OATSOutcomes & Assessment-Informed

Treatment Strategies& Implementation Issues

Norman G. Hoffmann, Ph.D.Adjunct Professor of Psychology

Western Carolina Universitywww.evnceassessment.com

Evidence-Based TreatmentUtilize a treatment model documented to be effective in controlled clinical research

Question of whether the model is implemented with fidelity

No guarantees that it will work in routine clinical practice even if implemented properly

No verification of outcomes

Assessment-Informed TreatmentAssessment documents nature and severity of conditions and initial differential treatment needsDuring treatment integrate assessment data with treatment response to document progress and identify risk and resiliency variables Use findings to adjust treatment plan and refine future assessment and treatment decisionsDevelop empirically justified foundation for determining medical/clinical necessity

Outcomes-Informed TreatmentMonitor baseline and initial relevant outcomes for all clients – outcomes can be clinical and/or societal/financialMonitoring done during typical continuum of care (e.g., during maintenance services)Uses information already required for quality care – store in useable formatRetrieval of data for analysesDocument medical/clinical necessity

Potential Uses forOutcomes DocumentationIdentify Differential Treatment NeedsIdentifying Differential Relapse RiskEmpirically Derived Medical NecessityEnhancing Client MotivationTreatment ImprovementMarketing ServicesJustifying Treatment Costs - ROIPublic Relations

AssessmentsIdentify Differential

Treatment Needs and Relapse Risk

Substance Use Disorder Criteria1.Use in larger amounts or longer than intended2. Desire or unsuccessful effort to cut down3. Great deal of time using or recovering4. Craving or strong urge to use5. Role obligation failure6. Continued use despite social/interpersonal

problems7. Sacrificing activities to use or because of use8. Use in situations where it is hazardous

DSM-5 SUD Criteria continued9. Continued use despite knowledge of having a

physical or psychological problem caused or exacerbated by use

10.Tolerance11. Withdrawal

Criteria 1-4 relate to use; Criteria 5-8 relate to behavioral issues

associated with use; Criteria 9-11 relate to physical/emotional issues

DSM-5 Initial VS. DSM-5 FinalInitially the proposed DSM-5 had two diagnostic categories: moderate and severe defined by 2-3 and 4+ positive criteria – conforms best to abuse – dependence classification

Final formulation has three categories: mild (2-3), moderate (4-5), and severe (6+ positive criteria)

Original “moderate” becomes “mild” – no empirical foundation for either distinction

Sustained RemissionNo positive diagnostic findings (other than craving) for 12 consecutive monthsSubstance use is NOT part of the remission definitionPossible levels of outcome: 1) abstinence without problems; 2) some use without problems; 3) use with sub-diagnostic problems; 4) meets current diagnosisYou get paid for remission NOT recovery

DSM-5 Criteria DifferentialsAll criteria are not equal in implications

Some criteria are found predominately among those with the severe alcohol or other substance use disorder diagnoses

Other criteria are more common among the mild to moderate alcohol use disorder group

Tolerance and dangerous use are actually common among those with no diagnosis

SUD CRITERIA PRIMARILY IN SEVERE DESIGNATION

The “Big Five”

Criteria 2:Wanting to cut down/setting rules

Criteria 4: Craving and/or compulsion to use

Criteria 5: Failure at role fulfillment due to use

Criteria 7: Sacrifice activities to use

Criteria 11: Withdrawal symptoms

Sample of AlcoholDiagnostic Documentation

Alcohol Diagnosis Diagnostic Criteria1 2 3 4 5 6 7 8 9 10 11

Case 1 X X X X X X X XCase 2 X X XCase 3 X X X X XCase 4 X X X X X

Severe MildModerateModerate

Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes

CASE 3: Positive DSM-5 Criteria3. Great deal of time using10. Tolerance1. Unplanned use: more or longer use8. Use in hazardous situation (impaired driving)6. Recurrent interpersonal conflicts

Conclusions No loss of control indicated Misuse and possible irresponsible behavior Moderation may be a reasonable initial goal

