States and Substance Abuse Treatment Programs: Priorities, Guidelines and Funding for Infection-related Services S. Kritz, MD; L.S. Brown, MD, MPH; R.

States and Substance Abuse Treatment States and Substance Abuse Treatment Programs: Priorities, Guidelines and Programs: Priorities, Guidelines and Funding for Infection-related ServicesFunding for Infection-related Services

S. Kritz, MD; L.S. Brown, MD, MPH; R. J. S. Kritz, MD; L.S. Brown, MD, MPH; R. J. Goldsmith, MD; E.J. Bini, MD, MPH; J. Robinson, Goldsmith, MD; E.J. Bini, MD, MPH; J. Robinson, MEd, D. Alderson, MS; J. Rotrosen, MD and the MEd, D. Alderson, MS; J. Rotrosen, MD and the NIDA Clinical Trials Network Infections Study NIDA Clinical Trials Network Infections Study (CTN-0012) Team(CTN-0012) Team

Addiction Research & Treatment Corp, Brooklyn, Addiction Research & Treatment Corp, Brooklyn, NY; University of Cincinnati Medical Center and NY; University of Cincinnati Medical Center and VA Hospital, Cincinnati, OH; NYU School of VA Hospital, Cincinnati, OH; NYU School of Medicine and VA Hospital, NY, NY; Nathan Kline Medicine and VA Hospital, NY, NY; Nathan Kline Institute, Orangeburg, NY; and NYS Psychiatric Institute, Orangeburg, NY; and NYS Psychiatric Institute, NY, NYInstitute, NY, NY

ABSTRACTABSTRACTObjectives: This survey study examined associations between substance abuse treatment programs and state agencies regarding written guidelines and funding for 8 infection-related services for HIV/AIDS, hepatitis C virus and sexually transmitted infections.

Methods: State substance abuse and health departments were surveyed regarding priorities, guidelines and funding availability. Program administrators and clinicians were surveyed regarding clarity of guidelines, and administrators were surveyed regarding funding availability for the infection-related services for the 3 infection groups.

Results: Surveys were received from 48 (96%) states and DC, 269 (84%) administrators and 1723 (78%) clinicians. In states with guidelines for infection-related services a significantly higher percent of program administrators and clinicians indicated that treatment program guidelines were clear. Although state agencies indicated that funding is widely available for infection-related services, treatment program administrators were significantly less aware of its availability. There was general agreement across states and between the departments within states regarding priorities, written guidelines and funding availability.

Conclusions: While states have established priorities, guidelines and funding, system complexity and challenges to accessing information may restrict availability of resources at the treatment program level.

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS• Research Supported by the National Institute on Research Supported by the National Institute on

Drug Abuse (NIDA) as part of a Cooperative Drug Abuse (NIDA) as part of a Cooperative Agreement (1U10DA013046) between the Lead Agreement (1U10DA013046) between the Lead Node in NY and the NIDA Clinical Trials Network Node in NY and the NIDA Clinical Trials Network (CTN) (CTN)

• Protocol team members and collaborators Protocol team members and collaborators consisting of:consisting of: Randy Seewald, MD; Frank McCorry, PhD; Dennis Randy Seewald, MD; Frank McCorry, PhD; Dennis

McCarty, PhD; Donald Calsyn, PhD; Steve Kipnis, MD; McCarty, PhD; Donald Calsyn, PhD; Steve Kipnis, MD; Leonard Handelsman, MD; Al Hassen, MSW; Leonard Handelsman, MD; Al Hassen, MSW; Shirley Shirley Irons; Irons; Karen Reese, CAC-AD; Sherryl Baker, PhD; Karen Reese, CAC-AD; Sherryl Baker, PhD; Kathlene Tracy, PhD Kathlene Tracy, PhD

• Node Protocol Managers, CTN Community Node Protocol Managers, CTN Community Treatment Programs (CTPs) and affiliated site Treatment Programs (CTPs) and affiliated site administrators and cliniciansadministrators and clinicians

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

• National Association of State Alcohol National Association of State Alcohol and Drug Abuse Directors (NASADAD) and Drug Abuse Directors (NASADAD)

• Association of State and Territorial Association of State and Territorial Health Officials (ASTHO)Health Officials (ASTHO)

• National Alliance of State and Territorial National Alliance of State and Territorial AIDS Directors (NASTAD). AIDS Directors (NASTAD).

