Transcript Supporting a Field with Evidence and Logic

Substance Use
Disorder Treatment
Supporting the Field with
Evidence and Logic
Prepared by:
The Pennsylvania Practice Improvement
Collaborative (PA PIC)
Funded by:
The Substance Abuse Mental Health
Services Administration (SAMHSA)
With assistance from:
The Northeast ATTC (NeATTC)
And a Part of:
The Institute for Research, Education,
and Training in Addictions (IRETA)
Regional Enterprise Tower
Suite 1710
Pittsburgh, PA 15219
www.ireta.org
Substance Use Disorder:
A Unique Public
Health Issue
A Unique Public Health Issue
Addiction is viewed as a moral issue.
The public is skeptical about the efficacy of
addiction treatment.
The popular view of a “typical addict” is an
unemployed member of an inner-city minority
group.
Two-thirds of the US population receives their
information on addiction from the mass media.
Marwick, C. 1998: Treatment Works for Substance Abuse Offenders, JAMA, 280(13), 1126-1127.
Substance Use Disorder is One of
the Most Important Public Health
Issues Our Nation Faces Today.
“There are more deaths,
illnesses, and disabilities
from substance abuse than
from any other preventable
health condition.”
The Robert Wood Johnson Foundation. (1993). Substance Abuse: The Nation’s Number One Problem: Key
Indicators for Policy. Princeton, NJ.
$238 billion are spent annually on issues of alcohol
and other drug use and dependency.
Alcohol and other drug abuse and dependency are
related to:
Criminal Activity
Losses in Wages
Losses in Productivity
Health Problems
Increased Health Care
Utilization
Mental Retardation
Mental Health Problems
Mortality
The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem,
Key Indictors for Policy, Princeton, NJ.
Smoking
$80 Billion Health Care Costs in 1985
10%
2%
12%
Hospitals
Physician Servces
51%
Nursing Homes
Pharmaceuticals
Home Health Services
25%
The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key
Indictors for Policy, Princeton, NJ.
Note: Percentages may not add up to 100% due to rounding.
Alcohol Abuse
$22.5 Billion Health Care Costs in 1985
5%
3% 3%
8%
32%
Hospitals
Specialty Services
FAS Treatment
Physician Services
Pharmaceuticals
9%
Other Health Professions
Nursing Homes
Health Insurance Administration
10%
30%
The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key
Indictors for Policy, Princeton, NJ.
Note: Percentages may not add up to 100% due to rounding.
Drug Abuse
$11.9 Billion Health Care Costs in 1985
6% 3%
10%
Specialty Services
44%
Treatment for HIV/AIDS
Other Drug-Related Disease Groups
Hospitals
Health Insurance Administration
37%
The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key
Indictors for Policy, Princeton, NJ.
Note: Percentages may not add up to 100% due to rounding.
Trends in Substance
Use Disorder-Related Deaths
Deaths directly related to drug use have
more than doubled since the early ’80s.
Deaths related to alcohol have remained
more stable.
The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for
Policy, Princeton, NJ.
Number of Deaths in Thousands
25
Number of Deaths
20
19,576 Deaths
15
15,973 Deaths
10
5
0
79
81
Alcohol
83
85
Drugs
87
89
91
93
95
97
Years
The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for
Policy, Princeton, NJ.
Treatment Gap
In 2001, an
estimated 6.1
million people
aged 12 or older
(2.7 percent of the
total population)
needed treatment
for an illicit drug
abuse problem.
2001 National Household Survey on Drug Abuse (NHSDA).
Needed
Treatment
Treatment Gap
Of the 6.1 million
people needing
treatment, 1.1
million people
(17.3 percent of
the people who
needed treatment)
received treatment
at a specialty
facility.
2001 National Household Survey on Drug Abuse (NHSDA).
Received
Treatment
Treatment Gap
The treatment
gap was
estimated to be
5.0 million
people in 2001,
or 2.2 percent
of the total
population 12
and older.
Treatment
Gap
2001 National Household Survey on Drug Abuse (NHSDA).
Received
Treatment
Of the 5.0 million people who needed
but did not receive treatment in 2001…..
An estimated 377,000 reported that they
felt they needed treatment for their drug
problem. Of these:
– An estimated 101,000 reported that they had
made an effort but were unable to get
treatment.
– An estimated 276,000 reported making no
effort to get treatment.
2001 National Household Survey on Drug Abuse (NHSDA).
Treatment is Effective.
“Evidence that drug addiction treatments
are effective comes from a series of
reviews and additional data analyses of
more than 600 peer reviewed research
articles.”
Marwick, C. 1998. Study: Treatment Works for Substance Abuse Offenders, JAMA, 280(13), 1126-1127.
