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Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.)

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Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.

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Chapter 14. Administrative Considerations

In This Chapter …

Staffing

Medication Diversion Control Plans

The Community Effort

OTPs and National Community Education Initiatives

Evaluating Program and Staff Performance

This chapter describes policies, procedures, and considerations that make opioid treatment program (OTP) administrators and managers more effective, therefore contributing to improved treatment outcomes. OTPs are complex, dynamic environments, and their staffing and management are challenging. OTP directors influence patient outcomes positively by providing sound leadership and staff management (Magura et al. 1999). Managers are responsible for keeping staff members focused on patient care and improved treatment outcomes. Conflict or misunderstanding about treatment goals can increase the stress of working in an OTP (Bell 1998). Managers should set clear staff guidelines, supply the needed resources, and create a culture that nurtures professional growth and staff retention.

Staffing

How … interactions [between OTP staff and patients] are conducted, and particularly the attitude of staff members, is probably the next most important determinant of treatment effectiveness after an adequate dose of methadone. (Bell 1998, p. 168)

Successful treatment outcomes depend on staff competence, values, and attitudes. To develop a stable group of competent personnel, OTP administrators should recruit qualified, capable, culturally competent people; offer competitive benefit packages; and provide careful supervision and ongoing training. Employees then can increase their understanding of medication-assisted treatment for opioid addiction (MAT).

Qualifications

Licensing, certification, and credentialing

The complexities of treating patients who are opioid addicted demand highly trained caregivers who can provide direct patient care and coordinate access to other services that their OTP cannot provide. To ensure these qualifications, OTPs should hire individuals who are licensed or credentialed under State regulations and have a record of working effectively with the types of patients served by the OTP. Licensed and credentialed staff members also may be viewed as having more legitimacy by State regulators, community members, and third-party payers.

Staff interpersonal characteristics

In addition to hiring licensed or credentialed staff, administrators should employ people with empathy, sensitivity, and flexibility, particularly regarding patients in MAT. Empathic staff members create a therapeutic milieu (Joe et al. 2001). In addition, staff members should maintain appropriate professional boundaries with patients.

Transference and countertransference. Some patients with addictions project feelings or emotions onto their treatment providers or cast providers in unintended roles, a phenomenon known as transference. Countertransference occurs when treatment providers project their feelings onto patients, which can interfere with treatment and be destructive to therapeutic relationships. OTP supervisors should ensure that staff members avoid countertransference (e.g., displaying anger toward patients or disappointment with them). TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000d ), contains a detailed discussion of these topics.

Sensitivity to cultural, gender, and age issues . In a review of the literature on culturally relevant health care interventions and their effect on treatment outcomes, Kehoe and colleagues (2003) found that treatment provider knowledge of cross-cultural principles significantly improved outcomes for patients with drug addictions. OTP staff members should be willing to work with people from diverse backgrounds, explore and accept other value systems, and understand how culture and values can relate to patients' behavior. Support staff should be accepting and understanding of patients from diverse groups because these staff members often are the first people a new patient sees at the OTP and those with whom the patient interacts most. If possible, management should recruit employees who reflect patient demographics and should consider hiring people who are recovering from addiction (see below).

People working with diverse groups should remember that diversity also exists within cultures. It is important to be sensitive to cultural differences but to avoid acting on cultural assumptions. Understanding both a patient's cultural influences and his or her individuality requires taking time to know the patient.

Treatment staff should be sensitive to other factors that can affect recovery, such as patients' sexual orientations or ages, but should avoid generalizing about patients based on these factors. Correctly identifying such factors requires an effort to see the world through each patient's eyes. Information on cultural competence and diversity is available at Web sites of the National Association of Social Workers (www.socialworkers.org/diversity) and Substance Abuse and Mental Health Services Administration (SAMHSA) (www.samhsa.gov/search/search.html) and in “Cultural Competence for Social Workers” (Center for Substance Abuse Prevention 1995) and the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (CSAT forthcoming b ).

Multicultural and multilingual representation. The consensus panel is aware of no published data demonstrating improved outcomes from ethnic matching of patients and substance abuse treatment providers. Sterling and colleagues (2001) noted the existence of “equivocal findings of the effect that therapist and patient similarity plays in treatment outcome” (p. 1015) in substance abuse treatment programs and concluded that more research is needed. However, the panel believes that, when program staff generally reflects the demographics of the population served, patients are more likely to feel comfortable in the OTP. When multicultural representation among staff is limited, OTPs should find ways to communicate acceptance of diverse cultures and groups.

Programs with non—English-speaking patients should provide information in patients' first languages by employing staff members or interpreters who can communicate with patients. Federal and State resources are available for programs seeking literature in languages other than English. Community colleges, universities, and other institutions or agencies might assist in translating forms and pamphlets. Information about translation services is available via the Internet (visit www.atanet.org/bin/view.fpl/52076.html).

Flexibility in thinking, behavior, and attitudes.

Staff attitudes about MAT and opioid addiction can affect patient outcomes. Administrators should seek staff members who are free of rigid biases, are not judgmental, and do not have punitive attitudes toward patients (Bell 2000).

