Evidence based Practices

Size: px

Start display at page:

Download "Evidence based Practices"

Margery Todd
5 years ago
Views:

1 Evidence base Practices Adjunct Professor of Psychology, Western Carolina University President, Evince Clinical Assessments Evidence based Treatment Utilize treatment models documented to be effective in controlled clinical research with inclusions/exclusions Question of whether the model is (or can be) implemented with fidelity No guarantees that it will work in routine clinical practice No verification of outcomes The Evidence? Often based primarily on reductions in substance use Substance use is not part of the definition of remission in the DSM 5 Outcomes similar to those documented from good programs 20 years ago Methodology often lacks rigor Arbitrary Metrics Reliably measured Scientifically valid Irrelevant to the real world Reference on arbitrary metrics: Kazdin, A. E. (2006). American Psychologist, 61(1), Addiction Treatment Examples: Average days of use in past days Scores on a variety of psychological instruments Arbitrary Metric Example Programs A and B each treat 100 individuals Program A: Before treatment average days of use = 25 After treatment average days of use = 10 Program B: Before treatment average days of use = 25 After treatment average days of use = 8 Which program has the better outcomes? Arbitrary Metric Example Real world results: Program A: in sustained remission; minimal change Program B: Zero remission: All 100 still using but 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? 1

2 Lack of Methodological Rigor Use of arbitrary metrics Assumption that randomization equalizes everything Lack of diagnostic and severity documentation for all conditions Failure to account for services outside of the research protocol Assumption of a one size fits all approach no individualized services Hypothetical Issues from Project MATCH Different patients may require different approaches or emphasis irrespective of the general program model Motivational enhancement may be needed for those with low motivation to change in 12 Step or CBT programs 12 Step supports may be more important for those with no current support in MI and CBT programs Other Problems with Research Failure to address appropriately the range of clinical severity for substance use and mental health conditions Severity and prognostic indicators are virtually never the primary focus of research Assessment of the specific characteristics defining conditions and implications for treatment needs and prognosis is lacking Use of imprecise terms or terms lacking objective or empirical definition Fallacy of Best Practices There is no such thing as a best practice appropriate for everyone Individualized treatment, or client informed treatment, requires assessment findings coupled with outcome results to tailor treatment to the individual Obtaining improved results from treatment requires ongoing monitoring that combines assessment and outcome data to determine what works best for whom in general What Patients Want Validation presence of a condition warranting treatment/attention Assurance the condition is treatable Hope a positive outcome is both possible and likely Action plan logical, realistic, & acceptable What Clinicians Need Diagnosis you cannot effectively treat what you cannot identify Severity & Complications nature & scope of conditions/complications Prognosis identification of differential needs and expectations Action Plan empirically logical, realistic, & acceptable 2

3 FIT from OATS Fact Indicated Treatments from Outcomes & Assessment Informed Treatment Strategies Outcomes informed Treatment Monitor baseline and initial relevant outcomes for all clients outcomes can be clinical and/or societal Monitoring done during typical continuum of care ( primary + aftercare) Uses information already required for quality care Retrieval of data for analyses only additional requirement Assessment informed Treatment Detailed assessment findings not just a general diagnosis Assessment of both SUD and MHD Documentation of demographic and clinical risk indicators Retrieval of data for analyses and linkage to outcome findings The Challenge A wealth of practical research and evaluations can be done in the course of routine practice Electronic records, if properly designed, can provide a foundation for such research and evaluation with little effort or expense How? Consistent and objective assessment measures Routine documentation of treatments delivered, treatment response, and Document initial outcomes (6 mo. from intake) Substance Use Disorder Criteria 1.Use in larger amounts or longer than intended 2. Desire or unsuccessful effort to cut down 3. Great deal of time using or recovering 4. Craving or strong urge to use 5. Role obligation failure 6. Continued use despite social/interpersonal problems 7. Sacrificing activities to use or because of use 8. Use in situations where it is hazardous DSM 5 SUD Criteria continued 9. Continued use despite knowledge of having a physical or psychological problem caused or exacerbated by use 10.Tolerance 11. 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 3

