integrated substance abuse programs bridges have been built: is anyone using them? richard a....
TRANSCRIPT
Integrated Substance Abuse Programs
Bridges have been built: Bridges have been built: Is anyone using them? Is anyone using them?
Richard A. Rawson, Ph.D, ProfessorRichard A. Rawson, Ph.D, Professor
Supported by:Supported by: National Institute on Drug Abuse (NIDA) National Institute on Drug Abuse (NIDA)
Pacific Southwest Technology Transfer Center (SAMHSA) Pacific Southwest Technology Transfer Center (SAMHSA) United Nations Office of Drugs and Crime United Nations Office of Drugs and Crime
The Problem in 1996The Problem in 1996
The US Substance Abuse Research and The US Substance Abuse Research and Treatment Systems each spend billions of Treatment Systems each spend billions of dollars per year on the problem of dollars per year on the problem of substance abuse treatment.substance abuse treatment.
However, the efforts have traditionally However, the efforts have traditionally been completely disconnected. Despite been completely disconnected. Despite over 30 years of research findings, most over 30 years of research findings, most treatment services are based on practices treatment services are based on practices developed during the 1950s and 1960s.developed during the 1950s and 1960s.
U.S. Agencies Involved with Substance U.S. Agencies Involved with Substance Abuse Research and TreatmentAbuse Research and Treatment
Research AgenciesNIH
National Institutes of Health
NIDANational Institute on Drug Abuse
NIAAANational Institute on Alcohol Abuse & Alcoholism
U.S. Agencies Involved with Substance U.S. Agencies Involved with Substance Abuse Research and TreatmentAbuse Research and Treatment
Service Agencies
SAMHSASubstance Abuse, Mental Health Services Administration
CSATCenter for Substance Abuse Treatment
CSAPCenter for Substance Abuse Prevention
Traditional “Culture” of U.S. Traditional “Culture” of U.S. Substance Abuse Substance Abuse RESEARCHRESEARCH
SystemSystem
University-based, academic personnelUniversity-based, academic personnel Minimal community involvementMinimal community involvement Treatment viewed condescendinglyTreatment viewed condescendingly Publish data in professional journalsPublish data in professional journals Little systematic attempt to transfer Little systematic attempt to transfer
knowledgeknowledge Topics of research omit clinical concernsTopics of research omit clinical concerns
Traditional “Culture” of U.S. Substance Traditional “Culture” of U.S. Substance Abuse Abuse SERVICESERVICE Delivery System Delivery System
Recovering/paraprofessional staffRecovering/paraprofessional staff Minimal connections with academic traditionMinimal connections with academic tradition Personal ideology determines treatment Personal ideology determines treatment
choiceschoices Generally anti-medicationGenerally anti-medication Uneven and inadequate treatment fundingUneven and inadequate treatment funding Little attention to dataLittle attention to data Science viewed as irrelevantScience viewed as irrelevant
““Bridging the Gap”: A Benchmark Bridging the Gap”: A Benchmark
Institute of Medicine (1998). S. Lamb, Institute of Medicine (1998). S. Lamb, M.R. Greenlick, & D. McCarty, D. (Eds.), M.R. Greenlick, & D. McCarty, D. (Eds.), Bridging the gap between practice and Bridging the gap between practice and researchresearch: Forging partnerships with : Forging partnerships with community-based drug and alcohol community-based drug and alcohol treatmenttreatment. Washington, DC: National . Washington, DC: National Academy Press.Academy Press.
THE NATIONAL INSTITIUTE ON THE NATIONAL INSTITIUTE ON DRUG ABUSE (NIDA) CLINICAL DRUG ABUSE (NIDA) CLINICAL
TRIALS NETWORK (CTN)TRIALS NETWORK (CTN)www.nida.nih.gov/CTNwww.nida.nih.gov/CTN
NIDA Clinical Trials Network (CTN)NIDA Clinical Trials Network (CTN)
MissionMission
The mission of the Clinical Trials Network (CTN) is to improve the quality of The mission of the Clinical Trials Network (CTN) is to improve the quality of drug abuse treatment throughout the country using science as the vehicle.drug abuse treatment throughout the country using science as the vehicle.