• There are no financial interests or There are no financial interests or disclosures to report for any of the disclosures to report for any of the authors involved in this projectauthors involved in this project

Drug Abuse Treatment Clinical Trials Network

Philadelphia

Portland

Los Angeles

Charleston

Miami

Cincinnati

Denver

CTN Study Sites

Seattle

Raleigh/Durham

Long Island

Boston

San Francisco (CA/AZ Node)

New York City

Detroit

Albuquerque

Baltimore/Richmond

New Haven

17 Nodes with 116 Community Treatment 17 Nodes with 116 Community Treatment Agencies Reaching into 26 States!Agencies Reaching into 26 States!

STUDY RATIONALESTUDY RATIONALE

• HIV/HCV/STI: major causes of excess HIV/HCV/STI: major causes of excess morbidity and mortality in the USmorbidity and mortality in the US

• Substance abuse: a major vehicle for the Substance abuse: a major vehicle for the transmission of these infectionstransmission of these infections

• Scope of, and challenges to identifying, Scope of, and challenges to identifying, counseling, and treating persons with counseling, and treating persons with these infections in substance abuse these infections in substance abuse treatment can assist in developing treatment can assist in developing effective interventionseffective interventions

• Examine the interplay of substance abuse Examine the interplay of substance abuse treatment programs with state and DC treatment programs with state and DC substance abuse and health departmentssubstance abuse and health departments

DESIGN AND POPULATIONDESIGN AND POPULATION

•STUDY DESIGNSTUDY DESIGN– Cross-sectional Survey Cross-sectional Survey – Descriptive & ExploratoryDescriptive & Exploratory

•STUDY POPULATIONSTUDY POPULATION– Treatment Program AdministratorsTreatment Program Administrators– Treatment Program CliniciansTreatment Program Clinicians– Administrators of State and DC Administrators of State and DC

Substance Abuse and Health Substance Abuse and Health Departments Departments

IMPORTANT TERMSIMPORTANT TERMS• 3 infection groups: HIV/AIDS, HCV, STI 3 infection groups: HIV/AIDS, HCV, STI

• 8 infection-related services8 infection-related services

– Provider EducationProvider Education

– Patient EducationPatient Education

– Patient Risk AssessmentPatient Risk Assessment

– Patient CounselingPatient Counseling

– Patient Medical History & Physical ExamPatient Medical History & Physical Exam

– Patient Biological TestingPatient Biological Testing

– Patient TreatmentPatient Treatment

– Patient MonitoringPatient Monitoring

• CTN vs. non-CTN treatment programs CTN vs. non-CTN treatment programs

• State and DC substance abuse and health departmentsState and DC substance abuse and health departments

SELECTED SURVEY SELECTED SURVEY RESPONSESRESPONSES

Written regulations, policies or guidelines* (state Written regulations, policies or guidelines* (state survey)survey)• YesYes• NoNo * Elsewhere referred to as Guidelines* Elsewhere referred to as Guidelines

Clarity of Treatment Program Guidelines Clarity of Treatment Program Guidelines (treatment (treatment

program administrator and clinician surveys):program administrator and clinician surveys):• Clear*Clear*• Somewhat clearSomewhat clear• UnclearUnclear• Don’t know if guidelines existDon’t know if guidelines exist• No guidelines existNo guidelines exist

* Response used for this report* Response used for this report

SELECTED SURVEY SELECTED SURVEY RESPONSESRESPONSES

Availability of funding (treatment program Availability of funding (treatment program

administrator and state surveys):administrator and state surveys):• YesYes

• NoNo

Priorities (state survey):Priorities (state survey):• Not a priorityNot a priority

• Low priorityLow priority

• Medium priority*Medium priority*

• High priority*High priority*

* Response used for this report* Response used for this report

PRIMARY OBJECTIVES PRIMARY OBJECTIVES OF THIS REPORTOF THIS REPORT

TO EXAMINE ASSOCIATIONS BETWEEN: TO EXAMINE ASSOCIATIONS BETWEEN:

