Transcript GERARD M. SCHIPPERS

Translating Standards Into Practice
The Voluntary Approach In
.
The Netherlands
Gerard M. Schippers
EQUS, Brussels, june 2011
THE AMSTERDAM INSTITUTE FOR
ADDICTION
RESEARCH
pragmatic approach
of use …
and of treatment
Nevertheless, in the 90s, Dutch Substance
Abuse Treatment Services were publicly
criticized for a number of reasons, which
alarmed the management.
Criticisms on Substance
Abuse Treatment in the 90s
Public criticism (on nuisance, lack of effect, treating the
elite)
Applied treatment methods mainly based on clinical
intuition, tradition, and ideology, while
Scientific accomplishments not being implemented
Hardly any specialized education and training
Bad coordination between different fragmented
programs and program elements (scattered, island
culture)
Treatment methods barely transparent and explicit
Negative Consequences
Too much emphasis on abstinence oriented programs
Too few integration of mental health and substance
abuse treatment
Undervaluation of medication supported therapies
Too few attention for motivation enhancement
Too few insight in the chronic relapsing nature of addiction
Too much distinction (organizational and conceptual)
between kind of substances
Too few distinction between chronic and temporary
problems
Dutch Substance Abuse Treatment
Services (ca 16 mil inhabitants)
11 larger regional Centers
ca 4.000 fte staff
serving ca 60.000 new patients yearly
ca 55% alcohol dependent
from all illegal drug abusers
ca 70% are in regular contact with treatment services
(>50% in methadone maintenance)
ca 15% are IV-users
relatively low HIV prevalence
Areas 11 Dutch Substance
Abuse Treatment Centres
Where did this lead to?
Designing a Treatment
Renovation Program
based on a bottom-up initiative from the
managers of the service providers facing
the criticisms
“To Score Results”
National Reform Program
Dutch Substance Abuse Treatment Services
1998-2013
A cooperative effort of all larger treatment
substance abuse institutions, with the help of
additional funding from Ministry of Health
founding a national steering group
composed of managers, clinical
professional and scientists
Objectives Reform Program
Improvement of services for substance
abusers (primary processes) by
Implementing services based on scientific
evidence and/or clinical consensus
Monitoring clinical results and feeding them
back to professionals and the public
Improving education in addiction
Designing a Treatment Reform Program
2002
2010
Implementing renewed
services for
Prevention, Treatment
and Matching
What does research tell us
on the effectiveness of
treatment on addictive
behavior?
Effective Treatment Through the Internet
fully self-guided internet module, or with counsellor effective
Evidence on Effectiveness Is
Ample Available
Nevertheless, in the last years,
focus has changed from
evidence-based to client-based,
due to increased influence of
financers (competing assurance
companies)
Characteristics Dutch professional
Substance Abuse Treatment Methods
Evidence based treatment methods
No diversion between alcohol and drug treatment
Treatment and harm reduction provided by the
same organisations
Redesigned Treatment Modules*
Brief CBT individual
Standard CBT individual
Brief CBT group
Standard CBT group
Screening, Needs
Assessment &Treatment
Allocation
User Rooms**
Crisis intervention
Detoxification
Integrating Self Help Groups in
Regular Care
After Care
Opiate Substitution Treatment
Suicide in addiction care
Casemanagement
MATE: Assessment for Triage
and Patient Placement
Adolescent Cannabis Abuse
Substance Abuse &
Depression
* 15 Treatment & Rehabilitation, 1 Harm Reduction**:
No distinction in the Netherlands
Examples: National Consensus
Guidelines
Dutch National Guidelines on the Treatment of
Alcohol Use Disorders (2009)
Dutch National Guidelines on the Treatment of
Heroin Dependency (2011)
Examples: Psychosocial Behaviororiented Treatment Modalities
(“Life Style Training Program”)
1.
2.
•
•
•
•
Brief MI/CBT (intake + ca. 4 sessions)
Standard MI/CBT (intake + ca. 10 sessions)
for individuals and groups
general applicable for all substances
based on cognitive behavior therapy
motivational interviewing as basic counseling style
Measurement in the Addictions
for Triage and Evaluation
New instrument for measuring patient
characteristics in substance abuse
treatment
www.mateinfo.eu
How Well are the New Modules
Implemented?
Evaluation study in 2005, 2008 and 2011*
20 to 27 modules disseminated. Drug treatments
also in the EQUS project
11 Out of 12 institutions observed, covering
3800 (77%) of the 5000 patient-related workers
Interview with 40 key persons
*
Preliminary data
How Well are the New Modules
Implemented?
Evaluation study in 2005, 2008 and 2011*
20 to 27 modules disseminated. Drug treatments
also in the EQUS project
11 Out of 12 institutions observed, covering
3800 (77%) of the 5000 patient-related workers
Interview with 40 key persons
*
Preliminary data
Level of Implementation of protocols
100%
% treatment centers
80%
60%
40%
20%
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2005
2008
2011
Level of Implementation in treatment centers
100%
Implemented
Not implemented
% modules
80%
Unknown
60%
2008, 23 modules
40%
20%
0%
1
2
3
4
5
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8
Treatment Centers
9 10 11
REQUIRED:
Coalition of multiple
stakeholders: financers,
centre administrators;
clinicians, and service
consumers
Necessary (although not Sufficient)
Conditions for Implementation
Adequate resources
A reasonably well managed institute
Coalition of multiple stakeholders: financers,
centres administrators; clinicians, and service
consumers
Support on central management level
Trusted enthusiastic mediator
Training, supervision and booster training
Factors Promoting the Implementation
Minor local variations should be possible
(‘not-invented-here-syndrome’)
Changes should not be too large and too quick
although … radical changes sometimes work better
New modules should replace old practice
Continuation in coercion and support from central
management are essential
Increasing convenience (e.g. electronic
implementation)
External pressure helps
Training, training, training …
Factors Hindering the Implementation
Instability in team management and team
personnel
Organisational changes (new way of working
e.g. care pathways and Assertive Community
treatment)
Too few publicity new guidelines
No support from management
Guidelines get outdated
Financial problems or no funding
Dutch clinicians are alike
their colleagues all over
the world in eagerness
and willingness to learn
and change
but
… the changing of
habitual behavior is
tedious and takes a
long breath.