1. OATS Outcomes & Assessment-Informed Treatment Strategies & Implementation Issues
Norman G. Hoffmann, Ph.D.
Adjunct Professor of Psychology
Western Carolina University

2. Evidence-Based Treatment
Utilize a treatment model documented to be effective in controlled clinical research
Question of whether the model is implemented with fidelity
No guarantees that it will work in routine clinical practice even if implemented properly
No verification of outcomes

3. Assessment-Informed Treatment
Assessment documents nature and severity of conditions and initial differential treatment needs
During treatment integrate assessment data with treatment response to document progress and identify risk and resiliency variables
Use findings to adjust treatment plan and refine future assessment and treatment decisions
Develop empirically justified foundation for determining medical/clinical necessity

4. Outcomes-Informed Treatment
Monitor baseline and initial relevant outcomes for all clients – outcomes can be clinical and/or societal/financial
Monitoring done during typical continuum of care (e.g., during maintenance services)
Uses information already required for quality care – store in useable format
Retrieval of data for analyses
Document medical/clinical necessity

5. Potential Uses for Outcomes Documentation
Identify Differential Treatment Needs
Identifying Differential Relapse Risk
Empirically Derived Medical Necessity
Enhancing Client Motivation
Treatment Improvement
Marketing Services
Justifying Treatment Costs - ROI
Public Relations

6. Assessments Identify Differential Treatment Needs and Relapse Risk

7. Substance Use Disorder Criteria
Use in larger amounts or longer than intended
Desire or unsuccessful effort to cut down
Great deal of time using or recovering
Craving or strong urge to use
Role obligation failure
Continued use despite social/interpersonal problems
Sacrificing activities to use or because of use
Use in situations where it is hazardous

8. DSM-5 SUD Criteria continued
Continued use despite knowledge of having a physical or psychological problem caused or exacerbated by use
Tolerance
Withdrawal
Criteria 1-4 relate to use; Criteria 5-8 relate to behavioral issues associated with use; Criteria 9-11 relate to physical/emotional issues

9. DSM-5 Initial VS. DSM-5 Final
Initially the proposed DSM-5 had two diagnostic categories: moderate and severe defined by 2-3 and 4+ positive criteria – conforms best to abuse – dependence classification
Final formulation has three categories: mild (2-3), moderate (4-5), and severe (6+ positive criteria)
Original “moderate” becomes “mild” – no empirical foundation for either distinction

10. Sustained Remission
No positive diagnostic findings (other than craving) for 12 consecutive months
Substance use is NOT part of the remission definition
Possible levels of outcome: 1) abstinence without problems; 2) some use without problems; 3) use with sub-diagnostic problems; 4) meets current diagnosis
You get paid for remission NOT recovery

11. DSM-5 Criteria Differentials
All criteria are not equal in implications
Some criteria are found predominately among those with the severe alcohol or other substance use disorder diagnoses
Other criteria are more common among the mild to moderate alcohol use disorder group
Tolerance and dangerous use are actually common among those with no diagnosis

12. SUD CRITERIA PRIMARILY IN SEVERE DESIGNATION
The “Big Five” Criteria 2:Wanting to cut down/setting rules Criteria 4: Craving and/or compulsion to use Criteria 5: Failure at role fulfillment due to use Criteria 7: Sacrifice activities to use Criteria 11: Withdrawal symptoms

13. Sample of Alcohol Diagnostic Documentation
Alcohol Diagnosis
Diagnostic Criteria 1 2 3 4 5 6 7 8 9 10 11
Case 1 X
Case 2
Case 3
Case 4
Severe
Mild
Moderate
Moderate
Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes

14. CASE 3: Positive DSM-5 Criteria
3. Great deal of time using 10. Tolerance 1. Unplanned use: more or longer use 8. Use in hazardous situation (impaired driving) 6. Recurrent interpersonal conflicts
Conclusions
No loss of control indicated
Misuse and possible irresponsible behavior
Moderation may be a reasonable initial goal

15. CASE 4: Positive DSM-5 Criteria
1. Unplanned use: more or longer use 2. Desire/efforts to cut down 4. Craving/compulsion to use 5. Role obligation failures 7. Sacrificing activities to use
Conclusions
Loss of control clearly indicated
Positive on 4 of the “Big Five”
Abstinence indicated goal for recovery

16. Implications for Disposition
Education and brief counseling may be appropriate for majority of mild use disorders
For those with a moderate diagnosis, the pattern may be as important as the number of positive criteria
Those positive on any of the Big Five criteria should be carefully evaluated regarding the current and projected trajectory of their condition