The CTN provides an enterprise in which the National Institute on Drug The CTN provides an enterprise in which the National Institute on Drug Abuse, treatment researchers, and community-based service providers Abuse, treatment researchers, and community-based service providers cooperatively develop, validate, refine, and deliver new treatment options cooperatively develop, validate, refine, and deliver new treatment options to patients in community-level clinical practice. This unique partnership to patients in community-level clinical practice. This unique partnership between community treatment providers and academic research leaders between community treatment providers and academic research leaders aims to achieve the following objectives:aims to achieve the following objectives:
Conducting studies of behavioral, pharmacological, and integrated Conducting studies of behavioral, pharmacological, and integrated behavioral and pharmacological treatment interventions of therapeutic behavioral and pharmacological treatment interventions of therapeutic effect in rigorous, multi-site clinical trials to determine effectiveness across effect in rigorous, multi-site clinical trials to determine effectiveness across a broad range of community-based treatment settings and diversified a broad range of community-based treatment settings and diversified patient populations; and patient populations; and
Ensuring the transfer of research results to physicians, clinicians, Ensuring the transfer of research results to physicians, clinicians, providers, and patients. providers, and patients.
The NIDA CTN: What is it?The NIDA CTN: What is it?
Network OrganizationNetwork Organization The CTN framework consists of seventeen The CTN framework consists of seventeen Nodes Nodes
(Regional Research and Training Centers, linked with (Regional Research and Training Centers, linked with five to ten or more Community-based Treatment five to ten or more Community-based Treatment programs), a Clinical Coordinating Center, and a Data programs), a Clinical Coordinating Center, and a Data and Statistical Center. and Statistical Center.
This allows the CTN to provide a broad and powerful This allows the CTN to provide a broad and powerful infrastructure for rapid, multi-site testing of promising infrastructure for rapid, multi-site testing of promising science-based therapies and the subsequent delivery of science-based therapies and the subsequent delivery of these treatments to patients in community-based these treatments to patients in community-based treatment settings across the country.treatment settings across the country.
The Pacific Node of the CTNThe Pacific Node of the CTN
The Pacific Region Node is a partnership The Pacific Region Node is a partnership between the Regents of the University of between the Regents of the University of California, Los Angeles and several community California, Los Angeles and several community treatment programs in the State. treatment programs in the State.
The Pacific Node incorporates researchers and The Pacific Node incorporates researchers and clinicians from throughout California. Many of clinicians from throughout California. Many of the clinical networks have been involved in the the clinical networks have been involved in the transfer of research into practice for over a transfer of research into practice for over a decadedecade
NIDA CTN: How does it work?NIDA CTN: How does it work?
Research concepts are generated at each Research concepts are generated at each of the Nodes after discussion between of the Nodes after discussion between researchers and clinicians.researchers and clinicians.
These concepts are proposed to the CTN These concepts are proposed to the CTN group and are voted on. Those receiving group and are voted on. Those receiving highest vote go to director of NIDA for highest vote go to director of NIDA for approval.approval.
Pacific Region Protocol Pacific Region Protocol InvolvementInvolvement
PROTOCOL0001 PROTOCOL0001 Buprenorphine/NaloxoneBuprenorphine/Naloxone for Opiate Detoxification - for Opiate Detoxification - INpatientINpatient
PROTOCOL0002 PROTOCOL0002 Buprenorphine/NaloxoneBuprenorphine/Naloxone for Opiate Detoxification - for Opiate Detoxification - OUTpatientOUTpatient
PROTOCOL0004 PROTOCOL0004 Motivational Enhancement Treatment (MET)Motivational Enhancement Treatment (MET)
PROTOCOL0006 PROTOCOL0006 Motivational Incentives - Drug Free Clinics Motivational Incentives - Drug Free Clinics
PROTOCOL0007 PROTOCOL0007 Motivational Incentives - Methadone Clinics Motivational Incentives - Methadone Clinics
PROTOCOL0008 PROTOCOL0008 A Baseline for Investigating Diffusion of InnovationA Baseline for Investigating Diffusion of Innovation
Pacific Region Protocol Pacific Region Protocol InvolvementInvolvement
PROTOCOL0009 PROTOCOL0009 Smoking Cessation Treatment With Smoking Cessation Treatment With TransdermalTransdermal Nicotine Replacement Therapy In Substance Abuse Re Nicotine Replacement Therapy In Substance Abuse Rehabilitation Programs habilitation Programs
PROTOCOL0012 PROTOCOL0012 Characteristics of Screening, Evaluation, and Treatment Characteristics of Screening, Evaluation, and Treatment of HIV/AIDS, Hepatitis C Viral Infection, and Sexually Traof HIV/AIDS, Hepatitis C Viral Infection, and Sexually Transmitted Infections in Substance Abuse Treatment Progrnsmitted Infections in Substance Abuse Treatment Programs ams
