1. Changing Organizations and Policy for Substance Abuse Treatment: Implications for HIV and Other Disorders Thomas D’Aunno, Ph.D. Columbia University Harold Pollack, Ph.D. University of Chicago HIV Center for Clinical and Behavioral Studies HIV Center for Clinical and Behavioral Studies New York State Psychiatric Institute and Columbia University June 23, 2011

2. Objectives To test a comprehensive model of the diffusion (implementation) of evidence-based practices (among opioid treatment programs) Science focused on developing evidence-based practices (EBPs) has improved substantially, but the science of ensuring that new treatments and services actually reach intended patients or populations lags behind Present analyses testing part of the model using data from the National Drug Abuse Treatment System Survey (NDATSS) (NIDA-supported since 1982) Promote interest in implementation research

3. Roadmap Background and conceptual approach The case of methadone (and HIV testing) as an evidence-based practice –Data and analyses: 1988-2005 National Drug Abuse Treatment System Survey (NDATSS) –Results: Descriptive, regression –Discussion: Implications for quality of care and implementation research

4. Conceptual Approach: Four Models of Diffusion Socio-technical model that emphasizes how well the innovation matches the work needs and characteristics of its intended users Organizational-managerial model that emphasizes technical and social support for the innovation within its host organization Market model that focuses on the dynamics of local competition and social networks in the diffusion of innovations State regulation model that emphasizes the role of government rules that hinder or support innovation

5. Conceptual Approach: How Do These Models Relate to Each Other? More work is needed to evaluate these models: –Are the effects of these models additive, such that they combine to account for the diffusion and implementation of innovations? –Or, do the key factors in each model interact, for example, even to the extent that some factors cancel the effects of others? –Do the effects of some factors mediate the effects of others, creating causal pathways?

6. Cumulative Adoption Curve Time Cumulative Adopters 100% Typically expected Typically experienced

7. External Environment Clients/Referral and Funding Sources/Other Service Providers/ State Regulation/Community Strategy & Structure TASK Technology, Routines PEOPLE Identity, Staff Mix, Culture Organizational Performance

8. Organizational, Managerial and Socio-Technical Models Strategic Design Perspective Rewards & incentive systems Formal organizational structure Political Perspective Power and politics Informal organizational structures Cultural Perspective Organizational culture Organizational Adoption and Use of Evidence-Based Practices

9. Market Model: The Role of Social Networks Which manager is more likely to adopt evidence-based practices?

10. How does it work? Network types: dense v. sparse Dense –High trust –Facilitates cooperation –Ideal for network among team members 1 2 3 4 5 1 2 3 4 5 Sparse High reach Facilitates access and innovation

11. The Case of Methadone as an Evidence-Based Practice Many studies indicate that MMT is highly cost- effective –Studies indicate significant long-term gains in health, employment, reduced drug use, and reduced crime –Very large reduction in estimated crime costs probably larger than the costs of the program –Reduced HIV transmission, though less effective in preventing hepatitis C Well-implemented MMT appears more effective than other treatment approaches in preventing relapse or drop-out from treatment

12. Ambivalence About Methadone Despite relative success, MMT remains controversial (e.g., see NYT, October 6, 2005) DEA had closely regulated methadone, now CSAT Diverse reaction in Europe, as well Concerns about replacing one addiction with another, side-effects, black-market diversion

13. Methadone Dosing: The Low Dose Problem Ambivalence about methadone often expressed in low doses provided to patients and short treatment duration Randomized trials: Doses below 60 mg/day do not reliably provide blocking dose –Low doses associated with high rates of relapse/ non-adherence/poor treatment outcomes. –More recent research shows superior results at doses > 80 mg/day (Strain et al., 1999; Donny et al., 2005)

14. The Methadone Dosing Problem Committees of U.S. Institute of Medicine and other authorities endorse higher doses (1994; 1997) Continued (though weakening) resistance to increased dosages

