By Michael G. Boyle, The Fayette Companies
The title of this commentary was taken from the first chapter of a book edited by William Miller and Kathleen Carroll titled Rethinking Substance Abuse: What the science shows and what we should do about it. (Miller and Carroll, 2006). In 2004, Miller organized a meeting of researchers within diverse areas of addictions to discuss their findings and the implications for interventions. The research results over the last 20 years were reviewed. This meeting was titled "The Conference on Approaches for Combating the Use of Substances", the CACTUS summit, held in New Mexico, of course. The summations of research discussed were complied in the manuscript. In the last chapter, Miller and Carroll summarize these findings into ten principles and ten recommendations.
Miller and Carroll utilized a group of scientists to inform on the results of their research. David Gustafson utilizes the opinions of persons from both within and outside of the addiction treatment field to identify the essential ingredients of a redesigned system of addiction treatment. The recommendations are remarkably consistent including rapid access to services, involvement of family and social supports, and the use of evidence based practices.
The differences in the two reports is that while Miller and Carroll identify what treatment processes should be used, Gustafson also addresses system components to achieve recommended changes. Gustafson is an industrial engineer at the University of Wisconsin – Madison's College of Engineering skilled in process improvement. He develops and researches improvements in the treatment of and recovery from chronic health conditions. His focus on substance use illnesses centers not only on what should be changed but also how the recommended changes could be reinforced and implemented.
One of Gustafson's ingredients for redesigning addiction treatment is to take advantage of emerging technologies. These new and developing technologies have the potential to provide immediate access to services while decreasing variance in utilization of evidence based practices. Many of these technologies did not exist when the CACTUS summit was held and thus their use in achieving improved clinical approaches could not be conceptualized. Examples include smart phones and computer tablets that allow two way video conferencing in addition to anytime/anywhere applications that could be used to implement many of the principles developed from the CACTUS meeting. An overview of the potential benefits of using technology based interventions is provided in an editorial in a recent edition of Substance Use & Misuse (Marsch, 2011) as well as a review of recent studies of computer-based interventions (Bickel, Christensen, & Marsh 2011). The authors point out the potential for the use of computer technologies to increase access, provide evidence-based interventions with high fidelity, and achieve the same results as clinician delivered services at lower costs. Marsch points out that these technology delivered interventions can be used as "clinician extenders".
Gustafson and colleagues (Gustafson, Boyle, Shaw, et.al.2011) recently completed a literature review of randomized controlled trials of information and communication technologies to address chronic diseases. Of the 34 studies meeting the criteria for inclusion in the review, 10 were targeted at addressing substance use illnesses. All 10 studies demonstrated a positive effect. The technologies used in the trials was computer delivered in 6 studies, provided by telephone in 3 of the approaches and through television in one study. None used cell phones. This manuscript also describes the Alcohol Comprehensive Health Enhancement Support System (ACHESS) currently being tested in a NIAAA RCT. ACHESS uses smart phones to delivery a variety of recovery support services. Dave Gustafson is the principal investigator for this research project.
New uses of information and communication technologies are likely to grow very rapidly and hold great promise for re-designing the address of substance use and other illnesses as well as for prevention and promotion of wellness. A caution is that new web-based applications for resolving addictions are currently being marketed that have not undergone scientific testing of their efficacy or effectiveness. Some of these may be compared to selling the "snake oil" cures for alcoholism in the 19th century.
In his paper for The Bridge, Gustafson makes an interesting observation: "I sometimes wonder whether the addiction treatment should offer anything but continuing care". Treatment and continuing care have been segmented into silos within the existing system, usually delivered by different staff members requiring a "hand-off" of the patient and, at least historically, continuing care, or aftercare as it was formerly known, was often an afterthought. We have structured our systems to separate treatment and continuing care. In fact, this is built into treatment programs such as residential and intensive outpatient in the form of a "graduation" service in which the patient is recognized and provided with symbol of their success such as a coin or coffee mug. A message may be being sent that they have completed treatment. Few graduates of the educational system think they need to return to campus for more classes that next day. And, if they return to use as most do at some point, they and the providers assume they must return to formal treatment. Thus, we have developed a series of programs not a system of recovery support. This model was even followed in the development of the ACHESS intervention that originally was designed to provide recovery support following a residential treatment episode.
A re-designed system could tear down these artificial walls and silos. Recovery supports could begin immediately upon a person beginning to receive any service. In reality, many treatment organizations have implemented a similar system for decades by "introducing" people to 12 step programs. The problem is that this was the only "choice" for recovery support being offered. Other mutual aid and faith based options should be offered to each patient so they may choose the best option for them. Many of the services offered in ACHESS such as GPS notification of approaching a high risk location, the discussion groups and the panic button to alert selected individuals for their support could be utilized at the start of a treatment episode rather than only after completion of treatment.
Use of the new technologies could combine treatment within what is now deemed continuing care. Patients may want "booster" sessions on how to address specific problems. These could easily be selected and delivered through technology without having to return to the formal treatment setting. Further, the new technologies have the capacity of delivering a face-to-face counseling session on a 24/7 basis.
