What

1
Whats Wrong With Addiction Treatment?
A. Thomas McLellan NADAAC Presentation Washington,
D.C. September 15, 2003
2
Three Problems

• How We Treat It Acute vs Continuing Care
• How We Evaluate It As Though we Have a Cure
• Treatment Infrastructure Can it Support
  Expectations

3
Problem 1 How We Treat It
4
A Nice Simple Rehab Model
Substance Abusing Patient
Meds, Therapies, Services
Treatment
NTOMS Sample of 250 Programs
Non- Substance Abusing Patient
5
State of the Field

• Treatment Has Not Met Publics Expectations
  There is No Cure
• Treatments CAN Work But Patients Do Not
  Cooperate

6

• Treatment Compliance Is Low
• 85 of all treatment in US is Outpatient
• About 60 of outpatients drop out of treatment
  within one month.
• Even court-ordered patients do not complete
  treatment

7

• Relapse Rates Are High
• About 60 use drugs within 6 mos. following
  treatment discharge
• No difference between Brief and Intensive
  Treatments
• No difference between Inpatient and Outpatient
  Treatments

8
Maybe We Have the Wrong Model?
9
How Are Other Illnesses Treated Evaluated?
10
Why Isnt Addiction More Like Other
Illnesses? Implications for Evaluation and
Treatment Lessons learned from Chronic Illnesses
11
A Comparison With Three Chronic Medical Illnesses

• Hypertension
• Diabetes
• Asthma

12
Why These Illnesses?

• No Doubt They Are Illnesses
• All Chronic Conditions
• Influenced by Genetic, Metabolic and
  Behavioral Factors
• No Cures - But Effective Treatments
  Are Available

13
HYPERTENSION
Adherence to medication regime lt
60 Adherence to diet and exercise lt 30
Retreated in 12 months 50 - 60 (by
Physician, ER, or Hospital)
Treatment Research Institute
14
DIABETES (Adult Onset)
Adherence to medication regime lt
50 Adherence to diet and exercise lt 30
Retreated in 12 months 30 - 50 (by
Physician, ER, or Hospital)
Treatment Research Institute
15
ASTHMA
Adherence to medication lt 30
Retreated in 12 months 60 - 80 (by
Physician, ER, or Hospital)
Treatment Research Institute
16
RELAPSE
Predictive Factors - All 3 Illnesses
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
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A Three Stage Model

• Different Goals for Each Stage
• Different Components in Each Stage
• Last Stages Depend on the Success of the First
  Stages

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A Nice Simple Model
Substance Abusing Patient
Treatment
NTOMS Sample of 250 Programs
Non- Substance Abusing Patient
19
An Ideal Model No Discharge
Substance Abusing Patient
Tele Monitoring
Hospital Detox
Residential Rehab
IOP Rehab
Outpatient Cont Care
AA -Tele Monitoring
Regular Performance Eval
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A More Typical Model
Detox- Only Admissions
Tele Monitoring
Hospital Detox
Residential Rehab
IOP Rehab
Outpatient Cont Care
AA -Tele Monitoring
42 of Philadelphia Episodes _at_ 750 - 1500 each
21
A Desirable Model
Continuing Care / Monitoring Early Detection of
Relapse
Tele Monitoring
Hospital Detox
Residential Rehab
IOP Rehab
Outpatient Cont Care
AA -Tele Monitoring
20 of Philadelphia Episodes
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Problem 2 How We Evaluate It
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Why Does Treatment Seem So Ineffective?
24
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.
25
Outcome In Hypertension
Pre - During - Post
Treatment Research Institute
26
Outcome In Addiction
Pre - Post
Treatment Research Institute
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Rehabilitation Model

• .. treatment benefits should be sustained
  following discharge for addiction treatment to be
  worth it

(McLellan,1998).
28
Comparing Treatments Testing Three Treatments
in a Rehabilitation Model
Treatment Research Institute
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Project MATCH

• RCT - 3 Research-Derived Therapies
• 27 Million Dollar NIAAA Study
• Different Mechanisms of Action
• Fixed Interventions No Changes
• Goal Achieve Lasting Abstinence or Improved
  Drinking Post Completion

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Project Match Fixed Time - Fixed Content Rehab
Oriented
Treatment Type
Post Treatment Evaluations
6 12 18 24
30 39
45
38
27
MET
CBT
12-Step
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Improvement in Project MATCH
32
Again.
Maybe We Have the Wrong Model?
33
Comparing Rehabilitation Treatments
Treatment
Control
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Points

• Evaluate during not after treatment
• We may be missing important effects because of
  our evaluation model

35
Comparing Treatments Testing Three Treatments
in a Continuing Care Model
Treatment Research Institute
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ALLHAT The Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack
Treatment Research Institute
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ALLHAT

• Groups Explicitly Different Mechanisms of
  Action and Cost
• Diuretic - 0.10 /pill
• Calcium Channel Blocker - 1.50 /pill
• ACE Inhibitor - 4.00 /pill
• Goal to Reach Pre-Specified Criterion DURING
  TREATMENT

Treatment Research Institute
38

ALLHAT Pre-Specified Criteria Adjustment
Oriented
DURING Treatment Evaluations
Start 27 Control
Step 1 Step 2 Step 3
63
40
54
Diuretic
66
56
42
CCB
64
44
54
ACE
39
Improvement Comparison
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An Ideal Model No Discharge
Substance Abusing Patient
Tele Monitoring
Hospital Detox
Residential Rehab
IOP Rehab
Outpatient Cont Care
AA -Tele Monitoring
Regular Performance Eval
41
Considerations for Addiction

