Suppose We Try Something New in

Addiction?

Different Perspectives andResearch Implications

1. Build National System of “Prevention Prepared Communities”

2. Train primary care to intervene early with emerging abuse

3. Integrate addiction treatment into mainstream healthcare

4. Smarter, safer management of drug-related offenders

A Nice Simple Rehab Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

ASSUMPTIONS• Some fixed amount or duration of

treatment will resolve the problem

• Clinical efforts put toward correctly placing patients and getting them to complete treatment

• Evaluation of effectiveness should occur following completion

– Poor outcome means treatment/patient failure

But this hasn’t worked well…

• About 60% of outpatients drop out prematurely (< 1 month).

• Relapse rates are high – 50% @ 6-mos.

Studies show few differences between…

• Brief and Intensive Treatments

• Inpatient and Outpatient Treatments

• Conceptually Different Treatments

• “Matched” and “Mismatched” Trt.

• Gender or Culturally Oriented Trt.

How Do Other

Treatments Work? Chronic Illness & Continuing Care

A Continuing Care Model

PrimaryContinuing Care

Primary Care

Specialty Care

In Chronic Illnesses….

1 – The effects of treatment do not last very long after care stops

2 – Patients who are out of treatment/contact are at elevated risk for relapse

So, For Treatment….1 – One goal is to retain patients at an appropriate level of care and monitoring

2 – Another goal is to prepare patients to do well in the next level of care

3 - The effects of treatment are evaluated during treatment – not post-discharge

• Maybe Results Depend on Perspective

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Pre During During During Post

Treatment Research Institute

Outcome In Hypertension

0

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Pre During During During Post

Treatment Research Institute

Outcome In Addiction

Maybe this is why…

Studies show few differences between…

• Brief and Intensive Treatments

• Inpatient and Outpatient Treatments

• Conceptually Different Treatments

• “Matched” and “Mismatched” Trt.

• Gender or Culturally Oriented Trt.

OK, But Could This Work in Addiction?

Several Reasons To Think ofAddiction as a Chronic Illness

Continuing Care In Addiction

RecoverySupport Services

Primary Care

Specialty Care

ScreenInterveneMonitorRefer

Re-InterveneMonitor/Support

StabilizeMotivate/MedicateTrain Self-MgmntRefer

Implications?

1. For Current Addiction TreatmentSystem

2. For Expanding Treatment3. For Evaluation

~ 12,000 specialty programs in US

• 31% treat less than 200 patients per year

• Very Few Doctors • Most of those eligible do not want

care

7. Integrate Addiction Treatment into Federal Healthcare Systems

8. Performance Contracting in State Treatment Systems

9. Consumer Choice Through Vouchers for Recovery Services

How to Evaluate?

1. Model is There2. What are Performance Measures3. When/How to Measure Outcome4. How will public understand