The UK government is grappling with a problem that bedevils all of us who provide, teach, administer or advocate for addiction treatment: Treatment outcomes are often disappointing. Among the quality problems that contribute to this situation are organizational dysfunction, excessive paperwork, the stigmatized nature of the enterprise, lack of connection between addiction services and the rest of the health care system, lack of attention to evidence about effective interventions, and a short-term treatment model (“treat ’em and street ’em”) that is more suited to an acute disorder than a chronic one.
Addiction treatment programs in developed countries also frequently face staffing challenges, including low morale, high turnover and insufficient medical training (e.g., how to recognize an underlying psychosis or depression, what to do about infected abscesses or liver cirrhosis). To echo the last post in the series about the need for recovery-related advocacy, Lord Ramsbotham recently pointed out to me a further problem with staffing, namely that some of the people most interested in becoming health and social care providers in the drugs field — people recovering from drug addiction — are increasingly banned from jobs because they have a criminal record, which follows them everywhere in age of electronic records and Internet background searches.
Good government policy thus has to address not just the need for more treatment, but better treatment that leads more people to recovery. Having spent a zillion hours trying to help the last two U.S. administrations meet this challenge, I can attest that improving quality is easier agreed to in principle than implemented in practice. Quality is hard to measure, produce and sustain, and sometimes the various stakeholders (patients, families, employers, insurers, judges, the public) do not agree on what quality means and what addiction treatment outcomes are to be improved.
After an era when the focus has been on treatment quantity (how many patients are in drug treatment), the UK government is aflurry with proposals for improving quality and thereby getting better results from treatment. In the past two weeks alone, there have been well-attended meetings of energetic stakeholders organized by the UK Drug Policy Commission, the Advisory Council on the Misuse of Drugs and the Home Office; the PM’s strategy and policy teams are also meaningfully engaged. Most of the initiatives being debated mention the term “payment by results”, but as yet that’s really a bureaucratic shorthand for a farrago of competing ideas rather than a reflection of a unified approach or widely shared understanding.
Initiatives to improve the quality of care break down into those that focus on some clinical process (e.g., retaining patients in care, reducing waiting time, implementing evidence-based treatment guidelines) that is intended to translate into better patient outcome, and those that focus on outcomes directly (e.g., publicly ranking programs on their success rates, rewarding programs or patients for achieving certain outcomes regardless of what processes were employed to achieve it). Let’s take a look at each broad strategy in turn. (Pack your bags, we are headed to wonkville).
The good news about efforts to improve clinical and organizational processes in addiction treatment is that policy initiatives really can change what treatment programs and individual providers do. The Network for the Improvement of Addiction Treatment in the U.S. taught program managers good business practices which enabled them to reduce waiting times and increase patient retention and satisfaction. The U.S. Veterans Health Administration (VHA) showed that measuring and incentivizing practices such as screening for problem drinking in primary care and encouraging psychiatric patients to attempt smoking cessation does indeed make clinicians engage in these practices more often. The U.K. National Health Service has had similar successes.
But these changes in clinical practices have yielded disappointingly small gains in patient outcomes over time. The UK National Treatment Agency is now emphasizing the need for patients to be retained in treatment for 12 weeks. I wish them luck, but when the VHA did this the proportion of patients retained for 12 weeks increased but the proportion who got better barely budged. Similar findings have emerged in other fields. Even major improvements in the quality of a hospital’s care for heart attacks, for example, makes only a slight impact on mortality rates.
This is less surprising than it first may seem. Physical health is profoundly influenced by behavior and environment. The moment a patient leaves treatment (or in an outpatient setting, even while they are in treatment) the environment presses on them in many ways that can advance or impede their health. A patient who is discharged from a residential rehabilitation program to their hovel in a depressed, crime ridden neighborhood with many liquor stores and corner drug dealers may relapse immediately no matter how good or bad the rehabilitation program. Other patients return to recovery-supportive environments that can overcome the effect even of poor treatment services.
The weak connection between changes in treatment process and patient outcomes has led some policymakers to incentivize outcomes directly. We know this can work at least in the short term for patients. For example, methadone patients who are given take home doses in response to a week of heroin-free urines are more likely to stay clean.
Efforts to reward treatment programs for good outcomes (e.g., in the State of Maine) have run into problems though, including the tendency of agencies to begin “creaming” their caseload, i.e., finding reasons not to admit patients who are unlikely to improve. Further, if the outcome assessment is done after treatment, there are significant costs in finding patients again to assess them. Last but not least, if the treatment program does the post-treatment assessment itself through self-report (rings up to ask “You are still sober, right?”), it’s pretty easy to game the system and overstate outcomes.
These problems can be surmounted to some extent by rewarding programs for outcomes measured biologically (these are harder to game than self-reports) while the patient is in treatment (and is thus easier to find). This approach would require regular urine, blood or breath tests of all patients during treatment, but treatment programs should be doing that anyway just as a cardiologist should be checking blood pressure every time he or she sees a hypertension patient.
A more radical approach to improving quality is to make treatment services more like a free market and let patients buy services that will help them recover. This approach brings in normal market pressures for quality, i.e., Providers offer better services because they are in competition with other providers for the patients’ money. The Bush Administration adopted and the Obama Administration expanded this approach with a $100M voucher program known as Access to Recovery. After their initial stabilization in early addiction treatment, patients receive a voucher worth about $1500 to buy things like work clothes, resume-writing help, dental care, community college courses, babysitting, bus tokens etc. The first evaluation of this approach was conducted in the State of Washington and found that patients receiving vouchers had higher rates of employment and treatment retention than similar patients who did not.
None of these approaches to treatment effectiveness improvement need be applied singly. Indeed a mix of approaches is particularly likely given the current UK government’s push for more local decision making. Whatever policy(ies) are ultimately implemented in the UK will face substantial bureaucratic inertia and some provider skepticism, but also might generate enthusiasm within the more innovation-minded sectors of the treatment field.
This is the last extended post on a single topic in this series about UK drug and alcohol policy. My next and final post will briefly address a range of topics which have been raised along the way by readers of this series.
Thanks for this, Keith. A really interesting review of the options that have been, and are being, tried to improve recovery outcomes. The many shortcomings are depressing, though, and I wish you had better news to report. And whilst it's clear that simple measurable outcomes must play an important role in determining what works and what doesn't, so often these 'deliverables' turn into targets which can produce too narrow and blinkered a view as to the way forward. For instance, news this morning that alcohol-related harm in Britain may be reduced by selling beer in plastic bottles, not glass. Yet it's not the glass that persuades someone to slash another's face is it? But the alcohol inside fueling the rage? Your blog is leading the way in bigger-picture thinking about these massively important issues and I hope influential people find it nutritious food for thought.
In 2007 Dr Linda Sobell spent a day at Scotland's Futures Forum discussing the work which she, Harald Klingemann and colleagues were doing on evidence in the population about self-change or so called "natural recovery" from harmful substance use. We were struck by the four key factors in the self change process they identified: the decisional balance; the affective hook; the monitoring of behaviour and; social support. We formed the opinion that effective outcomes in treatment services would likely occur when the staff were highly in touch with the patient/client regarding the same 4 factors. A real challenge, as the first two require forming accessible, flexible and trusting relationships while the fourth often requires a lot of coordination of other socioeconomic services and opportunities in the wider community. The monitoring of behaviour seems the easiest to do something about but if the other factors aren't done well, behaviour monitoring can become a negative and punitive experience. I guess that using a voucher system or if they just had more choice, the patient/client would go where the word on the street or published outcome data pointed to services which have their act together on these factors.