translating standards into practice the voluntary approach in the netherlands gerard m. schippers...

Translating Standards Into Practice

The Voluntary Approach In The Netherlands

Gerard M. SchippersGerard M. Schippers

EQUS, Brussels, june 2011EQUS, Brussels, june 2011

THE AMSTERDAM INSTITUTE FOR ADDICTION RESEARCH

.

pragmatic approach

of use …

and of treatment

Nevertheless, in the 90s, Dutch Substance Abuse Treatment Services were publicly criticized for a number of reasons, which

alarmed the management.

Criticisms on Substance Abuse Treatment in the 90sPublic criticism (on nuisance, lack of effect, treating the elite)Applied treatment methods mainly based on clinical intuition, tradition, and ideology, while Scientific accomplishments not being implementedHardly any specialized education and trainingBad coordination between different fragmented programs and program elements (scattered, island culture)Treatment methods barely transparent and explicit

Negative Consequences

Too much emphasis on abstinence oriented programsToo few integration of mental health and substance abuse treatmentUndervaluation of medication supported therapies Too few attention for motivation enhancementToo few insight in the chronic relapsing nature of addictionToo much distinction (organizational and conceptual) between kind of substancesToo few distinction between chronic and temporary problems

Dutch Substance Abuse Treatment Services (ca 16 mil inhabitants)

11 larger regional Centers ca 4.000 fte staff

serving ca 60.000 new patients yearlyca 55% alcohol dependent

from all illegal drug abusersca 70% are in regular contact with treatment services (>50% in methadone maintenance)ca 15% are IV-usersrelatively low HIV prevalence

Areas 11 Dutch Substance Abuse Treatment Centres

Where did this lead to?Where did this lead to?

Designing a Treatment Designing a Treatment Renovation ProgramRenovation Program

based on a bottom-up initiative from the managers of the service providers facing the criticisms

“To Score Results”

National Reform ProgramDutch Substance Abuse Treatment Services

1998-2013

A cooperative effort of all larger treatment substance abuse institutions, with the help of

additional funding from Ministry of Health

founding a national steering group composed of managers, clinical

professional and scientists

Objectives Reform Program

Improvement of services for substance abusers (primary processes) byImplementing services based on scientific evidence and/or clinical consensus

Monitoring clinical results and feeding them back to professionals and the public

Improving education in addiction

Designing a Treatment Reform Program

2002

2010

Implementing renewed Implementing renewed services for services for

Prevention,Prevention, Treatment Treatment and Matchingand Matching

What does What does researchresearch tell us tell us on the effectiveness of on the effectiveness of treatment on addictive treatment on addictive

behavior?behavior?

Effective Treatment Through the InternetEffective Treatment Through the Internet

fully self-guided internet module, or with counsellor effective

Evidence on Effectiveness Is Evidence on Effectiveness Is Ample AvailableAmple Available

Nevertheless, in the last years, Nevertheless, in the last years, focus has changed from focus has changed from

evidence-based to client-based, evidence-based to client-based, due to increased influence of due to increased influence of

financers (competing assurance financers (competing assurance companies)companies)

Characteristics Dutch professional Substance Abuse Treatment Methods

Evidence based treatment methods

No diversion between alcohol and drug treatment

Treatment and harm reduction provided by the same organisations

Redesigned Treatment Modules*Brief CBT individual

Standard CBT individual

Brief CBT group

Standard CBT group

Screening, Needs Assessment &Treatment Allocation

User Rooms**

Crisis intervention

Detoxification

Integrating Self Help Groups in Regular Care

After Care

Opiate Substitution Treatment

Suicide in addiction care

Casemanagement

MATE: Assessment for Triage and Patient Placement

Adolescent Cannabis Abuse

Substance Abuse & Depression

* 15 Treatment & Rehabilitation, 1 Harm Reduction**: * 15 Treatment & Rehabilitation, 1 Harm Reduction**: No distinction in the NetherlandsNo distinction in the Netherlands

