Changing Organizations and Policy for Substance Abuse Treatment: Implications for HIV and Other Disorders Thomas D’Aunno, Ph.D. Columbia University Harold.

Changing Organizations and Policy for Substance Abuse Treatment:  

Implications for HIV and Other Disorders

Thomas D’Aunno, Ph.D.

Columbia University

Harold Pollack, Ph.D.

University of Chicago

HIV Center for Clinical and Behavioral StudiesNew York State Psychiatric Institute and Columbia University

June 23, 2011

Objectives

• To test a comprehensive model of the diffusion (implementation) of evidence-based practices (among opioid treatment programs)

• Science focused on developing evidence-based practices (EBPs) has improved substantially, but the science of ensuring that new treatments and services actually reach intended patients or populations lags behind

• Present analyses testing part of the model • using data from the National Drug Abuse Treatment System Survey (NDATSS)

(NIDA-supported since 1982)

• Promote interest in implementation research

Roadmap

• Background and conceptual approach

• The case of methadone (and HIV testing) as an evidence-based practice – Data and analyses: 1988-2005 National Drug

Abuse Treatment System Survey (NDATSS)– Results: Descriptive, regression– Discussion: Implications for quality of care

and implementation research

Conceptual Approach: Four Models of Diffusion

• Socio-technical model that emphasizes how well the innovation matches the work needs and characteristics of its intended users

• Organizational-managerial model that emphasizes technical and social support for the innovation within its host organization

• Market model that focuses on the dynamics of local competition and social networks in the diffusion of innovations

• State regulation model that emphasizes the role of government rules that hinder or support innovation

Conceptual Approach: How Do These Models Relate to Each Other?

• More work is needed to evaluate these models:

– Are the effects of these models additive, such that they combine to account for the diffusion and implementation of innovations?

– Or, do the key factors in each model interact, for example, even to the extent that some factors cancel the effects of others?

– Do the effects of some factors mediate the effects of others,

creating causal pathways?

Cumulative Adoption Curve

Time

CumulativeAdopters

100%

Typicallyexpected

Typicallyexperienced

External Environment

Clients/Referral and Funding Sources/Other Service Providers/ State Regulation/Community

Strategy &Structure

TASKTechnology, Routines

PEOPLEIdentity, Staff Mix,

Culture

Organizational Performance

Organizational, Managerial and Socio-Technical Models

Strategic Design Perspective•Rewards & incentive systems •Formal organizational structure

Political Perspective•Power and politics •Informal organizational structures

Cultural PerspectiveOrganizational culture

Organizational Adoption and Use of Evidence-Based Practices

Market Model: The Role of Social Networks

Which manager is more likely to adopt evidence-based practices?

How does it work?Network types: dense v. sparse

Dense– High trust– Facilitates cooperation– Ideal for network among

team members

12

3

4

5

123

4

5

Sparse

• High reach• Facilitates access and

innovation

The Case of Methadone as an Evidence-Based Practice

• Many studies indicate that MMT is highly cost-effective– Studies indicate significant long-term gains in health,

employment, reduced drug use, and reduced crime– Very large reduction in estimated crime costs

probably larger than the costs of the program– Reduced HIV transmission, though less effective in

preventing hepatitis C

• Well-implemented MMT appears more effective than other treatment approaches in preventing relapse or drop-out from treatment

Ambivalence About Methadone

• Despite relative success, MMT remains controversial (e.g., see NYT, October 6, 2005)

• DEA had closely regulated methadone, now CSAT• Diverse reaction in Europe, as well• Concerns about replacing one addiction with

another, side-effects, black-market diversion

Methadone Dosing: The Low Dose Problem

• Ambivalence about methadone often expressed in low doses provided to patients and short treatment duration

• Randomized trials: Doses below 60 mg/day do not reliably provide blocking dose– Low doses associated with high rates of relapse/

non-adherence/poor treatment outcomes.– More recent research shows superior results at

doses > 80 mg/day (Strain et al., 1999; Donny et al., 2005)

The Methadone Dosing Problem

• Committees of U.S. Institute of Medicine and other authorities endorse higher doses (1994; 1997)

