American Association for the Treatment of Opioid Dependence, American Association for the Treatment of Opioid Dependence, Inc. 2006 National Conference, AtlantaInc. 2006 National Conference, Atlanta

April 25, 2006April 25, 2006

Evaluation of the Impact of Opioid Evaluation of the Impact of Opioid Treatment Program (OTP) Treatment Program (OTP)

AccreditationAccreditation

Arlene Stanton, PhDArlene Stanton, PhDGovernment Project OfficerGovernment Project Officer

Substance Abuse and Mental Health Services Administration, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (SAMHSA/CSAT)Center for Substance Abuse Treatment (SAMHSA/CSAT)

Under Contract # RFP 277-00-6507 with Northrop Grumman Information Under Contract # RFP 277-00-6507 with Northrop Grumman Information TechnologyTechnology

For more information contactArlene Stanton, Ph.D., N.C.C., Government Task Order OfficerDivision for Pharmacologic TherapiesCenter for Substance Abuse TreatmentSubstance Abuse & Mental Health Services AdministrationRockville, Maryland 20857

Phone:  240-276-2718Fax: 240-276-2710Email:   arlene.stanton@samhsa.hhs.gov

DesignDesign

• 478 Post-Accreditation 478 Post-Accreditation QuestionnairesQuestionnaires• 82% First Accreditation82% First Accreditation

• 171 6-Month Follow-up 171 6-Month Follow-up QuestionnairesQuestionnaires

• 590 Patient Interviews590 Patient Interviews

• Key Policy Variables for AnalysisKey Policy Variables for Analysis• Accrediting Body (CARF, JCAHO, Other)Accrediting Body (CARF, JCAHO, Other)• OTP size (0-100, 101-200, 201-300, 400+)OTP size (0-100, 101-200, 201-300, 400+)• Financial Structure (For profit, Non profit, Financial Structure (For profit, Non profit,

Gov)Gov)• Organizational Setting (Hospital, Other)Organizational Setting (Hospital, Other)• Treatment Type (Detox, Maintenance, Treatment Type (Detox, Maintenance,

Both)Both)

A. Study PopulationA. Study Population

• What are the descriptive What are the descriptive characteristics of the participating characteristics of the participating OTPs along selected relevant OTPs along selected relevant dimensions?dimensions?

Treatment Setting by Type of Treatment Setting by Type of TreatmentTreatment

20

50

30

6

31

64

Hospital (n=113) Non-Hospital (n=357)

Detox-onlyMaintenance-OnlyBoth

OTP Clinic SettingOTP Clinic Setting

Treatment Setting by Financial Treatment Setting by Financial StructureStructure

11

63

27

50

39

11

Hospital (n=113) Non-Hospital (n=357)

For-ProfitNon-ProfitGovernment

OTP Clinic SettingOTP Clinic Setting

Treatment Setting by Treatment Setting by Accreditation Source Accreditation Source (N=467)(N=467)

89

120

27

68

6

Hospital (n=113) Non-Hospital (n=354)

JCAHOCARFOther

OTP Clinic SettingOTP Clinic Setting

Descriptive Characteristics Descriptive Characteristics of Patient Populationof Patient Population

Site visits conducted to 22 OTPs/590 patients interviewed

Average Number of Months in Current Program: 26 months

Average Total Number of Years in Treatment: 6 years

Average Age of Patients: 35 years old

% in Opioid Treatment Prior to Current Episode: 64%

Drug Being Treated For:

•69% heroin only

•12% heroin and pain medication

•19% pain medication only

B. Administrative Evaluation B. Administrative Evaluation QuestionsQuestions

• What are OTP staff perceptions of What are OTP staff perceptions of accreditation's impact on the OTP?accreditation's impact on the OTP?

Perceived Areas of Impact of the Perceived Areas of Impact of the Accreditation Process Accreditation Process (N=468)(N=468)

% % % Great

Impact Area None Some Extent

Require more document of pt. progress 21 64 15

Enhance efficiency of treatment 28 53 18

Improve coordination of care 26 59 14

Improve treatment practices 27 58 15

Require new QA procedures 20 53 27

Hinder staff from daily tasks 59 33 8

Lead to purchasing computer equip. 71 23 7

Increase monitoring of pt. outcomes 24 53 24

Require doing more with less 42 35 24

Improve ability to monitor pt. progress 32 56 11

Improve links w/ community resources 47 44 9

Improve safety 37 51 12

Increase pt. participation in OTP planning 37 53 10

Increase pt. participation in indiv. tx plan 43 45 12

OTP Providers’ Perceived Impact of OTP Providers’ Perceived Impact of Accreditation on Their Program Accreditation on Their Program

(N=445)(N=445)

23

63

10

2 <1

SignificantImpact

SomewhatImproved OTP

No Impact onOTP

SomewhatWorsened OTP

SignificantlyWorsened OTP

Which OTPs Are More Likely to Rate Which OTPs Are More Likely to Rate the the Impact of Accreditation on Their Impact of Accreditation on Their

Program Program as Being Positiveas Being Positive??

