care Model
PrimaryContinuing Care
Primary Care
Specialty 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 elevatedrisk 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’tLike Other Diseases
A Comparison With ThreeChronic Medical Illnesses
Hypertension
Diabetes
Asthma
Why These?
No Doubt They Are Illnesses
All Chronic Conditions
Influenced by Genetic, Metabolicand Behavioral Factors
No Cures - But EffectiveTreatments Are Available
ASTHMA (adult only) .35 - .70
DIABETES (insulin dep) .70 - .95 (males)
HYPERTENSION .25 - .50 (males)
Heritability EstimatesTwin Studies
ALCOHOL (dependence) .55 - .65 (males)
OPIATE (dependence) .35 - .50 (males)
Eye Color 1.00
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
• Implications of How We Evaluate
• Differences in OutcomeExpectations
I
If many or most cases ofaddiction are really chronic then:
1) We may be evaluating theeffectiveness of addictiontreatments in the wrong way.
Studies show fewdifferences between…
• Brief and Intensive Treatments
• Inpatient and Outpatient Treatments
• Conceptually Different Treatments
• “Matched” and “Mismatched” Trt.
• Gender or Culturally Oriented Trt.
0
2
4
6
8
10
Pre During During During Post
Treatment Research Institute
Outcome In Hypertension
0
2
4
6
8
10
Pre During During During Post
Treatment Research Institute
Outcome In Addiction
Studies show fewdifferences 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 ofPatient
Be Culturally and GenderSensitive
Computer Assisted System forPatient Assessment and Referral
CASPAR• Start with Computer Assisted ASI
– Reduced training & administration time
– Generates, state forms, JCAHO narrativeand 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
Treatment Research Institute
•Alcohol
•Drugs
•Medical
•Employment
•Family
•Psychiatric
•Legal
GED training
Resume Development
Job Finding
Mentoring Sessions
Training Loans
From United Way
Problem-Services Linkage
Treatment Research Institute
•Alcohol
•Drugs
•Medical
•Employment
•Family
•Psychiatric
•Legal
Domestic Violence
Parenting Skills
Specialized Babysitting
Safe Housing
Legal Aid
From United Way
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
0
2
4
6
8
10
12
14
D/A Med Emp Legal Family Psych
Standard Group Enhanced Group
Mean Number of Services Received
Percent Retained at 30 Days
68%
39%
20
40
60
80
Extra Standard
Percent Retained at 60 Days
49%
12%10
30
50
70
Extra Standard
Average Percent Positive
9%
16%
0
5
10
15
20
Extra Standard
*trend
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 PerformanceBased Contracting
• 2002 Budget – 90% of 2001 Budget
• Opportunity to Make 106%
• One Criterion: Active Participation
• Audit for accuracy and access
Delaware’s ResultsYears 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
3000
3500
4000
4500
5000
5500
6000
6500
Av
era
ge
Da
ily
Cen
sus
2001 2002 2003 2004 2005
% Attending
20
30
40
50
60
70
80
2001 2002 2003 2004 2005
>30 days >60 days
Philadelphia
Contracting for PublicHealth 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 DetoxificationShort 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 Detoxification1-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
• Treatment Programs MUST Change
– Meet Customer Needs – Offer New Options
Purchasers CAN
• 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
• Treatment Programs MUST Change
– Meet Customer Needs – Offer New Options
Purchasers CAN
