1. Substance Use Disorder Treatment Supporting the Field with Evidence and Logic

2. Prepared by: The Pennsylvania Practice Improvement Collaborative (PA PIC) Funded by: The Substance Abuse Mental Health Services Administration (SAMHSA) With assistance from: The Northeast ATTC (NeATTC) And a Part of: The Institute for Research, Education, and Training in Addictions (IRETA) Regional Enterprise Tower Suite 1710 Pittsburgh, PA 15219 www.ireta.org

3. A Unique Public Health Issue Substance Use Disorder:

4. A Unique Public Health Issue Addiction is viewed as a moral issue. The public is skeptical about the efficacy of addiction treatment. The popular view of a “typical addict” is an unemployed member of an inner-city minority group. Two-thirds of the US population receives their information on addiction from the mass media. Marwick, C. 1998: Treatment Works for Substance Abuse Offenders, JAMA, 280(13), 1126-1127.

5. Substance Use Disorder is One of the Most Important Public Health Issues Our Nation Faces Today.

6. “There are more deaths, illnesses, and disabilities from substance abuse than from any other preventable health condition.” The Robert Wood Johnson Foundation. (1993). Substance Abuse: The Nation’s Number One Problem: Key Indicators for Policy. Princeton, NJ.

7.  $238 billion are spent annually on issues of alcohol and other drug use and dependency.  Alcohol and other drug abuse and dependency are related to: Criminal Activity Losses in Wages Losses in Productivity Health Problems Increased Health Care Utilization Mental Retardation Mental Health Problems Mortality The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for Policy, Princeton, NJ.

8. Smoking $80 Billion Health Care Costs in 1985 The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for Policy, Princeton, NJ. Note: Percentages may not add up to 100% due to rounding.

9. Alcohol Abuse $22.5 Billion Health Care Costs in 1985 The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for Policy, Princeton, NJ. Note: Percentages may not add up to 100% due to rounding.

10. Drug Abuse $11.9 Billion Health Care Costs in 1985 The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for Policy, Princeton, NJ. Note: Percentages may not add up to 100% due to rounding.

11. Trends in Substance Use Disorder-Related Deaths Deaths directly related to drug use have more than doubled since the early ’80s. Deaths related to alcohol have remained more stable. The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for Policy, Princeton, NJ.

12. Number of Deaths in Thousands The Robert Wood Johnson Foundation, 1993. Substance Abuse: The Nation’s Number One Problem, Key Indictors for Policy, Princeton, NJ. 19,576 Deaths 15,973 Deaths

13. Treatment Gap In 2001, an estimated 6.1 million people aged 12 or older (2.7 percent of the total population) needed treatment for an illicit drug abuse problem. 2001 National Household Survey on Drug Abuse (NHSDA). Needed Treatment

14. Treatment Gap Of the 6.1 million people needing treatment, 1.1 million people (17.3 percent of the people who needed treatment) received treatment at a specialty facility. Received Treatment 2001 National Household Survey on Drug Abuse (NHSDA).

15. Treatment Gap The treatment gap was estimated to be 5.0 million people in 2001, or 2.2 percent of the total population 12 and older. Received Treatment Treatment Gap 2001 National Household Survey on Drug Abuse (NHSDA).

16. Of the 5.0 million people who needed but did not receive treatment in 2001….. An estimated 377,000 reported that they felt they needed treatment for their drug problem. Of these: –An estimated 101,000 reported that they had made an effort but were unable to get treatment. –An estimated 276,000 reported making no effort to get treatment. 2001 National Household Survey on Drug Abuse (NHSDA).

17. Treatment is Effective. “Evidence that drug addiction treatments are effective comes from a series of reviews and additional data analyses of more than 600 peer reviewed research articles.” Marwick, C. 1998. Study: Treatment Works for Substance Abuse Offenders, JAMA, 280(13), 1126-1127.

18. Treatment is Effective A 5-year follow-up study of 1799 persons (representative of the 976,012 individuals discharged from chemical dependency treatment programs in the 90s) reported: A 21% Reduction in Drug Use A 14% Reduction in Alcohol Use Marwick, C. 1998. Study: Treatment Works for Substance Abuse Offenders, JAMA, 280(13), 1126-1127.

19. Treatment is Effective Results of the 2-year California Drug and Alcohol Treatment Assessment (CALDATA) study indicate that, for every dollar spent on treatment, more than National Clearinghouse for Alcohol and Drug Information. http://www.health.org/govpubs/bkd168/20h.htm $7 in future costs were saved.

20. Is Addiction Treatment as Effective as Treatment for Other Health Problems?

21. Why Might We Not be Viewing Addiction Treatment Appropriately?

22. Treatment for Hypertension: Did Treatment Work?

23. Hypertension is a chronic disease. Treatment is applied consistently over time (anti-hypertensive therapy with consistent follow up).

