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Demonization Criminalization Psychiatric views Socialization Medicalization Addiction Paradigms Sinful/Immoral Criminal/Illegal Mental Disorder- DSM Learned Behavior/Habit Acute (Brain) Disease Neuro-Science & Longitudinal Research Chronic Illness Leshner, 2001; Anglin et al., 1997
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Addiction is a chronic disease Addiction is a chronic disease and it mattersand it matters
Richard A. Rawson, Ph.D, ProfessorRichard A. Rawson, Ph.D, ProfessorSemel Institute for Neuroscience and Human BehaviorSemel Institute for Neuroscience and Human Behavior
David Geffen School of MedicineDavid Geffen School of MedicineUniversity of California at Los AngelesUniversity of California at Los Angeles
Supported by:Supported by: National Institute on Drug Abuse (NIDA)National Institute on Drug Abuse (NIDA)
Pacific Southwest Technology Transfer Center (SAMHSA)Pacific Southwest Technology Transfer Center (SAMHSA)International Network of Treatment and Rehabilitation Resource Centres (UNODC)International Network of Treatment and Rehabilitation Resource Centres (UNODC)
Is Addiction a Chronic Disease?Is Addiction a Chronic Disease?
DemonizationCriminalization
Psychiatric viewsSocialization
Medicalization
Addiction Paradigms
Sinful/ImmoralCriminal/Illegal
Mental Disorder- DSMLearned Behavior/HabitAcute (Brain) Disease
Neuro-Science & Longitudinal Research
Chronic Illness
Leshner, 2001; Anglin et al., 1997
Addiction is a Brain Disease: Implications Addiction is a Brain Disease: Implications for Treatment and Recoveryfor Treatment and Recovery
Neuroscience SupportsNeuroscience SupportsAddiction = Chronic Health ProblemAddiction = Chronic Health Problem
…with biological, sociological and
psychological components
Why Do People Try Drugs?Why Do People Try Drugs?•Curiosity
•Availability Peer Pressure•To have fun •Gain Energy
•Lose Weight•Reduce Pain
Why Do People Like Drugs?Why Do People Like Drugs?To feel good
To have novel:Feelings
SensationsExperiences
AND To share them
To feel betterTo lessen:Anxiety WorriesFearsDepression HopelessnessWithdrawal
In other words:
A Major Reason People Take a Drug is they Like
What It Does to Their Brains
Pathway for Understanding Pathway for Understanding Addictive Effects Addictive Effects of Drugs on the Brain & Behaviorof Drugs on the Brain & Behavior
Reward Pathway
Gray Matter Deficits in CortexGray Matter Deficits in Cortex
PM Thompson et al., J. Neurosci., 2004
Gray Matter Deficit inGray Matter Deficit inPrefrontal CortexPrefrontal Cortex
PM Thompson et al., J. Neurosci. 2004
0
50
100
150
200
0 60 120 180Time (min)
% o
f Bas
al D
A O
utpu
t
NAc shell
EmptyBox Feeding
Source: Di Chiara et al.
FOOD
100
150
200
DA
Con
cent
ratio
n (%
Bas
elin
e)
MountsIntromissionsEjaculations
15
0
5
10
Copulation Frequency
SampleNumber
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
ScrScrBasFemale 1 Present
ScrFemale 2 PresentScr
Source: Fiorino and Phillips
SEX
Natural Rewards Elevate Dopamine in the BrainNatural Rewards Elevate Dopamine in the Brain
0100200300400500600700800900
10001100
0 1 2 3 4 5 hrTime After Amphetamine
% o
f Bas
al R
elea
se
DADOPACHVA
Accumbens AMPHETAMINE
0
100
200
300
400
0 1 2 3 4 5 hrTime After Cocaine
% o
f Bas
al R
elea
se
DADOPACHVA
AccumbensCOCAINE
0
100
150
200
250
0 1 2 3 4 5hrTime After Morphine
% o
f Bas
al R
elea
se
Accumbens
0.51.02.510
Dose (mg/kg)MORPHINE
0
100
150
200
250
0 1 2 3 hrTime After Nicotine
% o
f Bas
al R
elea
se
AccumbensCaudate
NICOTINE
Drugs Also Bring Reward (via Dopamine)Drugs Also Bring Reward (via Dopamine)
Behavioral ResponsesBehavioral ResponsesHow Drugs WorkHow Drugs Work
Loss of controlLoss of control
Continued compulsive Continued compulsive use despite harmful use despite harmful consequencesconsequences Multiple relapses Multiple relapses preceding stable preceding stable recoveryrecovery
What have we learned through Positron Emission Tomography (PET)?
