Suppose We Try Something New in Addiction? Different Perspectives and Research Implications

1.Build National System of “Prevention Prepared Communities” 2. Train primary care to intervene early with emerging abuse 3. Integrate addiction treatment into mainstream healthcare 4. Smarter, safer management of drug- related offenders

A Nice Simple Rehab Model NTOMS Sample of 250 Programs Treatment Substance Abusing Patient Non- Substance Abusing Patient

ASSUMPTIONS Some fixed amount or duration of treatment will resolve the problem Clinical efforts put toward correctly placing patients and getting them to complete treatment Evaluation of effectiveness should occur following completion –Poor outcome means treatment/patient failure

But this hasn’t worked well… About 60% of outpatients drop out prematurely (< 1 month). Relapse rates are high – 6-mos.

Studies show few differences between… Brief and Intensive Treatments Inpatient and Outpatient Treatments Conceptually Different Treatments “Matched” and “Mismatched” Trt. Gender or Culturally Oriented Trt.

How Do Other Treatments Work? Chronic Illness & Continuing Care

A Continuing Care Model Primary Continuing Care Primary Care Specialty Care

In Chronic Illnesses…. 1 – The effects of treatment do not last very long after care stops 2 – Patients who are out of treatment/contact are at elevated risk for relapse

So, For Treatment…. 1 – One goal is to retain patients at an appropriate level of care and monitoring 2 – Another goal is to prepare patients to do well in the next level of care 3 - The effects of treatment are evaluated during treatment – not post-discharge

Maybe Results Depend on Perspective

Treatment Research Institute Outcome In Hypertension

Treatment Research Institute Outcome In Addiction

Maybe this is why…

Studies show few differences between… Brief and Intensive Treatments Inpatient and Outpatient Treatments Conceptually Different Treatments “Matched” and “Mismatched” Trt. Gender or Culturally Oriented Trt.

OK, But Could This Work in Addiction? Several Reasons To Think of Addiction as a Chronic Illness

Continuing Care In Addiction Recovery Support Services Primary Care Specialty Care Screen Intervene Monitor Refer Re-Intervene Monitor/Support Stabilize Motivate/Medicate Train Self-Mgmnt Refer

Implications? 1. For Current Addiction Treatment System 2. For Expanding Treatment 3. For Evaluation

~ 12,000 specialty programs in US 31% treat less than 200 patients per year Very Few Doctors Most of those eligible do not want care

7.Integrate Addiction Treatment into Federal Healthcare Systems 8. Performance Contracting in State Treatment Systems 9. Consumer Choice Through Vouchers for Recovery Services

How to Evaluate? 1. Model is There 2. What are Performance Measures 3. When/How to Measure Outcome 4. How will public understand