Treatment is Effective
A 5-year follow-up study of 1799 persons
(representative of the 976,012 individuals discharged
from chemical dependency treatment programs in the
90s) reported:
A 21%
Reduction in
Drug Use
A 14%
Reduction in
Alcohol Use
Marwick, C. 1998. Study: Treatment Works for Substance Abuse Offenders, JAMA, 280(13), 1126-1127.
Treatment is Effective
Results of the 2-year California Drug
and Alcohol Treatment Assessment
(CALDATA) study indicate that, for
every dollar spent on treatment, more
than $7 in future costs were saved.
National Clearinghouse for Alcohol and Drug Information. http://www.health.org/govpubs/bkd168/20h.htm
Is Addiction Treatment as
Effective as Treatment for
Other Health Problems?
Why Might We Not be
Viewing Addiction
Treatment
Appropriately?
Blood Pressure: mm Hg
Treatment for Hypertension:
Did Treatment Work?
No Tx
Tx
Tx
Tx
Treatment Status over Time
No Tx
Hypertension is a chronic disease.
Treatment is applied consistently
over time (anti-hypertensive
therapy with consistent follow up).
With Addiction . . .
Should We Also Be Using a
Chronic/Rehabilitative
Treatment Model INSTEAD of
an Acute/Single Episode
Treatment Model?`
Alcohol Cpnsumption
Treatment for Alcoholism:
Did Treatment Work?
No Tx
Tx
Tx
Tx
Treatment Status over Time
No Tx
Consider……
An insulin-dependent diabetic
who has been non-compliant with
treatment presenting at an
Emergency Room.
Should treatment be denied?
Should the patient be arrested?
Addiction/Chronic Illness
Compliance
Rate (%)
Relapse Rate
(%)
Alcohol
30-50
50
Opioid
30-50
40
Cocaine
30-50
45
Nicotine
30-50
70
Medication
<50
30-50
Diet and Foot Care
<50
30-50
Medication
<30
50-60
Diet
<30
50-60
<30
60-80
Addiction/Chronic Illness
Insulin Dependent Diabetes
Hypertension
Asthma
Medication
O’Brien CP, McLellan AT. Myths about the Treatment of Addiction (1996). The Lancet, Volume 347(8996), 237-240.
What is the Latest
Knowledge about Substance
Use Disorder Treatment That
We Can Use to IMPROVE
and SUPPORT the Field?
Components of Comprehensive
Substance Use Disorder Treatment
Child Care
Services
Family
Services
Housing/
Transportation
Services
Financial
Services
Behavioral Therapy
and Counseling
Clinical
and Care
Management
Vocational
Services
Intake
Processing/
Assessment
Treatment Plan
Pharmacotherapy
Substance Use
Monitoring
Self-Help/Peer
Support Groups
Continuing
Care
Educational
Services
Legal
Services
AIDS/HIV
Services
National Institute on Drug Abuse, 1999. Principles of Drug Addiction Treatment,
Mental Health
Services
Medical
Services
Evidenced-Based
Principles of Treatment
1. No single treatment is appropriate for all
individuals.
2. Treatment needs to be readily available.
3. Effective treatment attends to multiple
needs of the individual, not just his or her
drug use.
Evidenced-Based
Principles of Treatment
4. An individual’s treatment and service
plan must be assessed continually and
modified as necessary to ensure that the
plan meets the person’s changing needs.
5. Remaining in treatment for an adequate
period of time is critical for treatment
effectiveness.
Evidenced-Based
Principles of Treatment
6. Counseling (individual and/or group) and
other behavioral therapies are critical
components of effective treatment for
addiction.
7. Medications are an important element of
treatment for many patients, especially
when combined with counseling and
other behavioral therapies.
Evidenced-Based
Principles of Treatment
8. Addicted or drug-abusing individuals with
co-existing mental disorders should have
both disorders treated in an integrated
way.
9. Medical detoxification is only the first
stage of addiction treatment and by itself
does little to change long-term drug use.
Evidenced-Based
Principles of Treatment
10. Treatment does not need to be voluntary
to be effective.
11. Possible drug use during treatment must
be monitored continuously.
Evidenced-Based
Principles of Treatment
12. Treatment programs should provide
assessment for HIV/AIDS, hepatitis B
and C, tuberculosis, and other infectious
diseases, and counseling to help patients
modify or change behaviors that place
themselves or others at risk of infection.
Evidenced-Based
Principles of Treatment
13. Recovery from drug addiction can be a
long-term process and frequently
requires multiple episodes of treatment.
What are the Components of
a Comprehensive Substance
Use Disorder Model?
What Does the Latest
Research Say about How
Specific Interventions
Enhance the Effectiveness of
These Treatment
Components?
Overview of major studies providing the
evidence base for a Treatment Process Model
Interventions in
the TCU Treatment
Process Model
D. Dwayne Simpson
and Colleagues
Texas Christian University
Copyright © 2002 Texas Christian University, Fort Worth, Texas. All rights reserved.