Examples: National Consensus Guidelines

Dutch National Guidelines on the Treatment of Alcohol Use Disorders (2009)

Dutch National Guidelines on the Treatment of Heroin Dependency (2011)

Examples: Psychosocial Behavior-Examples: Psychosocial Behavior-oriented Treatment Modalities oriented Treatment Modalities (“Life Style Training Program”)(“Life Style Training Program”)

1.1. Brief MI/CBT (intake Brief MI/CBT (intake + ca.+ ca. 4 sessions) 4 sessions)

2.2. Standard MI/CBT (intake Standard MI/CBT (intake + ca.+ ca. 10 sessions) 10 sessions)

• for individuals and groups• general applicable for all substances• based on cognitive behavior therapy • motivational interviewing as basic counseling style

www.mateinfo.eu

Measurement in the Addictions for Triage and Evaluation

New instrument for measuring patient characteristics in substance abuse treatment

How Well are the New Modules How Well are the New Modules Implemented?Implemented?

Evaluation study in 2005, 2008 and 2011* Evaluation study in 2005, 2008 and 2011* 20 to 27 modules disseminated. Drug treatments 20 to 27 modules disseminated. Drug treatments also in the EQUS projectalso in the EQUS project

11 Out of 12 institutions observed, covering 11 Out of 12 institutions observed, covering 3800 (77%) of the 5000 patient-related workers3800 (77%) of the 5000 patient-related workersInterview with 40 key personsInterview with 40 key persons

** Preliminary data Preliminary data

How Well are the New Modules How Well are the New Modules Implemented?Implemented?

Evaluation study in 2005, 2008 and 2011* Evaluation study in 2005, 2008 and 2011* 20 to 27 modules disseminated. Drug treatments 20 to 27 modules disseminated. Drug treatments also in the EQUS projectalso in the EQUS project

11 Out of 12 institutions observed, covering 11 Out of 12 institutions observed, covering 3800 (77%) of the 5000 patient-related workers3800 (77%) of the 5000 patient-related workersInterview with 40 key personsInterview with 40 key persons

** Preliminary data Preliminary data

Level of Implementation of protocols

0%

20%

40%

60%

80%

100%

2005

20082011

% t

reat

men

t ce

nter

s

0%

20%

40%

60%

80%

100%

1 2 3 4 5 6 7 8 9 10 11

Treatment Centers

Implemented

Not implemented

Unknown

2008, 23 modules

% m

odul

esLevel of Implementation in treatment centers

REQUIRED:

Coalition of multiple stakeholders: financers, centre administrators; clinicians, and service consumers

Necessary (although not Sufficient) Necessary (although not Sufficient) Conditions for ImplementationConditions for Implementation

Adequate resourcesAdequate resources

A reasonably well managed institute A reasonably well managed institute

Coalition of multiple stakeholders: financers, Coalition of multiple stakeholders: financers, centres administrators; clinicians, and service centres administrators; clinicians, and service consumersconsumers

Support on central management levelSupport on central management level

Trusted enthusiastic mediatorTrusted enthusiastic mediator

Training, supervision and booster trainingTraining, supervision and booster training

Factors Promoting the ImplementationFactors Promoting the Implementation

Minor local variations should be possible (‘not-invented-here-syndrome’)

Changes should not be too large and too quickalthough … radical changes sometimes work better

New modules should replace old practice

Continuation in coercion and support from central management are essential

Increasing convenience (e.g. electronic implementation)

External pressure helps

Training, training, training …

Factors Hindering the ImplementationFactors Hindering the Implementation

Instability in team management and team personnel

Organisational changes (new way of working e.g. care pathways and Assertive Community treatment)

Too few publicity new guidelines

No support from management

Guidelines get outdated

Financial problems or no funding

Dutch clinicians are alike Dutch clinicians are alike their colleagues all over their colleagues all over the world in eagerness the world in eagerness and willingness to learn and willingness to learn

and changeand change

butbut

… … the changing of the changing of habitual behavior is habitual behavior is tedious and takes a tedious and takes a

long breath.long breath.