OTP staff members sometimes hold negative attitudes toward patients (Caplehorn et al. 1997) or MAT (Forman et al. 2001). At least one study has associated such attitudes with lower rates of patient retention and poorer patient outcomes (Caplehorn et al. 1998). OTP managers should be vigilant about monitoring staff attitudes and conduct inservice training to create or sustain appropriate attitudes about patients and MAT.

The verbal expressions used by OTP staff members can reflect how they feel toward patients. Treatment staff members, who might have absorbed society's antipathy toward people in MAT, sometimes use countertherapeutic language, for example, the phrase “dirty urine” to describe an unsatisfactory urine drug test (“positive test” is less judgmental). Staff should avoid terms suggesting the criminal justice system, such as “probation” or “probationary,” to refer to the status of patients doing poorly in treatment. “Termination” should be avoided in reference to patient discharge. Other preferred expressions in MAT include “patients” not “clients” and “dose tapering” or “medically supervised withdrawal” not “detox” in reference to withdrawal from treatment medication. Applying words derived from “toxin” to treatment medication suggests that the medication is a toxin; “detoxification” should refer only to withdrawal from substances of abuse.

Inclusion of recovering patients. The consensus panel believes that employing treatment professionals and support staff who are in recovery also adds valuable perspectives to treatment and provides role models for patients. OTP policies on hiring people who are in addiction recovery should be in writing and include procedures for addressing staff members who relapse. State regulations may establish a minimum abstinence period before an OTP can hire someone in recovery. Policies also must comply with Federal and many State laws prohibiting discrimination against people who are addicted (CSAT forthcoming b ). Staff members who are in recovery and their colleagues who have no addiction history should be treated similarly.

Staff Retention

Retaining staff is important for several reasons:

  • Stability of treatment staff may affect treatment outcomes.
  • High staff turnover can undermine relations with the community, funders, and others.
  • Investment in recruitment and training is lost when staff members leave.
  • Unfilled staff positions result in longer patient waiting lists.
  • Reducing staff turnover minimizes disruption to patients' treatment.
  • Accreditation standards place importance on the stability of OTP staff.

Factors that may contribute to high staff turnover include low salaries and benefits, negative stereotypes of MAT and its patients, job stress, excessive counselor workload, unreasonable operating hours, and unsafe OTP locations. Staff members can experience burnout when they work in isolation with difficult patients and inadequate support or feedback. Managers should take concrete steps to retain staff, including the following:

  • Establish and maintain clear policies and procedures, and apply them consistently.
  • Avoid excessive caseloads. Even the most professional, committed counselor struggles when the caseload is too large. Managers can use a monitoring system that focuses on the number of counseling hours a caseload requires, which can differ dramatically from the number of cases assigned per counselor, depending on the requirements of individual patients.
  • Encourage a team approach. Staff members usually feel less isolated and overwhelmed when a team makes treatment decisions. When a lack of cohesion exists, staff members risk burnout, disillusionment, or cynicism. A well-coordinated team also reduces the level of intrastaff disagreements about patient care and decreases the likelihood of “staff splitting,” when patients pit staff members against one another.
  • Encourage a culture of mutual respect through team cooperation, clear and effective communication, and inclusive, interdepartmental decisionmaking. Managers should hold regular staff meetings. Staff cooperation also can be fostered through training and retreats. The program director or manager should mediate disputes among staff members.
  • Establish job descriptions that clearly delineate roles, responsibilities, and lines of communication (Bell 1998), and review them annually with personnel.
  • Establish objective performance standards derived from job descriptions, and conduct regular performance evaluations that include feedback based on patient outcomes.
  • Establish regular consulting sessions among counselors, their supervisors, and other staff members. Supervisors should be well trained and supported.
  • Provide opportunities for professional training, either by onsite training or by permitting staff members to attend offsite training during work hours.
  • Encourage professional development by supporting staff certifications.
  • Establish personnel policies that demonstrate concern for staff well-being, including flexible work schedules to reduce stress.
  • Offer routine praise and recognition for staff contributions and achievements.

The forthcoming TIP Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT forthcoming c ) provides more information on supervision, and Newman (1997) provides information on the therapeutic alliance between patients and treatment providers.

Training

Training should be offered for all staff members, including secretaries, nurses, counselors, supervisors, and managers, to ensure a strong knowledge base so that staff members do their best and to affirm that all staff members are valued members of the treatment team. The importance of training has increased because accreditation standards require OTPs to provide continuing staff education, with many States requiring such education for OTPs to maintain licensure. OTPs should help professional staff members acquire education credits to maintain their licensure by offering onsite training, collaborating with other agencies for reciprocal training, or paying for educational leave or tuition.