24. With Addiction... Should We Also Be Using a Chronic/Rehabilitative Treatment Model INSTEAD of an Acute/Single Episode Treatment Model?`

25. Treatment for Alcoholism: Did Treatment Work?

26. Consider…… An insulin-dependent diabetic who has been non-compliant with treatment presenting at an Emergency Room.  Should treatment be denied?  Should the patient be arrested?

27. Addiction/Chronic Illness Compliance Rate (%) Relapse Rate (%) Alcohol30-5050 Opioid30-5040 Cocaine30-5045 Nicotine30-5070 Insulin Dependent Diabetes Medication Medication<5030-50 Diet and Foot Care Diet and Foot Care<5030-50 Hypertension Medication Medication<3050-60 Diet Diet<3050-60 Asthma Medication Medication<3060-80 O’Brien CP, McLellan AT. Myths about the Treatment of Addiction (1996). The Lancet, Volume 347(8996), 237-240.

28. What is the Latest Knowledge about Substance Use Disorder Treatment That We Can Use to IMPROVE and SUPPORT the Field?

29. Intake Processing/ Assessment Treatment Plan Pharmacotherapy Continuing Care Behavioral Therapy and Counseling Clinical and Care Management Substance Use Monitoring Self-Help/Peer Support Groups Legal Services AIDS/HIV Services Educational Services Medical Services Mental Health Services Vocational Services Child Care Services Family Services Housing/ Transportation Services Financial Services Components of Comprehensive Substance Use Disorder Treatment National Institute on Drug Abuse, 1999. Principles of Drug Addiction Treatment,

30. Evidenced-Based Principles of Treatment 1. No single treatment is appropriate for all individuals. 2. Treatment needs to be readily available. 3. Effective treatment attends to multiple needs of the individual, not just his or her drug use.

31. Evidenced-Based Principles of Treatment 4. An individual’s treatment and service plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs. 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness.

32. Evidenced-Based Principles of Treatment 6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

33. Evidenced-Based Principles of Treatment 8. Addicted or drug-abusing individuals with co-existing mental disorders should have both disorders treated in an integrated way. 9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.

34. Evidenced-Based Principles of Treatment 10. Treatment does not need to be voluntary to be effective. 11. Possible drug use during treatment must be monitored continuously.

35. Evidenced-Based Principles of Treatment 12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection.

36. Evidenced-Based Principles of Treatment 13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.

37. What are the Components of a Comprehensive Substance Use Disorder Model?

38. What Does the Latest Research Say about How Specific Interventions Enhance the Effectiveness of These Treatment Components?

39. Interventions in the TCU Treatment Process Model D. Dwayne Simpson and Colleagues Texas Christian University Overview of major studies providing the evidence base for a Treatment Process Model Copyright © 2002 Texas Christian University, Fort Worth, Texas. All rights reserved. Contact: ibr@tcu.edu or phone, 817-257-7226.

40. TCU Treatment Process Model SufficientRetentionSufficientRetention EarlyEngagementEarlyRecovery Posttreatment DrugUseDrugUse CrimeCrime SocialRelationsSocialRelations ProgramParticipationProgramParticipation TherapeuticRelationshipTherapeuticRelationship BehavioralChangeBehavioralChange Psycho-SocialChangePsycho-SocialChange PatientAttributes at Intake PatientAttributes Motiv How can “interventions” impact this process ? Simpson, 2001 (Addiction)

41. Sufficient Retention Early Engagement Early Recovery Posttreatment Drug Use Crime Social Relations Program Participation Therapeutic Relationship Behavioral Change Psycho-Social Change Patient Attributes at Intake Motiv Induction to Treatment (Readiness Training) Blankenship et al., 1999 (PJ); Sia, Dansereau, & Czuchry, 2000 (JSAT); Czuchry & Dansereau, 2000 (AJDAA)

42. Treatment Readiness Training Personal inventory (self- esteem) Personal inventory (self- esteem) Board game on “drug use risks” Board game on “drug use risks” Meditation & mental focus Meditation & mental focus Planning workbooks (cognitive) Planning workbooks (cognitive) Blankenship et al., 1999 (PJ); Sia, Dansereau, & Czuchry, 2000 (JSAT); Czuchry & Dansereau, 2000 (AJDAA)