4 Sustained Remission No positive diagnostic findings (other than craving) for 12 consecutive months Substance use is NOT part of the remission definition This remission definition is appropriate for both misuse and chronic addiction Possible levels of outcome: 1) abstinence without problems; 2) some use without problems; 3) use with sub diagnostic problems; 4) meets current diagnosis Remission vs. Recovery Remission is clearly defined by the DSM 5: no problems irrespective of continued use Recovery has many definitions The concept of recovery tends to involve much more than remission Treatment is typically not reimbursed for some aspects of recovery e.g., serenity, interpersonal relationships, employable, etc. Payment for treatment is based primarily on achieving remission not recovery DSM 5 CRITERIA Differentials All criteria are not equal in implications Some criteria are found almost exclusively among those in 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 Distribution of Generic Positive Alcohol Criteria for 6,871 MALES DSM IV TR Designations No Dx DSM 5 Designations Mild Moderate to Severe Pop. Total Compulsion 0% 1% 99% 21% Preoccupation <1% 3% 97% 20% Rule setting 1% 4% 95% 21% Role fulfillment <1% 3% 96% 25% Sacrifice activities <1% 3% 97% 23% Withdrawal 1% 3% 96% 19% Time spent using 1% 7% 92% 28% Distribution of Generic Positive Alcohol Criteria for 6,871 MALES DSM IV TR Designations No Dx DSM 5 Designations Mild Moderate to Severe Pop. Total Unplanned use 2% 9% 89% 27% Consequences 3% 10% 87% % Conflicts, interpersonal 4% 13% 83% 34% Tolerance 13% 11% 76% 33% Dangerous use 9% 15% 76% 36% Legal problems 10% 14% 76% 26% To relieve distress 6% 10% 84% 20% Distribution of Generic Positive Alcohol Criteria for 801 Females DSM IV TR Designations No Dx DSM 5 Designations Mild Moderate to Severe Pop. Total Compulsion 0% 0% 100% 18% Preoccupation 1% 1% 98% 21% Rule setting 0% 2% 98% 24% Role fulfillment 1% 5% 94% 26% Sacrifice activities 1% 2% 97% 24% Withdrawal 0% 2% 98% 20% Time spent using 0% 2% 98% 26% 4

5 Distribution of Generic Positive Alcohol Criteria for 801 Females DSM IV TR Designations No Dx DSM 5 Designations Mild Moderate to Severe Pop. Total Unplanned use 3% 8% 89% 31% Consequences 3% 10% 87% 32% Conflicts,Interpersonal 3% 10% 87% 33% Tolerance 10% 5% 85% 32% Dangerous use 6% 8% 86% 29% Legal problems 6% 12% 82% 23% To relieve distress 6% 9% 85% 32% DSM 5 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 THE BIG FIVE CRITERIA Reflect components of the concept of loss of control inability to moderate use The basic Big Five pattern holds for alcohol, cannabis, and cocaine May indicate individuals who are distinct from those with milder forms of SUD Abstinence is most likely to be essential for these individuals to achieve remission Sample of Alcohol Diagnostic Documentation Alcohol Diagnosis Diagnostic Criteria Case 1 Severe X X X X X X X X Case 2 Mild X X X Case 3 Moderate X X X X X Case 4 Moderate X X X X X Big Five criteria underlined Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes For a given individual, the lines of this matrix would designate findings for different substance categories CASE 3: Positive DSM 5 Criteria 3. Great deal of time using 10. Tolerance 1. Unplanned use: more or longer use 8. 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 Criteria 1. Unplanned use: more or longer use 2. Desire/efforts to cut down 4. Craving/compulsion to use 5. Role obligation failures 7. Sacrificing activities to use Conclusions Loss of control indicated Positive on 4 of the Big Five Abstinence likely required for recovery 5

CLINICAL IMPLICATIONS Most of those in the mild designation can probably benefit from moderation and related harm reduction strategies Those in the severe designation will require more intensive and

designation with positive Big Five findings will require a more intensive and longer continuum of care to achieved treatment effectiveness Persons in the mild designation typically will benefit from