• Continued (though weakening) resistance to increased dosages

Analytic Approach

• Prior work suggests dose levels relate to key factors from the organizational- managerial, socio-technical and state regulation models:– Mix of client profiles (especially race)– Management and staff training and attitudes– Unit focus on quality of care (JCAHO)– Managed care

NDATSS

• Nationally representative split panel study of outpatient substance abuse treatment (OSAT) units in the U.S. (N=745)

• High response rates described in previous studies (above 82%)

• Five waves of survey data (wave six underway)– 1988, 1990, 1995, 2000, 2005, 2011

NDATSS

• In each NDATSS wave, director and clinical supervisor of each unit completed phone interviews – Directors provided information concerning

ownership, therapy activities, environment, finances, organizational structure, and managed care arrangements

– Clinical supervisors provided information regarding staff composition, client characteristics, and available ancillary services

NDATSS: MMT Sample

• Population of MMT units identified in FDA lists

• Split-panel design: 47 units added in 2000 to represent MMT programs new since 1988; 40 units added in 2004

• N= 172, 140, 116, 150, 146 • Checks for non-response bias• Multiple reliability and validity checks

(e.g., vs. client charts)

NDATSS Check with Drug Services Research Survey (DSRS)(1990)

DSRS NDATSS

Dose level 50 (mg/d) 46# clients 309 306# staff 14.5 16.3Time in treatment 16.4 19.0

DSRS: national random sample of 26 units;261 randomly-selected patient records

Comparison of Methadone Dose Levels in the National Evaluation of Substance Abuse Treatment Study (NESAT) and NDATSS

NESAT NDATSS

(1997) (1995) (2000)Percent of Patients

Receiving Dose Levels

Below:

40 mg/d 17.5 19.4 13.5

60 mg/d 42.0 50.0 35.1

80 mg/d 69.9 77.9 69.1

NESAT: National random sample of 49 MMT units

Limitations

• (Pre-emptive surrender slide)

• Unit-level data do not allow exploration of individual patient/counselor characteristics

Regression Analysis

• Regression analysis of dose levels

• Panel analysis of pooled 1988-2005 data• Random-effects analysis used to account for

persistent unobserved characteristics of a given MMT unit repeatedly sampled in the NDATSS study (also, Hausman test compared fixed-effects model to random-effects model)

– Cross-sectional analysis of 2005 wave to examine current patterns

National Descriptive Statistics (2005)

• Client characteristics: 61% male; 34% African-American; 22% Hispanic; 45% unemployed; average age 38 years

• 29% JCAHO-accredited; 55% CARF-accredited

• 73% have a parent organization

• Ownership: 42% for-profit; 35% private non-profit; 23% public

National Descriptive Statistics (2005)

• 15.5% central US; 61% eastern; 8% mountain; 15.5% pacific

• Access: MMT 2.4 times as likely to turn away clients as non-MMT outpatient programs; MMT only 2/3 as likely to admit within 48 hours

• Services: MMT more likely to provide physical exams and routine medical care, but not psycho-social services

National Descriptive Statistics (2005)

• Time in treatment: average is 19 months 13% <3 months

29% 3-11 months

21% 12-23 months

15% 24-35 months

22% 36 or more months

Overall population:% of methadone patients whose facilities provide HIV testing to at least 1% of patients% of methadone patients who receive HIV tests

90%

45.6

94%

44.7

Public Units:% of methadone patients whose facilities provide HIV testing to at least 1% of patients% of methadone patients who receive HIV tests

91%

37.9

94%

45.5

Nonprofit private units:% of methadone patients whose facilities provide HIV testing to at least 1% of patients% of methadone patients who receive HIV tests

96%

53.5

94%

34.7

For-profit private units:% of methadone patients whose facilities provide HIV testing to at least 1% of patients% of methadone patients who receive HIV tests

54%

37.5

90%

55.7  

 HIV Counseling and Testing, 1995 and 2005

National Descriptive Statistics: Dose Levels

% of Patients Below 40mg/day

% of Patients Below 60mg/day

% of Patients Below 80mg/day

1988 44.8 79.5 94.2

1990 36.0 70.2 89.4

1995 19.4 50.0 77.9

2000 13.5 35.1 69.1

2005 17.1 34.4 56.3

Data from T. D’Aunno & H. Pollack, Journal of the American Medical Association, 2001 and 2005 data from National Drug Abuse Treatment Systems Survey

