# Presentation: 037376

## Welcome

## Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

- Module 13: TIP Chapter 14

## Course Goals

- The goals of this training are to...
- Familiarize you with the content of TIP 43; and
- Increase your awareness of issues related to medication-assisted treatment of opioid addiction.

## Module 13: Administrative Considerations in OTPs

- During this module, you will:
- Identify preferred staffing requirements for OTPs;
- Describe features of medication diversion control plans;
- Examine relationship issues between OTPs and local communities;
- Identify resources in the area of national community education; and
- Describe rationales and strategies for MAT program evaluation.

## Staffing

- Chapter 14 describes policies, procedures, and considerations that make OTP administrators and managers more effective.
- Treatment outcomes are improved by providing leadership and staff management.
- OTP manager responsibilities include:
- Focusing on patient care and treatment outcomes;
- Setting clear guidelines;
- Supplying needed resources; and
- Nurturing staff growth and retention.

## Staffing

- Interactions between staff and patients and staff attitude are the next most important determinant of treatment effectiveness, after adequate dose of methadone.
- Successful treatment outcomes depend on staff competence, values, and attitudes.
- Administrators should:
- Recruit qualified, capable, culturally competent people;
- Offer competitive benefit packages; and
- Provide supervision and ongoing training.

## Staffing:  Qualifications

- Treating opioid addicted patients requires highly trained caregivers to provide patient care and coordinate access to services.
- Hire individuals who are licensed or credentialed, and work effectively with the types of patients served by the OTP.
- Employ people with empathy, sensitivity, and flexibility to create a therapeutic milieu.
- Staff members should maintain appropriate professional boundaries.

## Staffing:  Qualifications

- Transference:  Patients project feelings or emotions onto providers.
- Countertransference:  Providers project feelings or emotions onto patients (e.g., displaying anger or disappointment with patients).
- Supervisors should ensure staff members avoid countertransference.

## Staffing:  Qualifications

- Knowledge of cross-cultural principles improved patient outcomes.
- Support staff should be willing to:
- Work with people from diverse backgrounds;
- Explore and accept other value systems; and
- Understand how culture and values relate to patient behavior.
- Recruit employees who reflect patient demographics, and consider hiring people in recovery.

## Staffing:  Qualifications

- Diversity also exists within cultures.
- Treatment staff should:
- Be sensitive to cultural differences but avoid acting on assumptions;
- Accept patients’ cultural influences and individuality; and
- Be aware of factors that affect recovery (e.g. sexual orientation or age) but avoid generalizing.

## Staffing:  Qualifications

- Information on cultural competence and diversity is available at:
- National Association of Social Workers (www.socialworkers.org/diversity);
- Substance Abuse and Mental Health Services Administration (www.samhsa.gov/search/search.html); and
- ”Cultural Competence for Social Workers“ (Center for Substance Abuse Prevention 1995).

## Staffing:  Multicultural and Multilingual Representation

- No data demonstrating improved outcomes from ethnic matching of patients and providers.
- One study noted “...equivocal findings of the effect that therapist and patient similarity plays in treatment outcome" and concluded more research is needed.
- However, if program staff reflects the population served, patients are more likely to feel comfortable.

## Staffing:  Multicultural and Multilingual Representation

- When multicultural representation among staff is limited, OTPs should find ways to communicate acceptance of diversity.
- Federal and State resources are available for literature in languages other than English.
- Information about translation services are available online, at www.atanet.org/bin/view.fpl/52076.html.

## Staffing:  Flexibility

- Staff attitudes about MAT and opioid addiction can affect patient outcomes.
- Staff members should be free of rigid biases, non-judgmental, and should not have punitive attitudes toward patients.
- Therefore, managers should:
- Monitor staff attitudes; and
- Provide training to create or sustain appropriate attitudes.

## Staffing:  Flexibility

- Verbal expressions used by OTP staff members can reflect how they feel toward patients.
- Treatment staff members sometimes use countertherapeutic language.
- Avoid terms suggesting the criminal justice system to refer to patients doing poorly in treatment.
- Applying words derived from “toxin” to treatment medication suggests the medication is a toxin; “detoxification” should refer only to withdrawal from substances of abuse.

