Improving Retention In OST: Examining Agency Practices

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Improving Retention In OSTExamining Agency
Practices

• Ron Jackson, M.S.W.
• Evergreen Treatment Services
• Seattle, WA

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FACTORS EFFECTING CHEMICAL DEPENDENCY TREATMENT
OUTCOMES

• 1. PRE-TREATMENT VARIABLES
• Patient's age, gender, race/ethnicity,
  socio-economic status, drugs of dependence
  abuse, abuse and dependence history (including
  age of onset), number of prior treatment
  attempts, psychiatric problems, medical problems,
  level of motivation
• 2. TREATMENT VARIABLES
• Type of treatment, length of treatment episode,
  counselor qualifications, variety of treatment
  services provided
• 3. POST-TREATMENT VARIABLES
• Patient's employment status, living conditions,
  social environment, support group network

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Treatment Outcome Prospective Study (TOPS)

• Comparisons between 21 OST programs
• Programs with Longer Retention had
• Better assessment program planning
• Higher MM dose better UA monitoring
• Comprehensive (wrap-around) services
• Higher patient ratings for meeting needs

Joe, Simpson, Hubbard, 1991 (J Sub Abuse)
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Program Retention Rates in OST(for 360 days or
longer)
of Admissions to 10 OMT Programs (with 40
patients)
DATOS Study 1991-93 Simpson, Hubbard, Anglin
Fletcher
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Methadone Maintenance vs.180 Day Detoxification

• 12 month study of 179 opioid dependent patients
  randomly assigned to
• Methadone Maintenance
• mean dose85.3mg
• for 14 months
• 180 Day Methadone Detoxification
• mean dose86.3 mg prior to taper at 120 days
• followed by psychosocial Tx for 8 months
• Methadone maintenance therapy resulted in
  greater treatment retention and lower heroin use
  rates than did detoxification.
• K.L. Sees et al., JAMA 2000

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Retention OutcomesETS Fixed Site-Van Comparison
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Retention Benchmarks

• 90 days
• 80-85
• 180 days
• 70-80
• One year
• 50-60
• Two years
• 25-30
• How and how often do you measure your agencys
  retention?
• Why is this important?

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Agency Orientation

• Treatment Policies and Procedures flow from
  agencys orientation
• Recovery oriented
• Focus on discontinuation of all illicit drug use
  and legal drug misuse
• Focus on psychosocial rehabilitation
• Harm reduction oriented
• Many definitions of this

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Characteristics of Successful Methadone Treatment
Programs

• Adequate Dosing Policies
• Average Dose Between 60 120mg.
• Individualized Treatment
• Comprehensive Services
• Well-trained Stable Staff
• Coordinated Services
• Medical, Counseling Administration

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Methadone DoseHow much is enough?
Leavitt, SB, et.al., When Enough is Not Enough.
Mt Sinai Journal of Medicine 2000 67(56)
404-411.
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NIH Consensus Panel onEffective Medical
Treatment of Opiate Addiction

• 12 member multi-disciplinary panel, Nov. 1997
• heard testimony from 25 experts
• reviewed 941 research reports published over the
  period Jan. 1994 - Sept. 1997
• Of the various treatments available, MMT,
  combined with attention to medical, psychiatric,
  and socioeconomic issues, as well as drug
  counseling, has the highest probability of being
  effective.

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Individualized Treatment

• Use of multi-dimensional tool at intake that
  assesses patients unmet need for services in a
  variety of life domains, not just their
  drug/alcohol problems
• That assessment guides initial treatment plan and
  service delivery
• Clinician and supervisor issues
• Periodic re-assessment of unmet needs

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Comprehensive Services

• For patients with co-occurring Axis I mood or
  anxiety disorders, integrated psychiatric
  services with OST improves both retention and
  outcomes.
• Medical evaluations and referral to primary
  medical services
• Case management
• Housing services

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Agency Practices Leading to Involuntary Treatment
Termination of Patients
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Urine Testing Practices

• How often? Observed?
• Alcohol breath testing?
• What do with results?
• Change in treatment plan
• Dose adjustments
• Policies for continued positive urine tests
  and/or observed intoxication?
• Opioids
• Other drugs
• Failing to leave samples

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Drug Use Length of Time in Methadone Treatment
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Drug Use by Patients in Methadone Treatment
of total census
Evergreen Treatment Services, May 2003 n 781
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Counseling Attendance Practices

• How often?
• What to do with missed appointments
• Counselor responsibilities
• Reminders
• Dose holds
• Patient responsibilities
• Policies for continued missed counseling
  appointments?

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Missed Dosing Practices

• How many in a row leads to discharge?
• Any total number over some period (for example)14
  over 90 days lead to action?
• If so what are the actions

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Resources

• TIP 43, Medication-Assisted Treatment for Opioid
  Addiction in Opioid Treatment Programs
  www.health.org
• TIP 40, Clinical Guidelines for the Use of
  Buprenorphine in the Treatment of Opioid
  Addiction www.health.org
• Addiction Treatment Forum www.atforum.com
• Web sites
• kap.samhsa.gov CSATs Knowledge Application
  Program
• www.aatod.org AATOD
• buprenorphine.samhsa.gov/index.html CSATs
  buprenorphine Web site, including FAQs
• www.drugpolicy.org Drug Policy Alliance
• About Methadone
• www.nida.nih.gov NIDA