PROTOCOL0014 PROTOCOL0014 Brief Strategic Family Therapy (BSFT) For Adolescent DrBrief Strategic Family Therapy (BSFT) For Adolescent Drug Abusersug Abusers
Pacific Region Protocol Pacific Region Protocol InvolvementInvolvement
PROTOCOL0018 PROTOCOL0018 Reducing HIV/STD Risk Behaviors: A Research Study foReducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment r Men in Drug Abuse Treatment
PROTOCOL0019 PROTOCOL0019 Reducing HIV/STD Risk Behaviors: A Research Study foReducing HIV/STD Risk Behaviors: A Research Study for Women in Drug Abuse Treatment r Women in Drug Abuse Treatment
PROTOCOL0027 PROTOCOL0027 Starting Treatment with Agonist Replacement Therapies Starting Treatment with Agonist Replacement Therapies – START– START
PROTOCOL0030 PROTOCOL0030 Prescription Prescription OpioidOpioid Addiction Treatment Study (POATS) Addiction Treatment Study (POATS)
CTN: StrengthsCTN: Strengths
Has provided a true forum for researchers and Has provided a true forum for researchers and clinicians to interact cooperatively and clinicians to interact cooperatively and collaborativelycollaboratively
Has generated a significant amount of new Has generated a significant amount of new published researchpublished research
Research and surrounding publications do Research and surrounding publications do appear to be promoting some transfer of appear to be promoting some transfer of research to practice in CTN-affiliated treatment research to practice in CTN-affiliated treatment organizationsorganizations
Annual “Blending” Conference and JournalAnnual “Blending” Conference and Journal
CTN: Limitations (opinion)CTN: Limitations (opinion)
Extremely expensiveExtremely expensive Extremely bureaucratic and committee Extremely bureaucratic and committee
heavyheavy Productivity not commensurate with Productivity not commensurate with
budgetbudget Bi-directionality of effort is only moderately Bi-directionality of effort is only moderately
successful (mostly researcher driven)successful (mostly researcher driven) Impact on the larger US treatment system Impact on the larger US treatment system
is unknownis unknown
Running the Trials is not enoughRunning the Trials is not enough
Diffusion of Innovations. 4Diffusion of Innovations. 4thth Edition Edition Everett M. Everett M. RogersRogers - 1995 - New York: - 1995 - New York:
Free Press Free Press
Research QuestionsResearch Questions
NIDA’s CTN offers an important opportunity NIDA’s CTN offers an important opportunity to examine if and how inter-organizational to examine if and how inter-organizational relationships promote innovation adoptionrelationships promote innovation adoption Focus on buprenorphine and voucher-based Focus on buprenorphine and voucher-based
motivational incentivesmotivational incentives Are CTPs in the CTN protocols significantly Are CTPs in the CTN protocols significantly
more likely to adopt bup and/or vouchers?more likely to adopt bup and/or vouchers? Is “trialability” a predictor of adoption?Is “trialability” a predictor of adoption?
Does membership in the CTN confer Does membership in the CTN confer advantages to CTPs that are not involved in advantages to CTPs that are not involved in these protocols?these protocols? Is “exposure” a predictor of adoption?Is “exposure” a predictor of adoption?
Adoption of BuprenorphineAdoption of Buprenorphine
46.0%
16.0%11.1%
0%
20%
40%
60%
CTPs in Trial Other CTPs Non-CTN
CTPs that participated in the buprenorphine trials CTPs that participated in the buprenorphine trials were significantly more likely to have adopted were significantly more likely to have adopted buprenorphine than CTPs not in the trials and non-buprenorphine than CTPs not in the trials and non-CTN centersCTN centers
Logistic Regression Model of Logistic Regression Model of Buprenorphine AdoptionBuprenorphine Adoption
Controlling for other organizational factors:Controlling for other organizational factors: CTPs in the buprenorphine protocols were 5.2 times more likely CTPs in the buprenorphine protocols were 5.2 times more likely
to use buprenorphine (at the 6-month follow-up) than non-CTN to use buprenorphine (at the 6-month follow-up) than non-CTN programs (p<.01)programs (p<.01)
Other significant predictors, net of effects of CTN Other significant predictors, net of effects of CTN exposure:exposure:
Center offers detox services (O.R. = 3.59)Center offers detox services (O.R. = 3.59) Center has a physician on staff or contract (O.R. = 3.94)Center has a physician on staff or contract (O.R. = 3.94) The percentage of primary opiate clients (O.R. = 1.009)The percentage of primary opiate clients (O.R. = 1.009)
Adoption of Voucher-Based Adoption of Voucher-Based Motivational IncentivesMotivational Incentives
44.4%
32.8% 31.2%
0%
20%
40%
60%
CTPs in Trial Other CTPs Non-CTN
These differences in adoption were not These differences in adoption were not statistically significantstatistically significant
DiscussionDiscussion The ability to compare CTN vs. non-CTN The ability to compare CTN vs. non-CTN
centers provides a unique opportunity to centers provides a unique opportunity to examine a variety of factors that influence examine a variety of factors that influence innovative behavior and the adoption of innovative behavior and the adoption of evidence-based practices at the organizational evidence-based practices at the organizational level.level.