BRAIN CHANGESBRAIN CHANGES appear appear prominently in PET scans of prominently in PET scans of current and past drug users current and past drug users
Drug users have far less Drug users have far less dopamine activity (dopamine activity (rightright), as is ), as is indicated by the depletion (dark indicated by the depletion (dark red shows disruption), red shows disruption), compared to the controls compared to the controls (left)(left)
Studies show that this Studies show that this difference contributes todifference contributes to dependence and a diseased dependence and a diseased brainbrain
Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.
Decreased dopamine transporter Decreased dopamine transporter binding in METH users resembles that binding in METH users resembles that
in Parkinsonin Parkinson’’s Disease s Disease
Control Meth PD
Partial Recovery of Dopamine Transporters After Prolonged Abstinence
Normal Control Meth user(1 month abstinent)
Meth user(36 months abstinent)
Why is Continued Treatment Why is Continued Treatment Critical?Critical?
California Civil Addict Program California Civil Addict Program Follow-upFollow-up
A cohort of 581 male heroin addicts admitted to A cohort of 581 male heroin addicts admitted to the California Civil Addict Program (CAP) in 1962-the California Civil Addict Program (CAP) in 1962-64 has been followed-up and interviewed over 64 has been followed-up and interviewed over more than 30 years.more than 30 years.
The CAP was the only major publicly-funded drug The CAP was the only major publicly-funded drug treatment program available in California in the treatment program available in California in the 1960s.1960s.
The CAP provided a combination of inpatient and The CAP provided a combination of inpatient and outpatient drug treatment to narcotics-dependent outpatient drug treatment to narcotics-dependent criminal offenders committed under court order.criminal offenders committed under court order.
Unknown
Dead
Incarcerated
Daily Narcotic Use
Occasional Use
Abstinence
0
10
20
30
40
50
60
70
80
90
100
56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96
Years 1956 through 1996
% o
f Sam
ple
22%
48%
6%2%
4%7%
12%
Methadone Maintenance
Natural History of Narcotics Addiction Among CAP SampleNatural History of Narcotics Addiction Among CAP Sample(N=581)(N=581)
Status of Respondents atStatus of Respondents at 3 Interview Points 3 Interview Points
38%
56%
41%
30%
40%39%
14%19%
23%
0
20
40
60
1974-75 1985-86 1996-97
Inactive (neg UA) Active (pos UA & refusal) Incarcerated
Causes of Death Among CAP Causes of Death Among CAP Sample Sample
(N = 271)(N = 271)
59
1011
1228
31
3556
74
0 10 20 30 40 50 60 70 80
Number of Deaths
Infectious Diseases
Cerebrovascular Disease
Liver Disease (Non-Alcoholic)
Lung/Pulmonary Diseases
Other
Heart Disease
Cancer
Alcohol-Related
Accidents and Violence
Drug-Related
aIncludes overdose, poisoning, drug dependence, and suicide by drugsbIncludes motor vehicle, suicide, firearms, homicide, and fallscIncludes alcoholic cirrhosis, alcohol dependence, and poisoning by alcoholdIncludes kidney disease, diabetes, GI, and epilepsy seizureseIncludes viral hepatitis, AIDS, TB, and staphylococol depticemia
a
b
c
d
e
ConclusionsConclusions
The study findings show the long-term The study findings show the long-term effects of heroin addiction in terms of effects of heroin addiction in terms of morbidity, mortality, criminal justice morbidity, mortality, criminal justice system involvement, and overall level of system involvement, and overall level of functioning.functioning.
Compared to a US Population sample, Compared to a US Population sample, heroin addiction reduces life heroin addiction reduces life expectancy by an average of 18 years.expectancy by an average of 18 years.
Other Long-term Outcome Other Long-term Outcome StudiesStudies
Alcohol: Vaillant: multiple studies reporting a majority of Alcohol: Vaillant: multiple studies reporting a majority of alcoholics who enter treatment experience multiple relapses alcoholics who enter treatment experience multiple relapses and retreatments with about 30-50% achieving stable and retreatments with about 30-50% achieving stable abstinence.abstinence.
Cocaine; Hser: Ten year follow-up of cocaine dependent Cocaine; Hser: Ten year follow-up of cocaine dependent patients in treatment indicates that fewer than 50% achieve patients in treatment indicates that fewer than 50% achieve extended periods of abstinence. Most reenter treatment extended periods of abstinence. Most reenter treatment multiple times.multiple times.
Methamphetamine: Marinelli-Casey 3 year follow up indicates Methamphetamine: Marinelli-Casey 3 year follow up indicates of a cohort of 600 MA dependent individuals about 50% of a cohort of 600 MA dependent individuals about 50% continue to use MA at a moderate or severe level during the 3 continue to use MA at a moderate or severe level during the 3 year post treatment 36 month period. year post treatment 36 month period.
