# Presentation: 104358

##  I 

**Have We Evaluated Addiction**
**Treatment Correctly?**

**Implications From a Chronic Care Perspective**

** ****I **

##      Rehabilitation Model

**“****.. treatment benefits should be ****sustained following discharge**** for addiction treatment to be worth it ...”**

- (McLellan,1998).

## A Nice Simple Rehabilitation Model 

- A Nice Simple Rehabilitation Model

- NTOMS Sample of 250 Programs

**Treatment**

**Substance Abusing Patient**

**Non- Substance Abusing Patient**

**Meds,**
**Therapies,**
**Both**

## Re-Measure 6, 12, 24 mo Post Discharge 

**Evaluate**
**Prior to Admission**

**Treatment**

**Re-Measure 6, 12, 24 mo ****Post**** ****Discharge**** **

## Treatment Has Not Met Public’s Expectations – There is No Cure
Intensive, Expensive, Complex Treatments Seldom Work Better Than Cheap, Fast, Simple Treatments
Very Difficult to Predict Outcomes or to Show “Matching” Effects

**Treatment Has Not Met Public’s Expectations – There is No Cure**
**Intensive, Expensive, Complex Treatments Seldom Work Better Than Cheap, Fast, Simple Treatments**
**Very Difficult to Predict Outcomes or to Show “Matching” Effects**

*Based on This Model...*

## Made Sense For Inpatient/Residential Treatments – NOT for Outpatient
Have been Technically Challenging, Expensive and SLOW to do
Have not Informed Treatment Providers or Directed Individual Care

**Made Sense For Inpatient/Residential Treatments – ****NOT**** for Outpatient**
**Have been Technically Challenging, Expensive and SLOW to do**
**Have not Informed Treatment Providers or Directed Individual Care**

*Evaluations ...*

## Some Facts About Contemporary Treatment

## Treatment Compliance Is Low

>90% of all treatment in US is Outpatient

>50% of outpatients drop out of treatment within one month.

>50% of court-ordered patients do not complete treatment

**Treatment Compliance Is Low**
- >90% of all treatment in US is Outpatient
- >50% of outpatients drop out of treatment within one month.
- >50% of court-ordered patients do not complete treatment

## 	Relapse Rates Are High

About 60% use drugs within 6 mos. following treatment discharge

No difference between Brief and Intensive Treatments

No difference between Inpatient and Outpatient Treatments

**	****Relapse Rates Are High**
**About **60%** use drugs within ****6 mos****. following **treatment discharge
**No difference between Brief and Intensive Treatments**
**No difference between Inpatient and Outpatient Treatments**

## So What Does This Say About Treatment?

## How Are Other Illnesses Treated &  Evaluated?

##  Outcome In Hypertension

**Treatment Research Institute**

-  **Outcome In Hypertension**

**Pre - During - Post **

##  Outcome In Addiction

**Treatment Research Institute**

-  **Outcome In Addiction**

**Pre - Post **

## 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**

## Consider....

**If – in addiction treatment -effects are also significant but not long lasting after discharge...**

## Then....

**Post Discharge Evaluations will ****NOT**** be able to differentiate conceptually or procedurally different treatments**
**	**

##  Comparing Rehabilitation Treatments

-  **Comparing Rehabilitation Treatments**

**Treatment**** **

**Control**

## Examples...

**1 – Inpatient vs Outpatient Studies**
**2 – Project MATCH**
**3 – Brief vs Long Interventions**
**4 – Different Types of Therapies**

## Consider also....

**If treatment effects are significant but not long lasting after discharge...**

## Then....

**Most Treatment Measures will ****NOT**** be significant in: **
**  ****Matching Studies**
**  ****Prediction of Outcome Studies ****	**

##  Comparing Rehabilitation Treatments

-  **Comparing Rehabilitation Treatments**

## Examples...

**1 – Project MATCH**
**2 – National Cocaine Collaborative**
**3 – Many ASAM Placement Studies**
**	**

## How an Evaluation Question/Perspective Shapes an Answer

## Inpatient vs Outpatient Tx
Project Match

“Rehabilitation” and “Continuing Care”
Perspectives

**Inpatient **_**vs**_** Outpatient Tx**
**Project Match**
**“****Rehabilitation” and “Continuing Care”**
**Perspectives**