The longitudinal design of these studies will The longitudinal design of these studies will allow for observation of continued trends in allow for observation of continued trends in adoption of these techniques.adoption of these techniques.
Future research is planned to examine the use Future research is planned to examine the use of MET and motivational interviewing in CTN of MET and motivational interviewing in CTN and non-CTN samples.and non-CTN samples.
From a clinical trial to technology From a clinical trial to technology transfertransfer
S. Kellogg, M. Burns, P. Coleman, M. Stitzer, J. S. Kellogg, M. Burns, P. Coleman, M. Stitzer, J. Wale, M. Jeanne Kreek, M.D.Wale, M. Jeanne Kreek, M.D.
Something of value: The introduction of Something of value: The introduction of contingency management interventions into contingency management interventions into the New York City Health and Hospital the New York City Health and Hospital Addiction Treatment Service. Addiction Treatment Service.
Journal of Substance Abuse Treatment, 2005, Journal of Substance Abuse Treatment, 2005, Volume 28, Issue 1, Pages 57-65Volume 28, Issue 1, Pages 57-65
The NIDA The NIDA Methamphetamine Clinical Methamphetamine Clinical
Trials Group (MCTG)Trials Group (MCTG)
MCTG: The ProblemMCTG: The Problem
NIDA has a desire to speed up the development of NIDA has a desire to speed up the development of medications for the treatment of methamphetamine use medications for the treatment of methamphetamine use disorders. disorders.
Too few research groups available in areas of the US Too few research groups available in areas of the US with extensive methamphetamine use.with extensive methamphetamine use.
As complexity of medication testing and regulatory As complexity of medication testing and regulatory system becomes more complex it is difficult for new system becomes more complex it is difficult for new investigators to initiate researchinvestigators to initiate research
MCTG: The SolutionMCTG: The Solution Establish a training/coordinating center to train, Establish a training/coordinating center to train,
organize and monitor sites.organize and monitor sites. Establish a set of medication testing sites in Establish a set of medication testing sites in
regions with extensive methamphetamine use regions with extensive methamphetamine use and an MD and team that can conduct trials.and an MD and team that can conduct trials.
Decide on a medication(s) and protocol for studyDecide on a medication(s) and protocol for study Initiate studiesInitiate studies
Methamphetamine Clinical Trials Methamphetamine Clinical Trials GroupGroup
UCLA is the coordinating center for UCLA is the coordinating center for clinical studies clinical studies
5 Sites participate on a contractual 5 Sites participate on a contractual basisbasis
Primary focus-reduction of Primary focus-reduction of methamphetamine usemethamphetamine use
All trials use a behavioral platform All trials use a behavioral platform for all treated subjectsfor all treated subjects
San Diego, CA
South Bay Treatment Center
Joseph Mawhinney, PI
Division of Treatment Research & Development 19 September 2000
Methamphetamine Clinical Trials Group(MCTG)
Costa Mesa, CA
Friends Research Institute
Michael McCann, PI
Des Moines, IA Powell Chemical Dependency Center
Dennis Weis, PI
Kansas City, MO
University of Missouri, Kansas City
Services, Inc.
Jan Campbell, PIHonolulu, HI
John A. Burns School of
Medicine & Queens Hospital
William Haning, PI
Los Angeles, CA
UCLA Coordinating Center
Richard Rawson, PI
MCTG StudiesMCTG Studies Behavioral Platform Study (Completed Oct, Behavioral Platform Study (Completed Oct,
2002). (N=60)2002). (N=60) Ondansetron Study ( Completed Dec 1, 2003. Ondansetron Study ( Completed Dec 1, 2003.
(N=120(N=120 Bupropion Study (Completed June 1, 2005) Bupropion Study (Completed June 1, 2005)
(N=120)(N=120) Topirimate Study (Underway, projected Topirimate Study (Underway, projected
completion, April 1, 2007 (N=120)completion, April 1, 2007 (N=120) Modafinal Study (Projected to begin April 2007)Modafinal Study (Projected to begin April 2007)
MCTG: AccomplishmentsMCTG: Accomplishments
Transferred state-of-the-art clinical trials Transferred state-of-the-art clinical trials methods to clinical sites with no previous methods to clinical sites with no previous research experience.research experience.