At minimum, training should focus on the following areas:

  • Facts about MAT and the health effects of treatment medications. Educating OTP staff about the health effects of MAT medications and the value of remaining in treatment is essential. Some studies have revealed a high level of misinformation among OTP staff members about the health effects of maintenance medications (e.g., Kang et al. 1997). Other studies have shown that many staff members hold negative attitudes about MAT (e.g., Caplehorn et al. 1997), which negatively affect patient outcomes (Caplehorn et al. 1998). One way to address negative staff attitudes is to include successful patients in training (Bell 2000).
  • Up-to-date information about medications. Staff should be able to discuss medications with patients. Medical staff members should be able to assess patients and determine, with input from other treatment team members, which medication is most appropriate.
  • Up-to-date information about drugs of abuse . Training should ensure that staff members are knowledgeable about drug abuse trends in the community.
  • Up-to-date information about communicable diseases. Training should focus on both diseases commonly experienced by patients in MAT, such as hepatitis C, and emerging diseases in the community, possibly including tuberculosis or HIV/AIDS.
  • Skills training. Staff members should have access to generic skills training such as crisis management, communications, and problemsolving, as well as new evidence-based MAT treatments. They should have access to training about the populations the OTP serves, including cultural information and information about specific disorders.
  • Patient sensitivity training. The importance of emphasizing sensitivity to patient needs should be reviewed periodically. No matter how creative and naturally sensitive a staff member may be, factors such as burnout can affect how he or she responds.

A large OTP can tap into its own staff to provide training. A program physician might educate staff members about the etiology of addiction and effects of medications. A psychiatrist might distinguish primary mental disorders from those that are substance related and provide information on psychotropic medications. Therapists and social workers might teach behavior management techniques, parenting, and resource allocation. Nurses might provide training on gender and wellness, as well as the side effects of pharmacologic regimens. Consistent inservice training can help staff members understand the program's mission and the effects of MAT.

Federal and State agencies and professional associations offer seminars, courses, and workshops. SAMHSA's Addiction Technology Transfer Centers (ATTCs) offer an array of training events and resource materials (www.nattc.org). Some States offer training leading to certification for addiction specialists and counselors. Hospitals and large OTPs sometimes allow staff from smaller programs to attend their sessions. Professional societies, such as the American Society of Addiction Medicine, American Academy of Addiction Psychiatry, and Osteopathic Academy of Addiction Medicine, offer training for medical personnel in various therapeutic techniques. National counseling organizations, such as the Association for Addiction Professionals, and professional nursing societies also offer treatment courses.

OTP administrative, financial, clerical, maintenance, and custodial staff may lack direct treatment responsibilities, but they are very much part of the team. Reception staff members, often the first to speak with patients, play an important role. They should receive an orientation about MAT to ensure that they understand how the OTP operates so that they develop favorable attitudes about patients. If possible, all staff members should receive annual training in such areas as confidentiality requirements, cultural competence, prevention of workplace violence, and patient rights.

Medication Diversion Control Plans

Federal opioid treatment standards state that an OTP must maintain a current diversion control plan (DCP) that includes measures to reduce the possibility of medication diversion and assigns responsibility for control measures to medical and administrative staff members (42 Code of Federal Regulations [CFR], Part 8 § 12(c)(2)).

A DCP should address diversion of medication both by patients, who might sell or give their take-home medication to others, and by staff, who might steal medication or spill or otherwise waste it.

Reducing the Possibility of Diversion by Patients

Patients considered for take-home medication must meet Federal criteria. The medical director makes decisions about take-home medications (42 CFR, Part 8 § 12(i)(2)), and these decisions and their basis must be documented (42 CFR, Part 8 § 12(i)(3)). Staff should ensure that patients can store medications safely in their homes (42 CFR, Part 8 § 12(i)(2)(vii)). All take-home medication must be labeled with the OTP “name, address, and telephone number and … packaged in a manner that is designed to reduce the risk of accidental ingestion, including child-proof containers” (42 CFR, Part 8 § 12(i)(5)).

Callbacks (see chapter 5) help prevent patient diversion of take-home medication. Callbacks require OTPs to select patients at random to return to the OTP with their remaining take-home medication. A random-callback policy avoids patient complaints of being unfairly “picked on” by staff members. Programs also can require patients to undergo drug tests when they bring in their medications. OTPs should document that patients have been informed of their responsibilities regarding callbacks (e.g., how much notice they will receive beforehand) and about the consequences of failure to respond or of discrepancies in medication amounts. The OTP callback policy should be stated clearly in the program DCP.

A no-loitering policy is part of an effective DCP. The policy should be clarified at the beginning of treatment and enforced consistently. Extending OTP hours helps eliminate overcrowding and loitering. The OTP should include routine meetings with community leaders, attendance at neighborhood civic association meetings, and open communications with local law enforcement officials to help resolve community concerns.

Reducing the Possibility of Diversion by Staff Members

OTPs rely on the integrity of employees who handle U.S. Drug Enforcement Administration (DEA)-scheduled substances. Even so, protocols should be in place to reduce the risk that staff will divert medications. All scheduled substances should be accounted for rigorously and inventoried continuously. Receipt and dispensing should be noted in logbooks. Working stocks should be logged and tracked from receipt through dispensing and measured at the beginning and end of each workday. Measurements and daily reconciliations should be monitored by supervisors and checked periodically by dispensary managers. Any significant discrepancy should prompt an investigation. The dispensary manager, executive director, and medical director should follow up on investigation findings. The security of computerized records and systems also should be ensured to prevent employee theft of medication. Spills and other accidents should be reported immediately. Within the dispensary, employees should open the safe or work with scheduled substances only in the presence of other staff members. In matters of medication dispensing, OTPs must consult and comply with DEA regulations (Drug Enforcement Administration 2000).

