DALLAS COALITION FOR TREATMENT IMPROVEMENT A sudden rise in Heroin use among adolescents and young adults served as a call to action and inspired this treatment systems improvement project.

s: Treatment ProvidersHomeward Bound, Inc. - Adult - Detox, Residential, and Outpatient Nexus Recovery Center - Adult – Residential and Outpatient Women/children Adolescent - Residential and Outpatient Phoenix House - Adolescent - Residential and Outpatient Dallas County Juvenile Department - Adolescent - Day Treatment

Payers & Policy Makers Other ParticipantsTexas Department of State Health Services (DSHS) Carlos Tirado, MD, UT Southwestern Medical Center Value Options/North STAR Managed Care Program Medical Director, Nexus – MATDallas County

Jane Maxwell, PhD, Local Evaluator Center for Excellence in Drug Epidemiology, Addiction Research Gulf Coast Addiction Technology Transfer Center, UT-Austin

An under-funded system of care

Texas ranks 48th in the nation in substance abuse treatment funding and the Medicaid Substance Abuse benefit is very limited

Our substance abuse treatment system of care is funded to meet approximately

5% of the Adult need, and 7% of the Adolescent need

This is a perfect environment for implementing evidence-based practices that increases efficiency and effectiveness

The Problem

First noticed in 2005, the use of inhalable Heroin among adolescents in the Dallas area began to increase,

Several deaths from Heroin overdoses or complications were reported,

Numerous arrests for Heroin possession in the Dallas area ISD’s were reported,

IV Heroin admissions to adult detoxification services among persons 25 & under increased significantly,

Heroin is readily available in the schools and in the neighborhoods. It is cheap and highly addictive

The Challenge –

With no extra funding coming into the system, how do we:

1) Increase retention and time in treatment to reach a therapeutic dose or length of stay?

2) Prevent relapse to heroin use in a community where heroin is readily available to children, adolescents and adults?

Solutions in Science to Service

Our experience in the Texas Node of the CTN helped remove barriers and prepared us for the Robert Wood Johnson Advancing Recovery Project

1) Knowledge of the NIDA clinical trials and evidence–based practices opened our minds to new ideas for treatment improvement

2) Recognition of the importance of bringing science into service in the ‘real’ world

Selection of Evidence Based Practices to Overcome Barriers

To address our problems, we chose:CTN #0005 Motivational Interviewing as a

technique for engagement and retention

CTN #0010 Medication Assisted Treatment – Bup/Nx facilitated rehabilitation for heroin dependent adolescents

CTN #0030 Prescription Opioid Addiction Treatment Study (POATS)

Summary of EBP Implementation Data

Motivational Interviewing Over 300 clinicians attended DSHS coach

supported trainings in Austin, Dallas/Ft Worth, Houston, Corpus Christi, El Paso, Lubbock, and San Antonio in 2008/2009

130 support staff in Dallas/Ft. Worth area attended DSHS supported MI 101 training in 2008

Dallas County Community College provided MI training for professionals and support staff in 2009

Advancing Recovery agencies actively implement MI in their programming

Example of Results: Phoenix House significantly reduced their AMA rate by using the MI approach

0

5

10

15

20

25

3rd Q2008

4thQ2008

1st Q2009

2nd Q2009

AMA Rate

Eureka Moments

Phoenix House Traditional Therapeutic Community Initial Skepticism about MI Attended & Implemented MI Training Experienced Dramatically Reduced AMA

NIATx Processes - Rapid Change & Walk Through Actually work, and Can be applied to almost any problem or situation

Summary of EBP Implementation Data

Medication Assisted Treatment (MAT)

Overcame resistance to MAT through exposure to CTN data

Medical Directors get Suboxone waiver

Value Options, public payor, agreed to pay for Suboxone on a case by case basis

Implemented a small pilot study at Nexus that included adults and adolescents - 2008

Expansion at Homeward Bound for public and private pay clients – 2008 and 2009

Physicians are hesitant to prescribe adolescents Suboxone. Phoenix House psychiatrist just received his waiver. DCJD has a new psychiatrist who is MAT ‘friendly’

Number Suboxone

Clients per Month

Jan 09

Feb

09

Mar

09

April

09

May

09

Jun

09

Homeward Bound

45 40 37 23 25 29

Nexus Adults

5 7 7 9 12 13

Nexus Adolescent

0 5 5 1 2 3

DCJD &

Phoenix House

0 0 0 0 0 0

More Than Medication is Needed for Recovery Fidelity to the Recovery Model

Suboxone-MATPhysical Health MedicationsMental Health Medications

Mental Health Evaluation, Counseling, Case Management

Physical Health Assessment, Treatment, Follow-up

Substance Abuse Treatment Case Management

Wrap-around Services After-care and Peer Support

Sponsor 12 Step Program

FUTURE DIRECTIONS

Watch for EBTs coming out of the CTN, especially those supported by SAMHSA and the ATTCs, in looking for solutions for treatment improvement

Expand MAT to include Naltraxone, Vivitrol and others

Continue using NIATx analysis and change techniques to continuously evaluate and modify processes for systems improvement

Be innovative. For example: CYT + Promotora complementing MAT in the treatment of heroin dependent Latino adolescents