2. What’s Wrong With Addiction Treatment? A. Thomas McLellan NADAAC Presentation Washington, D.C. September 15, 2003

3. Three Problems 1) How We Treat It: Acute vs Continuing Care 2) How We Evaluate It: As Though we Have a Cure 3) Treatment Infrastructure: Can it Support Expectations

4. Problem 1 How We Treat It

5. A Nice Simple Rehab Model NTOMS Sample of 250 Programs Treatment Substance Abusing Patient Non- Substance Abusing Patient Meds, Therapies, Services

6. Treatment Has Not Met Public’s Expectations – There is No Cure Treatments CAN Work But…… Patients Do Not Cooperate

7. Treatment Compliance Is Low 85% of all treatment in US is Outpatient About 60% of outpatients drop out of treatment within one month. Even court-ordered patients do not complete treatment

8. Relapse Rates Are High About 60% use drugs within 6 mos. following treatment discharge No difference between Brief and Intensive Treatments No difference between Inpatient and Outpatient Treatments

9. Maybe We Have the Wrong Model?

10. How Are Other Illnesses Treated & Evaluated?

11. Why Isn’t Addiction More Like Other Illnesses? Implications for Evaluation and Treatment Lessons learned from Chronic Illnesses

12. A Comparison With Three Chronic Medical Illnesses Hypertension Diabetes Asthma

13. Why These Illnesses? u No Doubt They Are Illnesses u All Chronic Conditions u Influenced by Genetic, Metabolic and Behavioral Factors u No Cures - But Effective Treatments Are Available

14. Adherence to medication regime : < 60% Adherence to diet and exercise : < 30% Treatment Research Institute HYPERTENSION Retreated in 12 months : 50 - 60% (by Physician, ER, or Hospital)

15. Adherence to medication regime : < 50% Adherence to diet and exercise : < 30% Treatment Research Institute DIABETES (Adult Onset) Retreated in 12 months : 30 - 50% (by Physician, ER, or Hospital)

16. Adherence to medication: < 30% Treatment Research Institute ASTHMA Retreated in 12 months : 60 - 80% (by Physician, ER, or Hospital)

17. Predictive Factors - All 3 Illnesses RELAPSE #1 - Lack of Adherence to diet, medications, or behavior change #2 - Low Socioeconomic status #3 - Low Family Supports #4 - Psychiatric Co-Morbidity Sources: Natl Ctr Health Stats; Harrison, 13th Ed.; 30+ studies

18. Different Goals for Each Stage Different Components in Each Stage Last Stages Depend on the Success of the First Stages

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

20. An Ideal Model – No Discharge Substance Abusing Patient Regular “Performance” Eval Hospital Detox Residential Rehab IOP Rehab Outpatient Cont Care AA -Tele Monitoring Tele Monitoring

21. A More Typical Model Detox- Only Admissions 42% of Philadelphia Episodes @ $750 - $1500 each Hospital Detox Residential Rehab IOP Rehab Outpatient Cont Care AA -Tele Monitoring Tele Monitoring

22. A Desirable Model Continuing Care / Monitoring Early Detection of Relapse 20% of Philadelphia Episodes Hospital Detox Residential Rehab IOP Rehab Outpatient Cont Care AA -Tele Monitoring Tele Monitoring

23. Problem 2 How We Evaluate It

24. Why Does Treatment Seem So Ineffective?

25. If many or most cases of addiction are really chronic then: 1) We may be evaluating the effectiveness of addiction treatments in the wrong way.

26. Treatment Research Institute Outcome In Hypertension

27. Treatment Research Institute Outcome In Addiction

28. Rehabilitation Model “.. treatment benefits should be sustained following discharge for addiction treatment to be worth it …” (McLellan,1998).

29. Comparing Treatments Testing Three Treatments in a Rehabilitation Model Treatment Research Institute

30. Project MATCH RCT - 3 Research-Derived Therapies $27 Million Dollar NIAAA Study Different Mechanisms of Action Fixed Interventions – No Changes Goal – Achieve Lasting Abstinence or Improved Drinking Post Completion

31. MET CBT 12-Step Project Match Fixed Time - Fixed Content – Rehab Oriented 6 12 18 24 30 39 Treatment Type Post Treatment Evaluations 45% 38%27%

32. Improvement in Project MATCH

33. Maybe We Have the Wrong Model? Again….

34. Comparing Rehabilitation Treatments Treatment Control

35. Points Evaluate during – not after – treatment We may be missing important effects because of our evaluation model

36. Comparing Treatments Testing Three Treatments in a Continuing Care Model Treatment Research Institute

37. ALLHAT The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Treatment Research Institute

38. ALLHAT Groups – Explicitly Different Mechanisms of Action and Cost Diuretic - $0.10 /pill Calcium Channel Blocker - $1.50 /pill ACE Inhibitor - $4.00 /pill Goal – to Reach Pre-Specified Criterion DURING TREATMENT Treatment Research Institute

39. Diuretic CCB ACE ALLHAT Pre-Specified Criteria – Adjustment Oriented Step 1Step 2 Step 3 Start 27% Control DURING Treatment Evaluations 40% 42% 44% 54% 56% 54% 64% 66% 63%

40. Improvement Comparison

41. An Ideal Model – No Discharge Substance Abusing Patient Regular “Performance” Eval Hospital Detox Residential Rehab IOP Rehab Outpatient Cont Care AA -Tele Monitoring Tele Monitoring

42. Considerations for Addiction There are Promising, complementary Treatments Medications, therapies, services Adaptive Strategies are Feasible and Consistent With Care Management Switching - Given bad results or no acceptance Supplementing - Given sub-optimal results

43. Problem 3 The National Treatment Infrastructure

44. 20 Years of Research Shows Treatment Is Effective* * When delivered by qualified professionals, using empirically validated medications and therapies, applied for adequate durations and followed by monitoring and maintenance.

