1. New York State Treatment System
Presented March 25, 2011
Edward Freeman

2. 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)

4. 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

5. 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

6. Number of Treatment Programs
Treatment Services
Number of Treatment Programs
Program Category
Crisis Service 82
Inpatient 64
Methadone
132
Outpatient
558
Residential
228
Total
1,064

7. Treatment Services

8. 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 co-occurring disorders such as mental illness, smoking, gambling.

10. Co-Occuring Disorders at Admission
65% have secondary substance disorder
40% have mental illness
65% Daily tobacco use
1% Family members and Significant others

12. Treatment Services Program Capacities Crisis Beds 1,663 Inpatient Beds
2,445
Methadone Slots
42,411
Outpatient Visits
5,420,838
Residential Beds*
8992
* Does not inclued supportive living beds
171,000 indiv in outpatient annually.

14. Admissions to Treatment Programs, All Categories, 2009

15. Stage-Based Treatment
Initial Stage
Stabilization and Engagement
Active Treatment Stage
Early Recovery
Maintenance Stage
Continuing Care
Treatment Phases
Early Recovery – Stabilization and engagement
Learn new behaviors
Practice new behaviors
De-brief on new behaviors
Family counseling
Practice behavioral compliance
Psychological improvement
90 days – 1 year
Treatment Phase
Maintenance Phase
Continuing relapse prevention
Individual counseling as needed
Urinalysis
Alumni groups
Mentoring earlier phase clients
NA/AA & support groups
Phone Calls
Relapse Prevention will be covered more thoroughly in the next presentation

16. Crisis and Non-Crisis Services
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

17. 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

18. Pathways

19. 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.

20. Crisis Services
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.

21. 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.

22. Inpatient INPATIENT REHABILITATION SERVICES
provide intensive management of chemical dependence symptoms and medical management/monitoring of physical or mental complications from chemical dependence to
Lengths of stay are primarily in the day range.
conduct intensive evaluation, treatment and rehabilitation services in a medically supervised 24 hour/day, 7 days/week setting.
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.

23. 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
who are not in need of acute hospital or psychiatric care or chemical dependence inpatient services.
Admissions may come directly from crisis services or persons released from criminal justice facilities without prior inpatient rehabilitation treatment.
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.
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.

24. 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.

25. Residential
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.

26. 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
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.

27. OUTPATIENT SERVICES
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.

28. 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.:
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

29. 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.

30. Outpatient 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:

31. Outpatient Methadone Treatment Programs provide:
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.

32. Principles of Effective Treatment
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

33. Treatment Must Enhance
Motivation – Why change?
Insight – What to change?
Skills – How to change?

34. Issues in Treatment Addiction management Physical health
STD
Hepatitis
HIV/AIDS TB
Nicotine dependence
Mental illness
Strengthening the family
Legal
Financial
Child care
Housing
Parenting
Transportation
Education
Prevocational and work readiness