While I understand Gustafson's musing regarding the possibility of only needing continuing care, he still is using existing language to identify the system. We need new terminology that identifies a comprehensive and integrated approach.
Perhaps the most important ingredient Gustafson proposes for developing a re-designed treatment system is Pay for Performance. A related premise is that organizations will do what they are paid to do. If funded through a grant to treat a specific number of patients yearly, the numbers entering treatment will drive behaviors. If paid through fee-for-service, hours and days drive the performance metrics. There is no perfect funding methodology. Each has strengths and weaknesses including both positive and negative incentives. Yet, within each funding mechanism, contract specifications and related incentives could be introduced to drive providers toward behaviors that are associated with better outcomes.
The majority of the funding for the treatment of substance use illnesses, approximately 65%, is administered by a designated official within each state. The funds for which they are responsible include the SAMHSA block grant, Medicaid expenditures for substance use treatment in specialty settings and any general revenue or other funding allocated by each state.
When Miller and Carroll published their chapter "If ever there was a time..", they were correct that the time should be now. Five years later, there is scant evidence that organizations adopted the principles arising from the CACTUS summit. Access to knowledge does not automatically translate to change in processes. The gap between science and practice is not being bridged. External forces that disrupt the long-standing equilibrium within the addiction filed may be needed. This is the role that the designated state agency could implement on a state by state basis.
These "single state authorities" (SSA) have tremendous responsibility yet their annual allocation of funding is controlled by the state legislature. Below, I am providing a fantasy scenario of one of these authorities testifying before a legislative committee during the budgeting process. This would require great courage including the willingness to admit that the state's funding has not been managed to provide the best results in the past. My hope is that at least one of these individuals have the strength to step forward, take the risk, attempt to leave a significant legacy and serve as a model to their peers within other states.
"The treatment services we have been buying are predominately based on the ideology of the provider organizations, not on science. For example, we have allocated a significant portion of our resources to the purchase of residential treatment services, some extending the length of stay to six to twelve months. Yet, there is no scientific evidence that such long residential treatments produce superior results compared to outpatients services. Many complex surgeries now require an inpatient stay of but a few days. Why would the treatment of a substance use illness require months of residential treatment?
While "treatment works" has been a slogan of the field, the reality is that return to use of alcohol and drugs are common following treatment as are the returning symptoms of other chronic disorders such as diabetes and asthma. Thus, we need to adopt the disease management approaches used in the treatment of chronic healthcare problems that includes continuing care, ongoing monitoring and early re-intervention if needed.
New treatment episodes, if needed, should be adapted to the needs of the patient, their families and support systems. Enormous resources have been expended in providing the same treatment approaches multiple times when people return to use. If the initial treatment was not successful, we need to modify the approach and fine tune it.
Over thirty years of scientific research demonstrate that certain treatment approaches produce superior results. Organizations receiving funding from my department will have to demonstrate that these evidence based practices are the predominate approaches that they are utilizing in their funded services. Yet, we do not want to stifle innovations that may contribute to new approaches and potentially even better outcomes. Therefore, up to 10% of the annual contract amount may support such demonstration studies provided a design has been approved by scientific advisors to my department and includes an evaluation component.
Effective medications for treating alcohol and opiate dependence are available. My department will insist providers utilize these medications and will support this effort by moving a portion of the existing funding into contract line items that will be used to purchase the medication for those who are uninsured.
Advances in technology are allowing evidence-based treatments and recovery supports to be delivered through use of computers, smart phones and electronic tablets. Some of the features being delivered through smart phones today include a GPS function that warns people if they near a high risk location such as a favorite bar where they used to drink or a location they formerly bought drugs, a panic button that summons help from families and friends if they feel a high risk of using and a discussion board where they can post and respond to questions and requests for assistance on a 24/7 basis. In a sense, they have a counselor or recovery coach in their pocket at all times. The results of rigorous scientific studies of these applications are showing the outcomes of these technologically delivered services equal or exceed results from the usual treatment approaches. When combined with face-to-face services delivered by well trained counselors, these technologies can serve as clinician extenders and allow access for more patients.
To implement these needed changes to the system treating substance use illnesses within our state, we will move to a pay for performance purchasing methodology. Criteria demonstrating achievement of the objectives I have outlined will be developed with input from the providers. Both risk and potential rewards will be introduced into our contracts.
I cannot design and fully implement all of these changes within a single fiscal year. I pledge to bring back to you in a year with a very detailed progress report regarding all of the objectives I have outlined. I am simply requesting you maintain your current allocations of funds to our department while I implement and evaluate the results of improved treatment processes, outcomes and access to services.
I also wish to provide you with a cautionary note. Some of our current contracted provides will resist the changes I am proposing. Some may approach members of the legislature to protect them from the pay-for-performance requirements in their contracts. Their arguments may center on a theme that they have been providing their treatment approaches for many years and know they have many successes. I will address these requests for protection from the proposed changes with each of you at any time. My simple reply to their claims that no changes are needed is "if you were diagnosed with cancer, would your request be for the same treatment that your grandfather received 30 years ago?"