43. The Downward Spiral “Game” Financial / LegalSelf Opportunity Social Health Death Card!You lose!! Land on a square and draw a card – e.g. HEALTH Emotions Physical Thinking Judgment SOCIAL SUPPORT Significant Other Family Friends Personal Asset Scores SELF CONCEPT Self-esteem Personal Accomplishment Self-Confidence FINANCIAL ASSETS Car Equipment Jewelry Your kids are caught using drugs at school and they say they got the drugs from you. Lose 5 family points Fact Serious involvement with drugs is related to whether other family members are also drug users. Czuchry, Sia et al. (1997, 1998)

44. Sufficient Retention Early Engagement Early Recovery Posttreatment Drug Use Crime Social Relations Program Participation Therapeutic Relationship Behavioral Change Psycho-Social Change Patient Attributes at Intake Motiv Counseling Enhancements (TCU Cognitive “Mapping”) Dansereau et al., 1993 (JCP), 1995 (PAB); Joe et al., 1997 (JNMD); Pitre et al., 1998 (JSAT); Newbern et al., 1999 (AJDAA); Czuchry & Dansereau, 2000 (JSAT)

45. Improves Ratings of- “Mapping” Enhancements to Therapeutic Engagement Patient Ratings in Month 4 Pitre, Dees, Dansereau, & Simpson, 1997 (J Drug Issues). “Mapping” is like “flow-charting.” It leads to improved- communication on-task attention! and Counselors & Sessions Other Patients Staff Members Treatment Participation Self-Confidence

46. SufficientRetentionSufficientRetention EarlyEngagementEarlyRecovery Posttreatment DrugUseDrugUse CrimeCrime SocialRelationsSocialRelations ProgramParticipationProgramParticipation TherapeuticRelationshipTherapeuticRelationship BehavioralChangeBehavioralChange Psycho-SocialChangePsycho-SocialChange PatientAttributes at Intake PatientAttributes Motiv Can specific components be targeted for change? ProgramParticipationProgramParticipationBehavioralChangeBehavioralChange Psycho-SocialChangePsycho-SocialChange

47. 47 Sufficient Retention Early Engagement Early Recovery Posttreatment Drug Use Crime Social Relations Program Participation Therapeutic Relationship Behavioral Change Psycho-Social Change Patient Attributes at Intake Motiv Contingency Management (Token Rewards) Rowan-Szal et al., 1994 (JSAT); 1997 (JMA); Griffith, Rowan-Szal et al., 2000 (DAD).

48. Sufficient Retention Early Engagement Early Recovery Posttreatment Drug Use Crime Social Relations Program Participation Therapeutic Relationship Behavioral Change Psycho-Social Change Patient Attributes at Intake Motiv Specialized Interventions (TCU Counseling Manuals) Bartholomew et al., 1994 (JPD); 2000 (JSAT); Hiller et al., 1996 (SUM).

49. Counseling Modules & Manuals  Treatment Readiness/Induction  Cognitive Mapping  HIV/AIDS Education  Relationship Skills (women & men)  Parenting Skills  Cocaine Abuse  Transition Skills (to Aftercare)

50. SufficientRetentionSufficientRetention EarlyEngagementEarlyRecovery Posttreatment DrugUseDrugUse CrimeCrime SocialRelationsSocialRelations ProgramParticipationProgramParticipation TherapeuticRelationshipTherapeuticRelationship BehavioralChangeBehavioralChange Psycho-SocialChangePsycho-SocialChange PatientAttributes at Intake PatientAttributes Motiv Evidence-Based Treatment Model EnhancedCounseling BehavioralStrategies Social Skills Training Family & Friends SupportiveNetworksSupportiveNetworks Induction Personal Health Services Social Support Services ProgramCharacteristicsProgramCharacteristicsStaffAttributes & Skills StaffAttributes Simpson, 2001 (Addiction)

51. Conclusions 1. Long-term outcome studies -- –Indicate that treatment is effective –Lead to questions about HOW 2. Treatment process studies -- –Identify important therapeutic dynamics –Define “interim” performance measures –Clarify the role of interventions –Lead to management strategies

52. WHAT’S NEW ABOUT IBR STAFF PROJECTS NEWSLETTERS PUBLICATIONS PRESENTATIONS MANUALS FORMS OTHER LINKS Search Contents Site map IBR HOME PAGE SITE GUIDES: Data Collection Instruments Research Summary Research Roundup TCU Treatment Process Model now available for downloading TCU Counseling Manuals can be ordered or downloaded TCU Treatment Assessment Forms are organized for easy (& free) downloading by users Animated slide presentations IBR Research Summaries highlight special topics Current issue of Research Roundup Publication lists 10 most popular TCU forms for downloading Features: DATOS www.ibr.tcu.edu

53. How Can We Improve the Cultural Competency of Substance Use Disorder Treatment?

54. What is Cultural Competency? The Center for Substance Abuse Treatment (CSAT) has defined cultural competency as “a set of congruent practice skills, attitudes, policies and structures which come together in a system, agency, or among professionals that enable them to work effectively in the context of cultural differences.” Cross, T.L., Bazron, B. (1994). Train the trainers workshop: towards a culturally competent system of care. CASSP Technical Assistance Center.