Re-Addiction Following PrisonRe-Addiction Following Prison• Vaillant
• 447 opiate addicts 91% • Maddux & Desmond
• 594 opiate addicts 98% • Nurco & Hanlon
• 355 opiate addicts 88%• Hanlon & Nurco
• 237 mixed addicts 70%
Many Other Studies Including: (Simpson, Wexler, Inciardi, Hubbard, Anglin)
Treatment Research Institute
Acute vs Chronic TreatmentAcute vs Chronic Treatment
An Acute Model of Treatment vs An Acute Model of Treatment vs Chronic Model of TreatmentChronic Model of Treatment
Drug Abuse Treatment Drug Abuse Treatment CoreCore Components and Components and ComprehensiveComprehensive
ServicesServicesMental Mental HealthHealth
VocationalVocational
EducationalEducational
LegalLegalAIDS / AIDS / HIV RisksHIV Risks
FinancialFinancial
Housing & Housing & TransportationTransportation
Child Child CareCare
FamilyFamily
Continuing Care
Case Management
Urine Monitoring
Self-Help(AA/NA)
Pharmaco-therapy
Group/Individual Counseling
AbstinenceBasedIntake
Assessment
Treatment Plans
CoreCoreTreatmentTreatment
Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)
MedicalMedical
Treatment ServicesTreatment Services
Continuing Care/Aftercare Programs
Intensive Outpatient/Psychosoci
al Behavioral Treatment
Sober Living Residence
Long-term Residential Treatment
Short-term
Residential
Treatment
Detox/Inpatient
Detox/Outpatient
Medication Assisted Treatment
Public Expectations of Substance Public Expectations of Substance Abuse InterventionsAbuse Interventions
Safe, complete detoxificationSafe, complete detoxification Reduced use of medical servicesReduced use of medical services Eliminate crimeEliminate crime Return to employment/self supportReturn to employment/self support Eliminate family disruptionEliminate family disruption No return to drug useNo return to drug use
How Do We Think About Treatment?How Do We Think About Treatment? ““The 28 day cure”The 28 day cure” Put them in a box, something happens Put them in a box, something happens
and they come out fixed.and they come out fixed. The washing machine model: Put a “dirty The washing machine model: Put a “dirty
addict” in, run the washer, and take out a addict” in, run the washer, and take out a “clean citizen”.“clean citizen”.
A Nice Simple Treatment ModelA Nice Simple Treatment Model
Treatment
Addicted Patient
Non- Addicted Patient
Does the “Washing Machine” Model of Treatment Make
Sense?
A Chronic Care ModelA Chronic Care Model
Detox
Continuing CareRecovering Patient
RehabDurationDetermined byPerformanceCriteria
DurationDetermined byPerformanceCriteria
Stages of TreatmentStages of Treatment
1. Treatment EngagementDetoxification/Stabilization
Purposes: Safe/Adequate reduction of withdrawal symptomsPhysical/Emotional stabilization
Promote problem recognition Engage patient into rehabilitation
Stages of TreatmentStages of Treatment2. Rehabilitation
Purposes: Sustain stable abstinence
Teach self-management skills Identify & reduce threats to progressMedications (maintenance and relapse prevention)Engage patient in continuing care
Stages of TreatmentStages of Treatment
3. Continuing CarePurposes:
Monitor & Support AbstinenceEncourage Self-MonitoringIntervene Upon Threats to Relapse Promote Participation in Long Term
Support Activities
Effective Strategies During Effective Strategies During Treatment EngagementTreatment Engagement
MedicationsMedications Motivational InterviewingMotivational Interviewing Voucher-based TechniquesVoucher-based Techniques Counseling to Promote Transfer to Long Counseling to Promote Transfer to Long
Term CareTerm Care NIATx Strategies NIATx Strategies
Effective Strategies in Effective Strategies in Rehabilitation PhaseRehabilitation Phase
TherapiesTherapies Cognitive Behavioral Cognitive Behavioral Motivational Enhancement TreatmentMotivational Enhancement Treatment Behavioral Couples TherapyBehavioral Couples Therapy Multi Systemic Family TherapyMulti Systemic Family Therapy 12-Step Facilitation12-Step Facilitation Individual Drug CounselingIndividual Drug Counseling
Effective Strategies in Effective Strategies in Rehabilitation PhaseRehabilitation Phase
Interventions/ServicesInterventions/Services Clinical Case Management Clinical Case Management CRAFTCRAFT 12-Step Facilitation12-Step Facilitation Voucher ReinforcementVoucher Reinforcement Matrix Model TreatmentMatrix Model Treatment
MedicationsMedications Alcohol (Naltrexone, Disulfiram, Citalopram) Alcohol (Naltrexone, Disulfiram, Citalopram) Opiates (Naltrexone, Methadone, Buprenorphine)Opiates (Naltrexone, Methadone, Buprenorphine)
A Chronic Care ModelA Chronic Care Model
Detox
Continuing CareRecovering Patient
RehabDurationDetermined byPerformanceCriteria
DurationDetermined byPerformanceCriteria
