Re-Considering

1
Re-Considering Addiction Treatment
How Can Treatment be More Accountable and
Effective?
A Customer Perspective
2
Institute of Medicine Report
a new HEALTH system for the 21st century (IOM,
2001)
3
Improving Quality of Health Care for Mental and
Substance-Use Conditions
4
Part I

• The Specialty Care System A Customer
  Perspective
• Patient Survey
• Care Provided
• Infrastructure

5
The Alcohol Pyramid
In Spec Treatment 1,800,000
Abuse/Dependent 18,000,000
Harmful Users ??,000,000
6
Addiction Specialty Care

• 13,200 specialty programs in US
• 31 treat less than 200 patients per year
• 65 private, not for profit
• 80 primarily government funded Private
  insurance lt12
• Sources NSSATS, 2002 DAunno, 2004

7
Referral Sources

• Source 1990 2004
• Criminal Justice 38 59
• Employers/EAP 10 6
• Welfare/CPS 8 16
• Hosp/Phys 4 3

8
Why Dont Patients Want Treatment?
Sources 4 Review Articles Rapp et al. JSAT
2005 Stanton JMFT 2004 Appel et al. AJDA
2004 Tsogia et al. JMH 2001
9
Top Patient Reasons

• 1) No Problem/Can Handle 58
• 2) No Confidence in Trt 51
• 3) Bad Trt Experience 36
• 4) Abstinence-Only Goal 31

10
Top Patient Reasons

• 5) Privacy Concerns 28
• 6) Insurance/Costs 24
• 7) Lack of Svcs Needed 22
• 8) Wait List/Access Prob 21

11
Top Patient Reasons

• 2) No Confidence in Trt 51
• 3) Bad Trt Experience 36
• 7) Lack of Services needed 22

WOW !
12
WHY? Wont programs deliver quality care?
CANT
13
Program Infrastructure

• Phone Interviews With National Sample of 175
  Programs regarding personnel, management,
  information
• McL, Carise Kleber JSAT, 2003

14
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

15
STAFF TURNOVER!

• Counselor turnover 50 per year
• 50 of directors have been there Less Than 1
  year

16
Who Are the Directors ?

• 17 No College Education
• 58 Had BA Degree 20 Had a MA or MSW
• 2 Physicians in 175 programs
• 28 NOT Working Full Time
• Most had been clinicians _at_ program

17
Other Staff

• 54 Had no physician 34 Had P/T
  physician 39 Had a Nurse (part of full time)
• lt 25 Had a SW or a Psychologist
• Major professional group - Counselors

18
Kerwin et al. 2006
Regulations for license certification All 50
states and Washington, D.C. Both substance abuse
and mental health counselors
19
Degree Required?
Substance Mental Abuse Health No
Degree required 12 0 lt BA min 78
2 Masters min 10 98
20
Information Systems

• Modest Computer Availability
• Mostly For Administrative Work
• 80 Had a Computer
• 50 had Web Access
• Still very little computer/software availability
  for CLINICAL STAFF

21
Part II

• The Problems with the Acute Care Model
• Assumptions
• Separation from Rest of Medicine
• Evaluation and its Implications

22
The Acute Care Model

• The Acute Care Model
• Treatment Models for Other Illnesses

23
A Nice Simple Rehab Model
Substance Abusing Patient
Medications, Therapies, JCAHO, CARF, WC Ev. Based
Prac.
Treatment
NTOMS Sample of 250 Programs
Non- Substance Abusing Patient
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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 failure

25
How Do Other Treatments Work? Chronic Illness
Continuing Care
26
A Continuing Care Model
Primary Care
Specialty Care
Primary Continuing Care
27
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
28
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
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But That's Not How It's Evaluated
I

• Implications of How We Evaluate
• Differences in Outcome Expectations

30
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.
31

• 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.

32
Outcome In Hypertension
Pre - During - Post
Treatment Research Institute
33
Outcome In Addiction
Pre - Post
Treatment Research Institute
34
Comparing Rehabilitation Treatments
Treatment
Control
35
Maybe Thats Why..
36

• 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.

37
Comparing Treatments ExampleTesting Three
Treatments in a Rehabilitation Model
Treatment Research Institute
38
Project MATCH

• RCT - 3 Research-Derived Therapies
• 27 Million Dollar NIAAA Study
• Different Mechanisms of Action
• Fixed Interventions All Patients
• Goal Achieve Lasting Abstinence Post
  Completion

39

Project Match Fixed Time - Fixed Content Rehab
Oriented
Treatment Type
Post Treatment Evaluations
6 12 18 24
30 39
45
38
27
MET
CBT
12-Step
40
ALLHAT The Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack
Treatment Research Institute
41
ALLHAT

• 63 million 61 sites
• Three Groups Different drug actions,
  Different drug costs
• Diuretic - 0.10 / pill
• Calcium Channel Blocker - 1.50 /pill
• Ace Inhibitor - 4.00 /pill
• Goal Improvement on Pre-Specified Criterion
  DURING TREATMENT

42

ALLHAT Pre-Specified Criteria Adjustment
Oriented
DURING Treatment Evaluations
Start 27 Control
Step 1 Step 2 Step 3
42
55
64
Diuretic
CCB
ACE
43
Improvement Comparison
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Part III

• Integrating Addiction into Mainstream Healthcare
• The treatment system from the perspective of
  physicians
• Opportunities to integrate addiction into
  mainstream healthcare a business perspective

45
What can be done in Mainstream Healthcare?

• Serving the Customer
• Helping the Physician Do Better!