Successful conducted 3 studies to date Successful conducted 3 studies to date with one (bupropion) showing significant with one (bupropion) showing significant promisepromise
Sites now are capable of applying for Sites now are capable of applying for independent research fundingindependent research funding
Process Improvement 101
Reduce Waiting & No-Shows Increase Admissions & Continuation
Why Process Improvement?Why Process Improvement?
Customers are served by Customers are served by processesprocesses
85% of customer related 85% of customer related problems problems arearecaused by organizational processescaused by organizational processes
To better serve customers, organizationsTo better serve customers, organizationsmust improvemust improve processesprocesses
NIATx Four Project AimsNIATx Four Project Aims
Reduce Waiting TimesReduce Waiting Times
Reduce No-ShowsReduce No-Shows
Increase AdmissionsIncrease Admissions
Increase Continuation RatesIncrease Continuation Rates
NIATx ResultsNIATx Results
Reduce Waiting Times:Reduce Waiting Times: 51% reduction51% reduction (37 agencies reporting) (37 agencies reporting)
Reduce No-Shows: Reduce No-Shows: 41% reduction41% reduction (28 agencies reporting)(28 agencies reporting)
Increase Admissions: Increase Admissions: 56% increase56% increase
(23 agencies reporting)(23 agencies reporting)
Increase Continuation: Increase Continuation: 39% increase39% increase (39 agencies reporting)(39 agencies reporting)
Five Key PrinciplesEvidence-based predictors of change
Understand & Involve the CustomerUnderstand & Involve the Customer
Focus on Key Problems Focus on Key Problems
Select the Right Change AgentSelect the Right Change Agent
Seek Ideas from Outside the Field and Seek Ideas from Outside the Field and
OrganizationOrganization
Do Rapid-Cycle TestingDo Rapid-Cycle Testing
Most important of all the PrinciplesMost important of all the Principles
What is it like to be a customer? Staff What is it like to be a customer? Staff are customers, too!are customers, too!
Walk-through, focus groups…Walk-through, focus groups…
Understand and Involve the Understand and Involve the CustomerCustomer
Focus on Key Focus on Key ProblemsProblems
What is keeping the executive director What is keeping the executive director
awake at night?awake at night?
What processes have staff and What processes have staff and
customers identified as barriers to customers identified as barriers to
excellent service?excellent service?
Detour 1Detour 1
Unclear purpose!Unclear purpose!
Where are you going?Where are you going?
How will you know you have arrived?How will you know you have arrived?
Aim StatementAim Statement
ExampleExample Improve 30-day continuation rates from 30% to Improve 30-day continuation rates from 30% to
80% in outpatient services.80% in outpatient services.
NeedNeed TargetTarget Scope of work Scope of work
Detour 2Detour 2
No feedback!No feedback!
Need a tracking measure.Need a tracking measure.
Have a simple measure.Have a simple measure.
California’s Proposition 36:Did it California’s Proposition 36:Did it Work?Work?
The Problem:The Problem:California Prison Population, California Prison Population, Drug Offenses, 1980-2000Drug Offenses, 1980-2000
Source: California Department of Corrections.Source: California Department of Corrections.
42,947
33,513
23,853
5,1161,778
0
10,000
20,000
30,000
40,000
50,000
1980 1985 1990 1995 2000
Increase in California Prison Increase in California Prison Population, Drug Offenses, 1970-1999Population, Drug Offenses, 1970-1999
Rate per 100,000 PopulationRate per 100,000 Population
0
10
20
30
40
50
60
70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 99
YearSource: California Department of Corrections.Source: California Department of Corrections.
Solutions?Solutions?
Proposition 36Proposition 36Substance Abuse & Crime Prevention Act Substance Abuse & Crime Prevention Act
(SACPA)(SACPA) 2000 Ballot Measure: Passed by 61% of 2000 Ballot Measure: Passed by 61% of
California voters in 2000California voters in 2000 Authorized $600,000,000 in new funds for Authorized $600,000,000 in new funds for
implementation. 2001-2006.implementation. 2001-2006. Drug offenses: Non-sales, non-Drug offenses: Non-sales, non-
manufacturing.manufacturing. Restrictions on offenders with histories of Restrictions on offenders with histories of
serious or violent crimesserious or violent crimes Results in community supervision and Results in community supervision and
treatment instead of: Incarceration ortreatment instead of: Incarceration or supervision without treatmentsupervision without treatment
2000 Proposition 36 Ballot Wording:2000 Proposition 36 Ballot Wording:
Proposition 36Proposition 36. Drugs. Probation and . Drugs. Probation and Treatment Program. Treatment Program. Requires probation and Requires probation and drug treatment, not incarceration, for drug treatment, not incarceration, for possession, use, transportation of controlled possession, use, transportation of controlled substances and similar parole violations, except substances and similar parole violations, except sale or manufacture. Authorizes dismissal of sale or manufacture. Authorizes dismissal of charges after completion of treatment. charges after completion of treatment.