Types of Continuing CareTypes of Continuing Care Self/mutual help programsSelf/mutual help programs MedicationsMedications Traditional counseling visitsTraditional counseling visits Home visitsHome visits Recovery “check-ups”Recovery “check-ups”
Specialty care-basedSpecialty care-based Primary care-basedPrimary care-based
Telephone-based protocolsTelephone-based protocols Monitoring Monitoring Monitoring and counselingMonitoring and counseling
Other stuffOther stuff
Recovery Management CheckupsRecovery Management Checkups
Protocol developed by Dennis, Scott et al.Protocol developed by Dennis, Scott et al. Interview patients Interview patients every quarter for 2 yearsevery quarter for 2 years If patient reports any of the following……If patient reports any of the following……
• Use of alcohol or drugs on Use of alcohol or drugs on >> 2 weeks 2 weeks• Being drunk or high all day on any daysBeing drunk or high all day on any days• Alcohol/drug use led to not meeting Alcohol/drug use led to not meeting
responsibilitiesresponsibilities• Alcohol/drug use caused other problemsAlcohol/drug use caused other problems• Withdrawal symptomsWithdrawal symptoms
……Patient transferred to linkage managerPatient transferred to linkage manager
Recovery Management CheckupsRecovery Management Checkups
Linkage Manager provides the following:Linkage Manager provides the following: Personalized feedbackPersonalized feedback Explore possibility of returning to treatmentExplore possibility of returning to treatment Address barriers to returning to treatmentAddress barriers to returning to treatment Schedule an intake assessmentSchedule an intake assessment Reminder cards, transportation, and escort to Reminder cards, transportation, and escort to
intake appointmentintake appointment
Telephone as a continuing care toolTelephone as a continuing care tool Potential to promote better long-term Potential to promote better long-term
engagement and participation because:engagement and participation because: Convenient for clientConvenient for client Reduces stigma of weekly trips to the treatment Reduces stigma of weekly trips to the treatment
programprogram Individualized attentionIndividualized attention Can be automated (Helzer, Searles et al.)Can be automated (Helzer, Searles et al.) Lower costs of ongoing care (?)Lower costs of ongoing care (?)
Evidence Supporting Therapeutic Evidence Supporting Therapeutic Use of the TelephoneUse of the Telephone
Studies suggest the telephone can be effective Studies suggest the telephone can be effective in delivering treatment:in delivering treatment: Addiction (Foote & Erfurt, 1991)Addiction (Foote & Erfurt, 1991) Smoking (Smoking (LichtensteinLichtenstein et al., 1996) et al., 1996) Depression (Baer et al., 1995; Simon et al., 2004)Depression (Baer et al., 1995; Simon et al., 2004) OCD (Greist et al., 1998)OCD (Greist et al., 1998) Panic and Anxiety (Rollman et al., 2005)Panic and Anxiety (Rollman et al., 2005) Bulimia (Hugo et al., 1999)Bulimia (Hugo et al., 1999) Cardiac care (Jerant et al., 2001; Riegel et al., Cardiac care (Jerant et al., 2001; Riegel et al.,
2002)2002)
A Continuum of CareA Continuum of Care
HospitalDetox
ResidentialRehab
IOPCare
OutpatientCont Care
AA -TeleMonitoring
TeleMonitoring
Elements of Continuum of Services
Prevention Treatment/Intervention
Recovery Services
Otpt Tx
Detox
Intensive Otpt Tx
Long-term Res Care
Short-term Res Care
Methadone Maintenance
NTPDetox
Recovery
0100200300400500600700800900
1000
Detox Residential Outpatient NTP Detox
Total AdmissionsAny Transfers
County Profile SamplesCounty Profile SamplesCounty ACounty A
Adm
issi
ons
50%
20%25% 9%
Number of transfers within the past 30-days following tx discharge
0100200300400500600700800900
1000
Detox Residential Outpatient NTP Detox
Total AdmissionsAny Transfers
County Profile SamplesCounty Profile SamplesCounty BCounty B
Adm
issi
ons
20% 40%
75%
7%
Number of transfers within the past 30-days following tx discharge
Recovery Services
Prevention Treatment/Intervention
Recovery
Telephone Continuing Care
Recovery Coaches/ Centers
Recovery Services
Otpt Tx
Detox
Intensive Otpt Tx
Long-term Res Care
Short-term Res Care
Methadone Maintenance
NTPDetox
Considerations with the ContinuumConsiderations with the Continuum
Sober housing plus outpatient care vs Sober housing plus outpatient care vs residential treatmentresidential treatment
Integration of medication (including Integration of medication (including methadone) into the continuummethadone) into the continuum
Determining when to transfer levels of Determining when to transfer levels of carecare
Remember, sometimes treatment intensity Remember, sometimes treatment intensity needs to be increased, not just decreased needs to be increased, not just decreased
Do you really use the full continuum Do you really use the full continuum of care?of care?
