Transcript New York State Treatment System

New York State Treatment
System
Presented March 25, 2011
Edward Freeman
[email protected]
New York State
• New York is the US’ 3nd biggest State, after
California and Texas
• Population is nearly 20 million people,
• 40% (8 million) live in New York City
• 60% of New Yorkers live in the 9 NY counties
comprising the NYC Metropolitan Area
• Large sections of NY State are rural (see map)
Addiction is a complex illness characterized by
compulsive, at times uncontrollable drug
craving, seeking and use that persist even in
the face of extremely negative consequences.
For many people, addiction becomes chronic,
with relapses possible even after long periods
of abstinence
• New York State certifies a wide variety of
treatment programs
• Addiction programs are regulated by the state
to ensure the efficient, planned development
of local systems of services
• and assure adequate standards of care
Treatment Services
Number of Treatment Programs
Program Category
Crisis Service
82
Inpatient
64
Methadone
132
Outpatient
558
Residential
228
Total
1,064
Treatment Services
Figure 2.9 Unique Persons Served within Program
Category, Calendar Year 2009
N=261,295*
Crisis
51,432
Inpatient
34,271
Methadone
46,868
Outpatient
171,215
Residential
25,414
0
50,000
100,000
150,000
200,000
* Unique persons served in each program category do not sum to total unique persons served, as individuals
may be served in more than one program category.
Addiction Treatment System
NY System admits people who abuse or are
dependent on
alcohol,
opiates,
cocaine,
marijuana
and their family members.
The programs treat the primary substance abuse disorder, any
secondary substance abuse/dependence and identified cooccurring disorders such as mental illness, smoking, gambling.
Figure 2.12 Primary Substance at Admission, All
Program Categories, Calendar Year 2009
Cocaine/Crack, Other, 3%
12%
Opioids,
23%
Alcohol, 45%
Marijuana, 16%
Co-Occuring Disorders at Admission
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65% have secondary substance disorder
40% have mental illness
65% Daily tobacco use
1% Family members and Significant others
Figure 2.10 Average Daily Enrollment by Program
Category, Calendar Year 2009
N=107,458
Methadone
36%
Outpatient
53%
Inpatient
2%
Residential
8%
Crisis
1%
Treatment Services
Program Capacities
Crisis Beds
1,663
Inpatient Beds
2,445
Methadone Slots
42,411
Outpatient Visits
5,420,838
Residential Beds*
* Does not inclued supportive living beds
8992
Admissions to Treatment Programs, All Categories, 2009
N = 312,000
Figure 2.11 Admissions by Program Category
Calendar Year 2009
Residential
2%
Methadone
4%
Inpatient
13%
Outpatient
49%
Crisis
32%
Stage-Based Treatment
Initial Stage
Stabilization and Engagement
Active Treatment Stage
Early Recovery
Maintenance Stage
Continuing Care
Levels of Care
Crisis and Non-Crisis Services
Crisis Services (Withdrawal Services)
 Medically-managed detoxification (acute care
hospital)
 Inpatient/residential medically-supervised
 Outpatient medically-supervised
 Residential medically-monitored
Levels of Care
Non-Crisis Services
 Inpatient Rehabilitation
 Intensive Residential Rehabilitation
 Outpatient Rehabilitation
 Methadone (Opioid Replacement Therapy)
 Intensive Outpatient
 Outpatient (non-intensive)
 Community Residences & Supportive Living
Pathways
Crisis Services
• Medically Managed Detoxification services are indicated
when the individual is (1) at risk of severe withdrawal; (2) at
significant risk due to complications or comorbidities; or
(3)incapacitated by substances and there is substantial risk of
physical harm to the individual or others.
• Inpatient/Residential Medically Supervised Withdrawal
services are indicated when the
• individual is at risk of moderate withdrawal and there is lack
of support for early abstinence.
Crisis Services
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Outpatient Medically Supervised Withdrawal services are
indicated when the individual is at risk of moderate
withdrawal and lack of support for early abstinence is not a
problem.