17. Final Criticism of the DSM-IV
Loss of control not required for a dependence diagnosis – e.g., tolerance, spending time using, and occasionally drinking more/longer than intended – got the chronic diagnosis
Some abuse criteria are stronger indications of a serious condition than some dependence criteria
Role obligation failure is a Big Five criterion
Tolerance is often seen in mild cases or even among those with no diagnosis

18. CLINICAL (Medical) NECESSITY
Persons in the severe designation with positive “Big Five” findings will require a more intensive and longer continuum of care to achieved treatment effectiveness
Persons in the mild designation typically will benefit from shorter & less intensive interventions to achieve efficiency
Each treatment plan can be informed by prior empirical outcome data on comparable cases and modified based on the individual’s treatment response

19. Sample Hypotheses for Clinical Practice
Hypothesis #1: Clients positive on three or more of the “big five” will require initial residential placement and/or more intensive and longer continuum of care to achieve good results
Hypothesis #2: Clients in mild or moderate designations without any positive findings on the “big five” may be able to moderate or stop use with less intensive and briefer services

20. Beware of Arbitrary Outcome Metrics
Scientifically reliable and valid
Irrelevant to the real world
Addiction Treatment Examples:
Average days of use in past 30 days
Scores on a variety of psychological instruments
Reference on arbitrary metrics:
Kazdin, A. E. (2006). American Psychologist, 61(1),

21. Arbitrary Metric Example
Programs A and B each treat 100 cases
Program A: Before treatment average days of use = 25 After treatment average days of use = 10
Program B: Before treatment average days of use = 25 After treatment average days of use = 8
Which program has the better outcomes?

22. Arbitrary Metric Example
Real world results:
Program A: 60 in full remission; 40 minimal change
Program B: Zero remission: All 100 still using just on weekends, but all have continuing problems and meet current criteria for severe SUD (dependence)
To which program would you refer a family member?

23. Demographic Risk Scale
Less than 25 years of age.
No high school diploma or GED.
Unemployed.
Never married.
Three or more positive characteristics increases expected relapse rate by about 20% or more

24. Demographic Risk Scale and Observed Outcomes
35 Unites of service = threshold for low risk group
75 Unites of service = threshold for high risk group
Zywiak, Hoffmann, & Floyd, 1999

25. Client Motivation and Empowerment

26. Maintenance Care Thresholds
N = 12,783 Treatment Completers
Hoffmann & DeHart (1996). CATOR Fact Sheet

27. One Year Abstinence Rates for Older Alcohol Dependent Clients
Combinations of 4+ months of Maintenance Care and/or Weekly AA Attendance for 1,350 treatment completers
Hoffmann, DeHart & Gogineni (1998). The Southwest Journal on Aging, 14(1),

28. Additional Data Required for Differential Outcome Example
CONTINUED CARE & SELF-HELP GROUPS
Rate attendance using the scale:
1 = never/stopped = Several times a mo.
2 = Once a month or less 4 = At least once a week
How often did you attend the following during the past three months:
09. Formal aftercare ____
10. AA ____
11. NA ____
12. Other support group ____

29. Treatment Improvement

30. CLINICAL CONTINUOUS IMPROVEMENT COMPONENTS
Patient Assessment
Intake and ongoing assessments
Outcomes Treatment Plan
Initial clinical outcomes Define problems
Remission outcome Treatment priorities
Societal benefit measures Treatment placement
Financial benefit measures
Treatment Response/Progress
Biopsychosocial treatment
Process measurements
Adjustments to treatment plan as needed

31. TREATMENT RATINGS [asked by follow-up interviewer]
Rate how helpful the following treatment components have been for your recovery?
0 = not used 1 = poor; = fair; = good; = excellent
01. Group Therapy ____
02. Individual counseling ____
03. Lectures & education ____
04. Working the AA/NA steps ____
05. Peer-group meetings (e.g., AA) ____
06. Family portion of program ____
07. Talking with other clients ____
08. Overall rating for the program ____

32. Feedback on Helpfulness of Program Components
Helpfulness in remission – not satisfaction with the component
Low scores indicate opportunities for improvement
High scores indicate potential areas of excellence

33. Requirements for Clinical Outcomes Monitoring System
Capture demographic and descriptive information to describe the population
Document clinical information in sufficient detail to facilitate treatment refinement
Document response to the treatment services delivered
Document outcomes during typical continuum of care

34. Specialty Studies for Identifying Problem Issues

35. Pavillon Study of Trauma, Distress, and Craving
Evaluation of potential problems and relapse risks
Distress measure (DARNU), PTSD symptom count, and validated craving measures for alcohol and drugs
Explore the possibility of identifying level of distress and trauma relative to craving

