1. DALLAS COALITION FOR TREATMENT IMPROVEMENT A sudden rise in Heroin use among adolescents and young adults served as a call to action and inspired this treatment systems improvement project. s: Treatment Providers Homeward Bound, Inc. - Adult - Detox, Residential, and Outpatient Nexus Recovery Center - Adult – Residential and Outpatient Women/children Adolescent - Residential and Outpatient Phoenix House - Adolescent - Residential and Outpatient Dallas County Juvenile Department - Adolescent - Day Treatment Payers & Policy Makers Other Participants Texas Department of State Health Services (DSHS) Carlos Tirado, MD, UT Southwestern Medical Center Value Options/North STAR Managed Care Program Medical Director, Nexus – MAT Dallas County Jane Maxwell, PhD, Local Evaluator Center for Excellence in Drug Epidemiology, Addiction Research Gulf Coast Addiction Technology Transfer Center, UT-Austin

2. An under-funded system of care Texas ranks 48th in the nation in substance abuse treatment funding and the Medicaid Substance Abuse benefit is very limited Our substance abuse treatment system of care is funded to meet approximately 5% of the Adult need, and 7% of the Adolescent need This is a perfect environment for implementing evidence-based practices that increases efficiency and effectiveness

3. The Problem First noticed in 2005, the use of inhalable Heroin among adolescents in the Dallas area began to increase, Several deaths from Heroin overdoses or complications were reported, Numerous arrests for Heroin possession in the Dallas area ISD’s were reported, IV Heroin admissions to adult detoxification services among persons 25 & under increased significantly, Heroin is readily available in the schools and in the neighborhoods. It is cheap and highly addictive

4. The Challenge – With no extra funding coming into the system, how do we: 1) Increase retention and time in treatment to reach a therapeutic dose or length of stay? 2) Prevent relapse to heroin use in a community where heroin is readily available to children, adolescents and adults?

5. Solutions in Science to Service Our experience in the Texas Node of the CTN helped remove barriers and prepared us for the Robert Wood Johnson Advancing Recovery Project 1) Knowledge of the NIDA clinical trials and evidence–based practices opened our minds to new ideas for treatment improvement 2) Recognition of the importance of bringing science into service in the ‘real’ world

6. Selection of Evidence Based Practices to Overcome Barriers To address our problems, we chose: CTN #0005 Motivational Interviewing as a technique for engagement and retention CTN #0010 Medication Assisted Treatment – Bup/Nx facilitated rehabilitation for heroin dependent adolescents CTN #0030 Prescription Opioid Addiction Treatment Study (POATS)

7. Summary of EBP Implementation Data Motivational Interviewing Over 300 clinicians attended DSHS coach supported trainings in Austin, Dallas/Ft Worth, Houston, Corpus Christi, El Paso, Lubbock, and San Antonio in 2008/2009 130 support staff in Dallas/Ft. Worth area attended DSHS supported MI 101 training in 2008 Dallas County Community College provided MI training for professionals and support staff in 2009 Advancing Recovery agencies actively implement MI in their programming Example of Results: Phoenix House significantly reduced their AMA rate by using the MI approach

8. Eureka Moments Phoenix House Traditional Therapeutic Community Initial Skepticism about MI Attended & Implemented MI Training Experienced Dramatically Reduced AMA NIATx Processes - Rapid Change & Walk Through Actually work, and Can be applied to almost any problem or situation

9. Summary of EBP Implementation Data Medication Assisted Treatment (MAT) Overcame resistance to MAT through exposure to CTN data Medical Directors get Suboxone waiver Value Options, public payor, agreed to pay for Suboxone on a case by case basis Implemented a small pilot study at Nexus that included adults and adolescents - 2008 Expansion at Homeward Bound for public and private pay clients – 2008 and 2009 Physicians are hesitant to prescribe adolescents Suboxone. Phoenix House psychiatrist just received his waiver. DCJD has a new psychiatrist who is MAT ‘friendly’ Number Suboxone Clients per Month Jan 09 Feb 09 Mar 09 April 09 May 09 Jun 09 Homeward Bound 4540 37232529 Nexus Adults 57791213 Nexus Adolescent 055123 DCJD & Phoenix House 000000

10. More Than Medication is Needed for Recovery Fidelity to the Recovery Model Substance Abuse Treatment Case Management Wrap-around Services After-care and Peer Support Sponsor 12 Step Program Physical Health Assessment, Treatment, Follow-up Mental Health Evaluation, Counseling, Case Management Suboxone-MAT Physical Health Medications Mental Health Medications

11. FUTURE DIRECTIONS Watch for EBTs coming out of the CTN, especially those supported by SAMHSA and the ATTCs, in looking for solutions for treatment improvement Expand MAT to include Naltraxone, Vivitrol and others Continue using NIATx analysis and change techniques to continuously evaluate and modify processes for systems improvement Be innovative. For example: CYT + Promotora complementing MAT in the treatment of heroin dependent Latino adolescents