• Medically Monitored Withdrawal services are indicated
when the individual is (1) intoxicated and is experiencing a
situational crisis, or (2) unable to abstain without admission to
a supervised setting.
Inpatient
• Services are designed to initiate the treatment and
recovery process for individuals who are unable to
participate in or comply with treatment outside a 24-hour
structured treatment setting.
• provided in general hospitals, psychiatric hospitals, and
free-standing facilities.
• Inpatient treatment includes the management of physical
or mental complications or co-morbidities which may be
present.
• Nursing services are available on a 24-hour per day basis.
• Clients cannot be effectively served as outpatients and who
are not in need of medical detoxification or acute care.
Inpatient
INPATIENT REHABILITATION SERVICES
• provide intensive management of chemical dependence symptoms and medical
management/monitoring of physical or mental complications from chemical
dependence to
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Lengths of stay are primarily in the 20-40 day range.
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conduct intensive evaluation, treatment and rehabilitation services in a medically
supervised 24 hour/day, 7 days/week setting.
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Core clinical procedures: individual and group counseling and activities therapy;
alcohol and substance abuse disease awareness and relapse prevention;
education about, orientation to, and opportunity for participation in, available and
relevant self-help groups; assessment and referral services for patients, families
and significant others; HIV education, risk assessment and supportive counseling
and referral; vocational and/or educational assessment, and medical and
psychiatric evaluation.
Residential
RESIDENTIAL SERVICES
• assist individuals who suffer from chemical dependence, who are unable to maintain abstinence or
participate in treatment without the structure of a 24-hour/day, 7 day/week residential setting as
evidenced by recent unsuccessful attempts at abstinence or prior treatment unsuccessful episodes
of outpatient treatment and
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who are not in need of acute hospital or psychiatric care or chemical dependence inpatient
services.
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Admissions may come directly from crisis services or persons released from criminal justice
facilities without prior inpatient rehabilitation treatment.
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Length of stay ranges from an average of four months in a community residential service to up to
two years in the other residential service categories.
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All residential chemical dependence services provide the following procedures: individual and
group counseling, peer group counseling, supportive services, educational services, structured
activity and recreation and orientation to community services. Habi;itative and rehabilitative
procedures can be provided directly or through referral and are based on an individualized
assessment and treatment plan.
Residential
• INTENSIVE RESIDENTIAL : In addition to the
procedures required of all residential services, intensive
residential provide either directly or by referral:
– vocational services;
– Parenting skills;
– personal, social and community living skills training
including personal hygiene and leisure activities.
– a minimum of 40 hours/week of procedures within a
therapeutic milieu.
Residential
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COMMUNITY RESIDENTIAL or Halfway Houses: people served in this level of
care are in need of additional structured living after discharge from
inpatient rehabilitation or are admitted in combination with intensive
outpatient treatment as a substitute for inpatient rehabilitation. Typically
they are homeless or their living environment is not conducive to recovery
and maintaining abstinence. The program provides
• a structured therapeutic milieu while residents are concurrently receiving
• outpatient chemical dependence counseling;
• vocational services, such as vocational assessment, job skills training and
employment readiness training;
• personal, social and community living skills training including personal
hygiene and leisure activities.
Residential
SUPPORTIVE LIVING SERVICES: provide a minimum level of professional
support which includes a weekly visit to the site by a clinical staff member
for case management of the resident. Individuals appropriate for this
service include persons who:
• require support of a residence that provides an alcohol-and drug-free
environment;
• require the peer support of fellow residents to maintain abstinence;
• does not require 24 hour on-site supervision by clinical staff; and
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exhibit the skills and strengths necessary to maintain abstinence and
readapt to independent living in the community while receiving the
minimal clinical and peer support provided by this residential
environment.
OUTPATIENT SERVICES
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Chemical dependence outpatient services assist individuals who suffer from chemical abuse
or dependence and their family members and/or significant others.
Outpatient services may be delivered at different levels of intensity responsive to the severity
of the problems presented by the client.
