American Association for the Treatment of Opioid Dependence, Inc National Conference, Atlanta April 25, 2006 Evaluation of the Impact of Opioid Treatment Program (OTP) Accreditation Arlene Stanton, PhD Government Project Officer Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (SAMHSA/CSAT) Under Contract # RFP with Northrop Grumman Information Technology For more information contact Arlene Stanton, Ph.D., N.C.C., Government Task Order Officer Division for Pharmacologic Therapies Center for Substance Abuse Treatment Substance Abuse & Mental Health Services Administration Rockville, Maryland Phone: Fax:

Design 478 Post-Accreditation Questionnaires478 Post-Accreditation Questionnaires 82% First Accreditation82% First Accreditation Month Follow-up Questionnaires171 6-Month Follow-up Questionnaires 590 Patient Interviews590 Patient Interviews Key Policy Variables for AnalysisKey Policy Variables for Analysis Accrediting Body (CARF, JCAHO, Other)Accrediting Body (CARF, JCAHO, Other) OTP size (0-100, , , 400+)OTP size (0-100, , , 400+) Financial Structure (For profit, Non profit, Gov)Financial Structure (For profit, Non profit, Gov) Organizational Setting (Hospital, Other)Organizational Setting (Hospital, Other) Treatment Type (Detox, Maintenance, Both)Treatment Type (Detox, Maintenance, Both)

A. Study Population What are the descriptive characteristics of the participating OTPs along selected relevant dimensions?What are the descriptive characteristics of the participating OTPs along selected relevant dimensions?

Treatment Setting by Type of Treatment OTP Clinic Setting

Treatment Setting by Financial Structure OTP Clinic Setting

Treatment Setting by Accreditation Source (N=467) OTP Clinic Setting

Descriptive Characteristics of Patient Population Site visits conducted to 22 OTPs/590 patients interviewed Average Number of Months in Current Program: 26 months Average Total Number of Years in Treatment: 6 years Average Age of Patients: 35 years old % in Opioid Treatment Prior to Current Episode: 64% Drug Being Treated For: 69% heroin only 12% heroin and pain medication 19% pain medication only

B. Administrative Evaluation Questions What are OTP staff perceptions of accreditation's impact on the OTP? What are OTP staff perceptions of accreditation's impact on the OTP?

Perceived Areas of Impact of the Accreditation Process (N=468) % % % Great Impact Area None Some Extent Require more document of pt. progress Enhance efficiency of treatment Improve coordination of care Improve treatment practices Require new QA procedures Hinder staff from daily tasks Lead to purchasing computer equip Increase monitoring of pt. outcomes Require doing more with less Improve ability to monitor pt. progress Improve links w/ community resources Improve safety Increase pt. participation in OTP planning Increase pt. participation in indiv. tx plan

OTP Providers’ Perceived Impact of Accreditation on Their Program (N=445)

Which OTPs Are More Likely to Rate the Impact of Accreditation on Their Program as Being Positive? Larger programs (over 100 clients) were significantly more likely than smaller programs (< 100 clients) (Odds Ratio=2.71)Larger programs (over 100 clients) were significantly more likely than smaller programs (< 100 clients) (Odds Ratio=2.71) Maintenance/Other programs were more likely than Detox-only programsMaintenance/Other programs were more likely than Detox-only programs (Odds Ratio=3.35)

C. Clinical Evaluation Questions What are the effects on patients associated with operating as an accredited OTP with regard to various patient factors? What are the effects on patients associated with operating as an accredited OTP with regard to various patient factors?

Methadone Dose (N=468) MeanSDRange Admission37 mg/day Maintenance205 mg/day ,200 Note that variability in range may be the result of patient status (e.g., transfer versus 1 st admission)

Who Determines Max Dose and Length of Treatment (N=475)

Methadone Dose: Patient Influence & Take-Home Privileges (N=469) Dose Take Home Privileges

Changes in OTP Services Offered (N=171) % Offering Service Baseline Follow-Up General medical care 3943 HIV/AIDS-related medical care2938 Psychological testing5766 Psychiatric services5250 Educational assistance3542 Vocational assistance4346 Financial assistance2827 Legal assistance 915 Counseling9899 Housing/shelter assistance4039 Post-treatment follow-up7679 Acupuncture1315 Detox from a substance other than heroin4245 Treatment for alcohol abuse7272 Treatment for cocaine abuse7171 Individual/group therapy for opiate addiction9599 Nutritional counseling Step program4553 Smoking cessation2932 Case management7177 Childcare 6 6 Aftercare3655 Transportation2525

Patient Perceptions of Care 92% of patients reported that they were treated with as much respect as they would like. Asked the extent to their treatment plan met all of their treatment needs, patients said: Completely: 66% To some extent: 33% Patients rated their overall treatment during the past 3 months as: Very good/Excellent: 77% Good: 17% Poor/Fair: 6%

Effects on Patient Outcomes Extent that patient is involved in dosing decisions: Most/All of the time: 57% Often/Sometimes: 28% Never/Rarely: 15% Self-reporting of dosage levels: Too high: 7% Just right: 76% Too low: 16% Extent that patient is satisfied with take home schedule: Very satisfied: 57% Somewhat satisfied: 31% Not satisfied: 12%

Patient Self-Reported Effects on Treatment Outcomes Employment: 33% are employed Health Status Very Good/Excellent: 34% Good: 32% Poor/Fair: 34% Drug Use in Last 30 Days: 69% report using a drug (including alcohol-most common drug/stimulants-least common) –32% report using one drug –20% report using two different drugs –11% report using three different drugs – 6% report using between 4-7 different drugs

Preparing for Accreditation: Staff Level of Effort* 1st Accreditation 2 nd + Accreditation Hrs per Mo. (N=395 ) Hrs per Mo. (N=83) Staff meetings57 31 Staff training Review/update of records keeping57 40 Review/update of treatment & continuing care plans Development of quality assurance plan Preparation of accreditation application 11 6 Preparation of OTP documentation Interaction with external consultant 12 7 Accreditation survey25 16 *Denotes mean number of hours spent by all staff in an average month since OTP started preparing for first or subsequent accreditation.

Conclusions Overall, OTP providers report that the accreditation process significantly improved their programs. Overall, patients reported that their treatment needs were being met and that they were satisfied with treatment. Programs with an enrollment of over 100 clients, and programs that provided maintenance rated the accreditation process more favorably than their counterparts. Consistent with the goals of accreditation, patients reported having a major influence on dosing levels. Less staff time per month was spent preparing for a subsequent accreditation.