## Staffing:  Terminology

- _Judgmental Term_
- Dirty urine
- Probationary
- Termination
- Clients
- Detox

- _Preferred Expression_
- Positive drug test
- Doing poorly in treatment
- Discharge
- Patients
- Dose tapering or medically supervised withdrawal

## Staffing: Inclusion of Recovering Patients

- Employing treatment professionals and support staff who are in recovery adds valuable perspectives to treatment and provides role models for patients.
- OTP policies on hiring people who are in addiction recovery should be in writing and include procedures for addressing staff members who relapse.
- Hiring policies should comply with State and Federal laws prohibiting discrimination against people who are addicted.
- Staff members who are in recovery, and their colleagues who have no addiction history, should be treated similarly.

## Staffing:  Retention

- Retaining staff is important for several reasons:
- Stability of treatment staff may affect treatment outcomes.
- High staff turnover can undermine relations with community, funders, and others.
- Investment in recruitment and training is lost when staff members leave.
- Unfilled staff positions result in longer patient waiting lists.
- Reducing staff turnover minimizes disruption to patients’ treatment.
- Accreditation standards place importance on stability of OTP staff.

## Staffing:  Retention

- Factors that contribute to high staff turnover include:
- Low salaries and benefits;
- Negative stereotypes of MAT and its patients;
- Job stress;
- Excessive counselor workload;
- Unreasonable operating hours; and
- Unsafe OTP locations.
- Staff members can experience burnout if they work in isolation with difficult patients, and receive inadequate support or feedback.

## Staffing:  Retention

- Managers should take concrete steps to retain staff, including the following:
- Establish, maintain, and apply consistent policies and procedures;
- Avoid excessive caseloads;
- Encourage team approach;
- Reduce intrastaff disagreements;
- Decrease “staff splitting”;
- Encourage mutual respect;
- Hold regular staff meetings; and
- Develop and annually review job descriptions that delineate roles, responsibilities, and lines of communication.

## Staffing:  Retention

- Managers should also establish:
- Performance standards with evaluations;
- Regular consulting sessions;
- Opportunities for training;
- Praise and recognition; and
- Caring personnel policies.

## Staffing:  Training

- Training should be offered for all staff.
- Accreditation standards require OTPs to provide continuing staff education, with many States requiring such education to maintain licensure.
- OTPs should help staff members by offering onsite training, collaboration with other training agencies, or paying for educational leave or tuition.

## Staffing:  Training

- Training should focus on the following:
- Facts about MAT and the health effects of treatment medications;
- Up-to-date information about medications;
- Up-to-date information about drugs of abuse;
- Up-to-date information about communicable diseases;
- Skills training (such as crisis management, communications, and problem solving); and
- Patient sensitivity training.

## Staffing:  Training

- Consistent inservice training can help staff members understand program's mission and the effects of MAT.
- OTP administrative staff may lack direct treatment responsibilities, but they are often the first to speak with patients.
- Orientation about MAT ensures understanding of how OTP operates and develops favorable attitudes about patients.
- If possible, all staff members should receive annual training in such areas as confidentiality requirements, cultural competence, prevention of workplace violence, and patient rights.

## Medication Diversion Control Plans

- OTPs must maintain a current diversion control plan (DCP) to reduce the possibility of medication diversion and assign responsibility for control measures to medical and administrative staff members.
- A DCP should address diversion of medication both by patients, who might sell or give their take-home medication to others, and by staff, who might steal medication or spill or otherwise waste it.

## Medication Diversion Control Plans:  Patients

- Patients must meet Federal criteria for take-home medications.
- OTP’s medical director makes and documents decisions about take-home medications.
- Staff should ensure that patients store medications safely.
- All take-home medications must be labeled and packaged in a manner designed to reduce risk of accidental ingestion, including child-proof containers.

## Medication Diversion Control Plans:  Patients

- Callbacks help prevent patient diversion of take-home medication.
- OTPs select patients at random to return remaining take-home medication; random policy avoids patient complaints of being unfairly “picked on.”
- Programs can require patients to undergo drug tests when they bring in medications.
- Inform patients of responsibilities and consequences regarding callback policy.
- No-loitering policy part of an effective DCP.