% of Patients ]Below 40mg/day[95% CI]

% of Patients Below 60mg/day[95% CI]

% of Patients Below 80mg/day[95% CI]

1988 30.5***

[25.2, 35.9]47.7***

[42.2, 53.3]37.2***

[32.6, 41.9]

1990 20.8***

[15.4, 26.2]39.5***

[33.9, 45.1]35.7***

[31.0, 40.3]

1995 6.9**

[1.8, 12.1]19.7***

[14.3, 25.0]34.6***

[18.8, 27.7]

2000 2.1[-3.2, 7.4]

11.51**[0.1, 11.3]

23.02***

[6.7, 16.0]

2005 ---- ---- ----

JCAHO Accreditation -2.42[-7.1, 2.2]

-501*

[-9.2, 0.1]-6.0***

[-9.8, -2.2]

Percent African-American 0.129**

[-0.003, 0.20]0.273***

[0.13, 0.32]0.284***

[0.13, 0.29]

Percent Hispanic 0.09*[-0.07, 0.18]

0.125*[-0.07, 0.16]

0.119*[-0.06, 0.14]

Private non-profit 3.0[-2.17, 8.21]

3.2[-1.8,8.3]

0.33[-3.8, 4.5]

Private for-profit 3.38[-5.6, 12.4]

5.4[-3.3, 14.2]

1.3[-6.0, 8.5]

1988-2005 Pooled Cross-SectionResults (selected coefficients)

% Patients Below 40mg/day[95% CI]

% Patients Below 60mg/day [95% CI]

% Patients Below 80mg/day [95% CI]

Unit size 0.0020[0.0011, 0.0028]

0.0015[-0.00014, 0.0031]

0.00091[-0.00090,0.0027]

JCAHO Accreditation 0.68[-3.56, 4.92]

-2.57[-10.30, 5.16]

-3.67[-12.45, 5.11]

Percent of patients who are African-American 0.128*[0.030, 0.23]

0.399***[0.22, 0.58]

0.47***[0.27, 0.68]

Percent patients who are Hispanic 0.042[-0.049, 0.13]

0.15[-0.014, 0.32]

0.32***[0.13, 0.51]

Private non-profit 4.18[-1.39,9.74]

5.00[-5.18, 15.17]

5.13[-6.43, 16.68]

Private for-profit 2.24[-3.59, 8.08]

8.46[-2.18, 19.11]

7.17[-4.91, 19.3]

Percentage of staff who are ex-addicts 0.0034[-0.080, 0.086]

0.020[-0.13, 0.17]

0.087[-0.085, 0.26]

Percentage of clients who are unemployed -0.049[-0.17, 0.067]

-0.089[-0.31, 0.13]

0.024[-0.22, 0.27]

Percent of clients in HMO/PPO -0.044[-0.15, 0.060]

-0.087[-0.277, 0.10]

-0.19+[-0.41, 0.025]

Percent of clients requiring preauthorization 0.084*[0.02, 0.15]

0.16**[0.048, 0.28]

0.22**[0.083, 0.35]

2005 Cross-Sectional Results(selected coefficients)

Director attitudes % Patients Below 40mg/day[95% CI]

% Patients Below 60mg/day [95% CI]

% Patients Below 80mg/day [95% CI]

Conducts HIV prevention -6.308[-10.10, -2.515]

-12.82[-19.39,-6.25]

-15.52*[-23.5, -7.545]

Opposes syringe exchange 1.68[-2.43, 5.79]

7.95*[.814,15.09]

8.698*[.0357, 17.36]

Supports AA effectiveness 4.80[.5777, 9. 04]

6.23[-1.09,13.56]

8.24*[-.649,17.13]

Joint significance: harm reduction/HIV prevention variables

p=.097 p=.006 p=.0001

Summary of 2005 Results

• Dose levels correlated with– Managerial attitudes concerning harm reduction and

abstinence– High proportion of African-American patients– High proportion of Hispanic patients– Units that enroll many patients in stringent managed care

plans (percent requiring pre-authorization before treatment)

• Results differ from 1988-2000 concerning JCAHO

Discussion

• Increased methadone dose levels since 1988 represents improved quality

– In 1988, 80 percent of patients received doses below 60 mg/day

– By 2000, two-thirds of patients received at least 60 mg/day

• But, many patients still receive sub-optimal doses: 17% below 40 mg/day in 2005

Discussion: Reasons for Concern

• Loss of JCAHO effect

• Managed care

• Low-dose link to units with high proportions of racial minorities

• Managerial and staff beliefs

• HIV Counseling & Testing levels on-site same as in 1995

• The Changing Role of JCAHO– 2005 shows no effect vs. strong effect in

earlier analyses…why?