If you work in a residential treatment program, If you work in a residential treatment program, when was the last time, you referred a client into when was the last time, you referred a client into an intensive outpatient program (other than your an intensive outpatient program (other than your own) after they completed residential care?own) after they completed residential care?
If you work in an NTP, when was the last time If you work in an NTP, when was the last time you ever referred a patient into a residential you ever referred a patient into a residential treatment program, if they were doing poorly on treatment program, if they were doing poorly on methadone?methadone?
If you work in an outpatient treatment program, If you work in an outpatient treatment program, when was the last time you ever put one of your when was the last time you ever put one of your relapsing opiate addicts on buprenorphine, while relapsing opiate addicts on buprenorphine, while they were in your outpatient program? they were in your outpatient program?
Lessons from Chronic Illness:Lessons from Chronic Illness:
1.1. Medications and discussions of Medications and discussions of feelings can relieve symptoms feelings can relieve symptoms but…. behavioral change is but…. behavioral change is necessary for sustained benefitnecessary for sustained benefit
Lessons from Chronic Illness:Lessons from Chronic Illness:
2. Treatment effects 2. Treatment effects usuallyusually don’t don’t last very long after treatment last very long after treatment stops.stops.
Lessons from Chronic Illness:Lessons from Chronic Illness:
3. 3. Patients who are not inPatients who are not in some some form of treatment or monitoringform of treatment or monitoring are at elevated risk for relapseare at elevated risk for relapse..
Multiple Episodes of Acute Care IS
NOT Chronic Care
Patient Retention is Critical
Monitoring in Treatment is Essential
Lessons from Chronic Illness:Lessons from Chronic Illness:
Medical Detoxification Treatment Medical Detoxification Treatment ProgramsPrograms
Medical Detoxification is a treatment service used to Medical Detoxification is a treatment service used to systematically withdraw individuals from a substance in systematically withdraw individuals from a substance in an inpatient or outpatient setting. an inpatient or outpatient setting.
Treatment is provided under the care of a medical doctor.Treatment is provided under the care of a medical doctor. Detoxification is a short treatment and does not address Detoxification is a short treatment and does not address
the psychosocial and behavioral issues linked to the psychosocial and behavioral issues linked to addiction. addiction.
Detoxification is most valuable when it encompasses Detoxification is most valuable when it encompasses formal processes of assessment and results with a formal processes of assessment and results with a referral to successive substance abuse treatment. referral to successive substance abuse treatment.
Detox/Inpatient
Detox/Outpatient
Inpatient Residential TreatmentInpatient Residential Treatment Short-term Residential Treatment Short-term Residential Treatment
(commonly referred to as the Minnesota (commonly referred to as the Minnesota Model) focuses on the introduction to the Model) focuses on the introduction to the 12 Step Program and long term 12 Step Program and long term participation in 12 Step programs for participation in 12 Step programs for recovery support.recovery support.
Long-term Residential Treatment (often Long-term Residential Treatment (often referred to as the modified Therapeutic referred to as the modified Therapeutic Community approach) involves an Community approach) involves an extended period (3-12 months) of living extended period (3-12 months) of living within a highly structured recovery within a highly structured recovery community. “Treatment” is delivered via community. “Treatment” is delivered via peer interactions within the community. peer interactions within the community.
Sober Living Residence is a living Sober Living Residence is a living environment that has supervision and a environment that has supervision and a recovery environment. It should be used in recovery environment. It should be used in conjunction with outpatient treatment and conjunction with outpatient treatment and is not considered “treatment” on its ownis not considered “treatment” on its own
Sober Living Residence
Long-term Residential Treatment
Short-term Residential Treatment
Intensive Outpatient TreatmentIntensive Outpatient Treatment
Outpatient Treatment varies in length of stay, Outpatient Treatment varies in length of stay, but typically lasts at least 90 days and is but typically lasts at least 90 days and is followed by outpatient continuing care. followed by outpatient continuing care.