•State and DC guidelines and clarity of State and DC guidelines and clarity of program guidelinesprogram guidelines

•Availability of funding as reported by state Availability of funding as reported by state and DC agencies vs. availability of funding as and DC agencies vs. availability of funding as reported by treatment program administratorsreported by treatment program administrators

•State and DC substance abuse and health State and DC substance abuse and health departments for priorities, guidelines and departments for priorities, guidelines and funding for infection-related services in order funding for infection-related services in order to determine generalizability of the findings to determine generalizability of the findings

STATISTICAL MEASURESSTATISTICAL MEASURES For state and DC agencies vs. treatment For state and DC agencies vs. treatment

programs:programs:•Chi-square statistical associations between state and Chi-square statistical associations between state and

DC guidelines, as reported by state and DC DC guidelines, as reported by state and DC administrators, and “Clear” treatment program administrators, and “Clear” treatment program guidelines, as separately reported by treatment guidelines, as separately reported by treatment program administrators and cliniciansprogram administrators and clinicians

•Chi-square statistical associations for availability of Chi-square statistical associations for availability of fundingfunding

For state and DC agencies:For state and DC agencies:•Chi-square statistical comparisons of priorities vs. Chi-square statistical comparisons of priorities vs.

funding funding •Chi-square statistical comparisons between Chi-square statistical comparisons between

jurisdictions with and without CTN programs for jurisdictions with and without CTN programs for priorities, guidelines and fundingpriorities, guidelines and funding

•Chi-square statistical comparisons between Chi-square statistical comparisons between substance abuse vs. health departmentssubstance abuse vs. health departments

FINDINGSFINDINGS

• 269 administrators responded 269 administrators responded (84%)(84%) out of 319 substance abuse program out of 319 substance abuse program administrators surveyed from 95 CTPs administrators surveyed from 95 CTPs in the NIDA CTN, covering 25 states & in the NIDA CTN, covering 25 states & DCDC

• 1723 clinicians of 2210 targeted 1723 clinicians of 2210 targeted (78%)(78%)

• At least one substance abuse or health At least one substance abuse or health department administrator from 48 department administrator from 48 states and DC states and DC (96%).(96%).

Clarity of Treatment Program Guidelines in States with and Clarity of Treatment Program Guidelines in States with and without Written Guidelines without Written Guidelines for for HIVHIV Services: Services: Program Program

Administrator (n=269) and Clinician (n=1723) PerspectivesAdministrator (n=269) and Clinician (n=1723) Perspectives

SERVICESERVICE

% of Administrators % of Administrators Reporting “Clear” Program Reporting “Clear” Program

GuidelinesGuidelines

State Guidelines No State State Guidelines No State GuidelinesGuidelines

% of Clinicians Reporting % of Clinicians Reporting “Clear” Program “Clear” Program

GuidelinesGuidelines

State Guidelines No State State Guidelines No State GuidelinesGuidelines

Provider Provider EducationEducation

64*64* 4444 59*59* 4848

Patient Patient EducationEducation

6868 5050 63*63* 3434

Risk AssessmentRisk Assessment 81*81* 5757 68*68* 4848History & History & Physical Physical ExaminationExamination

7777 7474 72*72* 6060

TestingTesting 7777 7777 56*56* 4747CounselingCounseling 6565 5959 5555 5656TreatmentTreatment 78*78* 6161 64*64* 4949MonitoringMonitoring 81*81* 6262 61*61* 4343 * p<0.05 comparing programs in states with and without guidelines* p<0.05 comparing programs in states with and without guidelines

Clarity of Treatment Program Guidelines in States with and Clarity of Treatment Program Guidelines in States with and without Written Guidelines without Written Guidelines for for HCVHCV Services: Services: Program Program

Administrator (n=269) and Clinician (n=1723) PerspectivesAdministrator (n=269) and Clinician (n=1723) Perspectives

% of Administrators % of Administrators Reporting “Clear” Program Reporting “Clear” Program