ResultResult
6,199,992 / 6,199,992 / 60.8%60.8% Yes Yes votes votes 3,991,153 / 3,991,153 / 39.2%39.2% No No votes votes
Proposition 36 passed and was enacted as the:Proposition 36 passed and was enacted as the:
Substance Abuse & Crime Prevention ActSubstance Abuse & Crime Prevention Act
(SACPA)(SACPA)
Arrest or
ParoleViolation
Treatment
Conviction and Court Order of
Probation and
Treatment; or Parole Referral
Treatment Completion
ConvictionDismissed
(probation)
Assessment
No shows
No
shows
Repeated violation
and dropouts
Ineligible No
petition, petition denied
Attrition
PipelinePipeline
ImplementationImplementationShow RatesShow Rates
Referred Assessed Placed Show rate (%)
Year 17/01-6/02
44,043 37,495 30,469 69.2
Year 27/02-6/03
50,335 42,972 35,947 71.4
Year 37/03-6/04
51,033 42,880 37,103 72.6
Total 145,411 123,347 103,519 71.1
Client CharacteristicsClient Characteristics
Half use methamphetaminesHalf use methamphetamines
Half used primary drug more than 10 yearsHalf used primary drug more than 10 years
Half are in treatment for first timeHalf are in treatment for first time
Treatment SummaryTreatment Summary
34% of clients who enter treatment complete 34% of clients who enter treatment complete it it
Most clients are sent to outpatient treatmentMost clients are sent to outpatient treatment Heroin users rarely get methadone treatmentHeroin users rarely get methadone treatment Heroin users are least likely to completeHeroin users are least likely to complete
50.9
10.9
3.1
53.2
8.52.5
35.0
5.71.5
0
20
40
60
80
100
New drug arrest New property arrest New violent arrest
Per
cent
of
offe
nder
s
Referred but untreated (N = 10,196)
Entered but did not complete treatment(N = 14,597)
Completed treatment(N = 5,176)
Re-offendingRe-offendingNew ArrestsNew Arrests
One Year After Offense, Year 1 (7/01 - 6/02) PopulationOne Year After Offense, Year 1 (7/01 - 6/02) Population
53.9a,b
42.2b
40.8a
0
20
40
60
80
100
Assessed but untreated(N = 178)
Entered but did not completetreatment(N = 425)
Completed treatment(N = 149)
Per
cen
t of
off
end
ers
Any Work in the Past 30 DaysAny Work in the Past 30 Days
a,b Group differences are statistically significant, p = .04. Pre-post differences (not shown) are all statistically significant, p <.0001.
17.7a,b
27.4b34.6
a
0
20
40
60
80
100
Assessed but untreated(N = 178)
Entered but did not completetreatment(N = 426)
Completed treatment(N = 149)
Per
cent
of
offe
nder
sAny Drug Use in the Past 30 Any Drug Use in the Past 30
DaysDays
Group differences are statistically significant. ap<.05, bp<.02.
Outcome Summary: Outcome Summary: Effect of SACPA As PolicyEffect of SACPA As Policy
SACPA-era offenders have more drug SACPA-era offenders have more drug arrests in the initial 12 monthsarrests in the initial 12 months
Initial re-offending is affected by Initial re-offending is affected by differences in incarceration ratesdifferences in incarceration rates
Violent re-offending is low in all groupsViolent re-offending is low in all groups
What about costs?What about costs?
-$3,547
-$1,531
$198
-$221
$1,326
$743
$230
-$59
-$2,861
-$4,000
-$3,000
-$2,000
-$1,000
$0
$1,000
$2,000
Prison Jail
Probation
Parole
Arrest andConviction
Treatment Health
Tax Total
Do
llars
pe
r of
fend
er
-$3,547
-$1,531
$198
-$221
$1,326
$743
$230
-$59
-$2,861
-$4,000
-$3,000
-$2,000
-$1,000
$0
$1,000
$2,000
Prison Jail
Probation
Parole
Arrest andConviction
Treatment Health
Tax Total
Do
llars
pe
r of
fend
er
SUMMARY OF FINDINGSSUMMARY OF FINDINGS
Notes: Figure provides a summary of cost offsets. The zero-line can be interpreted as cost neutral. Any bar above the line represents a cost increase and any bar below the line represents a cost saving.