Contact: [email protected] or phone, 817-257-7226.
TCU Treatment Process
Model
Motiv
Patient
Attributes
at Intake
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Drug
Use
Sufficient
Retention
Crime
Therapeutic Psycho-Social
Relationship
Change
Social
Relations
Posttreatment
How can “interventions”
impact this process ?
Simpson, 2001 (Addiction)
Induction to Treatment
(Readiness Training)
Motiv
Patient
Attributes
at Intake
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Sufficient
Retention
Therapeutic
Relationship
Psycho-Social
Change
Drug
Use
Crime
Social
Relations
Posttreatment
Blankenship et al., 1999 (PJ); Sia, Dansereau, & Czuchry, 2000 (JSAT);
Czuchry & Dansereau, 2000 (AJDAA)
Treatment Readiness
Training
Personal inventory (selfesteem)
Board game on “drug use
risks”
Meditation & mental focus
Blankenship et al., 1999 (PJ); Sia, Dansereau, & Czuchry, 2000 (JSAT);
Czuchry & Dansereau, 2000 (AJDAA)
Planning workbooks
The Downward Spiral “Game”
Personal Asset Scores
HEALTH
Emotions
Physical
Thinking
Judgment
SELF CONCEPT
Self-esteem
Personal
Accomplishment
Self-Confidence
SOCIAL SUPPORT
Significant Other
Family
Friends
FINANCIAL ASSETS
Car
Equipment
Jewelry
Land on a square and draw a card – e.g.
Death Card!
Opportunity
You lose!!
Your kids are caught using
drugs at school and they say
they got the drugs from you.
Lose 5 family points
Fact
Self
Health
Financial / Legal
Czuchry, Sia et al. (1997, 1998)
Social
Serious involvement with drugs is
related to whether other family
members are also drug users.
Counseling Enhancements
(TCU Cognitive “Mapping”)
Motiv
Patient
Attributes
at Intake
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Drug
Use
Sufficient
Retention
Therapeutic
Relationship
Crime
Psycho-Social
Change
Social
Relations
Posttreatment
Dansereau et al., 1993 (JCP), 1995 (PAB); Joe et al., 1997 (JNMD); Pitre et al.,
1998 (JSAT); Newbern et al., 1999 (AJDAA); Czuchry & Dansereau, 2000 (JSAT)
“Mapping” Enhancements to
Therapeutic Engagement
“Mapping”
is like
“flow-charting.”
It leads to improvedcommunication
and
on-task attention!
Improves Ratings ofCounselors & Sessions
Other Patients
Staff Members
Treatment Participation
Self-Confidence
Patient Ratings in Month 4
Pitre, Dees, Dansereau, & Simpson, 1997 (J Drug Issues).
Can specific components
be targeted for change?
Motiv
Patient
Attributes
at Intake
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Sufficient
Retention
Therapeutic Psycho-Social
Relationship
Change
Drug
Use
Crime
Social
Relations
Posttreatment
Contingency Management
(Token Rewards)
Motiv
Patient
Attributes
at Intake
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Sufficient
Retention
Therapeutic
Relationship
Psycho-Social
Change
Drug
Use
Crime
Social
Relations
Posttreatment
Rowan-Szal et al., 1994 (JSAT); 1997 (JMA);
Griffith, Rowan-Szal et al., 2000 (DAD).
47
Specialized Interventions
(TCU Counseling Manuals)
Motiv
Patient
Attributes
at Intake
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Sufficient
Retention
Therapeutic
Relationship
Psycho-Social
Change
Drug
Use
Crime
Social
Relations
Posttreatment
Bartholomew et al., 1994 (JPD); 2000 (JSAT);
Hiller et al., 1996 (SUM).
Counseling Modules &
Manuals
 Treatment Readiness/Induction
 Cognitive Mapping
 HIV/AIDS Education
 Relationship Skills (women & men)
 Parenting Skills
 Cocaine Abuse
 Transition Skills (to Aftercare)
Evidence-Based Treatment
Model
Induction
Motiv
Patient
Attributes
at Intake
Staff
Attributes
& Skills
Behavioral
Strategies
Family &
Friends
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Personal Health Services
Supportive
Networks
Sufficient
Retention
Therapeutic Psycho-Social
Relationship
Change
Program
Characteristics
Drug
Use
Crime
Social
Relations
Posttreatment
Enhanced
Counseling
Social Skills
Training
Simpson, 2001 (Addiction)
Social Support Services
Conclusions
1. Long-term outcome studies -– Indicate that treatment is effective
– Lead to questions about HOW
2. Treatment process studies -– Identify important therapeutic dynamics
– Define “interim” performance measures
– Clarify the role of interventions
– Lead to management strategies
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How Can We Improve the
Cultural Competency of
Substance Use Disorder
Treatment?