GuidelinesGuidelines

State Guidelines No State State Guidelines No State GuidelinesGuidelines

% of Clinicians Reporting % of Clinicians Reporting “Clear” Program “Clear” Program

GuidelinesGuidelines

State Guidelines No State State Guidelines No State GuidelinesGuidelines

SERVICESERVICE

Provider Provider EducationEducation

53*53* 3939 4848 4444

Patient Patient EducationEducation

5656 6161 5151 5252

Risk AssessmentRisk Assessment 7171 6464 5555 5151History & History & Physical Physical ExaminationExamination

7676 7272 69*69* 5757

TestingTesting 7070 6969 4040 49*49*CounselingCounseling 5858 5050 4747 4848TreatmentTreatment 83*83* 6060 57*57* 4747MonitoringMonitoring 6767 6161 3333 44*44*

* p<0.05 comparing programs in states with and without guidelines* p<0.05 comparing programs in states with and without guidelines

Clarity of Treatment Program Guidelines in States with and Clarity of Treatment Program Guidelines in States with and without Written Guidelines without Written Guidelines for for STISTI Services: Services: Program Program

Administrator (n=269) and Clinician (n=1723) PerspectivesAdministrator (n=269) and Clinician (n=1723) Perspectives

% of Administrators % of Administrators Reporting “Clear” Program Reporting “Clear” Program

GuidelinesGuidelines

State Guidelines No State State Guidelines No State GuidelinesGuidelines

% of Clinicians Reporting % of Clinicians Reporting “Clear” Program “Clear” Program

GuidelinesGuidelines

State Guidelines No State State Guidelines No State GuidelinesGuidelines

SERVICESERVICE

Provider Provider EducationEducation

51*51* 2929 48*48* 3737

Patient Patient EducationEducation

5757 4949 52*52* 4545

Risk AssessmentRisk Assessment 69*69* 5050 57*57* 4040History & History & Physical Physical ExaminationExamination

6767 6363 66*66* 5656

TestingTesting 7070 6767 4545 4343CounselingCounseling 5252 4949 48*48* 4141TreatmentTreatment 80*80* 5757 57*57* 4747MonitoringMonitoring 73*73* 5252 51*51* 3636

* p<0.05 comparing programs in states with and without guidelines* p<0.05 comparing programs in states with and without guidelines

Percent of State and Treatment Program Percent of State and Treatment Program Administrator “Yes” Responses to Availability Administrator “Yes” Responses to Availability

of Funding for of Funding for HIVHIV Services (* p Services (* p<<0.05)0.05)

ServiceService State Response State Response (%)(%)

Program Program Response (%)Response (%)

Provider EducationProvider Education 93*93* 6060Patient EducationPatient Education 100*100* 5959Patient Risk Patient Risk AssessmentAssessment

98*98* 4848

Patient CounselingPatient Counseling 98*98* 6060Medical History & Medical History & ExamExam

93*93* 5454

Biological TestingBiological Testing 93*93* 6565Patient TreatmentPatient Treatment 96*96* 7272Patient MonitoringPatient Monitoring 93*93* 7272

Note: Only includes CTN programs offering the infection-related serviceNote: Only includes CTN programs offering the infection-related service

Percent of State and Treatment Program Percent of State and Treatment Program Administrator “Yes” Responses to Availability Administrator “Yes” Responses to Availability

of Funding for of Funding for HCVHCV Services (* p Services (* p<<0.05)0.05)

ServiceService State Response State Response (%)(%)

Program Program Response (%)Response (%)

Provider EducationProvider Education 6262 6161

Patient EducationPatient Education 7171 6161

Patient Risk Patient Risk AssessmentAssessment

67*67* 4848

Patient CounselingPatient Counseling 80*80* 6161

Medical History & Medical History & ExamExam

89*89* 5050

Biological TestingBiological Testing 7171 6060

Patient TreatmentPatient Treatment 7676 6969

Patient MonitoringPatient Monitoring 6464 6464 Note: Only includes CTN programs offering the infection-related serviceNote: Only includes CTN programs offering the infection-related service