COSTS UNDER SACPACOSTS UNDER SACPA Savings primarily from prison, jail reductions.
Cost increases primarily from increased treatment, new crimes.
Costs are $2,861 per offender lower than what we would expect in the absence of SACPA.
Benefit-to-cost ratio of about 2.5:1.
For treatment completers, the cost savings reflect a benefit-to-cost ratio of about 4:1
KEY COST ANALYSIS KEY COST ANALYSIS FINDINGSFINDINGS
Substantially reduced incarceration Substantially reduced incarceration costs.costs.
Greater cost savings for some offenders Greater cost savings for some offenders than for othersthan for others
Can be improvedCan be improved
42,947
33,513
23,853
5,1161,778
0
10,000
20,000
30,000
40,000
50,000
1980 1985 1990 1995 2000
California Prison Population, California Prison Population, Drug Offenses, 1980-2000Drug Offenses, 1980-2000
Source: California Department of Corrections.Source: California Department of Corrections.
33,777
42,947
33,513
23,853
5,1161,778
0
10,000
20,000
30,000
40,000
50,000
1980 1985 1990 1995 2000 2004
California Prison Population, California Prison Population, Drug Offenses, 1980-2004Drug Offenses, 1980-2004
Source: California Department of Corrections.Source: California Department of Corrections.
ConclusionConclusion 70% of referrals have entered treatment70% of referrals have entered treatment Methamphetamine is the most common drugMethamphetamine is the most common drug Half are in treatment for the first timeHalf are in treatment for the first time 34% of clients have completed treatment34% of clients have completed treatment Initial re-offending is lowest for completersInitial re-offending is lowest for completers Employment is highest for completersEmployment is highest for completers Abstinence is highest for completers, but overall Abstinence is highest for completers, but overall
drug use outcomes are unevendrug use outcomes are uneven
Prop 26 (SACPA): Is it good policy?Prop 26 (SACPA): Is it good policy?
Approximately 200,000 individuals will have received Approximately 200,000 individuals will have received treatment over programtreatment over program
Final report currently in processFinal report currently in process Fiscal impact appears quite positiveFiscal impact appears quite positive
No group has come out to revoke SACPANo group has come out to revoke SACPA Disagreements concern exact provisionsDisagreements concern exact provisions Failure to pass revised SACPA provisions could result in Failure to pass revised SACPA provisions could result in
funding responsibility being passed on to counties.funding responsibility being passed on to counties.
UNODC International Network of UNODC International Network of Treatment and Rehabilitation Resource Treatment and Rehabilitation Resource
CentresCentres
Recognizing and Addressing the Need to Expand Training Recognizing and Addressing the Need to Expand Training and Treatment Capacity to Address Substance Abuse and Treatment Capacity to Address Substance Abuse
ProblemsProblems
There is a need for trained professionals to deliver effective There is a need for trained professionals to deliver effective rehabilitation and harm reduction interventions for substance rehabilitation and harm reduction interventions for substance abuse and dependence around the worldabuse and dependence around the world
The paucity of properly trained professional is a barrier to the The paucity of properly trained professional is a barrier to the development and delivery of effective treatment services, development and delivery of effective treatment services, especially regarding underserved and inappropriately served especially regarding underserved and inappropriately served populations of drug abusers, including women and childrenpopulations of drug abusers, including women and children
There is a worldwide shortage of qualified training experts and There is a worldwide shortage of qualified training experts and educational settings in which drug abuse treatment training is educational settings in which drug abuse treatment training is provided, particularly in developing regionsprovided, particularly in developing regions
A goal of this training effort is to train clinicians and educate A goal of this training effort is to train clinicians and educate
academics who will train additional professionals to address academics who will train additional professionals to address the problems of drug abuse in an empirically rational methodthe problems of drug abuse in an empirically rational method
Capacity Building PlanCapacity Building Plan
In short, the goal of the capacity building plan is to increase In short, the goal of the capacity building plan is to increase the number of personnel who can disseminate and the number of personnel who can disseminate and
promote the use of effective, scientifically-supported and promote the use of effective, scientifically-supported and practical drug abuse treatment practices around the practical drug abuse treatment practices around the
world.world.