46
The Alcohol Pyramid
In Spec Treatment 1,000,000
Abuse/Dependent 18,000,000
Harmful Users ??,000,000
47
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM,
2001)
48

• CONCLUSION
• It is not possible to deliver safe or adequate
  healthcare without simultaneous consideration of
  general health, mental health and substance use
  issues.

49
Referral Sources

• Source 1990 2004
• Criminal Justice 38 59
• Employers/EAP 10 6
• Welfare/CPS 8 16
• Hosp/Phys 4 3

50
Recent Evidence

• 1/3 of primary care patients screened for an
  alcohol problem
• Of those, 1/2 were given any intervention to
  address it
• Edlund et al. Medical Care 2004

51
Top Physician ReasonsSource 426 PCPs _at_ SGIM

• 1) Dont know what to do 69
• 2) No Time 55
• 3) Not really a medical prob 26
• 4) No Effective Treatments 19

52
Disorders with Higher Prevalence Among Substance
Abusers
Percent
Substance abusing patients 747 Matched
controls 3,690
Weisner et al. Arch Intern Med. In press.
53
What Conditions DO Primary Care Docs Treat?

• 1 Chronic Illnesses 55
• Asthma Cancers
• Hypertension Diabetes
• Pain Sleep Disorders

54
Disorders with Higher Prevalence Among Substance
Abusers
Percent
Substance abusing patients 747 Matched
controls 3,690
Weisner et al. Arch Intern Med. In press.
55
What can be done in Mainstream Healthcare?

• Serving the Customer
• Helping the Physician Do Better!

56
PRISM
Chronic Illness Care

• Program of Research to Integrate Substance Use
  Information into Mainstream Healthcare

57
The PRISM Approach

• Physicians want information to help them manage
  common chronic illnesses So
• Provide information about alcohol use that can
  help to manage common chronic illnesses.

58
Systematic Reviews

• Diabetes Howard et al. Effect of alcohol
  consumption on diabetes mellitus a systematic
  review.
• Annals of Internal Medicine. 2004 Feb
  3140(3)211-9.
• HypertensionMcFadden, et al. Systematic Review
  of the Effect of Daily Alcohol Intake on Blood
  Pressure.
• American Journal of Hypertension. In press.
• Depression Sullivan, et al. The Prevalence and
  Impact of Alcohol Problems in Major Depression A
  Systematic Review. American Journal of Medicine.
  In press.

59
Published Articles

• Prevalence and costs of substance abuse
  disorders
• Mertens et al. Hazardous Drinkers and Drug
  Users in HMO Primary Care What Do They Cost.
• Medical Care. 2005.
• Weisner et al. Medical and Psychiatric
  Conditions of Alcohol and Drug Treatment Patients
  in an HMO Comparison to Matched Controls.
• Archives of Internal Medicine. 2006.

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Known Alcohol Effects

• Protective effect of Alcohol
• Non Hodgkins Lymphoma
• Problematic effect of Alcohol
• Breast Cancer
• Sleep
• Obesity
• Dose-Dependent Effect of Alcohol
• (Usually gt2-3 drinks per day)
• Hypertension
• Diabetes

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Alcohol and Hypertension

• McFadden et al. Am J Hypertension. In press.

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Systematic Review Findings

• 11 randomized controlled trials
• Dose related effects
• lt 2 drinks/day or 10/week usually decrease
• gt 3 drinks/day or 14/week significant increase
• Magnitude of effect about the same as salt intake
• Effect of alcohol greatest in subjects with
  pre-existing hypertension

63
Alcohol and Breast Cancer
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Alcohol and Risk for Breast Cancer
J. National Cancer Inst. 1995
1 drink daily (lifetime)
2 drink daily
3.5
3 drinks daily
4 drinks daily
Br J Cancer. 2002
2-3 drinks daily (mixed)
gt3 drinks daily
0 50 100 150
Added Risk
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CONCLUSIONS

• Specialty care system is in trouble
• Customers Do Not Want the Product
• System Change is Necessary
• Opportunities for Primary and other Medical Care
  BUT, need to show value
• Treatment MUST move out of Specialty Care
• Meet Customer Needs Not all cases are chronic!
• Offer New Options

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- The End -
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STAR-D Comparing a Switching to an Augmenting
Model in Continuing Care
Treatment Research Institute
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STAR-DStep 1 12 weeks

• Groups 4,041 start on one SSRI
• Results by 12 weeks
• Quit 28
• Remission 36 (no symptoms)
• Need More 36
• Could not tolerate Celexa
• Did not receive much relief

69
STAR-DStep 2 Augmenters, 12 wks

• Step 2 Groups N 565
• Wellbutrin (NEDA-RI)
• Buspirone (5HT partial agonist)
• Results by 12 weeks
• Remission 36 (Bup better)
• Need More 64

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STAR-D Remission, by Step