These services may be provided in a free standing setting, or may be co-located in a variety of
other health and human service settings. Sponsorship may be voluntary, proprietary or
county operated.
The length of stay and the intensity of services as measured by frequency and duration of
visits varies from one category of outpatient services to another and intensity will vary during
the course of treatment within a specific category.
In general, persons are engaged in outpatient treatment up to a year and visits are more
frequent earlier in the treatment process becoming less frequent as treatment progresses.
Outpatient
• MEDICALLY SUPERVISED OUTPATIENT SERVICES: Each chemical
dependence outpatient service provides the following procedures under
the oversight and involvement of a medical director who is part of the
multidisciplinary team and in accordance with an individualized
assessment and treatment plan.:
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group and individual counseling;
introduction to self help groups;
alcohol and substance abuse disease awareness and relapse prevention;
HIV and other communicable disease education, risk assessment,
supportive counseling and referral,
• family treatment,
• social and health care services, accessing community services, activity
therapies, information and education about nutritional requirements, and
vocational and educational evaluation, either directly or through written
agreements. Procedures are provided
Outpatient
• OUTPATIENT REHABILITATION SERVICES: under the oversight and
involvement of a medical director who is part of the
multidisciplinary team and in accordance with an individualized
assessment and treatment plan service level is designed to serve
more chronic individuals who
• have inadequate support systems, and either have substantial
deficits in functional skills or have health care needs requiring
attention or monitoring by health care staff.
• These programs provide social and health care services, addiction
counseling and vocational and educational evaluation.
• Clients initially receive these procedures five days a week for at
least four hours per day.
• There is a richer staff to client ratio for these services including
medical staff.
Outpatient
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METHADONE TREATMENT SERVICES
a medical service designed to manage heroin
addiction.
by prescription, in conjunction with a variety of other
rehabilitative service
delivered primarily on an ambulatory basis, either a
community or hospital setting.
a few programs deliver services in a prison setting.
Rehabilitative assistance includes primary medical care,
counseling and support services:
Outpatient
Methadone Treatment Programs provide:
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Primary Medical Care is provided on site or through service agreements with hospitals, medical
centers and specialty clinics. All MTPs have medical staff with a physician as medical director, who is
responsible for the coordination of all medical and rehabilitative services.
Counseling is provided to each patient by an individual counselor who, in conjunction with other
clinical staff, is responsible for developing and coordinating a treatment plan which addresses the
major needs of the patient. Individual and group counseling is offered in appropriate frequency,
duration and intensity.
Support Services include vocational, educational, legal, mental health and alcoholism information.
When appropriate, each patient shall be enrolled in an education program, be engaged in a
vocational activity or make documented efforts to seek gainful employment.
Methadone may be prescribed and administered through a variety of medical protocols, as per
individual needs:
Maintenance utilizes methadone administered daily at stabilized dose over an extended period of
time.
Methadone to Abstinence utilizes methadone in gradually decreasing doses to the point of
abstinence, followed by continued drug free treatment.
Medically supervised Withdrawal is a short term (not more than 30 days) or long term (not more
than 180 days) protocol that utilizes methadone to alleviate withdrawal symptoms caused by the
use of opiates.
Principles of Effective Treatment
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No single treatment is appropriate for all individuals
Treatment needs to be readily available
Must address multiple needs, not just addiction
Individual’s treatment must be continually reassessed and updated
Time in treatment matters – adequate period (3 mos min) is critical
Counseling essential
Medications are important
Must treat co-occurring in integrated way
Detoxification is only first stage
Treatment need not be voluntary BUT in New York all treatment for
addiction is voluntary.
– Drug use must be monitoring continually during treatment
Treatment Must Enhance
Motivation – Why change?
Insight – What to change?
Skills – How to change?
Issues in Treatment
– Addiction management
– Physical health
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STD
Hepatitis
HIV/AIDS
TB
Nicotine dependence
Mental illness
Strengthening the family
Legal
Financial
Child care
Housing
Parenting
Transportation
Education
Prevocational and work readiness