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.