Treatnet MembersTreatnet Members RS Ketergantungan Obat The Drug RS Ketergantungan Obat The Drug
Dependence Hospital, Dependence Hospital, Indonesia Indonesia Iranian National Prison Organisation /Iranian Iranian National Prison Organisation /Iranian
National Centre for Addiction Studies INCAS, National Centre for Addiction Studies INCAS, Iran Iran
National Research and Clinical Centre on National Research and Clinical Centre on Medical and Social Problems of Drug, Medical and Social Problems of Drug, Kazakhstan Kazakhstan
Drug Rehabilitation Unit, Mathari Hospital, Drug Rehabilitation Unit, Mathari Hospital, Kenya Kenya
Centros de Integración Juvenil A.C., Centros de Integración Juvenil A.C., Mexico Mexico Neuropsychiatric Hospital Aro, Neuropsychiatric Hospital Aro, Nigeria Nigeria
Treatnet MembersTreatnet Members
Shanghai Drug Abuse Treatment Centre, Shanghai Drug Abuse Treatment Centre, China China Carisma Centre for Attention and Integral Mental Carisma Centre for Attention and Integral Mental
Health,Health, Colombia Colombia General Secretariat of Mental Health, General Secretariat of Mental Health, Egypt Egypt TT Ranganathan Clinical Research Foundation, TT Ranganathan Clinical Research Foundation, India India Regional Research Centre of Narcology and Regional Research Centre of Narcology and
Psychopharmacology affiliated to Psychopharmacology affiliated to St. Petersburg Pavlov State Medical University, St. Petersburg Pavlov State Medical University, RussiaRussia
Psychosocial Attention Centre for Alcohol and other Psychosocial Attention Centre for Alcohol and other Drugs, Drugs, BrazilBrazil
Treatnet MembersTreatnet Members Turning Point Alcohol and Drug Centre Inc., Turning Point Alcohol and Drug Centre Inc.,
Australia Australia Centre for Addiction and Mental Health CAMH, Centre for Addiction and Mental Health CAMH,
Canada Canada Mudra, Mudra, Germany Germany Asociación Proyecto Hombre, Asociación Proyecto Hombre, Spain Spain Maria Ungdom, Maria Ungdom, Sweden Sweden Cranstoun Drug Services, Cranstoun Drug Services, United Kingdom United Kingdom Fayette Companies, Fayette Companies, U.S.A. U.S.A. Stanley Street Treatment & Resources (SSTAR) Inc., Stanley Street Treatment & Resources (SSTAR) Inc.,
U.S.A.U.S.A.
Capacity Building Plan for UNODC Treatnet Capacity Building Plan for UNODC Treatnet Program: What are we trying to do?Program: What are we trying to do?
The purpose of the capacity building component for the The purpose of the capacity building component for the UNODC Treatnet Program is to develop a set of training UNODC Treatnet Program is to develop a set of training materials and a training plan for trainers from 20 Resource materials and a training plan for trainers from 20 Resource Centres established by UNODC. To accomplish this task, we Centres established by UNODC. To accomplish this task, we will:will:
1. Conduct a training needs assessment.1. Conduct a training needs assessment.2. Determine priority training/skill development topics.2. Determine priority training/skill development topics.3. Create a set of training modules to address #2.3. Create a set of training modules to address #2.4. Conduct a set of training, supervision and mentoring 4. Conduct a set of training, supervision and mentoring activities with two trainers from each of the resource centres.activities with two trainers from each of the resource centres.5. Collect information to contribute to the project evaluation. 5. Collect information to contribute to the project evaluation.
Need Assessment: A Brief SummaryNeed Assessment: A Brief Summary
The following topics received the most interestThe following topics received the most interest..
Motivational InterviewingMotivational Interviewing Relapse Prevention (CBT)Relapse Prevention (CBT) AssessmentAssessment Program managementProgram management Outreach strategiesOutreach strategies YouthYouth Building Service NetworksBuilding Service Networks FamilyFamily Co-occurringCo-occurring Drugs and the brainDrugs and the brain Brief interventionsBrief interventions Outpatient treatmentsOutpatient treatments Harm minimizationHarm minimization Basic knowledge of drugsBasic knowledge of drugs Research and evaluation methodsResearch and evaluation methods
SummarySummary
The issue of research practice integration has The issue of research practice integration has been a priority in the US for almost a decade.been a priority in the US for almost a decade.
Major initiatives have been established to cross Major initiatives have been established to cross the research-practice gap. the research-practice gap.
Clinicians are more aware of research value and Clinicians are more aware of research value and findingsfindings
Quality research can be done in clinical service Quality research can be done in clinical service delivery settingsdelivery settings
It continues to be a challenging, expensive, time It continues to be a challenging, expensive, time consuming processconsuming process