15. Analytic Approach Prior work suggests dose levels relate to key factors from the organizational- managerial, socio-technical and state regulation models: –Mix of client profiles (especially race) –Management and staff training and attitudes –Unit focus on quality of care (JCAHO) –Managed care

16. NDATSS Nationally representative split panel study of outpatient substance abuse treatment (OSAT) units in the U.S. (N=745) High response rates described in previous studies (above 82%) Five waves of survey data (wave six underway) –1988, 1990, 1995, 2000, 2005, 2011

17. NDATSS In each NDATSS wave, director and clinical supervisor of each unit completed phone interviews –Directors provided information concerning ownership, therapy activities, environment, finances, organizational structure, and managed care arrangements –Clinical supervisors provided information regarding staff composition, client characteristics, and available ancillary services

18. NDATSS: MMT Sample Population of MMT units identified in FDA lists Split-panel design: 47 units added in 2000 to represent MMT programs new since 1988; 40 units added in 2004 N= 172, 140, 116, 150, 146 Checks for non-response bias Multiple reliability and validity checks (e.g., vs. client charts)

19. NDATSS Check with Drug Services Research Survey (DSRS)(1990) DSRS NDATSS Dose level50 (mg/d)46 # clients309306 # staff14.516.3 Time in treatment 16.419.0 DSRS: national random sample of 26 units; 261 randomly-selected patient records

20. Comparison of Methadone Dose Levels in the National Evaluation of Substance Abuse Treatment Study (NESAT) and NDATSS NESAT NDATSS (1997) (1995) (2000) Percent of Patients Receiving Dose Levels Below: 40 mg/d 17.5 19.4 13.5 60 mg/d 42.0 50.0 35.1 80 mg/d 69.9 77.9 69.1 NESAT: National random sample of 49 MMT units

21. Limitations (Pre-emptive surrender slide) Unit-level data do not allow exploration of individual patient/counselor characteristics

22. Regression Analysis Regression analysis of dose levels Panel analysis of pooled 1988-2005 data Random-effects analysis used to account for persistent unobserved characteristics of a given MMT unit repeatedly sampled in the NDATSS study (also, Hausman test compared fixed-effects model to random-effects model) – Cross-sectional analysis of 2005 wave to examine current patterns

23. National Descriptive Statistics (2005) Client characteristics: 61% male; 34% African-American; 22% Hispanic; 45% unemployed; average age 38 years 29% JCAHO-accredited; 55% CARF- accredited 73% have a parent organization Ownership: 42% for-profit; 35% private non-profit; 23% public

24. National Descriptive Statistics (2005) 15.5% central US; 61% eastern; 8% mountain; 15.5% pacific Access: MMT 2.4 times as likely to turn away clients as non-MMT outpatient programs; MMT only 2/3 as likely to admit within 48 hours Services: MMT more likely to provide physical exams and routine medical care, but not psycho-social services

25. National Descriptive Statistics (2005) Time in treatment: average is 19 months 13% <3 months 29% 3-11 months 21% 12-23 months 15% 24-35 months 22% 36 or more months

26. Overall population: % of methadone patients whose facilities provide HIV testing to at least 1% of patients % of methadone patients who receive HIV tests 90% 45.6 94% 44.7 Public Units: % of methadone patients whose facilities provide HIV testing to at least 1% of patients % of methadone patients who receive HIV tests 91% 37.9 94% 45.5 Nonprofit private units: % of methadone patients whose facilities provide HIV testing to at least 1% of patients % of methadone patients who receive HIV tests 96% 53.5 94% 34.7 For-profit private units: % of methadone patients whose facilities provide HIV testing to at least 1% of patients % of methadone patients who receive HIV tests 54% 37.5 90% 55.7 HIV Counseling and Testing, 1995 and 2005

