By Dennis McCarty and Raina Croff, Oregon Health and Science University, and Mady Chalk, Kelly Alanis-Hirsch Treatment Research Institute
Atul Gawande's articulate and entertaining essays on the quality of health care challenge practitioners and systems of care to embrace change in the organization and delivery of care. Last year, he suggested that the Cheesecake Factory's strategies for consistent quality entrees could be applied to better care in intensive care units: An analysis of coaching and how it helped him maintain and improve his surgical skills noted that even professional athletes value coaching and provocatively suggested that all healthcare practitioners should have coaches. A July 2013 essay exploring fast and slow adoption of medical practices draws on Everett Rogers' (2003) classic text, Diffusion of Innovations. One-on-one conversations between peer leaders who know the new technology and inexperienced practitioners are a key to adoption of new ideas and change in practice. Dr. Gawande describes the Better Birth project in rural India to illustrate how cadres of childbirth-improvement workers reach out to midwives and nurses, teach better methods of care, and coach their practices till better care becomes routine.
In the field of addiction treatment, practitioners, patients, and patients' families resist many innovations that can improve treatment outcomes. One estimate suggests that only about 10% of individuals seeking treatment for opioid dependence receive an opioid agonist or antagonist medication to alleviate craving and protect early recovery (Knudsen & Roman, 2012). Some of the barriers are programmatic (e.g., segregated addiction treatment centers operating without physicians or other prescribers, lack of coverage for medications in publicly-funded systems of care). Other barriers reflect lack of training and outdated conceptions of treatment for alcohol and drug use disorders. Counselors, patients and families believe that addiction treatment relies on development of sobriety skills and that the use of medication inhibits the development. Unfortunately, this remnant belief from the early decades of alcohol and drug treatment continues to impede adoption of new medications that enhance response to care.
The Medication Research Partnership promotes the adoption of medication for treatment of alcohol and opioid dependence. Nine addiction treatment centers contracting with a large commercial health insurance company collaborate with the insurance company to implement organizational and system changes that support patients in their use of any medication approved for treatment of alcohol or opioid dependence. Participating sites receive coaching on organizational change and collaborate with the insurance provider to make systems changes. At the June 2013 Learning Session, sites reported on their change initiatives. Family and patient education emerged as perhaps the single most important intervention. Programs have learned that families and patients don't know about the available medications and don't believe that they enhance recovery. Without basic information on the medications, patients and their families are unable to consent to including medication in the treatment plan. With a little education, however, they become more open and willing to add medication to their recovery plans.
Treatment centers in the Medication Research Partnership integrate education about medication-assisted treatment into their programs. Each center crafted unique approaches but six elements seem essential: 1) educating from the inside out for buy-in from all levels of staff, 2) talking to patients about medication options while they are still in residential treatment, 3) standardizing information patients receive by using a regular group education format, 4) providing take-home educational materials like brochures, 5) involving the family and 6) making the education a routine part of how business is done. Three examples illustrate the approaches.
White Deer Run in Allenwood, Pennsylvania includes a 2-day family program during residential care. Participating family members provide support through recovery. Families and patients usually know about opioid agonists (methadone and buprenorphine), but few have information about antagonist therapy (extended-release naltrexone). Twenty-minute presentations on medication-assisted treatment are offered twice weekly for patients and their families. Prior to initiation of the family education, White Deer Run trained physicians, counselors, clinical directors, nurses and administrative staff about medication options. The center is a big believer in family education: "We try to hit the clients and the family right at the door in terms of the information that we give them." If patients choose to use medications to assist their recovery, their families are more likely to support the decision. From January to June 2013, 66 patients selected extended-release naltrexone and 30% of the patients (n = 20) participated in the family services program (an increase from 17% December 2012).
Livengrin Foundation in Allentown, Pennsylvania emphasizes the importance of multiple access points for patients to learn about treatment options, "At any time a patient can enter or explore getting into the medication-assisted treatment part of the program….We have multiple doors and they're always wide open." Counselors and aides are trained to support medication options and patient education occurs in peer groups, individual counseling sessions, and formal group educational sessions. Livengrin also provides free seminars on medication-assisted treatment for families, educators and health care professionals.
Mountain Manor's Avery Road Treatment Center in Rockville, MD encourages young adult opioid patients (18 to 30 years of age) to use agonist or antagonist medication to support early recovery. Before reaching out to patients, the treatment center first made sure to have a solid core—an educated internal staff and across-the-board buy-in to the use of medications. To improve the transition between detoxification and outpatient care, outpatient counselors meet with patients prior to residential discharge and discharge planning is coordinated for a warm hand-off. "[We] welcome them early. Say, 'So excited you're coming.' Because the value in that is great. I won't back away from the idea that you need to get out of your office, walk across the street, welcome them early." Clinicians learned about patient concerns and misconceptions about medication options. The treatment center established a weekly group education session on the benefits and barriers to medication assisted treatment with agonist and antagonist medications. Everyone at every level knows the routine because it is precisely that—a well-integrated, normal part of how business is done. Implementing these changes positively affected the percent of patients referred from detox to the youth outpatient program, as well as increasing the number of patients showing up for their first outpatient appointments.
Atul Gawande notes that it's the personal touch of childbirth improvement workers that help midwives and mothers reduce the mortality risks associated with childbirth. The addiction treatment field needs to develop similar change agents working with programs, counselors, patients and families to reduce the risks of return to use and promote development of stable recovery supported by the use of medication. Treatment providers, patients and their families can no longer use 20th century technology and beliefs to treat alcohol and opioid use disorders in the 21st century. It is time for a cadre of peer supporters promoting the adoption and use of medication to enhance early recovery.