• Between 2000 and 2004, accreditation by JCAHO or CARF became mandatory…early movers vs. necessary adopters

The Changing Role of JCAHO

The Role of Managed Care•Higher-dose course of treatment requires more time;

managed care shortens treatment duration

•Significant link between higher methadone doses and longer treatment duration(e.g., Hubbard et al., 1989)

•Significant link between managed care and shorter treatment duration (Lemak, 2001)

Why the Low-Dose Relationship with Proportion of Patients Who Are Racial

Minorities?

Units that provide low doses may lack human and financial resources:

well-trained, well-paid and stable work forces management systems:

information systemsquality of care indicatorssystematic checks of these

Managerial and Staff AttitudesSome managers and staff continue to hold attitudes

inimical to high methadone doses Against “substituting one addiction for another”

Support treatment models that discourage or limit medication-based approaches

If methadone is used in treatment,

it should be used as briefly and in as low dosage as possible

If Time Permits….Two Case Studies in Chicago

• One-unit study of efforts to improve treatment practices; data at counselor level (HP)

• Three-unit study of organizational readiness to change (TD)

Preliminary Results from One Treatment Unit

• The challenge within a treatment unit to encourage higher doses and consistent practices

• Unit challenged by accreditation bodies to increase dose

• Director wants to increase doses, but not all counselors appear to agree

• HP examined records for 718 patients, stratified across counselors

Descriptive Analysis of One Treatment Unit

• Snapshot of 718 patients, stratified by 17 members of counseling staff

• Clients assigned to counselors based on immediate caseloads and time of arrival

• Not randomized assignment, but unsystematic and based on reasons other than dose levels

• These are pilot data used for organizational improvement rather than research purposes

Overall Descriptive: Similar to U.S. Average

• 7 percent of patients receive doses below 40 mg/day

• 23 percent of patients receive doses below 60 mg/day

• 47 percent of patients receive doses below 80 mg/day

• Note: 31 percent of patients receive doses over 100 mg/day

Patient Dose Histogram

0

50

100

150

200

250

300

350

400

0 4 8 11 15 19 23 26 30 34 38 42 45 49 53 57 60 64 68 72 75 79 83 87 90 94 98

Percentile

Mill

igra

m p

er d

ay

Broad Variation by Counselor

Mean Dose Levels

0

10

20

30

40

50

60

70

80

90

100

110

120

Counselor

Mea

n Do

se (m

g/da

y)

Percent Under 40mg/day

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Counselor

Perc

ent o

f clie

nts

unde

r 40

mg/

day

Percent Under 60mg/day

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Counselor

Perc

ent o

f pat

ient

s be

low

60m

g/da

y

0%

10%

20%

30%

40%

50%

60%

70%

Counselor

Perc

ent o

f pat

ient

s ov

er 1

00m

g/da

y

Percent Over 100mg/day

Percent below 80mg/day

0%

10%

20%

30%

40%

50%

60%

70%

80%

Counselor

Perc

ent o

f pat

ient

s un

der 8

0 m

g/da

y

Observations About Unit

• Unit-level statistics are similar to national averages– Many patients receive doses below current

recommended practice guidelines

• This masks large variation across counselors in the same unit

• Counselors vary in dosing practices, though each counselor provides diverse dose levels to his/her current patients.

Organizational Readiness for Improvement

• Case studies of 3 inner-city Chicago programs that are not JCAHO-accredited and have majority of African-American clients; extensive interviews and surveys

• Data show staff members do not have adequate knowledge or training in MMT (vs. clinical supervisors and managers)

• Too few staff members

Organizational Readiness (2)

• Very few psycho-social services to address concomitant client problems

• Relatively low methadone doses

• Little team-work or coordination or efforts to develop and monitor treatment plans

• Procedures for changing dose levels are unclear or inconsistent

• Central intake dose levels are too low