Re-Considering Addiction Treatment How Can Treatment be More Accountable and Effective? Lessons from...

Re-Considering Addiction Treatment

How Can Treatment be More Accountable and

Effective?

Lessons from Mainstream Healthcare

What is Treatment?A 3-Stage Description

Part 1

A Nice Simple Treatment Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

NON - Substance Abusing Patient

A Continuing Care Model

Detox


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%)


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%)


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

• Compared to What?– What would you do if you didn’t treat?

– Lessons from comparisons

Part 3

Treatment Comparisons

a. No Treatment

b. Role of Motivation

c. Incarceration/Parole

d. Other Chronic Illnesses

No Treatment

Out of treatment groups

a.

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


Six Year HIV Infection Rates by Treatment Status at Time of Enrollment

Role of Motivation

Pregnant Cocaine Users

in Prenatal Care

b.

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

Cocaine + Urine at Delivery

• 46 Control Women

63%

• 100 Treated Women

*37%

Weight and Gestational Age


2534 gms

34 wks


*2939 gms

*39 wks

NICU Stay and Costs


39 days

$46,700


*7 days

*$14,500

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)


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

Other Illnesses

Addiction Treatment Compared With Treatments for Other Illnesses

A Comparison With Three Chronic Medical Illnesses

Hypertension

Diabetes

Asthma

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%


ADHERENCE

Addiction 30 - 50%

Hypertension: 50 - 60%

Diabetes 30 - 50%

Asthma 60 - 80%


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…

SO…

Why Does Treatment Seem So Ineffective

The “Gap”

Why the Gap Between What Treatment Can

Do and What it Does?

Two Problems With Addiction Treatment

Treatment Infrastructure:Infrastructure and Expectations

Treatment Concepts:Acute vs. Continuing Care Model:

Part 4

Problem 1

The National TreatmentInfrastructure

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

Problem 2

How Do We Deliver and Evaluate

Addiction Treatment ?

What is the model ?

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


Non- Substance Abusing Patient

Meds,Therapies,Services

0

2

4

6

8

10

Pre During During During Post


Outcome In Hypertension

0

2

4

6

8

10

Pre During During During Post


Outcome In Addiction

Lessons from Chronic Illness:

1. Medications relieve symptoms but…. behavioral change is necessary for sustained benefit


2. Treatment effects usually don’t last very long after care stops.


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

Re-Considering Addiction Treatment How Can Treatment be More Accountable and Effective? Lessons from...

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