CASE 4: Positive DSM-5 Criteria1. Unplanned use: more or longer use2. Desire/efforts to cut down4. Craving/compulsion to use5. Role obligation failures7. Sacrificing activities to use

Conclusions Loss of control clearly indicated Positive on 4 of the “Big Five” Abstinence indicated goal for recovery

Implications for DispositionEducation and brief counseling may be appropriate for majority of mild use disordersFor those with a moderate diagnosis, the pattern may be as important as the number of positive criteriaThose positive on any of the Big Five criteria should be carefully evaluated regarding the current and projected trajectory of their condition

Final Criticism of the DSM-IV Loss of control not required for a dependence diagnosis – e.g., tolerance, spending time using, and occasionally drinking more/longer than intended – got the chronic diagnosisSome abuse criteria are stronger indications of a serious condition than some dependence criteria

Role obligation failure is a Big Five criterionTolerance is often seen in mild cases or even among those with no diagnosis

CLINICAL (Medical) NECESSITYPersons in the severe designation with positive “Big Five” findings will require a more intensive and longer continuum of care to achieved treatment effectivenessPersons in the mild designation typically will benefit from shorter & less intensive interventions to achieve efficiencyEach treatment plan can be informed by prior empirical outcome data on comparable cases and modified based on the individual’s treatment response

Sample Hypotheses for Clinical Practice

Hypothesis #1: Clients positive on three or more of the “big five” will require initial residential placement and/or more intensive and longer continuum of care to achieve good resultsHypothesis #2: Clients in mild or moderate designations without any positive findings on the “big five” may be able to moderate or stop use with less intensive and briefer services

Beware of Arbitrary Outcome Metrics

Scientifically reliable and validIrrelevant to the real world

Addiction Treatment Examples:Average days of use in past 30 daysScores on a variety of psychological instruments

Reference on arbitrary metrics:Kazdin, A. E. (2006). American Psychologist, 61(1), 42-79.

Arbitrary Metric ExamplePrograms A and B each treat 100 cases

Program A: Before treatment average days of use = 25After treatment average days of use = 10

Program B: Before treatment average days of use = 25After treatment average days of use = 8

Which program has the better outcomes?

Arbitrary Metric ExampleReal world results:Program A: 60 in full remission; 40 minimal change

Program B: Zero remission: All 100 still using just on weekends, but all have continuing problems and meet current criteria for severe SUD (dependence)

To which program would you refer a family member?

Demographic Risk ScaleLess than 25 years of age.No high school diploma or GED.Unemployed.Never married.

Three or more positive characteristics increases expected relapse rate by about 20% or more

Demographic Risk Scale and Observed Outcomes

High Risk Low Risk0%

10%

20%

30%

40%

50%

60%

70%

80%

Subthreshold

Threshold +

Ab

stin

ence

Mo

nth

s 7-

12

35 Unites of service = threshold for low risk group75 Unites of service = threshold for high risk group

Zywiak, Hoffmann, & Floyd, 1999

Client Motivation and Empowerment

Maintenance Care Thresholds

Months of Maintenance Care (Aftercare)20%

30%

40%

50%

60%

70%

80%

53%60%

73%

0-2 months

3- months

5-6 months

% A

bst

inen

t at

On

e Y

ear

N = 12,783 Treatment Completers

Hoffmann & DeHart (1996). CATOR Fact Sheet

One Year Abstinence Rates for Older Alcohol Dependent Clients

No Main. & No AA

Main. - No AA

AA - No Main.

Main. & AA

30

40

50

60

70

80

90

High Severity

Low Sever-ity

% o

f C

ases

Combinations of 4+ months of Maintenance Care and/or Weekly AA Attendance for 1,350 treatment completers

Hoffmann, DeHart & Gogineni (1998). The Southwest Journal on Aging, 14(1), 57-64.