The Community Effort

Community Opposition, Stigma, and the Importance of Community Relations

Community resistance to MAT has been chronicled for decades (e.g., Genevie et al. 1988; Joseph et al. 2000; Lewis 1999; Lowinson and Langrod 1975). The consensus panel believes that this resistance has been reduced since TIP 1, State Methadone Treatment Guidelines (CSAT 1993b ), was published, particularly through efforts to improve scientific clarity about opioid addiction, to affirm the efficacy and benefits of MAT, and to educate professionals and the public about MAT. The expanding patient advocacy movement effectively may be countering some stereotypes and misunderstandings about MAT. Some treatment providers have overcome community opposition—sometimes called not-in-my-backyard (NIMBY) syndrome—through outreach and educational efforts (e.g., Weber and Cowie 1995). Many prevention and treatment programs are becoming increasingly responsive to the needs of cultural and ethnic groups (i.e., more culturally competent). These successes provide models for effective community relations in other settings.

Despite progress, MAT remains stigmatized and controversial in many U.S. communities (Joseph et al. 2000). The association of MAT with substantial improvements in individual health and employment and with reductions in HIV risk and criminal behavior has been validated by research (e.g., Krantz and Mehler 2004; Mueller and Wyman 1997), but MAT remains misunderstood even among some health care professionals.

Sensationalized media coverage and successful NIMBY-type opposition have continued to delay or preempt the siting of new facilities (Lawmakers may restrict 2000; Shepard 2001; Sissenwein 2000; Zoning fight over Michigan 1998). Introducing MAT into communities is difficult without community support. However, the consensus panel believes that, since the early 1990s, the willingness of treatment professionals and patients; government officials; agencies representing health, mental health, addiction treatment, research, and criminal justice; and the general public to learn more about MAT and opioid addiction has increased. Organizations appear more willing to include OTPs in community health planning as well-regarded community services, but this effort remains a work in progress.

Good Community Relations

Good community relations are part of good treatment. When TIP 1 was published in 1993, Federal regulations guiding the operation of OTPs did not mandate efforts to improve community relations or educate the community. Transition in Federal oversight of substance abuse treatment from the U.S. Food and Drug Administration (FDA) to SAMHSA altered the Federal regulatory perspective, as reflected in SAMHSA regulations guiding OTPs (21 CFR, Part 291, and 42 CFR, Part 8 [Federal Register 66:4076–4102]). In the panel's view, this change in oversight is bringing OTPs into the medical mainstream, under the purview of SAMHSA, by establishing an OTP accreditation system similar to the requirements of other medical services. Furthermore, the new rules have codified SAMHSA's earlier guidelines for OTP accreditation (CSAT 1999b ), which recognize community relations, education, and stigma reduction as necessary operational elements. SAMHSA's approved OTP-accrediting organizations—including at this writing the Commission on Accreditation of Rehabilitation Facilities, Council on Accreditation for Children and Family Services, Joint Commission on Accreditation of Healthcare Organizations, National Commission for Correctional Health Care, State of Missouri Department of Mental Health Division of Alcohol and Drug Abuse, and Washington State Department of Social and Health Services Division of Alcohol and Substance Abuse—require that MAT providers demonstrate effective community relations and stigma-reduction efforts.

OTPs serve both patients and the community. They affect public health, education, and citizens' sense of well-being. Publicly funded OTPs often rely on community support. Moreover, MAT's placement within the medical and behavioral spectrum of health care affects relations with the payer community (Edmunds et al. 1997), including government and private insurers and managed care organizations. These connections increase the need for effective outreach to other community services and entities.

Overcoming Negative Community Reactions to OTPs

Joseph and colleagues (2000) reported that most community resistance involves concern about patient loitering, drug sales, and the diversion of methadone (see “Medication Diversion Control Plans” above). Adding alternative care models and longer acting pharmacotherapies to the services continuum can decrease loitering, illicit transactions, illegal parking, and other activities that increase community concerns. These options enable highly functioning patients who meet specific criteria to receive ongoing medical care and pharmacotherapy with fewer visits to the OTP. In the view of the consensus panel, incorporation of primary medical care, day treatment, and short-stay residential models into treatment options can affect community perceptions positively because patients involved in MAT are less likely to loiter near the OTP.

Facilities for onsite patient activities to limit outside loitering are beneficial. Having adequate onsite staff is equally important in avoiding and resolving community problems. Glezen and Lowery (1999) provide other practical guidelines for addressing community concerns about substance abuse treatment facilities.

Community opposition can be triggered when community groups believe that they have been informed or consulted insufficiently. OTP administrators should meet regularly with community leaders to ensure that all parties are heard. The physical appearance of facilities should be conceived carefully. The OTP should be clean and orderly to distinguish it as a professional, responsible facility. Surrounding property (e.g., entrances, sidewalks, fencing, trash receptacles, signs) and OTP hours should not impede pedestrian or vehicle traffic. The availability of public transportation is important when considering an OTP's location (Glezen and Lowery 1999).

Some communities have found mobile treatment facilities more acceptable than fixed-site OTPs. Mobile services allow more people addicted to opioids to be treated without confronting NIMBY reactions. Pilot studies have confirmed their success (e.g., Gleghorn 2002; Ho 1999).

