Dr. John Dyben, DHSc, MCAP, CMHP|Chief Clinical Officer
Today we understand substance use disorders and addictions better than we ever have, and yet, we have so much more to learn. According to the National Institute on Drug Abuse (NIDA), as of 2018, there were around 14,500 facilities in the US treating addiction. One would think that with this level of work happening across the country, we must be learning and improving care all of the time. Unfortunately, this is not the case. How can we treat patients more effectively?
In health care, improvements are made only when a disciplined approach of measurement is applied.
This means first that the problems and their desired outcomes must be defined. Second, the interventions or methods that will be used to achieve the desired outcomes must be established. Third, the outcomes must be measured and objectively studied. Finally, the interventions should be modified as needed, based on data, in order to improve those outcomes.
And then we repeat this process again, and again, and… well, you get the picture.
Medical centers and hospitals have been reporting on outcome measures for years. This data has been studied and has driven medical advances that have vastly improved that domain of the healthcare system. Unfortunately, behavioral healthcare, and especially addiction treatment as a field, has been lax in this area resulting in fewer advancements and a great deal of stagnancy.
So, what does the field of behavioral healthcare need to do in order to get “unstuck” and truly move in the direction of improving overall outcomes for its patients? Four actions are required: measure, analyze, refocus, and repeat. Let’s look closely at each one of these.
There are two very broad yet equally important types of measurement in the provision of healthcare: measurement-based care (MBC) and outcome studies. MBC measures how patients are presenting and responding to treatment during the treatment process. Outcome studies look at how a treated condition improved or didn’t improve after treatment concluded.
For example, MBC in a diabetes clinic would measure a patient’s blood glucose to understand their illness, to establish necessary interventions like insulin administration, and to measure how those interventions are working with the patient so doctors can modify the treatment plan as needed. An outcomes study would compare the patient’s illness before vs. after treatment to measure the effectiveness of their program.
In the actual case of the diabetes clinic above (Haslacher et al., 2018) researchers found that 30-40% of the patients who participated had significant improvement at the end of the three-week program, which was considered a good percentage in this study. In analyzing the outcomes though, the providers looked not only at the end results, they also observed a multitude of factors in order to try to better understand why a particular patient improved or did not. In this research example, they found that a combination of medication compliance along with lifestyle changes and positive peer pressure were all important in improving a patient’s health condition.
The results of measurement and analysis should be used to refocus treatment as needed. If a doctor measures blood pressure in a patient and finds the patient has mild hypertension, the doctor may recommend a change in diet and a program for weight loss. If subsequent measurements of blood pressure show the patient’s hypertension is getting worse, the doctor will refocus the intervention and likely add a medication. If outcome studies show poor results with the prescribed medication, the doctor may refocus by changing to a different medication.
In the same way a medical practitioner would never take one blood pressure measurement and base all the patient’s treatment on that single assessment, the process of improving treatment and overall care requires repeating this cycle of measuring, analyzing, and refocusing the plan of care without end.
What should this process for MBC and research look like in behavioral healthcare and addiction treatment in particular? The answer is that it should follow the exact same principles of measurement that we see in every other healthcare domain.
First, we much clearly define the problem and its desired outcomes. It is tempting when working with addiction to say, “The problem is drug use and the desired outcome is abstinence.” This type of oversimplification actually works against the process and moralizes addiction rather than treats it like the chronic illness it is. Instead, the problem is best defined as a constellation of symptoms that are caused or exacerbated by compulsive drug use where the patient has lost control of the ability to choose. The desired outcome is not simply ceasing drug usage, but improving quality of life in the areas that comprise that constellation of symptoms.
Origins Behavioral HealthCare recently completed an outcomes study where nearly 400 former patients allowed us to measure several areas of their lives in order to understand the impact of Origins’ treatment.
In this study, Origins’ looked at patients’ rates of use and readmission, quality of their most important relationships, physical health, and overall quality of life, among other things. There were several important findings:
- 81% of participants reported being abstinent for the past 30 days, and 72% reported they had maintained abstinence the entire time since leaving treatment. Of those who were using, 84% reported they were using less than when they came to treatment.
- 87% reported they did not have to return to treatment due to relapse.
- 94% reported their overall quality of life had improved since completing treatment.
- 87% reported their physical health had improved since completing treatment.
- 93% reported that relationships with those most important to them had improved since completing treatment.
Collecting this data was the “measure” part. Further analysis helped us to find important statistical correlations that reinforce the importance of addiction treatment:
- Patients who follow treatment and aftercare recommendations are more likely to report abstinence following treatment.
- Patients who report sustained abstinence after treatment are more likely to report significant improvements in the quality of their most important relationships, their physical health, and their overall quality of life.
So, though sustained abstinence is not the only goal, it is clear that it is important in the process of improving physical health, interpersonal relationships, and overall quality of life for persons who suffer from addiction. Thus, it remains an important data point on which to focus.
In 2000, the NIDA famously compared relapse rates for four different chronic health conditions. Relapse is essentially understood as a reoccurrence of a specific issue to problematic levels after a period of remission. Relapse is a phenomenon of most chronic conditions. NIDA’s comparison presented these relapse rates:
- 30-50% for patients with Type 1 diabetes
- 50-70% for patients with hypertension
- 50-70% for patients with asthma
- 40-60% for patients with addiction
Clearly, the overall rates for these chronic health conditions have many similarities. The important point is that addiction is no less treatable than other chronic conditions. Therefore, we must provide the same level of measured care to those with chronic addiction as we would for those with asthma, diabetes, or hypertension.
The relapse rates of patients treated at Origins are far lower than those reported by NIDA and are among some of the lowest reported relapse rates in the country.
Although this is wonderful to know, our work is nowhere close to being finished. Origins will continue to quantify patient outcomes utilizing a longitudinal method of measuring patients’ health and quality of life at several intervals post-treatment. We will then take deliberate actions to refocus our treatment delivery systems based on those outcomes.
Additionally, in June of 2020, Origins will launch a comprehensive MBC program for patients who are in the process of treatment. Just as a doctor measures blood pressure and glucose levels using specific testing equipment, every Origins’ patient will receive regular symptom measurement using psychometric assessments. Collected data will then be utilized to better understand where the patient is in their recovery, how they are responding to treatment, and what refocusing needs to be done. Rather than guessing or relying solely on self-reported outcomes, the standard of care for behavioral healthcare and addiction treatment will be improved through the repeated use of Origin’s regular measurement, analysis, and refocusing techniques.
Origins Behavioral HealthCare is a well-known provider offering a range of treatment programs targeting the recovery from substance use, mental health issues, and beyond. Our primary mission is to provide a clear path to a life of healing and restoration. We offer renowned clinical care for addiction and have the compassion and professional expertise to guide you toward lasting sobriety. For information on our programs, call us today: 561-841-1296.