*Two Examples*

##  Contrasting Rehabilitation and Continuing Care Models

- Treatment and Research Assumptions
- Implications
- Specific Examples
** ****Inpatient VS Outpatient Detoxification**
** ****Treatment Comparisons**

## A Nice Simple Model 

- NTOMS Sample of 250 Programs

**Treatment**

**Substance Abusing Patient**

**Non- Substance Abusing Patient**

##      ASSUMPTIONS

**Some **_**fixed amount**_** or duration of treatment should resolve the problem**
**Clinical efforts put toward **_**matching**_** treatment and getting patients to **_**complete**_** treatment**
_**Evaluation**_** of effectiveness **_**following completion**_** **
**Poor outcome means failure**

## A Continuing Care Model 

**Detox**

**Continuing Care**
**Recovering Patient**

**Rehab**

**Duration**
**Determined by**
**Performance**
**Criteria**

**Duration**
**Determined by**
**Performance**
**Criteria**

##      ASSUMPTIONS

**Patient will continue in treatment**
**There are agreed upon clinical targets at each stage of treatment**
**Achieving the clinical targets will prepare you for the next (reduced intensity) stage**
**There will be no discharge – just reduced intensity of care**

## Example IInpatient vs Outpatient Detoxification

**Detoxification as ****Preparation for Rehabilitation**
**An Example of How the Question Shapes the Answer**

##   OLD QUESTIONS

**Is Inpatient Treatment more effective than Outpatient Treatment?**
**	****Inpatient ****vs**** Outpatient Detox**
**	****Inpatient ****vs**** Day Hospital Rehab**
**	****Residential ****vs**** Outpatient Rehab**

## From Hayashida et al.  1988, NEJM

**Evaluate**
**Random Assignment**

**Inpatient**
**Detox**

**Outpatient**
**Detox**

**Evaluate @ 6 mo Post Discharge**

**From Hayashida et al.  1988, NEJM**

## Alcohol Abstinence Rates

**No Difference**

**No Difference**

**From Hayashida et al.  1988, NEJM**

## Costs Per Completion

**Big Difference**

**From Hayashida et al.  1988, NEJM**

##   NEW QUESTION

**Does “Effective” Detoxification Lead to More Effective Outpatient Rehabilitation?**
**	****Inpt Stabilization Prior to Outpatient**
**	****VS**
**	****Direct Admission to Outpatient**

## Evaluate 

**Evaluate**
**Random Assignment**

**Inpatient**
**5 Day**

**Outpatient**
**60 Day**

**Evaluate **
_**During**_** Rehab**

**Outpatient**
**60 Day**

##   Participants

**All Male Veterans - N = 104**
- Age - 48
- 72% Black
- 28% Employed
- 17% Probation/Parole
- Prior Treatments - 5

## Stabilization @ Day 5

*****

*****

******

## Drop Out – 2 Weeks

**Direct Entry**
**26%**

**Pre-Stabilized**
***8%**

## RETENTION for 30 Days

**Percent**

**48%**

**78%**

## RETENTION for 60 Days

**Percent**

**27%**

**58%**

## Positive Urinalysis @ 14 Days

**Percent**

**41%**

**18%**

## Comparing Treatments Example IITesting Three Treatments  in a Rehabilitation Model

**Comparing Treatments ****Example II****Testing Three Treatments  in a **_**Rehabilitation Model**_

**Treatment Research Institute**

## Project MATCH

**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**

## MATCH Results

**MATCH Results**

** ****Significant but ****Equal**** ****Improvements  **
**  ****Equal**** Outcomes at all points**
**  ****No**** Significant Matches Confirmed**
**  ****Outpatient Arm Did Best**