Patients generally receive 6 to 30 contact hours Patients generally receive 6 to 30 contact hours per week. per week. Core services include: group, individual and family Core services include: group, individual and family
counseling, psychoeducation, relapse prevention counseling, psychoeducation, relapse prevention training, positive reinforcement techniques; family training, positive reinforcement techniques; family involvement; urine and breath alcohol testing; 12 involvement; urine and breath alcohol testing; 12 Step (or alternative) participation; case Step (or alternative) participation; case management; medication, vocational and management; medication, vocational and educational services. educational services.
Intensive Outpatient/Psychosocial
Behavioral Treatment
Medication Assisted TreatmentMedication Assisted Treatment
Medication (e.g. Methadone, Buprenorphine) Medication (e.g. Methadone, Buprenorphine) provided in phases by a certified, licensed Opioid provided in phases by a certified, licensed Opioid Treatment Program (OTP) or a through a trained Treatment Program (OTP) or a through a trained medical doctor.medical doctor.
Medication Assisted treatment provides Medication Assisted treatment provides maintenance pharmacotherapy using an opioid maintenance pharmacotherapy using an opioid agonist, a partial agonist, or an antagonist agonist, a partial agonist, or an antagonist medication. medication.
The medication may be combined with other The medication may be combined with other treatment services, including medical and treatment services, including medical and psychosocial services. psychosocial services.
Medication Assisted Treatment
Effective ProgramsEffective Programs
Longer duration (2-4 years).Longer duration (2-4 years). Higher doses, > 60mg methadone.Higher doses, > 60mg methadone. Accessible prescriber and dispenser.Accessible prescriber and dispenser. Ancillary services.Ancillary services. Quality of therapeutic relationship.Quality of therapeutic relationship.
What is Treatment?What is Treatment?BuprenorphineBuprenorphine
A new opiate pharmacotherapyA new opiate pharmacotherapy Can be used for opiate withdrawal or maintenanceCan be used for opiate withdrawal or maintenance Can deliver from MD offices, not necessarily NTPsCan deliver from MD offices, not necessarily NTPs Medication is very safe, produces less Medication is very safe, produces less
dependence than methadone (withdrawal easier)dependence than methadone (withdrawal easier) Partial agonist, blocks other opiatesPartial agonist, blocks other opiates May not be potent enough for heavy, long time May not be potent enough for heavy, long time
usersusers Diversion is possible, but preventable.Diversion is possible, but preventable.
Treatment EpisodeTreatment Episode
Detox/Outpatient
Medication Assisted Treatment
Treatment EpisodeTreatment Episode
Continuing Care/Aftercare Programs
Sober Living ResidenceIntensive
Outpatient/Psychosocial Behavioral
Treatment
Long-term Residential Treatment
Treatment EpisodeTreatment Episode
Continuing Care/Aftercare Programs
Detox/Inpatient Long-term
Residential Treatment
Intensive Outpatient/Psychosoci
al Behavioral Treatment
Sober Living Residence
The Red Arrow – Transfer/ReferralThe Red Arrow – Transfer/Referral
Strategies for enhancing treatment service linkage:• Case management process
• Integrating staff from different treatment levels
• Create a personal linkage
• Transportation to facility
• Referral in appropriate geographical location
Measuring Program Performance: A Key to Measuring Program Performance: A Key to a Successful Continuum of Carea Successful Continuum of Care
Program Performance: What is it and how Program Performance: What is it and how will we measure it?will we measure it?
Measuring Measuring Program PerformanceProgram Performance
Definition: Definition: AOD treatment program performance is AOD treatment program performance is
evaluated by measuring the extent to evaluated by measuring the extent to which the clients of a treatment program which the clients of a treatment program
achieve specific benchmarks.achieve specific benchmarks.
In California, the key to this measurement In California, the key to this measurement will be the data collected in CalOMSwill be the data collected in CalOMS
How will CalOMS be used to How will CalOMS be used to improve program performance?improve program performance?
CalOMS data collection system that gives policymakers CalOMS data collection system that gives policymakers the ability to measure the performance of AOD the ability to measure the performance of AOD programs. programs.
The CalOMS data can be used to: The CalOMS data can be used to: 1. 1. monitor monitor treatment program performance treatment program performance 2. improve the 2. improve the managementmanagement of treatment services. of treatment services. 3. establish performance 3. establish performance benchmarksbenchmarks 4. recognize better/poorer performing programs.4. recognize better/poorer performing programs. 5. rewarding performance of better performing 5. rewarding performance of better performing
programs and targeting technical assistance to programs and targeting technical assistance to struggling programs.struggling programs.
How do we measure the performance How do we measure the performance of California’s treatment system?of California’s treatment system?
