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Norman G. Hoffmann, Ph.D. Adjunct Professor of Psychology

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1 OATS Outcomes & Assessment-Informed Treatment Strategies & Implementation Issues
Norman G. Hoffmann, Ph.D. Adjunct Professor of Psychology Western Carolina University

2 Evidence-Based Treatment
Utilize a treatment model documented to be effective in controlled clinical research Question of whether the model is implemented with fidelity No guarantees that it will work in routine clinical practice even if implemented properly No verification of outcomes

3 Assessment-Informed Treatment
Assessment documents nature and severity of conditions and initial differential treatment needs During treatment integrate assessment data with treatment response to document progress and identify risk and resiliency variables Use findings to adjust treatment plan and refine future assessment and treatment decisions Develop empirically justified foundation for determining medical/clinical necessity

4 Outcomes-Informed Treatment
Monitor baseline and initial relevant outcomes for all clients – outcomes can be clinical and/or societal/financial Monitoring done during typical continuum of care (e.g., during maintenance services) Uses information already required for quality care – store in useable format Retrieval of data for analyses Document medical/clinical necessity

5 Potential Uses for Outcomes Documentation
Identify Differential Treatment Needs Identifying Differential Relapse Risk Empirically Derived Medical Necessity Enhancing Client Motivation Treatment Improvement Marketing Services Justifying Treatment Costs - ROI Public Relations

6 Assessments Identify Differential Treatment Needs and Relapse Risk

7 Substance Use Disorder Criteria
Use in larger amounts or longer than intended Desire or unsuccessful effort to cut down Great deal of time using or recovering Craving or strong urge to use Role obligation failure Continued use despite social/interpersonal problems Sacrificing activities to use or because of use Use in situations where it is hazardous

8 DSM-5 SUD Criteria continued
Continued use despite knowledge of having a physical or psychological problem caused or exacerbated by use Tolerance Withdrawal Criteria 1-4 relate to use; Criteria 5-8 relate to behavioral issues associated with use; Criteria 9-11 relate to physical/emotional issues

9 DSM-5 Initial VS. DSM-5 Final
Initially the proposed DSM-5 had two diagnostic categories: moderate and severe defined by 2-3 and 4+ positive criteria – conforms best to abuse – dependence classification Final formulation has three categories: mild (2-3), moderate (4-5), and severe (6+ positive criteria) Original “moderate” becomes “mild” – no empirical foundation for either distinction

10 Sustained Remission No positive diagnostic findings (other than craving) for 12 consecutive months Substance use is NOT part of the remission definition Possible levels of outcome: 1) abstinence without problems; 2) some use without problems; 3) use with sub-diagnostic problems; 4) meets current diagnosis You get paid for remission NOT recovery

11 DSM-5 Criteria Differentials
All criteria are not equal in implications Some criteria are found predominately among those with the severe alcohol or other substance use disorder diagnoses Other criteria are more common among the mild to moderate alcohol use disorder group Tolerance and dangerous use are actually common among those with no diagnosis

The “Big Five” Criteria 2:Wanting to cut down/setting rules Criteria 4: Craving and/or compulsion to use Criteria 5: Failure at role fulfillment due to use Criteria 7: Sacrifice activities to use Criteria 11: Withdrawal symptoms

13 Sample of Alcohol Diagnostic Documentation
Alcohol Diagnosis Diagnostic Criteria 1 2 3 4 5 6 7 8 9 10 11 Case 1 X Case 2 Case 3 Case 4 Severe Mild Moderate Moderate Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes

14 CASE 3: Positive DSM-5 Criteria
3. Great deal of time using 10. Tolerance 1. Unplanned use: more or longer use 8. Use in hazardous situation (impaired driving) 6. Recurrent interpersonal conflicts Conclusions No loss of control indicated Misuse and possible irresponsible behavior Moderation may be a reasonable initial goal

15 CASE 4: Positive DSM-5 Criteria
1. Unplanned use: more or longer use 2. Desire/efforts to cut down 4. Craving/compulsion to use 5. Role obligation failures 7. Sacrificing activities to use Conclusions Loss of control clearly indicated Positive on 4 of the “Big Five” Abstinence indicated goal for recovery

16 Implications for Disposition
Education and brief counseling may be appropriate for majority of mild use disorders For those with a moderate diagnosis, the pattern may be as important as the number of positive criteria Those positive on any of the Big Five criteria should be carefully evaluated regarding the current and projected trajectory of their condition