Whether institution or community based, fixed site or mobile, OTPs should be situated, designed, and operated in accordance with accreditation standards, Federal guidelines, and State and local licensing, approval, and operating requirements. The consensus panel recommends that MAT providers thoroughly know and understand their communities and provide the levels of input and support requested by community leaders, representatives, and constituents to site a facility and develop services that are responsive to community needs.

Community Relations and Education Plan

Each OTP should develop a community relations and education plan that extends from its general mission statement. Staff and patients should be part of a multifaceted, proactive effort to educate community entities affected by OTP operations, including the medical community, neighbors, and agencies and individuals providing support services. Although program activities differ in specificity and scope, a community relations plan should address the following:

  • Learning about the community, its structures, and directly affected constituents
  • Delineating the community relations mission, goals, protocols, and staff roles
  • Initiating and maintaining contact with community liaisons
  • Educating and serving the community
  • Establishing effective media relations
  • Developing policies and procedures to address community concerns about the OTP
  • Documenting community contacts and community relations activities.

The forthcoming TIP Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT forthcoming c ) provides additional information on developing a community relations and education plan.

Delineating the community relations, mission, goals, protocols, and staff roles

In the opinion of the consensus panel, community relations and education should be an inherent function of OTP staff. OTPs with sufficient resources might employ or retain a community relations professional to establish links with local leaders, coordinate staff and patient participation in community activities, determine who will represent the OTP at local events and when, and arrange speaking and other community education activities. If funding for dedicated community relations staff is unavailable, the OTP should develop an internal plan for community relations and education. If the OTP is affiliated with a larger institution, it should ensure full cooperation from the parent organization's community relations department.

Initiating and maintaining contacts with community

Personal contact with community leaders permits open dialog, information sharing, and discussion of community developments, needs, and problems. Members of the consensus panel agree that such communication fosters trust in the OTP. Moreover, personal contact with community representatives

  • Encourages leaders to use the OTP as a resource on addiction and related health issues
  • Promotes MAT's public health benefits
  • Highlights the value of the OTP for community members with addiction- and other health-related problems.

Regular contact with key liaisons should include onsite and offsite meetings. Demystification of MAT occurs when treatment is viewed firsthand. Community members who visit OTPs can observe operations and speak with staff and consenting patients, assuming OTP operation is unimpaired and patient confidentiality is maintained.

Educating and serving the community

Information about MAT and the OTP can be presented through various media. Brochures and factsheets can be developed that cover the program's mission, its board membership, the types of services offered, and data on patients. Occasional press releases can notify the public about specific services, activities, accomplishments, announcements, improvements, or events. Highlights of an OTP's annual report can be shared with community officials, liaisons, and the general public. A program newsletter highlighting health and addiction issues and containing OTP information and patient and staff articles can be distributed. The Internet has enabled the public to view more information about opioid addiction and MAT. Government and private organizations, professional journals, sponsoring or research institutions, provider coalitions, advocacy organizations, and individual OTPs and patients offer Web sites that discuss MAT options, policies, services, and developments and frequently link to related Internet sites. Some examples are the following:

Some OTPs have developed speakers' bureaus for local events. Interested, successful patients, patient advisory committees, patient family groups, and OTP alumni can be promoted as potential speakers. Advocacy groups are becoming increasingly instrumental in empowering patients as active participants in public relations, community outreach, and program support initiatives and in local, State, and national community education efforts.

OTPs should take an aggressive, proactive stance in community projects and events, including some not directly tied to MAT. Sponsoring conferences, forums, exhibits, and awareness events establishes an OTP as a leader, resource, and participant in the community. Staff members with community development expertise can support other organizations in advocacy, promotional, and support efforts. OTPs can provide noninvasive medical-screening services (e.g., blood pressure, pulse, and weight checks; nutritional advice) to community members. Hospital-based OTPs and those licensed to provide primary medical services can furnish immunizations to community residents. OTPs can donate surplus office items or other products to organizations or groups. Consenting patients and staff can organize projects such as community cleanups and neighborhood patrols. Highly visible community services demonstrate an OTP's commitment to community improvement and counter negative stereotypes.

OTPs also serve communities by providing addiction treatment for community residents and offering jobs for qualified residents. The panel recommends that efforts be made to recruit and hire responsible, qualified personnel from the local community.

OTP administrators and staff can be active as representatives, speakers, or planners at professional conferences and as members or leaders in professional and community coalitions, including advisory councils. Such affiliations augment community relations efforts through increased professional education and public awareness, providing an opportunity to exchange information with and counter MAT stigmatization among other treatment professionals. These forums also may present community relations models that can be adapted effectively by OTPs. Staff participation on local planning or development bodies can contribute to community improvement, particularly in social and health services.

OTPs are encouraged to participate in national SAMHSA campaigns, for instance, by supporting National Alcohol and Drug Addiction Recovery Month or sponsoring events to emphasize that addiction recovery is possible and facilitating MAT as compassionate and a sound investment.

Establishing effective media relations

Print, broadcast, and Internet media play critical roles in reporting and educating, as well as influencing public opinion. Local and national media differ widely in their portrayals of opioid addiction, MAT, and people addicted to opioids. These differences reflect a combination of factors including journalistic integrity, reporting style and philosophy, political leanings, regional influences, and business considerations. News accounts and other depictions of MAT often seem limited, misinformed, and negative.