• There are Promising, complementary Treatments
• Medications, therapies, services
• Adaptive Strategies are Feasible and Consistent
  With Care Management
• Switching - Given bad results or no acceptance
• Supplementing - Given sub-optimal results

42
Problem 3 The National Treatment Infrastructure
43
20 Years of Research Shows Treatment Is
Effective When delivered by qualified
professionals, using empirically validated
medications and therapies, applied for adequate
durations and followed by monitoring and
maintenance.
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When delivered by qualified professionals,
using proven medications and therapies, applied
for adequate durations and followed by monitoring.
45
So, Is Contemporary Treatment Structured to Be
Effective ?
46
State of the Field

• Results of Initial Work on the National Treatment
  Outcomes Monitoring System (NTOMS)
• Leadership Management
• Staffing Information

47
Program Survey - 1

• 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

48
Program Survey - 2

• 50-60 of directors have been there Less Than 1
  year
• Counselor turnover is 50 per year

STAFF TURNOVER!
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Program Survey - 4

• Who Are the Directors ?
• 17 No College Education 58 Had BA
  Degree 20 Had a MA or MSW
• 28 NOT Working Full Time
• Most had been clinicians _at_ program

50
Program Survey - 5

• Other Staff
• 54 Had no physician 34 Had P/T
  physician 39 Had a Nurse (part of full time)
• lt 25 Had a SW or a Psychologist
• Major professional group - Counselors

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Program Survey - 6

• Admission Process
• No Standard Procedure or Instrument
• Total process often 3 hours
• 15 20 Dont Do Assessment
• No Use of/for Assessment
• Simply Paperwork

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Program Survey - 7

• Information Systems
• Improved Computer Availability
• Mostly For Administrative/Fiscal Work
• 80 Had a Computer
• 50 had Web Access
• Still very little computer/software availability
  for CLINICAL STAFF

53
Thank You For Sharing!
54
Can Research Help?

• Using Technology to Improve Retention
  Participation

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Background

• The JCAH-O wants to see customized treatment
  plans and wrap-around services
• BUT this can be time-consuming and costly
• Counselors need help to efficiently locate
  necessary services.

56
DENS-Resource Guide
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Site Counselor Characteristics

• 10 Community Treatment Programs
• All Required to Learn the ASI by the state
• 5 Counselors per program
• No experience with ASI previously
• 5 Admissions per counselor
• Essentially random selection

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Site Counselor Characteristics

• No significant differences to start
• Among Programs Very similar on the ATI
• Among Counselors - in ASI training,
  education, recovery status, tenure on job
• Among Patients Demographics and ASI scores

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SPLIT INTO TWO GROUPS

• ALL GET
• A Computer With ASI Software Installed
• Training in Admission Interviewing
• (8 Hrs CEU)
• HALF GET
• Training on the United Way First Call for Help to
  link ASI data to service availability

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Problem-Services Linkage

• Alcohol
• Drugs
• Medical
• Employment
• Family
• Psychiatric
• Legal

(e.g. Employ - related services
GED training Resume Development Job
Finding Mentoring Sessions Training Loans
Treatment Research Institute
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Counselor Turnover

• 50 Counselors from 10 Programs
• Within 5 months, 19 counselors had been promoted,
  fired or just quit (38)

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Findings
63
Hypothesis 1

• Patients of Extra Training counselors
• will receive more and
• better-matched services.

64
Mean Number of Services Received
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Hypothesis 2

• Patients of Extra Training counselors
• will remain in treatment longer.

66
Percent Retained at 30 Days
67
Percent Retained at 60 Days
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Unexpected Finding

• Counselors who received the Extra Training
• Remained on the job longer.

69
Percent Who Quit by 6 Months
70

- The End -
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Lessons Addiction Can Learn from Chronic
Care
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What Continuing Care Does NOT Imply

• 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 Purpose is to Teach Self Management

73
What Continuing Care Does Imply

• Need for Pre-Specified Treatment Goals
• Agreeable to the Patient, Measurable
• Need for Continuing Contact/Monitoring
• Tailored to the severity and needs of the patient
  
• Telephone and Internet Options
• Need for Multiple Options
• Most First Efforts Will Fail Hard to Predict
• Sensible Switching or Adding Time Frames

74
Lessons From Chronic Care

• Most Patients Do NOT Respond to Their First
  Treatment/Medication
• Need for more alternatives
• Improves retention
• Monitoring is Part of Health Care

75
Lessons From Chronic Care

• Monitoring is Part of Health Care
• Telephone and IVR Useful
• Saves Physician Time, Reduces Number and
  Severity of Relapses
• Not Currently Reimbursed

76
Lessons From Chronic Care

• Evaluations of Continuing Care Should Occur
  DURING Treatment
• Need for interim performance markers (retention,
  linkage, urines, pro-social behaviors, etc.)

77
Lessons Chronic Care Can Learn from
Addiction Treatment
78
Lessons From Addiction

• Symptom Improvement Does Not Continue Without
  Behavioral Change
• Social Support and Counseling Alone Can Improve
  Symptoms and Function
• Poor, Psychiatrically Ill Patients CAN DO
  Improve

79

- The End -