17 Final Criticism of the DSM-IV
Loss of control not required for a dependence diagnosis – e.g., tolerance, spending time using, and occasionally drinking more/longer than intended – got the chronic diagnosis Some abuse criteria are stronger indications of a serious condition than some dependence criteria Role obligation failure is a Big Five criterion Tolerance is often seen in mild cases or even among those with no diagnosis

Persons in the severe designation with positive “Big Five” findings will require a more intensive and longer continuum of care to achieved treatment effectiveness Persons in the mild designation typically will benefit from shorter & less intensive interventions to achieve efficiency Each treatment plan can be informed by prior empirical outcome data on comparable cases and modified based on the individual’s treatment response

19 Sample Hypotheses for Clinical Practice
Hypothesis #1: Clients positive on three or more of the “big five” will require initial residential placement and/or more intensive and longer continuum of care to achieve good results Hypothesis #2: Clients in mild or moderate designations without any positive findings on the “big five” may be able to moderate or stop use with less intensive and briefer services

20 Beware of Arbitrary Outcome Metrics
Scientifically reliable and valid Irrelevant to the real world Addiction Treatment Examples: Average days of use in past 30 days Scores on a variety of psychological instruments Reference on arbitrary metrics: Kazdin, A. E. (2006). American Psychologist, 61(1),

21 Arbitrary Metric Example
Programs A and B each treat 100 cases Program A: Before treatment average days of use = 25 After treatment average days of use = 10 Program B: Before treatment average days of use = 25 After treatment average days of use = 8 Which program has the better outcomes?

22 Arbitrary Metric Example
Real world results: Program A: 60 in full remission; 40 minimal change Program B: Zero remission: All 100 still using just on weekends, but all have continuing problems and meet current criteria for severe SUD (dependence) To which program would you refer a family member?

23 Demographic Risk Scale
Less than 25 years of age. No high school diploma or GED. Unemployed. Never married. Three or more positive characteristics increases expected relapse rate by about 20% or more

24 Demographic Risk Scale and Observed Outcomes
35 Unites of service = threshold for low risk group 75 Unites of service = threshold for high risk group Zywiak, Hoffmann, & Floyd, 1999

25 Client Motivation and Empowerment

26 Maintenance Care Thresholds
N = 12,783 Treatment Completers Hoffmann & DeHart (1996). CATOR Fact Sheet

27 One Year Abstinence Rates for Older Alcohol Dependent Clients
Combinations of 4+ months of Maintenance Care and/or Weekly AA Attendance for 1,350 treatment completers Hoffmann, DeHart & Gogineni (1998). The Southwest Journal on Aging, 14(1),

28 Additional Data Required for Differential Outcome Example
CONTINUED CARE & SELF-HELP GROUPS Rate attendance using the scale: 1 = never/stopped = Several times a mo. 2 = Once a month or less 4 = At least once a week How often did you attend the following during the past three months: 09. Formal aftercare ____ 10. AA ____ 11. NA ____ 12. Other support group ____

29 Treatment Improvement

Patient Assessment Intake and ongoing assessments Outcomes Treatment Plan Initial clinical outcomes Define problems Remission outcome Treatment priorities Societal benefit measures Treatment placement Financial benefit measures Treatment Response/Progress Biopsychosocial treatment Process measurements Adjustments to treatment plan as needed

31 TREATMENT RATINGS [asked by follow-up interviewer]
Rate how helpful the following treatment components have been for your recovery? 0 = not used 1 = poor; = fair; = good; = excellent 01. Group Therapy ____ 02. Individual counseling ____ 03. Lectures & education ____ 04. Working the AA/NA steps ____ 05. Peer-group meetings (e.g., AA) ____ 06. Family portion of program ____ 07. Talking with other clients ____ 08. Overall rating for the program ____

32 Feedback on Helpfulness of Program Components
Helpfulness in remission – not satisfaction with the component Low scores indicate opportunities for improvement High scores indicate potential areas of excellence

33 Requirements for Clinical Outcomes Monitoring System
Capture demographic and descriptive information to describe the population Document clinical information in sufficient detail to facilitate treatment refinement Document response to the treatment services delivered Document outcomes during typical continuum of care

34 Specialty Studies for Identifying Problem Issues

35 Pavillon Study of Trauma, Distress, and Craving
Evaluation of potential problems and relapse risks Distress measure (DARNU), PTSD symptom count, and validated craving measures for alcohol and drugs Explore the possibility of identifying level of distress and trauma relative to craving