6 CLINICAL IMPLICATIONS Most of those in the mild designation can probably benefit from moderation and related harm reduction strategies Those in the severe designation will require more intensive and extended services where abstinence is essential to remission The moderate group may contain cases that fit the mild or severe characteristics CLINICAL (Medical) NECESSITY Persons in the severe designation with positive Big Five findings will require a more intensive and longer continuum of care to achieved treatment effectiveness Persons in the mild designation typically will benefit from brief interventions to achieve treatment efficiency Each treatment plan can be informed by prior empirical outcome data Identifying Other Differential Needs and Relapse Risks ASAM Criteria Dimension 5: Relapse continued use/problem potential Defining the Case mix: The Population Served Clinical severity and prognostic indicators or scales and their relative prevalence in a treatment population Influences treatment type and duration required to produce outcome goal Frames expectations for treatment Levels the playing field for making program comparisons Demographic Risk Scale Less 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% Demorisk and Program Placement Demographic Risk Scale Score Percent by Program Type Inpatient N = 10,526 IOP N = 2,633 6

Demorisk and Outcome by Program Percent Abstinent at 12 Months 70 Inpatient IOP 20 Demographic Risk Scale Score Demographic Risks Do not appear strongly related to treatment placement Significantly

diagnoses Use of 2+ substances in past week Use of a needle to inject drugs Four or more indications of conduct disorder as an adolescent Arrested in the 12 months preceding admission Three or more

Program Type 70 20 10 0 Clinical Risk Scale Score * Inpatient IOP * Small Cell Size Clinical Risks Residential programs have greater proportion with higher clinical risk Generally residential

7 Demorisk and Outcome by Program Percent Abstinent at 12 Months 70 Inpatient IOP 20 Demographic Risk Scale Score Demographic Risks Do not appear strongly related to treatment placement Significantly related to probability of remission irrespective of placement Two or more risk factors appear related to higher relapse for IOP than residential placement Clinical Risk Scale Two or more dependence diagnoses Use of 2+ substances in past week Use of a needle to inject drugs Four or more indications of conduct disorder as an adolescent Arrested in the 12 months preceding admission Three or more considered as highest risk Clinical Risk Scale by Program Percent of Cases by Program Type Clinical Risk Scale Score Inpatient IOP Outcome and Clinical Risk 12 month Abstinence by Risk and Program Type Clinical Risk Scale Score * Inpatient IOP * Small Cell Size Clinical Risks Residential programs have greater proportion with higher clinical risk Generally residential outcomes are slightly better than IOP for higher risk The few IOP cases having highest clinical risk scores may be atypical or may have other strengths Greater clinical risk score is related to poorer outcomes irrespective of program placement 7

8 mo. Outcome Abstinence by Demographic and Clinical Risk Clinical Risk Scale Score Demographic Risk Score 3 or Demographic & Clinical Risk Demographic and clinical risk indicators appear to contribute independently to outcomes Demographic risk appears as important as clinical risk Both need to be considered in treatment planning and determining the case mix of a treatment population Other Differential Treatment Plans Based on ASAM Dimensions 4 & 6: Readiness to Change & Recovery Environment ASAM Example CASE 1: Dimension 4: Denial of problems Very resistant to the requirements of treatment No realistic commitment to recovery Dimension 6: Family very supportive of recovery Best friend also supportive of recovery Plan: Motivational enhancement a priority Explore engagement of family and friend to support treatment effort ASAM Example CASE 2 Dimension 4: Highly motivated to change Demonstrates understanding of addiction Willing to engage in peer support groups Dimension 6: Only friends are heavy users/drinkers Some close family members may have SUD Plan: Develop strategies for avoiding old friends Develop strategies to deal with family Stress engagement with support groups CLINICAL CONTINUOUS IMPROVEMENT COMPONENTS Patient Assessment Intake and ongoing assessments Outcomes Remission Societal benefit measures Financial benefit measures Treatment Plan Define problems Treatment priorities Treatment placement Treatment Response/Progress Biopsychosocial treatment Process measurements Adjustments to treatment plan as needed 8

DSM-5 AND ASAM CRITERIA. Presented by Jaime Goffin, LCSW

DSM-5 AND ASAM CRITERIA. Presented by Jaime Goffin, LCSW DSM-5 AND ASAM CRITERIA Presented by Jaime Goffin, LCSW MODULE 1: GOALS & OBJECTIVES What is your experience with using ASAM and DSM 5 criteria? What are your learning expectations for today? GOAL FOR