Re-ConsideringAddiction Treatment

Have We Been ThinkingCorrectly?

• FDA standards of effectiveness

• Do substance abuse treatmentsmeet those standards?

Part I

An FDA Perspective

A Drug is Approved for “An Indication”

2 -Randomized Clinical Trials:Often ask for separate investigators

Placebo Control:Movement to test vs approved medication

Treatment Research Institute

• Therapies– Cognitive Behavioral Therapy

– Motivational Enhancement Therapy

– Community Reinforcement and Family Training

– Behavioral Couples Therapy

– Multi Systemic Family Therapy

– 12-Step Facilitation

– Individual Drug Counseling

• Medications– Alcohol (Disulfiram, Naltrexone, Accamprosate)

– Opiates (Naltrexone, Methadone, Buprenorphine)

– Cocaine (Disulfiram, Topiramate)

– Marijuana (Rimanoban)

– Methamphetamine – Nothing Yet

The Specialty Care SystemA “Customer” Perspective

• Patient Survey

• Care Provided

• Infrastructure

The Alcohol Pyramid

In Spec Treatment – 1,800,000

Abuse/Dependent – 18,000,000

“Harmful Users” – ??,000,000

13,200 specialty programs in US

• 31% treat less than 200 patients per year

• 65% private, not for profit

• 80% primarily government funded

Private insurance <12%

Sources – NSSATS, 2002; D’Aunno, 2004

Referral Sources

Source 1990 2004

Criminal Justice 38% 59%

Employers/EAP 10% 6%

Welfare/CPS 8% 16%

Hosp/Phys 4% 3%

Sources: 4 Review ArticlesRapp et al. JSAT 2005 Stanton JMFT 2004

Appel et al. AJDA 2004 Tsogia et al. JMH 2001

Top Patient Reasons

1) No Problem/Can Handle 58%

2) No Confidence in Trt 51%

3) Bad Trt Experience 36%

4) Abstinence-Only Goal 31%

Won’t programs deliver qualitycare?

CAN’T

Four Reasons

a. The Infrastructure

b. The Acute Care Model

c. The Way it is Evaluated

d. The State as the Only Market

Phone Interviews With NationalSample of 175 Programs regardingpersonnel, management, information

McL, Carise & Kleber JSAT, 2003

The Treatment System

Modality 1975 1990 2005

Residential 64% 39% 9%

Outpatient 27% 59% 79%

Methadone 9% 10% 12%

• 12% had closed

• 13% had changed service operationRESULT – 25% FEWER PROGRAMS

• 31% of the rest had been taken over,usually by MH agenciesRESULT – STAFF CONFUSION

Program Changes In 16 Months:

• Counselor turnover

50% per year

• 50% of directorshave been thereLess Than 1 year

STAFF TURNOVER!

17% No College Education

58% Had BA Degree20% Had a MA or MSW

2 Physicians in 175 programs

28% NOT Working Full Time

• Most had been clinicians @ program

Who Are the Directors ?

• Modest Computer Availability

– Mostly For Administrative Work

– 80% Had a Computer

– 50% had Web Access

• Still very little computer/softwareavailability for CLINICAL STAFF

Information Systems:

Other 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

Regulations for license & certification

All 50 states and Washington, D.C.

Both substance abuse and mentalhealth counselors

Substance Mental

Abuse Health

No Degree required 13% 0%

< BA min 77% 2%

Masters min 10% 98%

• The Acute Care Model

• Treatment Models for OtherIllnesses

A Nice Simple Rehab Model

NTOMS Sample of250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

Medications,Therapies,JCAHO, CARF, WC

Ev. Based Prac.

ASSUMPTIONS• Some fixed amount or duration of

treatment will resolve the problem

• Clinical efforts put toward correctlyplacing patients and getting them tocomplete treatment

• Evaluation of effectiveness shouldoccur following completion

– Poor outcome means failure

How Do Other

Treatments Work?

Chronic Illness &Continuing Care

A Continuing Care Model

PrimaryContinuing Care

Primary Care

Specialty Care

In Chronic Illnesses….

1 – The effects of treatment do

not last very long after care stops

2 – Patients who are out of

treatment/contact are at elevatedrisk for relapse

So, For Treatment….1 – One goal is to retain patients at an

appropriate level of care and monitoring

2 – Another goal is to prepare patients to

do well in the next level of care

3 - The effects of treatment are evaluated

during treatment – not post-discharge

But Addiction Isn’tLike Other Diseases

A Comparison With ThreeChronic Medical Illnesses

Hypertension

Diabetes

Asthma

Why These?

No Doubt They Are Illnesses

All Chronic Conditions

Influenced by Genetic, Metabolicand Behavioral Factors

No Cures - But EffectiveTreatments Are Available

ASTHMA (adult only) .35 - .70

DIABETES (insulin dep) .70 - .95 (males)

HYPERTENSION .25 - .50 (males)

Heritability EstimatesTwin Studies

ALCOHOL (dependence) .55 - .65 (males)

OPIATE (dependence) .35 - .50 (males)

Eye Color 1.00

Adherence to medication regime: < 60%

Adherence to diet and exercise: < 30%

Treatment Research Institute

HYPERTENSION

Retreated in 12 months: 50 - 60%

(by Physician, ER, or Hospital)

Adherence to medication regime: < 50%

Adherence to diet and exercise: < 30%

Treatment Research Institute

DIABETES (Adult Onset)

Retreated in 12 months: 30 - 50%

(by Physician, ER, or Hospital)

Adherence to medication: < 30%

Treatment Research Institute

ASTHMA

Retreated in 12 months: 60 - 80%

(by Physician, ER, or Hospital)

Predictive Factors - All 3 Illnesses

RELAPSE

#1 - Lack of Adherence to diet, medications,or behavior change

#2 - Low Socioeconomic status#3 - Low Family Supports#4 - Psychiatric Co-Morbidity

Sources: Natl Ctr Health Stats; Harrison, 13th Ed.; 30+ studies

• Implications of How We Evaluate

• Differences in OutcomeExpectations

I

If many or most cases ofaddiction are really chronic then:

1) We may be evaluating theeffectiveness of addictiontreatments in the wrong way.

