Models of Evaluation of Addiction Treatment Outcome Post-Treatment vs. During Treatment Evaluation of Effectiveness

What are the beliefs about addiction?  the treatment isn’t effective  the prognosis is hopeless  reoccurrences of active disease are evidence of treatment failure  patients are non-compliant with treatment

What would an effective/worthwhile treatment outcome look like? 3 months after discharge from 28-day rehab (IOP or residential), the person’s level of symptoms is lower and the person’s functional level is better (less or no substance use, less absenteeism or ER visits or depression or criminal re-offense or HCV or HIV seroconversion) Or better yet: 12 months after discharge Or: one year after methadone, or one year after buprenorphine, or one year after detox, how is the person doing?

Evaluation of A Hypothetical Treatment PreDuring Post Symptom Severity HYPERTENSION PreDuring Post Stage of Treatment Symptom Severity ADDICTION Just Like Hypertension, Addiction Is A Chronic Disease That Requires Continued Care Source: McLellan, AT, Addiction 97, , 2002.

Therapeutic Pessismism It’s endemic It’s a creation of our own mental models What’s the definition of success? Is success measured during the application of treatment or is it measured after the withdrawal of treatment?

Addiction is Treatable But not via detox alone But not via acute interventions alone But not via treating psychiatric co- morbidities alone Compliance = for other chronic illnesses Outcomes = for other chronic illnesses

What are the beliefs about addiction?  it’s a behavior-based (i.e., self-imposed) condition  only end-stage cases are true cases

What are the facts about addiction?  it occurs secondary to biological vulnerability  it is a disease of the brain, manifested in aberrant behavior  it is a chronic disease, in which relapse and remission recur episodically…

Addiction is a Health Problem Not just a social problem Not just a criminal justice problem Not just a moral problem Not a personal weakness Not ‘willful misconduct’ ADDICTION IS NOT A DESIRED STATE

Addiction is a Chronic Disease Often Pediatric Onset Usually Progressive, Sometimes Fatal Chronic Course: Relapsing & Remitting

Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses Drug Dependence Drug Dependence Type I Diabetes Type I Diabetes Hypertension Asthma 40 to 60% 30 to 50% 50 to 70% Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, Percent of Patients Who Relapse Addiction Treatment Does Work

Treatment Research Institute Disease Outcomes

McLellan’s Newer Lines of Inquiry Rather than studying treatment interventions for addiction, showing that ‘treatment does work’, and trying to get policy makers and health care clinicians, administrators, funders and researchers to PAY ATTENTION TO THE EVIDENCE

McLellan’s Newer Lines of Inquiry …what about studying treatment interventions for highly-prevalent, high impact chronic medical illnesses, and look at the impact on treatment outcome that is contributed by co-morbid alcoholism or other drug addiction? [The biggest variable in compliance and treatment outcome for epilepsy is the degree of co-morbid behavioral health impairment (depression, anxiety, psychosis, alcoholism, drug addiction).]