CONTINUED CARE & SELF-HELP GROUPSRate attendance using the scale: 1 = never/stopped 3 = Several times a mo.2 = Once a month or less 4 = At least once a weekHow often did you attend the following during the past three months:

09. Formal aftercare ____10. AA ____11. NA ____12. Other support group ____

Additional Data Required for Differential Outcome Example

Treatment Improvement

CLINICAL CONTINUOUS IMPROVEMENT COMPONENTS

Patient Assessment Intake and ongoing assessments

Outcomes Treatment PlanInitial clinical outcomes Define problemsRemission outcome Treatment prioritiesSocietal benefit measures Treatment placementFinancial benefit measures

Treatment Response/ProgressBiopsychosocial treatment

Process measurementsAdjustments to treatment plan as needed

TREATMENT RATINGS [asked by follow-up interviewer]

Rate how helpful the following treatment components have been for your recovery?0 = not used 1 = poor; 2 = fair; 3 = good; 4 = excellent

01. Group Therapy ____02. Individual counseling ____03. Lectures & education ____04. Working the AA/NA steps ____05. Peer-group meetings (e.g., AA) ____06. Family portion of program ____07. Talking with other clients ____08. Overall rating for the program ____

Feedback on Helpfulness of Program Components

Helpfulness in remission – not satisfaction with the component

Low scores indicate opportunities for improvement

High scores indicate potential areas of excellence

Requirements for Clinical Outcomes Monitoring System

Capture demographic and descriptive information to describe the population

Document clinical information in sufficient detail to facilitate treatment refinement

Document response to the treatment services delivered

Document outcomes during typical continuum of care

Specialty Studies for Identifying Problem Issues

Pavillon Study ofTrauma, Distress, and Craving

Evaluation of potential problems and relapse risksDistress measure (DARNU), PTSD symptom count, and validated craving measures for alcohol and drugsExplore the possibility of identifying level of distress and trauma relative to craving

Trauma, Distress, and CravingDARNU: D – Dissatisfied A – Anxious

R – Restless N – NervousU – Uncomfortable18- item self-report scale

DARNU correlates highly with PTSD (r = .78) and craving (r = .36)

Implications:1. DARNU can identify probable PTSD2. Warning indication for greater craving

Distress (DARNU) and PTSD

Quartile 1 Quartile 2 Quartile 3 Quartile 40%

20%

40%

60%

80%

100%

DxPossibleNo DX

PTSD

DARNU elevation quartilesN = 124

Justifying Investment in Treatment

ROI: RETURN ON INVESTMENTThe good news:

ROI for addictions treatment is one of the largest in healthcare: between 4:1 to 7:1Returns accrue to society in areas outside of healthcare

The bad news:ROI within healthcare is a fraction of returns and may not pay for all treatment needsOther areas that benefit do not traditionally pay for clinical services

Healthcare Returns: Proportional to Effectiveness

Relapsed n = 1473

Recovering n = 2099

0

0.5

1

1.5

2

2.5

3

3.5

4

Before Tx

Year 1

Year 2

Hoffmann, DeHart, & Fulkerson (1993). Journal of addictive Disease, 12(1), 97-107.

Average Days of Hospitalization

Relapse vs. Recovery

Before Tx p = N.S.

Yr 1 & Yr 2 p < .001

Public Safety Issues by Diagnosis

0

10

20

30

40

50

60

Per

cen

t o

f sa

mp

le

DU Arrest MV Crash DroveImpaired 3

times

No Dx

Abuse

Depend.

N = 7,682 state prison inmates

Highway Safety Returns: Proportional to Effectiveness

21% 22%20%

12%10%

7%

0%

5%

10%

15%

20%

25%

30%

%

of

Cas

es

Before Treatment After Treatment

Relapsed n = 3,153

PartialAbstinencen = 3,425

Abstinent n = 9,326

Hoffmann & DeHart (1996). CATOR Report.

Motor Vehicle Accidents

Criminal Justice Returns: Proportional to Effectiveness

16% 16%

11%9%

6%

2%

0%

5%

10%

15%

20%

25%

30%

%

of

Cas

es

Before Treatment After Treatment

Relapsed n = 3,153

PartialAbstinencen = 3,425

Abstinent n = 9,326

Hoffmann & DeHart (1996). CATOR Report.