55. TCU Treatment Process Model SufficientRetentionSufficientRetention EarlyEngagementEarlyRecovery Posttreatment DrugUseDrugUse CrimeCrime SocialRelationsSocialRelations ProgramParticipationProgramParticipation TherapeuticRelationshipTherapeuticRelationship BehavioralChangeBehavioralChange Psycho-SocialChangePsycho-SocialChange PatientAttributes at Intake PatientAttributes Motiv Where can cultural competency impact this process ? Cultural Competency Cultural Competency and Neighborhood Issues

56. What Does the Research Say about How Wraparound Service Receipt Affects Substance Use Disorder Treatment?

57. Impact of Wraparound Services Outpatient addiction treatment clients who reported receiving wraparound services were more likely to report superior retention and treatment outcome than clients who did not receive wraparound services. Actively assessing clients in wraparound service receipt greatly improved retention and treatment outcome. Pringle et al. Accepted for publication in Addictive Disorders and Their Treatment.

58. How Can I Use This Information?

59. Did You Know About … IRETA

60. IRETA | NeATTC | PIC I nstitute for R esearch, E ducation, T raining in A ddictions N ortheast A ddiction T echnology T ransfer C enter P ractice I mprovement C ollaborative

61. IRETA IRETA is the entity within the Commonwealth of Pennsylvania where research is translated into practice and policy IRETA is funded through federal grants, private foundations (Scaife Family Foundation, Jewish Healthcare Foundation), state funds (BDAP), federal line item (SAMHSA), and private business contracts

62. Who is Involved with IRETA? State And Local Drug And Alcohol Programs Research Institutions Criminal Justice Organizations Other State And Local Organizations

63. NeATTC The NeATTC is designed to enhance the quality of addiction treatment and recovery services within the region by providing policymakers, providers, consumers, and other stakeholders with state-of-the-art information through technology translation and transfer activities. The NeATTC is part of a national network, comprised of 14 regional centers that serve all 50 states and the U.S. territories.

64. NeATTC The NeATTC serves the states of NY, NJ, and PA, and is administered by IRETA. The NeATTC is comprised of an Executive Director, Program Manager, Training Director, Logistics Coordinator, and three Information Specialists (IS are located in PA, NJ, and NY).

65. The NeATTC Goals Increase the knowledge and skills of addiction treatment practitioners Heighten the awareness, knowledge and skills of all professionals who have the opportunity to intervene in the lives of people with substance use disorders Foster regional and national alliances among practitioners, researchers, policymakers, funders, and consumers to support and implement best treatment practices

66. NeATTC 2002 Activities (Highlights) Administer needs assessments to determine the knowledge dissemination and adoption activities within each state Establish the toll-free InfoLine (866-246- 5344) to disseminate addictions-related information to the field Develop and maintain a resource web site

67. PIC The PIC program was initiated by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT) in 1999 to support and promote effective and efficient community-based treatment. CSAT has awarded 14 PICs, including 7 statewide and 7 metropolitan area projects.

68. PIC PICs address the treatment needs of diverse client populations, including ethnic and cultural minorities, clients involved in the justice system, clients with co-occurring mental health and substance use disorders, adolescents, and women with children. The PIC has a formally established structure, and is governed by community stake-holders, including providers, researchers, policy-makers, educators, and members of the recovery community.

69. PIC Activities (Highlights) Support education of probation officers and newly released parolees regarding addiction service needs of offenders and methods of facilitating service linkage Conduct a conference to present national efforts by which Medicaid and addiction treatment administrative data have been or may be utilized to monitor substance use disorder treatment delivery

70. Contact: Dr. Michael Flaherty Executive Director I.R.E.T.A. | NeATTC flahertym@ireta.org Victor Barbetti Program Manager NeATTC victor@ireta.org Sam Thompson Training Director NeATTC thompsons@ireta.org Dr. Janice Pringle Project Director PIC pringlej@ireta.org Funded by Center for Substance Abuse Treatment, SAMHSA, Scaife Family Foundation, Allegheny County Health Department, and the Jewish Healthcare Foundation

71. Here’s a product of the ATTC initiative which will assist you in making system change. You can access this book at the following website: http://www.nattc.org/pdf/changebook.pdf

72. You Can Download These Slides Yourself at ireta.org.

73. Want More Information?

74. Some Related Sites www.nih.gov www.niaaa.gov www.samhsa.gov www.nida.nih.gov