What is Cultural Competency?
The Center for Substance Abuse
Treatment (CSAT) has defined cultural
competency as “a set of congruent
practice skills, attitudes, policies and
structures which come together in a
system, agency, or among professionals
that enable them to work effectively in the
context of cultural differences.”
Cross, T.L., Bazron, B. (1994). Train the trainers workshop: towards a culturally competent system of care.
CASSP Technical Assistance Center.
TCU Treatment Process
Model
Cultural Competency and
Neighborhood Issues
Motiv
Patient
Attributes
at Intake
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Posttreatment
Sufficient
Retention
Therapeutic Psycho-Social
Relationship
Change
Cultural
Competency
Where can cultural
competency
impact this process ?
Drug
Use
Crime
Social
Relations
What Does the Research
Say about How Wraparound
Service Receipt Affects
Substance Use Disorder
Treatment?
Impact of Wraparound Services
Outpatient addiction treatment clients who
reported receiving wraparound services
were more likely to report superior
retention and treatment outcome than
clients who did not receive wraparound
services.
Actively assessing clients in wraparound
service receipt greatly improved retention
and treatment outcome.
Pringle et al. Accepted for publication in Addictive Disorders and Their Treatment.
How Can I Use This
Information?
Did You Know About …
IRETA
IRETA | NeATTC | PIC
Institute for Research, Education,
Training in Addictions
Northeast Addiction Technology
Transfer Center
Practice Improvement Collaborative
IRETA
IRETA is the entity within the Commonwealth of
Pennsylvania where research is translated into
practice and policy
IRETA is funded through federal grants, private
foundations (Scaife Family Foundation, Jewish
Healthcare Foundation), state funds (BDAP),
federal line item (SAMHSA), and private
business contracts
Who is Involved with IRETA?
State And Local Drug And Alcohol
Programs
Research Institutions
Criminal Justice Organizations
Other State And Local Organizations
NeATTC
The NeATTC is designed to enhance the
quality of addiction treatment and recovery
services within the region by providing
policymakers, providers, consumers, and
other stakeholders with state-of-the-art
information through technology translation
and transfer activities. The NeATTC is part of
a national network, comprised of 14 regional
centers that serve all 50 states and the U.S.
territories.
NeATTC
The NeATTC serves the states of NY, NJ,
and PA, and is administered by IRETA.
The NeATTC is comprised of an
Executive Director, Program Manager,
Training Director, Logistics Coordinator,
and three Information Specialists (IS are
located in PA, NJ, and NY).
The NeATTC Goals
Increase the knowledge and skills of addiction
treatment practitioners
Heighten the awareness, knowledge and skills
of all professionals who have the opportunity to
intervene in the lives of people with substance
use disorders
Foster regional and national alliances among
practitioners, researchers, policymakers,
funders, and consumers to support and
implement best treatment practices
NeATTC 2002 Activities (Highlights)
Administer needs assessments to
determine the knowledge dissemination
and adoption activities within each state
Establish the toll-free InfoLine (866-2465344) to disseminate addictions-related
information to the field
Develop and maintain a resource web site
PIC
The PIC program was initiated by the
Substance Abuse and Mental Health
Services Administration’s (SAMHSA)
Center for Substance Abuse Treatment
(CSAT) in 1999 to support and promote
effective and efficient community-based
treatment.
CSAT has awarded 14 PICs, including 7
statewide and 7 metropolitan area
projects.
PIC
PICs address the treatment needs of diverse
client populations, including ethnic and cultural
minorities, clients involved in the justice system,
clients with co-occurring mental health and
substance use disorders, adolescents, and
women with children.
The PIC has a formally established structure, and
is governed by community stake-holders,
including providers, researchers, policy-makers,
educators, and members of the recovery
community.
PIC Activities (Highlights)
Support education of probation officers and
newly released parolees regarding addiction
service needs of offenders and methods of
facilitating service linkage
Conduct a conference to present national efforts
by which Medicaid and addiction treatment
administrative data have been or may be utilized
to monitor substance use disorder treatment
delivery
Contact:
Dr. Michael Flaherty
Executive Director
I.R.E.T.A. | NeATTC
[email protected]
Victor Barbetti
Program Manager
NeATTC
[email protected]
Sam Thompson
Training Director
NeATTC
[email protected]
Dr. Janice Pringle
Project Director
PIC
[email protected]
Funded by Center for Substance Abuse Treatment, SAMHSA, Scaife Family Foundation, Allegheny County Health Department, and
the Jewish Healthcare Foundation
Here’s a product of the ATTC
initiative which will assist you
in making system change.
You can access this book at the following website:
http://www.nattc.org/pdf/changebook.pdf
You Can Download These
Slides Yourself at ireta.org.
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