**MET**

**CBT**

**12-Step**

**Project Match **
**Fixed Time - Fixed Content – Rehab Oriented**

**             ****6        12       18        24        30       39**

**Treatment Type**

**Post**** Treatment Evaluations**

**45%**

**38%**

**27%**

## Improvement in Project MATCH

## Maybe We Have the Wrong Model?

**Again....**

## Comparing Treatments Testing Three Treatments in a Continuing Care Model

**Comparing Treatments ****Testing Three Treatments in a **_**Continuing Care Model**_

**Treatment Research Institute**

## ALLHAT The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack

**ALLHAT ****The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack**

**Treatment Research Institute**

## ALLHAT

**ALLHAT**

** ****Groups**** – Different Mechanisms of Action – Very Different Costs**
** ****Diuretic**** - $0.10 / pill**
** ****Calcium Channel Blocker**** - $1.50 /pill**
** ****Ace Inhibitor**** - $4.00 /pill**
**  ****Goal**** – Improvement on Pre-Specified Criterion ****DURING TREATMENT**

** **

**Diuretic**

**CCB**

**ACE**

**ALLHAT **
**Pre-Specified Criteria – Adjustment Oriented**

**           ****Step 1****	****Step 2****	**** Step 3**

**Start**
**27% Control**

**DURING**** Treatment Evaluations**

**42%**

**55%**

**64%**

## Improvement Comparison

##     Lessons from Chronic Illness:

Medications relieve symptoms but.... behavioral change is necessary for sustained benefit

**    ****Lessons from Chronic Illness:**
**Medications relieve symptoms but.... ****behavioral change is necessary for sustained benefit**

##     Lessons from Chronic Illness:

2. Treatment effects usually don’t last very long after treatment stops.

**    ****Lessons from Chronic Illness:**
**2. Treatment effects ****usually**** don’t last very long after treatment stops.**

##     Lessons from Chronic Illness:

3. Patients who are not in some form of treatment or monitoring are at elevated risk for relapse.			
In addiction this could include monitoring or AA

**    ****Lessons from Chronic Illness:**
**3. ****Patients who are not in**** **_**some form of treatment or monitoring**_** ****are at elevated risk for relapse****.****	****	****	**
**In addiction this could include monitoring or AA**

## What Continuing Care Does NOT Imply

**Not every case of abuse or addiction needs Continuing Care**
**Some Patients Do Show Continuing Benefits From Acute Care**
**Brief Interventions – Studies of Untreated Individuals**
**Also Happens in Other Illnesses**
**May Be Less Severe or May Engage in Different Lifestyle (e.g. AA) **

## What Continuing Care Does NOT Imply

**A Continuing Care Strategy Does Not Imply Lack of Responsibility**
**Just the Opposite **
**Purpose is to Teach Self Management**

## What Continuing Care Does Imply

**Need for Pre-Specified Treatment Goals**
**Agreeable to the Patient**
**Measurable**
**Need for Continuing Contact/Monitoring**
**Tailored to the severity and needs of the patient **
**Telephone and Internet Options **
**Need for Multiple Options**
**Most First Efforts Will Fail – Hard to Predict**
**Sensible Switching or Adding Time Frames**

##   Multiple Acute Care Episodes IS NOT a Continuing Care Strategy

-  Expensive and Wasteful
-  Patient Education Necessary
-  Align Patient and Provider Incentives to   	Promote Adherence/Compliance

*Lessons From Chronic Care*

##   Most Patients Do NOT Respond to Their First Treatment/Medication

-  Need for more alternatives
-  Improves retention

*Lessons From Chronic Care*

##  Patient Retention is Critical 

-  Patient Retention is Critical
- Make Treatment Attractive
- Offer Options/Alternatives
- Increase Monitoring/Management

*Lessons From Chronic Care*

##  Monitoring is Part of Health Care

-  Telephone and IVR Useful
-  Saves Physician Time, Reduces Number and Severity of Relapses
-  Not Currently Reimbursed

*Lessons From Chronic Care*

##   Evaluations of Continuing Care Should Occur DURING Treatment

- Need for interim performance markers (retention, linkage, urines, pro-social behaviors, etc.)