Studies show fewdifferences between…

• Brief and Intensive Treatments

• Inpatient and Outpatient Treatments

• Conceptually Different Treatments

• “Matched” and “Mismatched” Trt.

• Gender or Culturally Oriented Trt.

0

2

4

6

8

10

Pre During During During Post

Treatment Research Institute

Outcome In Hypertension

0

2

4

6

8

10

Pre During During During Post

Treatment Research Institute

Outcome In Addiction

Studies show fewdifferences between…

• Brief and Intensive Treatments

• Inpatient and Outpatient Treatments

• Conceptually Different Treatments

• “Matched” and “Mismatched” Trt.

• Gender or Culturally Oriented Trt.

• Serving the Customer

• Helping the Counselor

Demands on Counselor

Do Comprehensive Assessement

Develop Individual Treatment Plan

Provide Services to Meet Needs ofPatient

Be Culturally and GenderSensitive

Computer Assisted System forPatient Assessment and Referral

CASPAR• Start with Computer Assisted ASI

– Reduced training & administration time

– Generates, state forms, JCAHO narrativeand treatment plan

• Add Free or Low Cost Service Referral– From United Way’s First Call for Help

– Easy match of services to problems

Problem-Services Linkage

Treatment Research Institute

•Alcohol

•Drugs

•Medical

•Employment

•Family

•Psychiatric

•Legal

GED training

Resume Development

Job Finding

Mentoring Sessions

Training Loans

From United Way

Problem-Services Linkage

Treatment Research Institute

•Alcohol

•Drugs

•Medical

•Employment

•Family

•Psychiatric

•Legal

Domestic Violence

Parenting Skills

Specialized Babysitting

Safe Housing

Legal Aid

From United Way

Results of CASPAR Training

Counselors now “get” ASI Now seen as part of engagement

They love United Way services Most counselors use it for most patients Many counselors use it themselves Patients who get more services stay

longer

0

2

4

6

8

10

12

14

D/A Med Emp Legal Family Psych

Standard Group Enhanced Group

Mean Number of Services Received

Percent Retained at 30 Days

68%

39%

20

40

60

80

Extra Standard

Percent Retained at 60 Days

49%

12%10

30

50

70

Extra Standard

Average Percent Positive

9%

16%

0

5

10

15

20

Extra Standard

*trend

Regulating Treatment Process

Vs

Purchasing Results

13,200 programs in US

• 65% private, not for profit

• 80% primarily government funded

Private insurance <12%

• 31% treat less than 200 patients per year

Sources – NSSATS, 2002; D’Aunno, 2004

State of Delaware

Performance Contracting

Delaware Situation 2002

• 11 Outpatient Providers

• Limited Budget

• No success with outcome evaluation

• Providers won’t/can’t use EBPs

Delaware’s PerformanceBased Contracting

• 2002 Budget – 90% of 2001 Budget

• Opportunity to Make 106%

• One Criterion: Active Participation

• Audit for accuracy and access

Delaware’s ResultsYears 1 & 2

• One program lost contract

• Two new providers entered, did well

– Mental Health and Employment Programs

• Programs worked together

– First, common sense business practices

– Second, incentives for teams or counselors

• 5 programs learned MI and MET

Utilization

3000

3500

4000

4500

5000

5500

6000

6500

Av

era

ge

Da

ily

Cen

sus

2001 2002 2003 2004 2005

% Attending

20

30

40

50

60

70

80

2001 2002 2003 2004 2005

>30 days >60 days

Philadelphia

Contracting for PublicHealth Value

Eliminating “Detox-Only”

40 – 70% of all Addiction Treatment

Episodes are Detox-Only

• Cost $1,750 - $2,400 per episode

• Re-Detox only tracked by 7 states

– Average = 40% (23 – 78% range)

– 28% admitted 3+ times/yr

2000 Inspector Gen Report

Inpatient Detoxification:1-year Follow-Up

Davison et al.,J. Add. Dis. 25, 2006

Treatment Research Institute

Inpatient DetoxificationShort Term Results

• 92 completed• All prescribed Opt. Care & Naltrex.

• 20 left AMA

• 73 Attended 1 or more sessions 65%

• 25 Still Attending at 60 Days 22%

• 5 Opiate free at 90 days 3%John Davison et al., J. Add Dis. 25(4), 2006

Inpatient Detoxification1-Year Results

• 92 Completed Detoxification• 23 Readmitted for Detox 21%• 21 Admitted to ER 19%

• 5 Died 5%

John Davison et al., J. Add Dis. 25(4), 2006

• State is the market for D-O• State could make market for continuity

– 85% Detox-only reimbursement

– 115% Detox+5 sessions of OPT

– 100% Detox + 5 days Residential

• Specialty care system is in trouble

– Customers Do Not Want the Product

– Ruled by Gov, Not Market Forces

• System Change is Necessary

– Public Health Value thru Patient Value

• Treatment Programs MUST Change

– Meet Customer Needs – Offer New Options

Purchasers CAN

• Specialty care system is in trouble

– Customers Do Not Want the Product

– Ruled by Gov, Not Market Forces

• System Change is Necessary

– Public Health Value thru Patient Value

• Treatment Programs MUST Change

– Meet Customer Needs – Offer New Options

Purchasers CAN