36. Trauma, Distress, and Craving
DARNU: D – Dissatisfied A – Anxious
R – Restless N – Nervous
U – Uncomfortable
18- item self-report scale
DARNU correlates highly with PTSD (r = .78) and craving (r = .36)
Implications:
DARNU can identify probable PTSD
Warning indication for greater craving

37. Distress (DARNU) and PTSD
DARNU elevation quartiles
N = 124

38. Justifying Investment in Treatment

39. ROI: RETURN ON INVESTMENT
The good news:
ROI for addictions treatment is one of the largest in healthcare: between 4:1 to 7:1
Returns accrue to society in areas outside of healthcare
The bad news:
ROI within healthcare is a fraction of returns and may not pay for all treatment needs
Other areas that benefit do not traditionally pay for clinical services

40. Healthcare Returns: Proportional to Effectiveness
Average Days of Hospitalization
Relapse vs. Recovery
Before Tx p = N.S.
Yr 1 & Yr 2 p < .001
Hoffmann, DeHart, & Fulkerson (1993). Journal of addictive Disease, 12(1),

41. Public Safety Issues by Diagnosis
N = 7,682 state prison inmates

42. Highway Safety Returns: Proportional to Effectiveness
Motor Vehicle Accidents
Hoffmann & DeHart (1996). CATOR Report.

43. Criminal Justice Returns: Proportional to Effectiveness
Proportion of Cases Arrested
Hoffmann & DeHart (1996). CATOR Report.

44. Healthcare Returns On Investment for Dependent Employees
Before Treatment
After Treatment
Employees Hospitalized
24%
10%
Employees Using ER
29%
21%
Total Days of Hospitalization
7639
5158

45. Vocational Functioning Returns On Investment
Problem types include: absenteeism, tardiness mistakes, lack of work completion, conflicts, and on the job injuries
Number of Problem Types
Before Treatment
After Treatment
None
35%
76%
One
23%
16%
Two
18% 5%
Three
11% 2%
Four plus
13% 1%

46. Medicare/Medicaid Funded Treatment and Recovery
Hoffmann (1994). Report for George Washington University

47. Medicare/Medicaid Funded Treatment and Recovery
Hoffmann (1994). Report for George Washington University

48. Marketing

49. Marketing to Whom? Potential clients and/or families of those affected
Employers with stable workforces consisting of employees who are difficult or expensive to replace
Public officials tasked with stretching limited budgets
Insurers – FOR GET IT

50. Personalized Marketing Points
The probability of a positive outcome for severe substance use disorders is as good as other chronic conditions
Recovery (or remission) is largely determined by client adherence to a realistic recovery plan
Some ongoing services may be required as is the case with other chronic conditions
Support systems exist for both the afflicted and their families

51. General Marketing Points
The probability of a positive outcome for severe substance use disorders is as good as other chronic conditions
Treatment for substance use disorders is comparatively inexpensive to those for other chronic conditions
Benefits from treatment services accrue not only to the person treated, but also to society at large

52. Public Relations

53. Public Relations Errors
Many people concerned about addictions:
Talk to the wrong people
About the wrong topics
Using the wrong terminology
And wonder why nothing changes

55. The Lesson of the Peacock
The peacock is among the most beautiful of birds.
However, its “song” is among the most awful of sounds.
Trying to teach a peacock to sing is a waste of time and neglects the beauty – focuses on weakness not strength

56. Voice of the Peacock
An alcohol or drug dependent person does not make an attractive poster child – biased perspectives – stigma.
Failures are very obvious and visible.
Successes tend to disappear from view.
The general public does not care whether dependent people recover.

57. Beauty of the Peacock
Return on investment is one of the greatest in the healthcare arena.
Reasonable recovery rates relative to other chronic illnesses can be documented.
Treatment costs are modest compared to other areas of healthcare.
Benefits of treatment are found throughout society

58. Who Cares About What?
The general public cares about safety and financial issues
Employers care about turnover and performance
Public officials want to support positions that will get them reelected
The media look for a good story that will get attention

59. Relationships with the General Population
The general public cares about safety and financial issues
Most people are not concerned about the welfare of addicted individuals
Most people do not have a realistic understanding of addictions or treatment

60. Relationships with Employers
Focus on employers with stable workforces and where employees are difficult or expensive to replace
Make the case that recovering employees make excellent workers
Educate them that afflicted workers can be identified and treated successfully

61. Relationships With Elected Officials
Most elected officials have no realistic understanding of addictions or treatment
Most are interested in the general welfare
To do what is right, some will need political cover to support treatment vs. punitive strategies

62. Relationships With the Media
Reporters are always looking for a good story – either good or bad news
Combining a personal recovery story with outcome data can be a powerful positive story
A little controversy can be a positive thing if you select the controversy

63. Norman G. Hoffmann, Ph.D. Adjunct Professor of Psychology Western Carolina University