## Medication Diversion Control Plans:  Staff Members

- Protocols should be in place to reduce risk of staff diversion.
- Scheduled substances should be accounted for rigorously and inventoried continuously.
- Working stocks should be logged and tracked from receipt through dispensing, and measured at the beginning and end of each workday.

## Medication Diversion Control Plans:  Staff Members

- Measurements and daily reconciliations should be monitored by supervisors and dispensary managers.
- Significant discrepancy should prompt an investigation, with dispensary manager, executive director, and medical director following up on investigation findings.
- In matters of medication dispensing, OTPs must consult and comply with DEA regulations.

## Community Relations

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## Community Relations:  Groups

- _Group 1_:  Community Opposition and Good Community Relations (pp. 231-232).
- _Group 2_:  Overcoming Negative Community Reactions and Community Relations and Education (pp. 232-233).
- _Group 3_:  Delineating Roles, Initiating and Maintaining Contacts (p. 233), and Establishing Effective Media Relations (p. 235).
- _Group 4_:  Educating and Serving the Community (pp. 233-235).
- _Group 5_:  Developing Policies and Documenting Community Contacts (pp. 235-236).

## National Education

- OTPs should be aware of and involved in the national dialog and efforts to promote MAT.
- OTPs should build on and contribute to these national initiatives within their communities.

## National Education

- Numerous resources are available to educate the public about MAT and assist OTPs with public relations.
- National organizations such as American Association for the Treatment of Opioid Dependence (AATOD) and the American Society of Addiction Medicine (ASAM) hold national and regional conferences.
- More detailed information on publications and other resources may be found on page 237 in TIP 43.

## Evaluating Program Performance

- Federal regulations and guidelines require OTPs to establish performance improvement programs.
- OTPs must demonstrate effectiveness and efficiency.
- Program evaluation contributes to improved treatment.
- For information on evaluation details, refer to Demystifying Evaluation: A Manual for Evaluating Your Substance Abuse Treatment Program—Volume 1 (CSAT 1997a).

## Evaluating Program Performance:  Background

- MAT is one of the most frequently studied addiction therapies, but evaluating program performance based on patient outcomes is relatively new.
- Many OTPs appear to be on their own in conducting program evaluations that comply with accreditation and State mandates.

## Evaluating Program Performance:  Outcome vs. Process Evaluation

- Earlier regulations stressed _process evaluation_, based on compliance with recommended treatment procedures.
- Process evaluation does not ask whether a recommended process has worked, only whether it has been followed.
- _Outcome evaluation_ focuses on patients and their progress during or after participation in MAT.

## Evaluating Program Performance:  Outcome Evaluation

- Outcome evaluation focuses on patients and their progress during or after MAT.
- Evaluation should focus on progress markers and behavioral improvements.
- Such study can set a baseline and provide a benchmark to evaluate the effects of changes in program practices.
- Measures selected for evaluation by an OTP should agree with target behaviors specified in program goals and objectives.

## Evaluating Program Performance: SAMHSA Accreditation

- SAMHSA’s accreditation guidelines list the following treatment outcomes as examples of what might be measured by OTPs:
- Reduce or eliminate use of illicit and problematic drugs;
- Reduce or eliminate associated criminal activities;
- Reduce behaviors contributing to the spread of diseases; and
- Improved quality of life by restoring physical and mental health and function.

## Evaluating Program Performance: Process Evaluation

- Process evaluation describes what is happening in the treatment program.
- For example, a process evaluation can document what actually happens during an intervention.
- Process evaluation also may describe what is happening within the “black box” of the treatment program. (Black box, a commonly used term in this context, refers to the unknown quality of some treatment programs).

## Evaluating Program Performance: Process Evaluation

- Permits others to replicate methods.
- Can lead to development of a manual.
- Can assess program strengths and weaknesses to improve operations.
- May help administrators understand program resources, leading to improved allocation.

## Evaluating Program Performance: Resources for Evaluation

- CSAT:  Demystifying Evaluation.
- NIDA:  Measuring and Improving Costs, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs.
- Institute of Behavioral Research at Texas Christian University:  core evaluation instruments.
- United Way of America:  Outcome Measurement Resource Network.
- National (ATTC):  The Change Book.
- Further details on page 240 of TIP 43.

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## Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

- Module 13: TIP Chapter 14