Proportion of Cases Arrested

Healthcare Returns On Investment for Dependent Employees

Before Treatment

After Treatment

Employees Hospitalized 24% 10%

Employees Using ER 29% 21%

Total Days of Hospitalization 7639 5158

Vocational Functioning Returns On Investment

Number of Problem Types

Before Treatment

After Treatment

None 35% 76%

One 23% 16%

Two 18% 5%

Three 11% 2%

Four plus 13% 1%

Problem types include: absenteeism, tardiness mistakes, lack of work completion, conflicts, and on the job injuries

Medicare/Medicaid Funded Treatment and Recovery

Hospitalizations ER Visits0%

5%

10%

15%

20%

25%

30%

35%

40%31%

37%

21%

26%Relapsed n = 378

Abstinentn = 364

%

of

Cas

es

Significancep < .001

Hoffmann (1994). Report for George Washington University

Medicare/Medicaid Funded Treatment and Recovery

Auto Accidents Arrests0%

5%

10%

15%

20%

10%

13%

2%3%

Relapsed n = 378

Abstinentn = 364

%

of

Cas

es

Significancep < .0001

Hoffmann (1994). Report for George Washington University

Marketing

Marketing to Whom?Potential clients and/or families of those affected

Employers with stable workforces consisting of employees who are difficult or expensive to replace

Public officials tasked with stretching limited budgets

Insurers – FOR GET IT

Personalized Marketing PointsThe probability of a positive outcome for severe substance use disorders is as good as other chronic conditions

Recovery (or remission) is largely determined by client adherence to a realistic recovery plan

Some ongoing services may be required as is the case with other chronic conditions

Support systems exist for both the afflicted and their families

General Marketing PointsThe probability of a positive outcome for severe substance use disorders is as good as other chronic conditions

Treatment for substance use disorders is comparatively inexpensive to those for other chronic conditions

Benefits from treatment services accrue not only to the person treated, but also to society at large

PublicRelations

Public Relations ErrorsMany people concerned about

addictions: Talk to the wrong people

About the wrong topics

Using the wrong terminology

And wonder why nothing changes

The Lesson of the Peacock

The peacock is among the most beautiful of birds.

However, its “song” is among the most awful of sounds.

Trying to teach a peacock to sing is a waste of time and neglects the beauty – focuses on weakness not strength

Voice of the PeacockAn alcohol or drug dependent person does not make an attractive poster child – biased perspectives – stigma.Failures are very obvious and visible.Successes tend to disappear from view.The general public does not care whether dependent people recover.

Beauty of the PeacockReturn on investment is one of the greatest in the healthcare arena.

Reasonable recovery rates relative to other chronic illnesses can be documented.

Treatment costs are modest compared to other areas of healthcare.

Benefits of treatment are found throughout society

Who Cares About What?The general public cares about safety and financial issues

Employers care about turnover and performance

Public officials want to support positions that will get them reelected

The media look for a good story that will get attention

Relationships with the General Population

The general public cares about safety and financial issues

Most people are not concerned about the welfare of addicted individuals

Most people do not have a realistic understanding of addictions or treatment

Relationships with EmployersFocus on employers with stable workforces and where employees are difficult or expensive to replace

Make the case that recovering employees make excellent workers

Educate them that afflicted workers can be identified and treated successfully

Relationships With Elected Officials

Most elected officials have no realistic understanding of addictions or treatment

Most are interested in the general welfare

To do what is right, some will need political cover to support treatment vs. punitive strategies

Relationships With the MediaReporters are always looking for a good story – either good or bad news

Combining a personal recovery story with outcome data can be a powerful positive story

A little controversy can be a positive thing if you select the controversy

Norman G. Hoffmann, Ph.D.Adjunct Professor of Psychology

Western Carolina Universityevinceassessment@aol.com

828-454-9960www.evinceassessment.com