Percent of State and Treatment Program Percent of State and Treatment Program Administrator “Yes” Responses to Availability Administrator “Yes” Responses to Availability

of Funding for of Funding for STISTI Services (* p Services (* p<<0.05)0.05)

ServiceService State Response State Response (%)(%)

Program Program Response (%)Response (%)

Provider EducationProvider Education 87*87* 5858

Patient EducationPatient Education 91*91* 6060

Patient Risk Patient Risk AssessmentAssessment

96*96* 6262

Patient CounselingPatient Counseling 98*98* 5454

Medical History & Medical History & ExamExam

96*96* 4848

Biological TestingBiological Testing 93*93* 5757

Patient TreatmentPatient Treatment 98*98* 6666

Patient MonitoringPatient Monitoring 84*84* 5959 Note: Only includes CTN programs offering the infection-related serviceNote: Only includes CTN programs offering the infection-related service

FINDINGSFINDINGS

Comparing state and DC agencies across Comparing state and DC agencies across the the

country, there were:country, there were:

• No statistically significant differences for 19 of No statistically significant differences for 19 of 24 comparisons of priorities vs. funding (8 24 comparisons of priorities vs. funding (8 infection-related services for the 3 infection infection-related services for the 3 infection groups)*groups)*

* Data not shown* Data not shown

FINDINGSFINDINGSComparing state and DC agencies with CTN Comparing state and DC agencies with CTN

treatment programs vs. state and DC treatment programs vs. state and DC

agencies without CTN programs, there agencies without CTN programs, there were:were:

• No statistically significant differences for 66 of No statistically significant differences for 66 of 72 comparisons of72 comparisons of priorities, written guidelines priorities, written guidelines and availability of funding (3 comparisons of and availability of funding (3 comparisons of the the 8 infection-related services for the 3 8 infection-related services for the 3 infection groups)*infection groups)*

* Data not shown* Data not shown

FINDINGSFINDINGSComparing state and DC substance abuse Comparing state and DC substance abuse

and health departments, there were:and health departments, there were:

• No statistically significant differences for 45 No statistically significant differences for 45 of 48 comparisons of of 48 comparisons of written guidelines and written guidelines and availability of funding (2 comparisons of the availability of funding (2 comparisons of the 8 infection-related services for the 3 8 infection-related services for the 3 infection groups)*infection groups)*

* Data not shown* Data not shown

CONCLUSIONSCONCLUSIONS

Looking at state and DC agencies and the Looking at state and DC agencies and the

treatment programs within their treatment programs within their jurisdiction, jurisdiction,

there was: there was:

• Strongly positive association between Strongly positive association between

presence of written state guidelines and presence of written state guidelines and

“ “Clear” treatment program guidelines, as Clear” treatment program guidelines, as

reported by both administrators and clinicians reported by both administrators and clinicians

• Little association between states and Little association between states and

treatment programs in their respective treatment programs in their respective

responses regarding availability of funding responses regarding availability of funding

CONCLUSIONSCONCLUSIONS

Looking at state and DC agencies, there was Looking at state and DC agencies, there was generalizability of the results:generalizability of the results:

• Between state and DC agencies across the USBetween state and DC agencies across the US• Between states with and without CTN treatment Between states with and without CTN treatment programs within their jurisdictionprograms within their jurisdiction• Between substance abuse and health Between substance abuse and health

departments departments across the USacross the US

SUMMARYSUMMARY• Treatment program administrators and Treatment program administrators and

clinicians in jurisdictions with written clinicians in jurisdictions with written guidelines for infection-related services were guidelines for infection-related services were more likely to report their own program more likely to report their own program guidelines as “clear” when compared to guidelines as “clear” when compared to jurisdictions without written guidelinesjurisdictions without written guidelines

• Although state agencies indicated that Although state agencies indicated that funding is widely available for infection-funding is widely available for infection-related services, treatment program related services, treatment program administrators were much less aware of its administrators were much less aware of its availabilityavailability

• While states have established priorities, While states have established priorities, guidelines and funding, system complexity guidelines and funding, system complexity and challenges to accessing information may and challenges to accessing information may restrict availability of resources at the restrict availability of resources at the treatment program level treatment program level