Treatment

Indicators

Some Additional Considerations

Moving On

More than 3 decades of research show that drug misuse treatments can be effective• In reducing drug use• Improving personal health & social functioning• Reducing public health & safety risks

Time for policy makers, providers & researchers to have a more ambitious agenda:• How can treatment be improved?• How can treatment be tailored to meet the needs of

clients?

Improving patient outcomes & treatment Treatment is more than just specific procedures Treatment is a complex process. Need to understand:

• Nature & severity of client problems• The process which occur during treatment• The role of staff competence & skills• The organization & provision of service

Don’t have a cure, an “antibiotic” - treatment & treatment process are intertwined more closely

Involvement of providers in understanding & improving process of treatment is essential.

Treatment Outcomes

4 major national drug treatment outcome studies:• NTORS (National Treatment Outcome Research Study ,

UK)• DARP (Drug Abuse Reporting Program, US)• TOPS (Treatment Outcome Prospective Study, US)• DATOS (Drug Abuse Treatment Outcome Study, US)

Findings

Substantial reductions in illegal drug misuse & other outcomes after treatment

Improved outcomes for injecting risk behaviour Most drug dependent clients were multiple

substance misusers, often with multiple dependencies• Focus on single substance disorders likely outdated

& misleading Reductions in crime levels provide substantial

& immediate cost savings for society

Findings (& considerations)

Most drug dependent clients received more than 1 episode of treatment• Not a failure of treatment, a reality to understand• Drug dependence for many is a chronic, relapsing

condition– Need to understand

• cumulative effects of multiple treatments• how episodes interact or interfere with each other• characteristics of clients most likely to require multiple treatments so we

can incorporate this into treatment processes

Drinking outcomes often poor • Many clients continuing to drink heavily• May reflect focus on illegal drugs in treatment &

insufficient attention to alcohol

Findings (& considerations)

Time in treatment & treatment completion associated with better treatment outcomes• Staying in treatment & completing treatment more likely

to achieve best outcomes regardless of outcome measure• Treatment duration effects reported from studies of range

of treatment interventions (drug-free, drug maintenance, residential, outpatient)

• Need an adequate exposure to treatment to achieve positive outcomes– Beyond 90 days for most drug problems– Beyond a year for those treated with methadone– Outcomes tend to improve as retention increases from 3

months to 12 or more

Retention in Treatment

Treatment effectiveness, outcomes improve with retention in treatment• In UK, National Treatment Agency developed Public

Service Agreement target to “ increase year on year the proportion of users successfully sustaining or completing treatment programmes”

Study of 2,616 client in community-based services, north west England• 49 specialist drug treatment services & 100 general

practitioners (physicians)

Study findings

Factors NOT associated with retention or completion:• Ethnicity of client• Type of drug misuser (heroin, crack cocaine or both)• Whether client injected drugs• Whether client using methadone at time of

presentation for treatment

Study findings

Factors associated with retention or completion• Younger clients more likely to drop out within 6 months• Males 1.5 times more likely to drop out early than females• Those with no previous treatment experience 1.7 times more

likely to drop out early than those with previous treatment• Clients referred from criminal justice system 2.7 times more

likely to drop out early • Clients attending the worst performing services 7.1 times

more likely to drop out early than clients attending the best Strongest predictor of retention or completion of treatment

NOT a characteristic of client but related to agency

Improving patient outcomes & treatment Treatment is more than just specific procedures Treatment is a complex process. Need to understand:

• Nature & severity of client problems• The process which occur during treatment• The role of staff competence & skills• The organization & provision of service

Don’t have a cure, an “antibiotic” - treatment & treatment process are intertwined more closely

Involvement of providers in understanding & improving process of treatment is essential.

Outcome domains

Increasing agreement on domains - area of life function or status that is expected to be positively influenced by treatment (patient level)• Substance use• Employment / self support• Crime • Stability in housing• Social connectedness• Perception of care (or services)• Access • Retention

SAMHSA - 2004

04/10/23

Indicadores de Resultados (SAMHSA, 2003)

Funcionamiento social• Soporte• Vínculos

Accesibilidad de servicios• Cobertura

Retención en tratamiento Percepción sobre la atención Costo efectividad Uso de prácticas basadas en la evidencia

04/10/23

Indicadores de Resultados (SAMHSA, 2003)

Reducción de Morbilidad• Abstinencia• Reducción de sintomas

Laboral / Académico• Permanencia• Recuperación

Delito / P. legales• Disminución

Residencia• Incremento de estabilidad de vivienda

Outcome Measures

Specific items, measures or tests of an individual’s functional status within a domain• For example domain of Employment

– Number of days worked– Dollars earned– Days of unexcused absence– Tax return for a year

Functional domains have many facets - multiple measures, tests or items often needed for each domain

Performance or quality indicators System level Traditional methods to measure outcomes &

effectiveness: costly, time-consuming, dependent on scarce research skills

Performance or quality indicators • measures to estimate & monitor extent a program or

provider conforms to best or evidence-based practices or other standards of quality

• Often derived from administrative information systems– Financial and/or client

No single measure or indicator At this point, available measures and

indicators have benefits & limitations No single measure or indicator = quality of

treatment or sufficient for accountability Needs & goals of treatment system should

determine the set of measures & indicators that will most efficiently provide the amount & detail of information to improve quality of care at a given time.

Opening the door together

Must ‘ open the door’ for scientific understanding of treatment

Look at ourselves, our services and help others understand

Dynamic process - based in monitoring & tailored to meet changing objective & goals.

Success depends upon collaboration of service providers, policy makers & researchers

Treatment process improvement & data-driven decisions Supporting providers to make process

improvement & data-driven decisions to improve client access to and retention in care

Success factors• Provider leadership valued data & provided

resources• Staff received training on data collection & use• Sharing of change results• Success making data-driven decisions

Gracias por su atención

Cuando es cuestión del tratamiento de las adicciones, nada justifica la falta de transparencia por parte de proveedores, centros, o autoridades publicas...Pacientes, contribuyentes, y legisladores deben exigir a los que proporcionan tratamiento a personas con adicciones pruebas razonables de intentos de control y mejora tanto de estos tratamientos como de los resultados conseguidos.-A.Thomas McLellan, Mady Chalk, John Bartlett

Journal of Substance Abuse Treatment 32 (2007)

Gracias por su atención