Improving the Quality of Treatment in OTPs

1
Improving the Quality of Treatment in OTPs
American Association for the Treatment of Opioid
Dependence (AATOD)

• Missouri Department of Mental Health Spring
  Training Institute
• Mark W. Parrino, M.P.A. Thursday, May
  17, 2007

2
Active Opioid Treatment Programs by State 1149
programs(as of July 2006)
20
5 VT
7
15
0
0
9
7 NH 46 MA
17 RI 35 CT 36 NJ 6 DE 45 MD 9
DC
0
0
15
166
37
0
9
4
54
9
1
13
13
154
59
9
8
19
5
10
8
34
28
9
8
11
2
12
33
1
21
12
73
1 VI
39
4 HI
3 AK
8 PR
Source Center for Substance Abuse Treatment
(CSAT)
3
Matching Patients to Individual Needs

• No single treatment is appropriate for all
  individuals
• Effective treatment attends to multiple needs of
  individual, not just his/her drug use
• Treatment must address medical, psychological,
  social , vocational and legal problems

Source National Institute on Drug Abuse (NIDA)
4
Duration of Treatment

• Depends on patient problems/needs
• Less than 90 days is of limited/no effectiveness
  for residential/outpatient setting
• A minimum of 12 months is required for methadone
  maintenance
• Longer treatment is often indicated

Source National Institute on Drug Abuse (NIDA)
5

• The problem was one of the rehabilitating people
  with a very complicated mixture of social
  problems on top of a specific medical problem,
  and that (practitioners) ought to tailor their
  problems to the kind of problem they were dealing
  with. The strength of the early programs as
  designed by Marie Nyswander was in their
  sensitivity to individual human problems. The
  stupidity of thinking that just giving methadone
  will solve a complicated problem seems to me
  beyond comprehension. Vincent P. Dole, M.D.,
  1989
• Source Courtwright, et. Al. Addiction Who
  Survived

6
Cost-Effectiveness of Drug Treatment

• Every 1.00 invested in treatment yields us to
  7.00 in reduced crime-related costs
• Savings can exceed costs by 121 when health care
  costs are included
• Reduced interpersonal conflicts
• Improved workplace productivity
• Fewer drug-related accidents

Source National Institute on Drug Abuse (NIDA)
7
Average Cost Per Year for One Heroin Addict
Security
Theft
Heroin
Adopted from New York State Division of Substance
Abuse Services, 1991 by Dole and De Jarlais
8
Proportions of Clients Who Reduced Costs to Tax
Paying Citizens by at least 50 in Year Following
Treatment Varies by Type of Treatment
California Drug and Alcohol Treatment Assessment
Dean Gerstein et al. 1994
9
Crime among 491 patients before and during MMT at
6 programsBaltimore Philadelphia New York
City
Crime Days Per Year
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
9
10
Major Types of Crime in New York City,
Philadelphia and Baltimore
1.1
1.6
.7
Source John Ball, J Drug Issues, 1991
11
HIV/AIDS, Hepatitis and Other Infectious Diseases

• Drug treatment is disease prevention
• Drug treatment reduces likelihood of HIV
  infection by 6 fold in injected drug users
• Drug treatment presents opportunities for
  screening, counseling and referral

Source National Institute on Drug Abuse (NIDA)
12
Lifetime and Recent Prevalence of Psychiatric
Symptoms Among Male Methadone Maintenance Patients

• Percent with Symptom
• Lifetime Past 30 days
• 48.3 16.6
• 51.7 22.9
• 8.6 2.3
• 28.0 16.6
• 24.9 7.9
• 15.3 3.5
• 8.5 0.4
• 68.4 35.4

• Psychiatric Symptoms
• Serious depressions
• Serious anxiety
• Hallucinations
• Difficulty Understanding, concentrating,
  remembering
• Trouble controlling violent behavior
• Thoughts of suicide
• Suicide attempt
• Had one or more symptoms
• Valid cases 567

Source Ball and Ross. The Effectiveness of
Methadone Maintenance Treatment
13
Buprenorphine, Methadone, LAAMOpioid Urine
Results
All Subjects
100
80
LAAM
49
60
Bup
40
High Dose Methadone
Mean Negative
40
39
Low Dose Methadone
20
19
0
1
3
5
7
9
11
13
15
17
Study Week
Adapted from Johnson, et al., 2000
14
Buprenorphine, Methadone, LAAM Treatment
Retention
100
73 High Dose Methadone
80
60
58 Bup
Percent Retained
53 LAAM
40
20
20 Low Dose Methadone
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Study Week
Adapted from Johnson, et al., 2000
15
Strategies for Improving Methadone Treatment
Process and Outcome
Journal Of Drug Issues 1997 Simpson, Joe,
Dansereau, Chatham
16
Emergency Room Mentions NationwideOXYCODONE
Mentions
17
Emergency Room Mentions NationwideMethadone
Mentions
18
Enforcement/Oversight Accreditation
Organizations

• Conduct inspections at least triennially - drug
  abuse treatment expertise
• Agree to conduct for cause inspections
• Require program to conduct deficiencies
• Notify SAMHSA regarding serious risk to patient
  care or public health/safety
• Complaint Response
• SAMHSA will evaluate performance with
  direct/indirect inspections
• Source Center for Substance Abuse Treatment

19
Federal Opioid Treatment Standards (8.12)

• Administration and organizational structure
• Quality Assurance/improvement
• Diversion control plan
• Staff credentials
• Patient admission criteria
• Required services
• Record keeping and patient confidentiality
• Medication administration, dispensing
• Unsupervised use
• Interim Maintenance
• Detoxification
• Source Center for Substance Abuse Treatment

20
Phases of Treatment - Continuum

• Medical Maintenance 14 to 30 day take-homes
  bimonthly/monthly reporting
• Medical Maintenance with off-site physician
  affiliated with an OTP, treating stabilized
  patients (10 approved)
• Medical Maintenance with off-site physician and
  pharmacy dispensing solid medications (2
  approved)
• Office-based treatment with non-stabilized
  patients, non-affiliated physicians (0 approved)
• Source Center for Substance Abuse Treatment