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What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C....

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What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003
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Page 1: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

What’s Wrong WithAddiction Treatment?

A. Thomas McLellanNADAAC Presentation

Washington, D.C.September 15, 2003

Page 2: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC 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

Page 3: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Problem 1

How We Treat It

Page 4: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

A Nice Simple Rehab Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

Meds,Therapies,Services

Page 5: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• Treatment Has Not Met Public’s Expectations – There is No Cure

• Treatments CAN Work But…… Patients Do Not Cooperate

Page 6: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 7: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 8: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Maybe We Have the Wrong

Model?

Page 9: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

How Are Other Illnesses Treated & Evaluated?

Page 10: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Why Isn’t Addiction More Like Other Illnesses?

Implications for Evaluation and Treatment

Lessons learned from Chronic Illnesses

Page 11: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

A Comparison With Three Chronic Medical Illnesses

Hypertension

Diabetes

Asthma

Page 12: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 13: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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)

Page 14: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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)

Page 15: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Adherence to medication: < 30%

Treatment Research Institute

ASTHMA

Retreated in 12 months: 60 - 80%

(by Physician, ER, or Hospital)

Page 16: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 17: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• Different Goals for Each Stage

• Different Components in Each Stage

• Last Stages Depend on the Success of the First Stages

Page 18: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

A Nice Simple Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

Page 19: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

An Ideal Model – No Discharge

Substance Abusing Patient

Regular “Performance” Eval

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

Page 20: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

A More Typical Model

Detox- Only Admissions

42% of Philadelphia Episodes @ $750 - $1500 each

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

Page 21: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

A Desirable Model

Continuing Care / MonitoringEarly Detection of Relapse

20% of Philadelphia Episodes

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

Page 22: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Problem 2

How We Evaluate It

Page 23: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Why Does Treatment Seem So Ineffective?

Page 24: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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.

Page 25: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

0

2

4

6

8

10

Pre During During During Post

Treatment Research Institute

Outcome In Hypertension

Page 26: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

0

2

4

6

8

10

Pre During During During Post

Treatment Research Institute

Outcome In Addiction

Page 27: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Rehabilitation Model

“.. treatment benefits should be sustained following discharge for addiction treatment to be worth it …”

(McLellan,1998).

Page 28: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Comparing Treatments

Testing Three Treatments in a Rehabilitation Model

Treatment Research Institute

Page 29: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 30: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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%

Page 31: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Improvement in Project MATCH

81

53

230

10

20

30

40

50

60

70

Baseline 6-Mo 39-Mo

% Days Drinking

Page 32: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Maybe We Have the Wrong

Model?

Again….

Page 33: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

0

2

4

6

8

10

Pre During During During Post 1 Post 2 Post 3

Comparing Rehabilitation Treatments

0

2

4

6

8

10

Pre During During During Post 1 Post 2 Post 3

Treatment

Control

Page 34: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Points

Evaluate during – not after – treatment

We may be missing important effects because of our evaluation model

Page 35: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Comparing Treatments

Testing Three Treatments in a Continuing Care Model

Treatment Research Institute

Page 36: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

ALLHAT

The Antihypertensive and Lipid-Lowering Treatment to

Prevent Heart Attack

Treatment Research Institute

Page 37: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 38: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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%

Page 39: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Improvement Comparison

22

8053

39

64

23

0

10

20

30

40

50

60

70

Baseline Yr 1 Yr 3

ALLHAT MATCH

Page 40: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

An Ideal Model – No Discharge

Substance Abusing Patient

Regular “Performance” Eval

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

Page 41: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 42: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Problem 3

The National TreatmentInfrastructure

Page 43: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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.

Page 44: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

* When delivered by qualified professionals, using proven medications and therapies, applied for adequate durations and followed by monitoring.

Page 45: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

So, Is Contemporary

Treatment Structured

to Be Effective ?

Page 46: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• Results of Initial Work on the National Treatment Outcomes Monitoring System (NTOMS)

• Leadership Management

• Staffing Information

Page 47: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 48: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• 50-60% of directors have been there Less Than 1 year

• Counselor turnover is 50% per year

Program Survey - 2

STAFF TURNOVER!

Page 49: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 50: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 51: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 52: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 53: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Thank You For Sharing!

Page 54: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Can Research Help?

• Using Technology to Improve Retention & Participation

Page 55: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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.

Page 56: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

DENS-Resource Guide

Page 57: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 58: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 59: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 60: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 61: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 62: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Findings

Page 63: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Hypothesis 1Patients of Extra Training counselorswill receive more and better-matched services.

Page 64: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

11

4

7

1

3

10

5

1 0 0 1 1

02468

101214

D/A Med Emp Legal Family Psych

Enhanced Group Standard Group

Mean Number of Services Received

Page 65: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Hypothesis 2

Patients of Extra Training counselors:will remain in treatment longer.

Page 66: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Percent Retained at 30 Days

68%

39%

20

40

60

80

Extra Standard

Page 67: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Percent Retained at 60 Days

49%

12%10

30

50

70

Extra Standard

Page 68: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Unexpected Finding

Counselors who received the Extra Training:

Remained on the job longer.

Page 69: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Percent Who Quit by 6 Months

20%

60%

10

30

50

70Extra Standard

Page 70: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.
Page 71: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Lessons

Addiction Can Learn from Chronic Care

Page 72: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 73: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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

Page 74: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• Most Patients Do NOT Respond to Their First Treatment/Medication

• Need for more alternatives

• Improves retention

• Monitoring is Part of Health Care

Page 75: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• Monitoring is Part of Health Care

• Telephone and IVR Useful

• Saves Physician Time, Reduces Number and Severity of Relapses

• Not Currently Reimbursed

Page 76: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• Evaluations of Continuing Care Should Occur DURING Treatment

•Need for interim performance markers (retention, linkage, urines, pro-social behaviors, etc.)

Page 77: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

Lessons

Chronic Care Can Learn from Addiction Treatment

Page 78: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

• 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

Page 79: What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003.

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