A Source of Confusion:A Source of Confusion:Outcomes vs PerformanceOutcomes vs Performance
Outcomes:Outcomes: OUTCOME MEASURES ARE USED AT OUTCOME MEASURES ARE USED AT THE PATIENT LEVEL AND MEASURE CHANGES IN THE PATIENT LEVEL AND MEASURE CHANGES IN PATIENT BEHAVIOR OR FUNCTIONING OVER TIMEPATIENT BEHAVIOR OR FUNCTIONING OVER TIME
Performance: Performance: PERFORMANCE MEASURES ARE PERFORMANCE MEASURES ARE USED AT THE TREATMENT PROGRAM LEVEL TO USED AT THE TREATMENT PROGRAM LEVEL TO EXAMINE THE FUNCTIONING OF THE TREATMENT EXAMINE THE FUNCTIONING OF THE TREATMENT PROGRAMPROGRAM
Treatment Initiation/EngagementTreatment Initiation/Engagement
Definitions: Definitions: InitiationInitiation: Do people who enter treatment receive : Do people who enter treatment receive
at least 2 treatment visits in the first 2 weeks?at least 2 treatment visits in the first 2 weeks?Engagement:Engagement: Do people who enter treatment Do people who enter treatment
receive at least 4 sessions in the first 30 days/receive at least 4 sessions in the first 30 days/
Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes Readily Accessible Data for Measures: ????Readily Accessible Data for Measures: ????
Treatment RetentionTreatment Retention
Definition: Definition: Retention: Number of days between admission Retention: Number of days between admission
and discharge.and discharge.
Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes
(maybe)(maybe) Readily Accessible Data for Measures: YesReadily Accessible Data for Measures: Yes
Continuity of CareContinuity of Care
Definition: Definition: Do individuals who enter treatment Do individuals who enter treatment
proceed through multiple service sets proceed through multiple service sets (levels of care)(levels of care)
Meaningful: YesMeaningful: Yes Clearly Defined: YesClearly Defined: Yes Reliability and Validity of Measures: YesReliability and Validity of Measures: Yes Readily Accessible Data for Measures: Readily Accessible Data for Measures:
YesYes
Treatment EpisodeTreatment Episode
Continuing Care/Aftercare Programs
Sober Living ResidenceIntensive
Outpatient/Psychosocial Behavioral
Treatment
Long-term Residential Treatment
Treatment CompletionTreatment Completion
Definition: Definition: Per CALOMS discharge, do people complete Per CALOMS discharge, do people complete
treatment treatment
Meaningful: YesMeaningful: Yes Clearly Defined: NoClearly Defined: No Reliability and Validity of Measures: NoReliability and Validity of Measures: No Readily Accessible Data for Measures: YesReadily Accessible Data for Measures: Yes
Other Discharge CategoriesOther Discharge CategoriesDefinitions: Definitions: Leave with Satisfactory ProgressLeave with Satisfactory Progress?: Do people ?: Do people
who enter treatment and leave before who enter treatment and leave before completion make satisfactory progress?completion make satisfactory progress?
Leave with Unsatisfactory ProgressLeave with Unsatisfactory Progress?: Do people ?: Do people who enter treatment and leave before who enter treatment and leave before completion have unsatisfactory progresscompletion have unsatisfactory progress
Meaningful: ??Meaningful: ?? Clearly Defined: NoClearly Defined: No Reliability and Validity of Measures: NoReliability and Validity of Measures: No Readily Accessible Data for Measures: YesReadily Accessible Data for Measures: Yes
Strategies for improving AOD Strategies for improving AOD program performanceprogram performance
Reduce staff turnoverReduce staff turnover Increase staff knowledge of other forms of Increase staff knowledge of other forms of
care to promote a “system of care” rather care to promote a “system of care” rather than isolated programsthan isolated programs
Increase staff knowledge and use of Increase staff knowledge and use of evidence-based practicesevidence-based practices
Employ process improvement (NIATx)Employ process improvement (NIATx)
A Continuing Care “System” of A Continuing Care “System” of AOD Treatment is more than a AOD Treatment is more than a
“Bunch of Programs”“Bunch of Programs”
Inpatient Inpatient DetoxDetox
Short-term Residential
Care
Long-term Long-term Residential Residential
Care Care
Current Publicly Funded Services
Residential
Facilities
Outpatient
Services
Narcotic Treatment
Program
Brief Treatment
Outpatient Treatment
IntensiveOutpatient Treatment
OutpatientDetox
MethadoneMaintenance
Sober Living Sober Living FacilitiesFacilities
Elements of Treatment System Not Currently Funded
Sober Living
Facilities
Addiction
Physicians
Continuing Care
Services
Medication Assisted
Treatment for Opiate Addiction:
Suboxone, Naltrexone
Recovery Centers
Recovery Check-ups
Medication Assisted
Treatment for Alcohol Abuse
and Dependence: Vivatrol,
Acamprosate, Ondansetron
Telephone SupportServices
Geographic Distribution of Services, __________ County, Geographic Distribution of Services, __________ County, CACA
NTP
RS
RS
OP
OP
OP
OP
OP OP
OP
OPOP
NTP
NTP
AP
AP
AP
SLSL SL
AP
SLSL
Client’s house
Geographic Distribution of Services, __________ County, Geographic Distribution of Services, __________ County, CACA
NTP
RS
RS
OP
OP
OP
OP
OP OP
OP
OPOP
NTP
NTP
AP
AP
AP
SLSL SL
AP
SLSL
Client’s house
Some Requirements of a “System” of CareSome Requirements of a “System” of Care
Individuals are treated with the most appropriate, Individuals are treated with the most appropriate, evidence-based treatment approaches and in the evidence-based treatment approaches and in the appropriate level of care.appropriate level of care.