Nevertheless, many noteworthy, responsible features have been produced, providing important, accurate information to the public about the science and policy of opioid addiction and treatment (e.g., Barry 2002; Hammack 2002; Moyers and Moyers 1998). Although treatment providers sometimes are disciplined to resist media exposure in order to protect patient confidentiality and avoid misrepresentation, the consensus panel believes that successful media outreach enhances an OTP's image, improves understanding of a program's mission and methods, and generates supportive public policies. Media outreach can demystify treatment, counteract stigma, and improve fairness of coverage.

OTPs operating in larger institutions can work with institutional public affairs professionals. Administrators should respond to or address members of the local press when necessary, as an outgrowth of providing service to the public. The panel believes that providing quality treatment and operating OTPs responsibly position programs to interact openly and confidently with the media.

The forthcoming TIP Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT forthcoming c ) provides additional details for establishing media relations.

Developing policies and procedures to address and resolve community concerns

The best intentions to educate and serve the community are undermined if they are not followed up to resolve problems and concerns about OTPs. The panel recommends that detailed strategies and procedures be in place to respond to sources of community anxiety and hostility.

It is essential for OTPs to take steps—possibly including staff or security patrols of the community, visits with local merchants or representatives, and establishment of a community hot line—to curtail loitering, drug sales, and the diversion of methadone before they prompt community complaints. These patrols should emphasize observation, not intervention. Logs summarizing observations should be maintained. Staff visibility reminds patients of the negative effect of loitering and similar behavior and demonstrates to neighbors that OTPs actively are committed to community safety and improving quality of life.

Patients observed loitering should be counseled, and their treatment plan should be revised to address this behavior. OTPs with loitering problems should investigate day treatment programs to provide increased treatment intensity. Discharge should be considered for patients observed in illegal transactions or medication diversion. Although discharge is counter to the mandates of voluntary treatment, patients who are unconcerned about an OTP's community acceptance might be better served by a facility equipped to handle their behaviors.

Decisions to discharge patients for loitering should balance consequences for the individual patient and public health against the need to ensure a stable OTP environment and maintain community-based services open to all patients. The panel recommends that loitering policies that culminate in patient discharge should first provide for progressive discipline and intervention and incorporate patient rights to a fair hearing and treatment (see discussion in Appendix D).

Community representatives should have OTP contact information to report problems involving patients. However, OTPs should clarify that they cannot assume a police role; in emergency and criminal matters, the police should be contacted first, not the OTP. Effective liaison with local law enforcement personnel is critical to OTP relations with the community. Although police officers are generally supportive, OTPs should correct any misconceptions police personnel have about OTPs. Patients should be differentiated from people actively using illicit drugs or abusing prescription drugs, and law enforcement personnel should be informed about OTP operations, with the understanding that police and OTPs share a purpose—addressing substance abuse in the community. Other community problems (e.g., drug sales, unsafe community conditions) identified during staff tours can be reported to law enforcement authorities. Local officers should be encouraged to contact the OTP about problems involving patients. Confidentiality remains paramount, so this relationship should be delineated carefully.

Documenting community contacts and community relations activities

Programs should document their efforts to establish productive community contacts and resolve community concerns. A database should be developed and updated (e.g., the number and nature of community complaints received and the program's response). Communications should be logged, and staff participation in community events should be summarized. Letters and communications substantiating community complaints and the program's followup should be on file. Records should be kept of staff participation in professional and community conferences, articles published in professional journals, and contributions to local news organizations.

Using this information, OTP administrators regularly should evaluate community relations efforts. Such reviews can identify organizations excluded from previous efforts or problems requiring revision of program policies or practices.

OTPs and National Community Education Initiatives

OTPs should be aware of and involved in the national dialog and efforts to promote MAT, improve and disseminate information about opioid addiction, and partner with other national organizations and agencies in public relations and community education efforts. In addition, OTPs should build on and contribute to these national initiatives within their communities.

Numerous resources are available to educate the public about MAT and assist OTPs with public relations. National organizations such as AATOD and the American Society of Addiction Medicine hold national and regional conferences that bring together treatment providers, policymakers, researchers, and advocates to share knowledge and discuss how to advance national drug policy and expand effective treatment models, including strategies to improve public relations and reduce stigma. Focused training sessions also provide critical information, for example, to encourage physicians not associated with OTPs to enter into MAT or explain how to improve their current treatment of patients who are opioid addicted. Other sessions may focus on improving staff attitudes and the treatment system regarding implementation of accreditation (Parrino 2001).

NIDA has invited professionals, practitioners, policymakers, and the public to sessions focused on merging research with everyday clinical practices in community-based drug treatment programs. For example, one conference, Blending Clinical Practice and Research—Forging Partnerships To Enhance Drug Addiction Treatment, held in April 2002 (National Institute on Drug Abuse 2002), incorporated a special forum focused on the media's role in presenting addiction treatment and research issues in the context of science reporting.