36 Trauma, Distress, and Craving
DARNU: D – Dissatisfied A – Anxious R – Restless N – Nervous U – Uncomfortable 18- item self-report scale DARNU correlates highly with PTSD (r = .78) and craving (r = .36) Implications: DARNU can identify probable PTSD Warning indication for greater craving

37 Distress (DARNU) and PTSD
DARNU elevation quartiles N = 124

38 Justifying Investment in Treatment

The good news: ROI for addictions treatment is one of the largest in healthcare: between 4:1 to 7:1 Returns accrue to society in areas outside of healthcare The bad news: ROI within healthcare is a fraction of returns and may not pay for all treatment needs Other areas that benefit do not traditionally pay for clinical services

40 Healthcare Returns: Proportional to Effectiveness
Average Days of Hospitalization Relapse vs. Recovery Before Tx p = N.S. Yr 1 & Yr 2 p < .001 Hoffmann, DeHart, & Fulkerson (1993). Journal of addictive Disease, 12(1),

41 Public Safety Issues by Diagnosis
N = 7,682 state prison inmates

42 Highway Safety Returns: Proportional to Effectiveness
Motor Vehicle Accidents Hoffmann & DeHart (1996). CATOR Report.

43 Criminal Justice Returns: Proportional to Effectiveness
Proportion of Cases Arrested Hoffmann & DeHart (1996). CATOR Report.

44 Healthcare Returns On Investment for Dependent Employees
Before Treatment After Treatment Employees Hospitalized 24% 10% Employees Using ER 29% 21% Total Days of Hospitalization 7639 5158

45 Vocational Functioning Returns On Investment
Problem types include: absenteeism, tardiness mistakes, lack of work completion, conflicts, and on the job injuries Number of Problem Types Before Treatment After Treatment None 35% 76% One 23% 16% Two 18% 5% Three 11% 2% Four plus 13% 1%

46 Medicare/Medicaid Funded Treatment and Recovery
Hoffmann (1994). Report for George Washington University

47 Medicare/Medicaid Funded Treatment and Recovery
Hoffmann (1994). Report for George Washington University

48 Marketing

49 Marketing to Whom? Potential clients and/or families of those affected
Employers with stable workforces consisting of employees who are difficult or expensive to replace Public officials tasked with stretching limited budgets Insurers – FOR GET IT

50 Personalized Marketing Points
The probability of a positive outcome for severe substance use disorders is as good as other chronic conditions Recovery (or remission) is largely determined by client adherence to a realistic recovery plan Some ongoing services may be required as is the case with other chronic conditions Support systems exist for both the afflicted and their families

51 General Marketing Points
The probability of a positive outcome for severe substance use disorders is as good as other chronic conditions Treatment for substance use disorders is comparatively inexpensive to those for other chronic conditions Benefits from treatment services accrue not only to the person treated, but also to society at large

52 Public Relations

53 Public Relations Errors
Many people concerned about addictions: Talk to the wrong people About the wrong topics Using the wrong terminology And wonder why nothing changes


55 The Lesson of the Peacock
The peacock is among the most beautiful of birds. However, its “song” is among the most awful of sounds. Trying to teach a peacock to sing is a waste of time and neglects the beauty – focuses on weakness not strength

56 Voice of the Peacock An alcohol or drug dependent person does not make an attractive poster child – biased perspectives – stigma. Failures are very obvious and visible. Successes tend to disappear from view. The general public does not care whether dependent people recover.

57 Beauty of the Peacock Return on investment is one of the greatest in the healthcare arena. Reasonable recovery rates relative to other chronic illnesses can be documented. Treatment costs are modest compared to other areas of healthcare. Benefits of treatment are found throughout society

58 Who Cares About What? The general public cares about safety and financial issues Employers care about turnover and performance Public officials want to support positions that will get them reelected The media look for a good story that will get attention

59 Relationships with the General Population
The general public cares about safety and financial issues Most people are not concerned about the welfare of addicted individuals Most people do not have a realistic understanding of addictions or treatment

60 Relationships with Employers
Focus on employers with stable workforces and where employees are difficult or expensive to replace Make the case that recovering employees make excellent workers Educate them that afflicted workers can be identified and treated successfully

61 Relationships With Elected Officials
Most elected officials have no realistic understanding of addictions or treatment Most are interested in the general welfare To do what is right, some will need political cover to support treatment vs. punitive strategies

62 Relationships With the Media
Reporters are always looking for a good story – either good or bad news Combining a personal recovery story with outcome data can be a powerful positive story A little controversy can be a positive thing if you select the controversy

63 Norman G. Hoffmann, Ph.D. Adjunct Professor of Psychology Western Carolina University

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