27. National Descriptive Statistics: Dose Levels % of Patients Below 40mg/day % of Patients Below 60mg/day % of Patients Below 80mg/day 198844.879.594.2 199036.070.289.4 199519.450.077.9 200013.535.169.1 200517.134.456.3 Data from T. D’Aunno & H. Pollack, Journal of the American Medical Association, 2001 and 2005 data from National Drug Abuse Treatment Systems Survey

28. % of Patients ]Below 40mg/day] [95% CI] % of Patients Below 60mg/day [95% CI] % of Patients Below 80mg/day [95% CI] 1988 30.5 *** [25.2, 35.9] 47.7 *** [42.2, 53.3] 37.2 *** [32.6, 41.9] 199020.8 *** [15.4, 26.2] 39.5 *** [33.9, 45.1] 35.7 *** [31.0, 40.3] 19956.9 ** [1.8, 12.1] 19.7 *** [14.3, 25.0] 34.6 *** [18.8, 27.7] 20002.1 [-3.2, 7.4] 11.51** [0.1, 11.3] 23.02 *** [6.7, 16.0] 2005---- JCAHO Accreditation-2.42 [-7.1, 2.2] -501 * [-9.2, 0.1] -6.0 *** [-9.8, -2.2] Percent African-American0.129 ** [-0.003, 0.20] 0.273 *** [0.13, 0.32] 0.284 *** [0.13, 0.29] Percent Hispanic0.09* [-0.07, 0.18] 0.125* [-0.07, 0.16] 0.119* [-0.06, 0.14] Private non-profit3.0 [-2.17, 8.21] 3.2 [-1.8,8.3] 0.33 [-3.8, 4.5] Private for-profit3.38 [-5.6, 12.4] 5.4 [-3.3, 14.2] 1.3 [-6.0, 8.5] 1988-2005 Pooled Cross-Section Results (selected coefficients)

29. % Patients Below 40mg/day [95% CI] % Patients Below 60mg/day [95% CI] % Patients Below 80mg/day [95% CI] Unit size0.0020 [0.0011, 0.0028] 0.0015 [-0.00014, 0.0031] 0.00091 [-0.00090,0.0027] JCAHO Accreditation0.68 [-3.56, 4.92] -2.57 [-10.30, 5.16] -3.67 [-12.45, 5.11] Percent of patients who are African-American0.128* [0.030, 0.23] 0.399*** [0.22, 0.58] 0.47*** [0.27, 0.68] Percent patients who are Hispanic0.042 [-0.049, 0.13] 0.15 [-0.014, 0.32] 0.32*** [0.13, 0.51] Private non-profit4.18 [-1.39,9.74] 5.00 [-5.18, 15.17] 5.13 [-6.43, 16.68] Private for-profit2.24 [-3.59, 8.08] 8.46 [-2.18, 19.11] 7.17 [-4.91, 19.3] Percentage of staff who are ex-addicts0.0034 [-0.080, 0.086] 0.020 [-0.13, 0.17] 0.087 [-0.085, 0.26] Percentage of clients who are unemployed-0.049 [-0.17, 0.067] -0.089 [-0.31, 0.13] 0.024 [-0.22, 0.27] Percent of clients in HMO/PPO-0.044 [-0.15, 0.060] -0.087 [-0.277, 0.10] -0.19+ [-0.41, 0.025] Percent of clients requiring preauthorization0.084* [0.02, 0.15] 0.16** [0.048, 0.28] 0.22** [0.083, 0.35] 2005 Cross-Sectional Results (selected coefficients)

30. Director attitudes % Patients Below 40mg/day [95% CI] % Patients Below 60mg/day [95% CI] % Patients Below 80mg/day [95% CI] Conducts HIV prevention-6.308 [-10.10, -2.515] -12.82 [-19.39,-6.25] -15.52* [-23.5, -7.545] Opposes syringe exchange1.68 [-2.43, 5.79] 7.95* [.814,15.09] 8.698* [.0357, 17.36] Supports AA effectiveness4.80 [.5777, 9. 04] 6.23 [-1.09,13.56] 8.24* [-.649,17.13] Joint significance: harm reduction/HIV prevention variables p=.097p=.006p=.0001