45. * When delivered by qualified professionals, using proven medications and therapies, applied for adequate durations and followed by monitoring.

46. So, Is Contemporary Treatment Structured to Be Effective ?

47. Results of Initial Work on the National Treatment Outcomes Monitoring System (NTOMS) LeadershipManagement StaffingInformation

48. Program Changes In 16 Months: 12% had closed 13% had changed service operation RESULT – 25% FEWER PROGRAMS 31% of the rest had been taken over, usually by MH agencies RESULT – STAFF CONFUSION Program Survey - 1

49. 50-60% of directors have been there Less Than 1 year Counselor turnover is 50% per year Program Survey - 2 STAFF TURNOVER!

50. Program Survey - 4 Who Are the Directors ? 17% No College Education 58% Had BA Degree 20% Had a MA or MSW 28% NOT Working Full Time Most had been clinicians @ program

51. Program Survey - 5 Other Staff : 54% Had no physician 34% Had P/T physician 39% Had a Nurse (part of full time) < 25% Had a SW or a Psychologist Major professional group - Counselors

52. Admission Process: No Standard Procedure or Instrument –Total process often 3 hours –15 – 20% Don’t Do Assessment No Use of/for Assessment –“Simply Paperwork” Program Survey - 6

53. Information Systems: Improved Computer Availability –Mostly For Administrative/Fiscal Work –80% Had a Computer – 50% had Web Access Still very little computer/software availability for CLINICAL STAFF Program Survey - 7

54. Thank You For Sharing!

55. Can Research Help? Using Technology to Improve Retention & Participation

56. Background The JCAH-O wants to see customized treatment plans and “wrap-around” services: BUT this can be time-consuming and costly Counselors need help to efficiently locate necessary services.

57. DENS-Resource Guide

58. Site & Counselor Characteristics 10 Community Treatment Programs –All Required to Learn the ASI – by the state 5 Counselors per program –No experience with ASI previously 5 Admissions per counselor –Essentially random selection

59. Site & Counselor Characteristics No significant differences to start: Among Programs – Very similar on the ATI Among Counselors - in ASI training, education, recovery status, tenure on job Among Patients – Demographics and ASI scores

60. SPLIT INTO TWO GROUPS ALL GET: A Computer With ASI Software Installed Training in Admission Interviewing (8 Hrs CEU) HALF GET: Training on the United Way First Call for Help to link ASI data to service availability

61. Problem-Services Linkage Treatment Research Institute Alcohol Drugs Medical Employment Family Psychiatric Legal GED training Resume Development Job Finding Mentoring Sessions Training Loans (e.g. Employ - related services

62. Counselor Turnover 50 Counselors from 10 Programs Within 5 months, 19 counselors had been promoted, fired or just quit (38%)

63. Findings

64. Hypothesis 1 Patients of Extra Training counselors will receive more and better-matched services.

65. Mean Number of Services Received

66. Hypothesis 2 Patients of Extra Training counselors: will remain in treatment longer.

67. Percent Retained at 30 Days

68. Percent Retained at 60 Days

69. Unexpected Finding Counselors who received the Extra Training: Remained on the job longer.

70. Percent Who Quit by 6 Months

72. Lessons Addiction Can Learn from Chronic Care

73. What Continuing Care Does NOT Imply Not Every Case of Substance Abuse Needs a Continuing Care Strategy –Not Clear When to Shift from Acute –Also Not Clear in Other Illnesses A Continuing Care Strategy Does Not Imply Lack of Responsibility –Just the Opposite –One Purpose is to Teach Self Management

74. What Continuing Care Does Imply Need for Pre-Specified Treatment Goals –Agreeable to the Patient, Measurable Need for Continuing Contact/Monitoring –Tailored to the severity and needs of the patient –Telephone and Internet Options Need for Multiple Options –Most First Efforts Will Fail – Hard to Predict –Sensible Switching or Adding Time Frames

75. Most Patients Do NOT Respond to Their First Treatment/Medication Need for more alternatives Improves retention Monitoring is Part of Health Care

76. Telephone and IVR Useful Saves Physician Time, Reduces Number and Severity of Relapses Not Currently Reimbursed

77. Evaluations of Continuing Care Should Occur DURING Treatment Need for interim performance markers (retention, linkage, urines, pro-social behaviors, etc.)

78. Lessons Chronic Care Can Learn from Addiction Treatment

79. Symptom Improvement Does Not Continue Without Behavioral Change Social Support and Counseling Alone Can Improve Symptoms and Function Poor, Psychiatrically Ill Patients CAN & DO Improve