• Larger programsLarger programs (over 100 clients) were (over 100 clients) were significantly more likely than smaller significantly more likely than smaller programs (< 100 clients)programs (< 100 clients) (Odds Ratio=2.71)(Odds Ratio=2.71)

• Maintenance/Other programsMaintenance/Other programs were more were more likely than Detox-only programslikely than Detox-only programs (Odds Ratio=3.35) (Odds Ratio=3.35)

C. Clinical Evaluation QuestionsC. Clinical Evaluation Questions

• What are the effects on patients What are the effects on patients associated with operating as an associated with operating as an accredited OTP with regard to accredited OTP with regard to various patient factors?various patient factors?

Methadone Dose Methadone Dose (N=468)(N=468)

Mean SD Range

Admission 37

mg/day

19 8-132

Maintenance 205

mg/day

111 20-1,200

Note that variability in range may be the result of patient status (e.g., transfer versus 1st admission)

Who Determines Max Dose Who Determines Max Dose and Length of Treatment and Length of Treatment (N=475)(N=475)

84

70

22

12

22 25

2 4 <110

Medical State Gov OTP Local Gov Payer

Max Dose

Max Trt Time

Methadone Dose: Methadone Dose: Patient Influence & Take-Home PrivilegesPatient Influence & Take-Home Privileges

(N=469)(N=469)

60

98

24

97

% Some/Great Extent % Yes

Detox-only

Maintenanceor both

DoseDose Take Home PrivilegesTake Home Privileges

Changes in OTP Services Offered Changes in OTP Services Offered (N=171)(N=171) % Offering Service

Baseline Follow-UpGeneral medical care 39 43HIV/AIDS-related medical care 29 38

Psychological testing 57 66

Psychiatric services 52 50Educational assistance 35 42Vocational assistance 43 46Financial assistance 28 27Legal assistance 9 15

Counseling 98 99Housing/shelter assistance 40 39Post-treatment follow-up 76 79Acupuncture 13 15Detox from a substance other than heroin 42 45Treatment for alcohol abuse 72 72Treatment for cocaine abuse 71 71Individual/group therapy for opiate addiction 95 99

Nutritional counseling 50 5812-Step program 45 53

Smoking cessation 29 32Case management 71 77Childcare 6 6Aftercare 36 55Transportation 25 25

Patient Perceptions of CarePatient Perceptions of Care

92% of patients reported that they were treated with as much respect as they would like.

Asked the extent to their treatment plan met all of their treatment needs, patients said:

• Completely: 66%• To some extent: 33%

Patients rated their overall treatment during the past 3 months as:

• Very good/Excellent: 77%• Good: 17%• Poor/Fair: 6%

Effects on Patient OutcomesEffects on Patient Outcomes

Extent that patient is involved in dosing decisions: • Most/All of the time: 57%• Often/Sometimes: 28%• Never/Rarely: 15%

Self-reporting of dosage levels: • Too high: 7%• Just right: 76%• Too low: 16%

Extent that patient is satisfied with take home schedule: • Very satisfied: 57%• Somewhat satisfied: 31%• Not satisfied: 12%

Patient Self-Reported Effects Patient Self-Reported Effects on Treatment Outcomeson Treatment Outcomes

Employment: • 33% are employed

Health Status • Very Good/Excellent: 34%• Good: 32%• Poor/Fair: 34%

Drug Use in Last 30 Days: • 69% report using a drug (including alcohol-most common

drug/stimulants-least common) – 32% report using one drug– 20% report using two different drugs– 11% report using three different drugs– 6% report using between 4-7 different drugs

Preparing for Accreditation: Preparing for Accreditation: Staff Level of Effort*Staff Level of Effort*

1st Accreditation 2nd + Accreditation Hrs per Mo. (N=395) Hrs per Mo. (N=83)

Staff meetings 57 31 Staff training 36 23 Review/update of records keeping 57 40 Review/update of treatment & continuing care plans 46 33Development of quality assurance plan 19 11 Preparation of accreditation application 11 6 Preparation of OTP documentation 38 22 Interaction with external consultant 12 7 Accreditation survey 25 16

*Denotes mean number of hours spent by all staff in an average month since OTP started preparing for first or subsequent accreditation.

ConclusionsConclusions

• Overall, OTP providers report that the accreditation process significantly improved their programs.

• Overall, patients reported that their treatment needs were being met and that they were satisfied with treatment.

• Programs with an enrollment of over 100 clients, and programs that provided maintenance rated the accreditation process more favorably than their counterparts.

• Consistent with the goals of accreditation, patients reported having a major influence on dosing levels.

• Less staff time per month was spent preparing for a subsequent accreditation.