31. Summary of 2005 Results Dose levels correlated with –Managerial attitudes concerning harm reduction and abstinence –High proportion of African-American patients –High proportion of Hispanic patients –Units that enroll many patients in stringent managed care plans (percent requiring pre-authorization before treatment) Results differ from 1988-2000 concerning JCAHO

32. Discussion Increased methadone dose levels since 1988 represents improved quality –In 1988, 80 percent of patients received doses below 60 mg/day –By 2000, two-thirds of patients received at least 60 mg/day But, many patients still receive sub-optimal doses: 17% below 40 mg/day in 2005

33. Discussion: Reasons for Concern Loss of JCAHO effect Managed care Low-dose link to units with high proportions of racial minorities Managerial and staff beliefs HIV Counseling & Testing levels on-site same as in 1995

34. The Changing Role of JCAHO –2005 shows no effect vs. strong effect in earlier analyses…why? Between 2000 and 2004, accreditation by JCAHO or CARF became mandatory…early movers vs. necessary adopters The Changing Role of JCAHO

35. The Role of Managed Care Higher-dose course of treatment requires more time; managed care shortens treatment duration Significant link between higher methadone doses and longer treatment duration (e.g., Hubbard et al., 1989) Significant link between managed care and shorter treatment duration (Lemak, 2001 )

36. Why the Low-Dose Relationship with Proportion of Patients Who Are Racial Minorities?  Units that provide low doses may lack human and financial resources:  well-trained, well-paid and stable work forces  management systems:  information systems  quality of care indicators  systematic checks of these

37. Managerial and Staff Attitudes  Some managers and staff continue to hold attitudes inimical to high methadone doses  Against “substituting one addiction for another”  Support treatment models that discourage or limit medication-based approaches  If methadone is used in treatment, it should be used as briefly and in as low dosage as possible

38. If Time Permits….Two Case Studies in Chicago One-unit study of efforts to improve treatment practices; data at counselor level (HP) Three-unit study of organizational readiness to change (TD)

39. Preliminary Results from One Treatment Unit The challenge within a treatment unit to encourage higher doses and consistent practices Unit challenged by accreditation bodies to increase dose Director wants to increase doses, but not all counselors appear to agree HP examined records for 718 patients, stratified across counselors

40. Descriptive Analysis of One Treatment Unit Snapshot of 718 patients, stratified by 17 members of counseling staff Clients assigned to counselors based on immediate caseloads and time of arrival Not randomized assignment, but unsystematic and based on reasons other than dose levels These are pilot data used for organizational improvement rather than research purposes

41. Overall Descriptive: Similar to U.S. Average 7 percent of patients receive doses below 40 mg/day 23 percent of patients receive doses below 60 mg/day 47 percent of patients receive doses below 80 mg/day Note: 31 percent of patients receive doses over 100 mg/day

42. Patient Dose Histogram

43. Broad Variation by Counselor

44. Mean Dose Levels

45. Percent Under 40mg/day

46. Percent Under 60mg/day

47. Percent Over 100mg/day

48. Percent below 80mg/day

49. Observations About Unit Unit-level statistics are similar to national averages –Many patients receive doses below current recommended practice guidelines This masks large variation across counselors in the same unit Counselors vary in dosing practices, though each counselor provides diverse dose levels to his/her current patients.

50. Organizational Readiness for Improvement Case studies of 3 inner-city Chicago programs that are not JCAHO-accredited and have majority of African-American clients; extensive interviews and surveys Data show staff members do not have adequate knowledge or training in MMT (vs. clinical supervisors and managers) Too few staff members

51. Organizational Readiness (2) Very few psycho-social services to address concomitant client problems Relatively low methadone doses Little team-work or coordination or efforts to develop and monitor treatment plans Procedures for changing dose levels are unclear or inconsistent Central intake dose levels are too low