SUBSTANCE DEPENDENCE

Report
Norman G. Hoffmann, Ph.D.
Adjunct Professor of Psychology
Western Carolina University
www.evnceassessment.com
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
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
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
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
Assessments
Identify Differential
Treatment Needs and
Relapse Risk
Substance Use Disorder Criteria
1.Use in larger amounts or longer than intended
2. Desire or unsuccessful effort to cut down
3. Great deal of time using or recovering
4. Craving or strong urge to use
5. Role obligation failure
6. Continued use despite social/interpersonal
problems
7. Sacrificing activities to use or because of use
8. Use in situations where it is hazardous
DSM-5 SUD Criteria continued
9. Continued use despite knowledge of having a
physical or psychological problem caused or
exacerbated by use
10.Tolerance
11. 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
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
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
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
SUD CRITERIA PRIMARILY IN
SEVERE DESIGNATION
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
Sample of Alcohol
Diagnostic Documentation
Alcohol Diagnosis
Case 1
Case 2
Case 3
Case 4
Diagnostic Criteria
1
2
3
4
Severe
Mild
X
X
X
X
X
X
Moderate
Moderate
X
X
X
X
5
6
7
8
X
X
9 10 11
X
X
X
X
X
X
X
X
Cases 3 & 4 with the same diagnosis may have different
prognoses if the Big Five are related to outcomes
X
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
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
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
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
CLINICAL (Medical) NECESSITY
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
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
Beware of Arbitrary
Outcome Metrics
Scientifically reliable and valid
Irrelevant to the real world
Reference on arbitrary metrics:
Kazdin, A. E. (2006). American Psychologist, 61(1), 42-79.
Addiction Treatment Examples:
Average days of use in past 30 days
Scores on a variety of psychological
instruments
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?
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?
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
Demographic Risk Scale
and Observed Outcomes
Abstinence Months 7-12
80%
70%
60%
Subthreshold
50%
Threshold +
40%
30%
20%
10%
0%
High Risk
Low Risk
35 Unites of service = threshold for low risk group
75 Unites of service = threshold for high risk group
Zywiak, Hoffmann, & Floyd, 1999
Client Motivation
and Empowerment
Maintenance Care Thresholds
N = 12,783 Treatment Completers
73%
% Abstinent at One Year
80%
70%
60%
60%
53%
0-2 months
50%
3- months
40%
5-6 months
30%
20%
Months of Maintenance Care
(Aftercare)
Hoffmann & DeHart (1996). CATOR Fact Sheet
One Year Abstinence Rates for
Older Alcohol Dependent Clients
90
% of Cases
80
High Severity
70
60
Low Severity
50
40
30
No Main.
& No AA
Main. No AA
AA No Main.
Main. &
AA
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), 57-64.
Additional Data Required for
Differential Outcome Example
CONTINUED CARE & SELF-HELP GROUPS
Rate attendance using the scale:
1 = never/stopped
3 = 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
____
____
____
____
Treatment
Improvement
CLINICAL CONTINUOUS
IMPROVEMENT COMPONENTS
Patient Assessment
Intake and ongoing assessments
Outcomes
Treatment Plan
Initial clinical outcomes
Remission outcome
Societal benefit measures
Financial benefit measures
Define problems
Treatment priorities
Treatment placement
Treatment Response/Progress
Biopsychosocial treatment
Process measurements
Adjustments to treatment plan as needed
TREATMENT RATINGS [asked by follow-up interviewer]
Rate how helpful the following treatment
components have been for your recovery?
0 = not used 1 = poor;
2 = fair;
3 = good;
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
4 = excellent
____
____
____
____
____
____
____
____
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
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
Specialty Studies
for Identifying
Problem Issues
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
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:
1. DARNU can identify probable PTSD
2. Warning indication for greater craving
Distress (DARNU) and PTSD
100%
80%
PTSD
Dx
60%
Possible
40%
No DX
20%
0%
Quartile 1
Quartile 2
Quartile 3
Quartile 4
DARNU elevation quartiles
N = 124
Justifying
Investment
in Treatment
ROI: RETURN ON INVESTMENT
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
Healthcare Returns:
Proportional to Effectiveness
Average Days of Hospitalization
4
3.5
Before Tx
3
2.5
Year 1
2
Year 2
1.5
Relapse vs. Recovery
1
Before Tx p = N.S.
0.5
Yr 1 & Yr 2 p < .001
0
Relapsed
n = 1473
Recovering
n = 2099
Hoffmann, DeHart, & Fulkerson (1993). Journal of addictive Disease, 12(1), 97-107.
Public Safety Issues by Diagnosis
N = 7,682 state prison inmates
Percent of sample
60
50
40
30
No Dx
Abuse
Depend.
20
10
0
DU Arrest
MV Crash
Drove
Impaired 3
times
Highway Safety Returns:
Proportional to Effectiveness
Motor Vehicle Accidents
30%
% of Cases
25%
Relapsed
n = 3,153
21% 22% 20%
20%
15%
12%
Partial
Abstinence
n = 3,425
10%
7%
10%
5%
0%
Before Treatment
After Treatment
Hoffmann & DeHart (1996). CATOR Report.
Abstinent
n = 9,326
Criminal Justice Returns:
Proportional to Effectiveness
Proportion of Cases Arrested
30%
Relapsed
n = 3,153
% of Cases
25%
20%
15%
16% 16%
11%
10%
Partial
Abstinence
n = 3,425
9%
Abstinent
n = 9,326
6%
2%
5%
0%
Before Treatment
After Treatment
Hoffmann & DeHart (1996). CATOR Report.
Healthcare Returns On Investment
for Dependent Employees
Before
After
Treatment Treatment
Employees Hospitalized
24%
10%
Employees Using ER
29%
21%
Total Days of Hospitalization
7639
5158
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
None
Before
Treatment
35%
After
Treatment
76%
One
23%
16%
Two
18%
5%
Three
11%
2%
Four plus
13%
1%
Medicare/Medicaid Funded
Treatment and Recovery
37%
40%
% of Cases
35%
31%
30%
25%
26%
Relapsed
n = 378
21%
20%
Abstinent
n = 364
15%
10%
5%
0%
Hospitalizations
ER Visits
Hoffmann (1994). Report for George Washington University
Significance
p < .001
Medicare/Medicaid Funded
Treatment and Recovery
% of Cases
20%
15%
Relapsed
n = 378
13%
10%
10%
5%
Abstinent
n = 364
3%
2%
0%
Auto Accidents
Arrests
Hoffmann (1994). Report for George Washington University
Significance
p < .0001
Marketing
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
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
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
Public
Relations
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
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
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.
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
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
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
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
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
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
Norman G. Hoffmann, Ph.D.
Adjunct Professor of Psychology
Western Carolina University
[email protected]
828-454-9960
www.evinceassessment.com

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