Workforce recognizes the benefits of all evidence based Workforce recognizes the benefits of all evidence based treatment approaches and attempts to place individuals treatment approaches and attempts to place individuals in most effective form of care.in most effective form of care.
Workforce is informed and knowledgeable about Workforce is informed and knowledgeable about treatment services delivered by other treatment treatment services delivered by other treatment organizations in the service area.organizations in the service area.
Some Requirements of a “System” of CareSome Requirements of a “System” of Care
Clients will be transferred along the continuum of care Clients will be transferred along the continuum of care with communication and cooperation (“warm with communication and cooperation (“warm referral”)between treatment organizations.referral”)between treatment organizations.
Performance data will be collected and used by County Performance data will be collected and used by County Administration and by treatment providers to monitor Administration and by treatment providers to monitor progress toward a Continuing Care System of AOD progress toward a Continuing Care System of AOD treatment.treatment.
Performance data must not add substantial data burden Performance data must not add substantial data burden to service providers and data must be given to providers to service providers and data must be given to providers in a timely manner and in a form that is clear and in a timely manner and in a form that is clear and meaningful.meaningful.
A word about data quality…A word about data quality…
Newer Measures for a Newer Measures for a System of CareSystem of Care
Fresno CalOMS Data from 2008Fresno CalOMS Data from 2008
0
1000
2000
3000
4000
5000
6000
7000
NTP Detox Detox Residential Outpatient Day Care Rehab
Number of Transfers within the past 30-days following Tx discharge
Total AdmissionsAny Transfers
Tx Modality
No.
of A
dmis
sion
sFresnoFresno
26%11%
9%20%32%
0
20000
40000
60000
80000
100000
120000
NTP Detox Detox Residential Outpatient Day Care Rehab
Number of Transfers within the past 30-days following Tx discharge
Total AdmissionsAny Transfers
Tx Modality
No.
of A
dmis
sion
sStateState
29%11%
13%21%30%
72%
3%
12%
13%
15%
1%
3%7%
74%
Nothing
Detox
Residential
Outpatient
Maintenance
Destination Treatment Type
FresnoFresnoDetox Total: 1078
*Transfers to NTP Detox = 0, Day Care Rehab = 1
StateStateDetox Total: 26670
*Transfers to NTP Detox = 4, Day Care Rehab = 71,
Maintenance= 126
Transfers from Detox
1%8%
10%
80%
1%
Nothing
Detox
Residential
Outpatient
Day Care Rehab
7%
75%
6%
11% 1%
Destination Treatment Type
*Transfers to NTP Detox = 2, Maintenance= 1 *Transfers to NTP Detox = 46, Maintenance= 98
Residential Total: 41,636Residential Total: 2154FresnoFresno StateState
Transfers from Residential
0
10
20
30
40
50
60
70
80
90
100
Rx (Oxycodone)
Heroin Cocaine Meth Alcohol Cannabis Benzo (tranquilizers)
Other*
Retention Days by Primary Drug
FresnoState
Mea
n N
o. o
f Day
s in
Tx
Drug Category
*Other = barbiturates, PCP, inhalants, ecstasy, hallucinogens, club drugs, and other stimulants and tranquilizers
0
20
40
60
80
100
120
NTP Detox Detox ResidentialOutpatient Day Care Rehab
Maint.
Retention Days by Treatment Type
FresnoState
Mea
n N
o. o
f Day
s in
Tx
Type of Tx Modality
Building Interactive Service Building Interactive Service SystemsSystems
To create a treatment system that To create a treatment system that produces the best outcomes for patients,produces the best outcomes for patients,
it is necessary for AOD services within a it is necessary for AOD services within a county to be delivered in a “system of county to be delivered in a “system of care” rather than a “bunch of isolated care” rather than a “bunch of isolated programs”.programs”.