Publications and other information resources, often available without charge or at low cost, highlight stories about the life-changing effects of MAT (e.g., American Methadone Treatment Association, Inc. 2000; CSAT 2000a ). To educate drug court judges and practitioners, AATOD has produced Drug Court Practitioner Fact Sheet (Parrino 2002). DEA and AATOD developed the first DEA-specific guidelines for OTPs, Narcotic Treatment Programs: Best Practice Guideline (Drug Enforcement Administration 2000), which is distributed nationally to MAT providers and addresses the safekeeping of and proper accountability for controlled opioid treatment medications. The Center for Substance Abuse Treatment's (CSAT's) Siting Drug and Alcohol Programs: Legal Challenges to the “NIMBY” Syndrome (Weber and Cowie 1995) provides assistance with problems related to siting treatment facilities including OTPs.

In 1999, SAMHSA convened expert panels and hearings to examine critical issues affecting the National Treatment Plan Initiative to improve and extend alcohol and drug treatment to all communities and people in need in the United States (CSAT 2000b ). This extensive exploration documented widespread stigma and bias and its effect on public support and policy, such as delaying the acknowledgment of addiction as a disease; inhibiting prevention, care, treatment, and research efforts; and diminishing the life opportunities of those stigmatized. Changing the Conversation—Improving Substance Abuse Treatment: The National Treatment Plan Initiative (CSAT 2000b ) affirmed the value of mass media public health education campaigns, comprehensive community-based health communications, media advocacy, and the application of commercial marketing technologies to programs to change social attitudes. This publication proposed a unique national approach to reducing stigma that incorporates science-based marketing research, a social marketing plan, facilitation and support of grassroots efforts by the recovery community, and promotion of the dignity of people in treatment.

NIDA's Community Epidemiology Surveillance Networks—multiagency work groups with a public health orientation—study the growth and development of drug abuse and related problems in communities nationwide. The primary objectives are to describe drug abuse patterns in defined geographic areas, identify changes in these patterns, detect emerging substances of abuse, and communicate and disseminate information so that appropriate community agencies and organizations can develop prevention and treatment strategies.

As government and provider-based organizations mobilize national efforts, patients in and providers of MAT, along with other interested citizens, have been encouraged to unite and organize, educate health providers and their communities, and actively engage in public relations initiatives and other advocacy efforts that advance knowledge and change attitudes about MAT. CSAT's Recovery Community Support Program assists advocacy organizations in promoting their messages (www.samhsa.gov/search/search.html).

Evaluating Program and Staff Performance

Why Program Evaluation and Performance Improvement Are Important

Recent developments lend urgency to the development of good program evaluation and performance improvement procedures in OTPs. Federal regulations (42 CFR, Part 8 § 12(c)) and guidelines (Guidelines for the Accreditation of Opioid Treatment Programs [CSAT 1999b ], Section III, Part C) require OTPs to establish performance improvement programs based on ongoing assessment of patient outcomes. SAMHSA-approved accrediting bodies (listed above) require performance improvement objectives in their guidelines. Many Single State Agencies and managed care organizations also require programs to collect and analyze outcome data. OTPs are pressed increasingly to demonstrate their effectiveness and efficiency. Administrators and staff must implement program evaluation processes that help meet these demands. Program evaluation contributes to improved treatment by enabling administrators to base changes in services on evidence of what works.

Beyond the general information below about program and staff evaluation in an OTP, readers who want to know more about the specific questions to ask and the considerations that should be made during evaluation should refer to Demystifying Evaluation: A Manual for Evaluating Your Substance Abuse Treatment Program—Volume 1 (CSAT 1997a ).

Background

MAT is one of the most frequently studied addiction therapies, but evaluating program performance based on patient outcomes is relatively new to OTPs. Previous regulations (21 CFR, Part 291), which gave regulatory oversight to FDA, stressed process evaluation based on compliance with recommended treatment procedures. Process evaluation does not ask whether a recommended process has worked, only whether it has been followed.

The Institute of Medicine (IOM) was among the first organizations to recommend an outcome evaluation system for OTPs based on “direct and valid measures of reduction in opiate and non-opiate drug use and improvement in positive social function” (Institute of Medicine 1995, p. 228), which could be used by OTPs, regulatory and funding agencies, and researchers. IOM looked to the Methadone Treatment Quality Assurance System (MTQAS)—a NIDA-funded effort lasting from 1989 to 1998—to develop a performance-based reporting and feedback system as the foundation for a formal performance improvement system in OTPs. MTQAS was never fully adopted because most OTPs lacked the “focused technical assistance” (Ducharme and Luckey 2000, p. 87) required to translate feedback into action. Eight States participated in the MTQAS study, but only Massachusetts and North Carolina are using elements of the system at this writing. Many OTPs appear to be on their own in conducting program evaluations that comply with accreditation and State mandates.

Outcome and Process Evaluation

Both performance outcome and process evaluations have value, but they answer different questions and require different approaches. Performance outcome evaluation focuses on results, for example, patient progress. Process evaluation focuses on how results were achieved—the active ingredients of treatment. The forthcoming TIP Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT forthcoming c ) and Demystifying Evaluation: A Manual for Evaluating Your Substance Abuse Treatment Program—Volume 1 (CSAT 1997a ) describe and contrast these two types of evaluations.