*Lessons From Chronic Care*

##  Symptom Improvement Does Not Continue Without Behavioral Change 

-  Social Support and Counseling _Alone_ Can Improve Symptoms and Function
-  Poor, Psychiatrically Ill Patients		 **CAN & DO** Improve

*Lessons From Addiction*

##   “Recovery Monitoring” A Way To Evaluate Continuing Care Models

- The Basic Assumptions
- The Clinician as Evaluator
- Specific Examples
** ****Inpatient VS Outpatient Detoxification**
** ****Treatment Comparisons**

## The Criteria

**The Same Traditional Outcomes**
**  ****Reduce Substance Use **
**  ****Improved Personal Health**
**  ****Reductions of Public Health and ****	****Public Safety Problems**
**Operational Definition of**** ****Recovery**

## The Evaluation Points

**Monthly **
**From the Start of Outpatient Care**
** **
**  ****Negotiated Treatment Plan**
**  ****Care Team as Evaluation Team**
**  ****Behavioral Criteria – ****NOT**** Time in ****	****Treatment or Process Fidelity**

## Clinical Considerations

_**Not Just More Standard Care**_
**  **_**Attractive**_** Alternatives**
**  ****Pre-Specified, Behavioral Goals**
**  ****New Ways of Monitoring**

## The Criteria

**The Same Traditional Outcomes**
**  ****Reduce Substance Use **
**  ****Improved Personal Health**
**  ****Reductions of Public Health and ****	****Public Safety Problems**
**Operational Definition of**** ****Recovery**

## The Evaluation Points

**Monthly **
**From the Start of Outpatient Care**
** **
**  ****Negotiated Treatment Plan**
**  ****Care Team as Evaluation Team**
**  ****Behavioral Criteria – ****NOT**** Time in ****	****Treatment or Process Fidelity**

## An Ideal Model – No Discharge  

**Substance Abusing Patient**

**Regular “Performance” Eval**

**Hospital**
**Detox**

**Residential**
**Rehab**

**IOP**
**Rehab**

**Outpatient**
**Cont Care**

**AA -Tele**
**Monitoring**

**Tele**
**Monitoring**

## A More Typical Model

**Detox- Only Admissions**

**42% of Philadelphia Episodes**
** ****@ $750 - $1500 each**

**Hospital**
**Detox**

**Residential**
**Rehab**

**IOP**
**Rehab**

**Outpatient**
**Cont Care**

**AA -Tele**
**Monitoring**

**Tele**
**Monitoring**

## Summary

-  The Continuing Care Model

## Important Caveats

**Not Every Case of Substance Abuse Needs a Continuing Care Strategy**
**Not Clear When to Shift from Acute**
**Also Not Clear in Other Illnesses**
**A Continuing Care Strategy Does Not Imply Lack of Responsibility**
**Just the Opposite **
**One Goal is Self-Management**

## Important Caveats

**Some Patients Do Show Continuing Benefits From Acute Care**
**Brief Interventions – Studies of Untreated Individuals**
**Also Happens in Other Illnesses**
**May Be Less Severe or May Engage in Different Lifestyle (e.g. AA) **

## Important Caveats

**Some Studies Do Show Different Effects of Treatments, Therapies**
**Many are in Methadone**
**Very Few in Outpatient Settings**

## What Continuing Care Does NOT Imply

**Not Every Case of Substance Abuse Needs a Continuing Care Strategy**
**Not Clear When to Shift from Acute**
**Also Not Clear in Other Illnesses**
**A Continuing Care Strategy Does Not Imply Lack of Responsibility**
**Just the Opposite **
**One Goal is Self Management**

## What Continuing Care Does Imply

**Need for Pre-Specified Treatment Goals**
**Agreeable to the Patient, Measurable**
**Need for Continuing Contact/Monitoring**
**Tailored to the severity and needs of the patient **
**Telephone and Internet Options **
**Need for Multiple Options**
**Most First Efforts Will Fail – Hard to Predict**
**Sensible Switching or Adding Time Frames**

-   -  The End  -