1. Translating Standards Into Practice The Voluntary Approach In The Netherlands Gerard M. Schippers EQUS, Brussels, june 2011 THE AMSTERDAM INSTITUTE FOR ADDICTION RESEARCH.

2. pragmatic approach of use … and of treatment

3. Nevertheless, in the 90s, Dutch Substance Abuse Treatment Services were publicly criticized for a number of reasons, which alarmed the management.

4. Criticisms on Substance Abuse Treatment in the 90s Public criticism (on nuisance, lack of effect, treating the elite) Applied treatment methods mainly based on clinical intuition, tradition, and ideology, while Scientific accomplishments not being implemented Hardly any specialized education and training Bad coordination between different fragmented programs and program elements (scattered, island culture) Treatment methods barely transparent and explicit

5. Negative Consequences Too much emphasis on abstinence oriented programs Too few integration of mental health and substance abuse treatment Undervaluation of medication supported therapies Too few attention for motivation enhancement Too few insight in the chronic relapsing nature of addiction Too much distinction (organizational and conceptual) between kind of substances Too few distinction between chronic and temporary problems

6. Dutch Substance Abuse Treatment Services (ca 16 mil inhabitants) 11 larger regional Centers ca 4.000 fte staff serving ca 60.000 new patients yearly ca 55% alcohol dependent from all illegal drug abusers ca 70% are in regular contact with treatment services (>50% in methadone maintenance) ca 15% are IV-users relatively low HIV prevalence

7. Areas 11 Dutch Substance Abuse Treatment Centres

8. Where did this lead to? Designing a Treatment Renovation Program based on a bottom-up initiative from the managers of the service providers facing the criticisms

9. To Score Results National Reform Program Dutch Substance Abuse Treatment Services 1998-2013 A cooperative effort of all larger treatment substance abuse institutions, with the help of additional funding from Ministry of Health founding a national steering group composed of managers, clinical professional and scientists

10. Objectives Reform Program Improvement of services for substance abusers (primary processes) by Implementing services based on scientific evidence and/or clinical consensus Monitoring clinical results and feeding them back to professionals and the public Improving education in addiction

11. Designing a Treatment Reform Program 2002 2010

12. Implementing renewed services for Prevention, Treatment and Matching

13. What does research tell us on the effectiveness of treatment on addictive behavior?

14. Effective Treatment Through the Internet fully self-guided internet module, or with counsellor effective

15. Evidence on Effectiveness Is Ample Available

17. Nevertheless, in the last years, focus has changed from evidence-based to client-based, due to increased influence of financers (competing assurance companies)

18. Characteristics Dutch professional Substance Abuse Treatment Methods Evidence based treatment methods No diversion between alcohol and drug treatment Treatment and harm reduction provided by the same organisations

19. Redesigned Treatment Modules* Brief CBT individual Standard CBT individual Brief CBT group Standard CBT group Screening, Needs Assessment &Treatment Allocation User Rooms** Crisis intervention Detoxification Integrating Self Help Groups in Regular Care After Care Opiate Substitution Treatment Suicide in addiction care Casemanagement MATE: Assessment for Triage and Patient Placement Adolescent Cannabis Abuse Substance Abuse & Depression * 15 Treatment & Rehabilitation, 1 Harm Reduction**: No distinction in the Netherlands

20. Examples: National Consensus Guidelines Dutch National Guidelines on the Treatment of Alcohol Use Disorders (2009) Dutch National Guidelines on the Treatment of Heroin Dependency (2011)

21. Examples: Psychosocial Behavior- oriented Treatment Modalities (Life Style Training Program) 1. Brief MI/CBT (intake + ca. 4 sessions) 2. Standard MI/CBT (intake + ca. 10 sessions) for individuals and groups general applicable for all substances based on cognitive behavior therapy motivational interviewing as basic counseling style

22. www.mateinfo.eu Measurement in the Addictions for Triage and Evaluation New instrument for measuring patient characteristics in substance abuse treatment

23. How Well are the New Modules Implemented? Evaluation study in 2005, 2008 and 2011* 20 to 27 modules disseminated. Drug treatments also in the EQUS project 11 Out of 12 institutions observed, covering 3800 (77%) of the 5000 patient-related workers Interview with 40 key persons *Preliminary data

24. How Well are the New Modules Implemented? Evaluation study in 2005, 2008 and 2011* 20 to 27 modules disseminated. Drug treatments also in the EQUS project 11 Out of 12 institutions observed, covering 3800 (77%) of the 5000 patient-related workers Interview with 40 key persons *Preliminary data

25. Level of Implementation of protocols % treatment centers

26. 2008, 23 modules % modules Level of Implementation in treatment centers

27. Dissemination & Implementation Slow, but steady Strong points: centralized organization and support renewal is seen as survival strategy Weak points: underdeveloped education/training infrastructure

28. REQUIRED: Coalition of multiple stakeholders: financers, centre administrators; clinicians, and service consumers

29. Necessary (although not Sufficient) Conditions for Implementation Adequate resources A reasonably well managed institute Coalition of multiple stakeholders: financers, centres administrators; clinicians, and service consumers Support on central management level Trusted enthusiastic mediator Training, supervision and booster training

30. Factors Promoting the Implementation Minor local variations should be possible (not-invented-here-syndrome) Changes should not be too large and too quick although … radical changes sometimes work better New modules should replace old practice Continuation in coercion and support from central management are essential Increasing convenience (e.g. electronic implementation) External pressure helps Training, training, training …

31. Factors Hindering the Implementation Instability in team management and team personnel Organisational changes (new way of working e.g. care pathways and Assertive Community treatment) Too few publicity new guidelines No support from management Guidelines get outdated Financial problems or no funding

32. Dutch clinicians are alike their colleagues all over the world in eagerness and willingness to learn and change but

33. … the changing of habitual behavior is tedious and takes a long breath.