Outcome evaluation in OTPs

Outcome evaluation in OTPs focuses on patients and their progress during or after participation in MAT. It should focus on progress markers (see chapter 7) and behavioral improvements as guideposts and avoid terms such as “success” and “failure.” Even small improvements may be significant. For example, an outcome evaluation might measure drug use (as quantified by drug testing) in patients who have spent various times in treatment. Such a study can set a baseline and provide a benchmark to evaluate the effects of changes in program practices, for example, prescribing individually appropriate dosages for patients. Researchers measure many variables to assess MAT treatment outcomes, including drug use, criminal activity, medical problems, vocational skills, employment, family relationships, and social activities. The measures selected by an OTP should agree with the target behaviors specified in program goals and objectives. For example, evaluation of a treatment initiative designed to reduce substance use, decrease criminal involvement, and increase job skills should be based on data in those areas. An OTP can measure other outcomes (such as patients' use of emergency rooms for medical care) to assess whether it has had other effects on patient behaviors or the community.

SAMHSA's accreditation guidelines list the following treatment outcomes as examples of what might be measured by OTPs:

  • “reducing or eliminating the use of illicit opioids, other illicit-drugs, and the problematic use of prescription drugs
  • reducing or eliminating associated criminal activities
  • reducing behaviors contributing to the spread of infectious diseases
  • improving quality of life by restoration of physical and mental health and functional status.” (CSAT 1999b , p. 7)

Outcome evaluation also can be focused narrowly; it can assess the results of particular treatment approaches on patient behavior. For example, an OTP might provide patients with bus tokens to defray transportation costs to and from treatment (some cities fund this kind of intervention). After a certain period, the OTP could evaluate whether providing bus tokens improved program attendance. This simple evaluation would require only attendance data. The most reliable evaluation uses a control group for comparison (e.g., a group of patients who must purchase their bus tokens), but this is not always practical or ethical.

Process evaluation

Process evaluation describes what is happening in the treatment program: what kind of treatment, who conducts the sessions, how many and how long the sessions are, and where the sessions occur. A process evaluation documents what actually happens during an intervention, how a new program or initiative is put into operation, who the players are and what steps they take, specific problems and barriers encountered, strategies used to overcome these problems and barriers, and necessary modifications to the original plan. Process evaluation also may describe what is happening within the “black box” of the treatment program. Black box, a commonly used term in this context (Ball and Ross 1991, p. 5), refers to the unknown quality of some treatment programs—that is, the fact that patients go into a program as known entities and come out with certain measurable outcomes, but what actually occurs in treatment is not readily apparent. Process evaluation permits others to replicate methods that achieve their goals by evaluating the factors responsible for those achievements. A process evaluation can lead to development of a manual describing the theories and practices of an OTP to guide others. Implementation analysis should document a process fully. It is well suited to documenting an OTP's efforts in community relations, which is required in the accreditation process.

A process evaluation can serve as a management tool for program development if it is used to assess the strengths and weaknesses of a program and suggest ways to improve operations. A process evaluation helps administrators understand how program resources, including both staff and time, are used and can lead to improved resource allocation. Process evaluation is useful for examining whether OTP procedures are congruent with its stated goals. For example, if a goal is to facilitate patients' use of peer support groups, the OTP could measure how often meetings of such groups are held on site, how often counselors provide patients with lists of local meetings, or whether patients actually receive interventions as intended. For example, an OTP intending to individualize care and match services to patients' needs may decide to use the Addiction Severity Index (ASI) as a guide to treatment planning because research shows that the ASI indicates effective patient—service matches (McLellan et al. 1997). A process evaluation might examine the degree to which treatment plans and service delivery were congruent with the needs identified by the ASI. If the program finds a lack of congruence, it can make corrections through training and supervision. The process evaluation also can measure the intensity and duration of services received by patients.

Resources for Program Evaluation and Performance Improvement

CSAT has published a comprehensive, detailed guide to program evaluation that provides a modularized learning approach, including exercises, for designing and conducting evaluations. Demystifying Evaluation: A Manual for Evaluating Your Substance Abuse Treatment Program—Volume 1 (CSAT 1997a ) is available from SAMHSA's National Clearinghouse for Alcohol and Drug Abuse Information at 800-729-6686 or www.ncadi.samhsa.gov.

For OTPs that want to use cost accounting as a form of program evaluation, NIDA has developed a manual based on a cost-procedure-process-outcome analysis model that has been well researched and tested in substance abuse treatment programs. Measuring and Improving Costs, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs—A Manual is available at www.nida.nih.gov/IMPCOST/IMPCOSTIndex.html.

The Institute of Behavioral Research at Texas Christian University has carried out a substantial body of research on treatment process and outcomes (Simpson, D.D., et al. 1997a , 2000). The institute's findings and experience in adapting assessments to field settings have guided development of a set of core instruments that are available at www.ibr.tcu.edu/pubs/datacoll/coresetforms.html. The Web site also contains useful program evaluation forms for gathering OTP data, including the organization's readiness to change and patient satisfaction with treatment.

United Way of America has developed an Outcome Measurement Resource Network that is available through national.unitedway.org/outcomes.

The Change Book, a guidebook for organizational change in OTPs, is produced and distributed by the National ATTC, which can be reached at 877-652-2882 or www.nattc.org/resPubs/cbResources.html#cb.

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