What’s Wrong WithAddiction Treatment?

A. Thomas McLellanNADAAC Presentation

Washington, D.C.September 15, 2003

Three Problems

1) How We Treat It:Acute vs Continuing Care

2) How We Evaluate It:As Though we Have a

Cure

3) Treatment Infrastructure:Can it Support

Expectations

Problem 1

How We Treat It

A Nice Simple Rehab Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

Meds,Therapies,Services

• Treatment Has Not Met Public’s Expectations – There is No Cure

• Treatments CAN Work But…… Patients Do Not Cooperate

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

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

Maybe We Have the Wrong

Model?

How Are Other Illnesses Treated & Evaluated?

Why Isn’t Addiction More Like Other Illnesses?

Implications for Evaluation and Treatment

Lessons learned from Chronic Illnesses

A Comparison With Three Chronic Medical Illnesses

Hypertension

Diabetes

Asthma

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

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

• Different Goals for Each Stage

• Different Components in Each Stage

• Last Stages Depend on the Success of the First Stages

A Nice Simple Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

An Ideal Model – No Discharge

Substance Abusing Patient

Regular “Performance” Eval

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

A More Typical Model

Detox- Only Admissions

42% of Philadelphia Episodes @ $750 - $1500 each

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

A Desirable Model

Continuing Care / MonitoringEarly Detection of Relapse

20% of Philadelphia Episodes

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

Problem 2

How We Evaluate It

Why Does Treatment Seem So Ineffective?

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.

0

2

4

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10

Pre During During During Post

Treatment Research Institute

Outcome In Hypertension

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4

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8

10

Pre During During During Post

Treatment Research Institute

Outcome In Addiction

Rehabilitation Model

“.. treatment benefits should be sustained following discharge for addiction treatment to be worth it …”

(McLellan,1998).

Comparing Treatments

Testing Three Treatments in a Rehabilitation Model

Treatment Research Institute

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

MET

CBT

12-Step

Project Match Fixed Time - Fixed Content – Rehab Oriented

6 12 18 24 30 39

Treatment Type

Post Treatment Evaluations

45% 38% 27%

Improvement in Project MATCH

81

53

230

10

20

30

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50

60

70

Baseline 6-Mo 39-Mo

% Days Drinking

Maybe We Have the Wrong

Model?

Again….

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Pre During During During Post 1 Post 2 Post 3

Comparing Rehabilitation Treatments

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Pre During During During Post 1 Post 2 Post 3

Treatment

Control

Points

Evaluate during – not after – treatment

We may be missing important effects because of our evaluation model

Comparing Treatments

Testing Three Treatments in a Continuing Care Model

Treatment Research Institute

ALLHAT

The Antihypertensive and Lipid-Lowering Treatment to

Prevent Heart Attack

Treatment Research Institute

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

Diuretic

CCB

ACE

ALLHAT Pre-Specified Criteria – Adjustment Oriented

Step 1 Step 2 Step 3Start

27% Control

DURING Treatment Evaluations

40%

42%

44% 54%

56%

54%

64%

66%

63%

Improvement Comparison

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8053

39

64

23

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Baseline Yr 1 Yr 3

ALLHAT MATCH

An Ideal Model – No Discharge

Substance Abusing Patient

Regular “Performance” Eval

HospitalDetox

ResidentialRehab

IOPRehab

OutpatientCont Care

AA -TeleMonitoring

TeleMonitoring

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

Problem 3

The National TreatmentInfrastructure

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.

* When delivered by qualified professionals, using proven medications and therapies, applied for adequate durations and followed by monitoring.

So, Is Contemporary

Treatment Structured

to Be Effective ?

• Results of Initial Work on the National Treatment Outcomes Monitoring System (NTOMS)

• Leadership Management

• Staffing Information

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

• 50-60% of directors have been there Less Than 1 year

• Counselor turnover is 50% per year

Program Survey - 2

STAFF TURNOVER!

Program Survey - 4Who Are the Directors ?

• 17% No College Education 58% Had BA Degree20% Had a MA or MSW

• 28% NOT Working Full Time

• Most had been clinicians @ program

Program Survey - 5Other 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

Admission Process:

• No Standard Procedure or Instrument

–Total process often 3 hours–15 – 20% Don’t Do Assessment

• No Use of/for Assessment

–“Simply Paperwork”

Program Survey - 6

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

Program Survey - 7

Thank You For Sharing!

Can Research Help?

• Using Technology to Improve Retention & Participation

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.

DENS-Resource Guide

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

Site & Counselor Characteristics

No significant differences to start:Among Programs – Very similar on the ATIAmong Counselors -

in ASI training, education, recovery status, tenure on jobAmong Patients – Demographics and ASI scores

SPLIT INTO TWO GROUPS ALL GET:A Computer With ASI Software InstalledTraining in Admission Interviewing (8 Hrs CEU)

HALF GET:Training on the United Way First Call for

Help to link ASI data to service availability

Problem-Services Linkage

Treatment Research Institute

•Alcohol

•Drugs

•Medical

•Employment

•Family

•Psychiatric

•Legal

GED training

Resume Development

Job Finding

Mentoring Sessions

Training Loans

(e.g. Employ - related services

Counselor Turnover• 50 Counselors

from 10 Programs

• Within 5 months, 19 counselors had been promoted, fired or just quit (38%)

28%

62%

Quit Study

Completed

Findings

Hypothesis 1Patients of Extra Training counselorswill receive more and better-matched services.

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02468

101214

D/A Med Emp Legal Family Psych

Enhanced Group Standard Group

Mean Number of Services Received

Hypothesis 2

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

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

Unexpected Finding

Counselors who received the Extra Training:

Remained on the job longer.

Percent Who Quit by 6 Months

20%

60%

10

30

50

70Extra Standard

Lessons

Addiction Can Learn from Chronic Care

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

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

• Most Patients Do NOT Respond to Their First Treatment/Medication

• Need for more alternatives

• Improves retention

• Monitoring is Part of Health Care

• Monitoring is Part of Health Care

• Telephone and IVR Useful

• Saves Physician Time, Reduces Number and Severity of Relapses

• Not Currently Reimbursed

• Evaluations of Continuing Care Should Occur DURING Treatment

•Need for interim performance markers (retention, linkage, urines, pro-social behaviors, etc.)

Lessons

Chronic Care Can Learn from Addiction Treatment

• 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