re-considering addiction treatment how can treatment be more accountable and effective? lessons from...
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Re-Considering Addiction Treatment
How Can Treatment be More Accountable and
Effective?
Lessons from Mainstream Healthcare
A Nice Simple Treatment Model
NTOMS Sample of 250 Programs
Treatment
Substance Abusing Patient
NON - Substance Abusing Patient
A Continuing Care Model
Detox
Substance Abusing Patient
Continuing CareRecovering Patient
RehabilitationDurationDetermined byPerformanceCriteria
DurationDetermined byPerformanceCriteria
Treatment Research Institute
Stages of Treatment
1. Detoxification/Stabilization
Purposes: Remove toxinsPhysical/Emotional Stabilization
Promote Problem Recognition Engage patient into rehabilitation
Setting – Hosp (80%), Res (10%), OPT (10%)
Treatment Research Institute
Stages of Treatment
2. Rehabilitation
Purposes:
Sustain stable abstinence
Teach self-management skills
Identify & reduce threats to progress
Engage in Continuing Care
Setting: Resid(10%) OPT (80%)OPT (80%) MM(10%)
Treatment Research Institute
Stages of Treatment
3. Aftercare-Continuing Care
Purposes:Monitor & Support Abstinence
Encourage Self-Monitoring
Intervene Upon Threats to Relapse
Types: AA, Pers. Ther., Opt Visits, Home Visits, Phone & Internet
• Abstinence/Sobriety– Is it too much to ask?
– Is it enough to ask?
• Lessons from Two Patients• The SAMHSA Outcome Domains
Part 2
Public Expectations of Substance Abuse Interventions
• Safe, complete detoxification
• Reduced use of medical services
• Eliminate crime
• Return to employment/self support
• Eliminate family disruption
• No return to drug use
Treatment Comparisons
a. No Treatment
b. Role of Motivation
c. Incarceration/Parole
d. Other Chronic Illnesses
21%
13%
18%
51%
21%
39%
0%
10%
20%
30%
40%
50%
60%
B 6 12 18 24 30 36 42 48 60 72
Baseline through 36 Months
Per
cen
t T
esti
ng
Pos
itiv
e
In Treatment Out of Treatment
Treatment Research Institute
Six Year HIV Infection Rates by Treatment Status at Time of Enrollment
UNMOTIVATED DRUG USERS
• Svikis et al. Johns Hopkins 146 Cocaine Abusing, Pregnant Women
• Seeking Pre-Natal Care - Not Treatment
• 100 Received - 1-Week Residential Tx.
• 46 Received - Standard Pre-Natal Care
• Costs and Complications of Delivery
Un-Motivated Drug Users
Summary - No Treatment
• 1. Treated patients show far more improvements than non-treated patients.
• 2. Motivation is an important but not critical ingredient.
• BUT Is Treatment better than Other Options?
Incarceration/Parole
• Why Bother – Just Incarcerate–Treatment During Incarceration
–Treatment During Parole/Prob.
c.
Re-Addiction Following Prison
Vaillant 447 opiate addicts 91% Maddux & Desmond 594 opiate addicts 98% Nurco & Hanlon 355 opiate addicts 88%Hanlon & Nurco 237 mixed addicts 70%
Many Other Studies Including: (Simpson, Wexler, Inciardi, Hubbard, Anglin)
Treatment Research Institute
Summary - Incarceration
• Treatment can be added to incarceration• Both the public safety and public health
concerns can be addressed
• BUT even big “doses” of treatment in jails – don’t produce lasting change
• Only those in continuing care seem to show cost effectiveness of treatment
Why These?
No Doubt They Are Illnesses All Chronic Conditions Influenced by Genetic, Metabolic
and Behavioral Factors No Cures - But Effective
Treatments Are Available
Hypertension: < 60%
Diabetes < 50%
Asthma < 30%
Treatment Research Institute
ADHERENCE
Addiction 30 - 50%
Hypertension: 50 - 60%
Diabetes 30 - 50%
Asthma 60 - 80%
Treatment Research Institute
RELAPSE
Addiction 50 - 60%
Summary – Treatment“Efficacy”
• Efficacy is impact under carefully controlled conditions – what treatment CAN do.
• Most efficacy studies show that treatment CAN work – CAN meet public expectations
• So…
Two Problems With Addiction Treatment
Treatment Infrastructure:Infrastructure and Expectations
Treatment Concepts:Acute vs. Continuing Care Model:
Part 4
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
• Counselor turnover is 50% per year
• 50-60% of Directors in job Less Than 1 year
Program Survey - 2
STAFF TURNOVER!
Program Survey - 4Other 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
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.
A Nice Simple Rehab Model
NTOMS Sample of 250 Programs
Treatment
Substance Abusing Patient
Non- Substance Abusing Patient
Meds,Therapies,Services
Lessons from Chronic Illness:
1. Medications relieve symptoms but…. behavioral change is necessary for sustained benefit
Lessons from Chronic Illness:
3. Patients who are not in
some form of treatment or monitoring are at elevated
risk for relapse.
Important Caveats• 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 Goal is Self-Management
Summary• Addiction Treatment can be scientifically evaluated
• Abstinence is not enough – use SAMHSA domains
• Programs can and should be held accountable – during care
• Practical monitoring systems are operating in several states