Volume 1, Issue 3

Mike BoyleWe Need Much Less of the Same: Transforming the Substance Abuse Workforce
By Mike Boyle, President/CEO
The Fayette Companies

The estimates of addiction treatment staff shortages in the near future all appear to assume the current treatment system will continue as it has for the past 40 years. An alternative approach is to envision what the treatment system may or perhaps should be in the future and identify staffing resources needed to implement different and hopefully more effective approaches.

The current system is an acute care model consisting of admission to structured programs, treatment and discharge. There is usually no continuing support following active treatment. Most services are delivered through groups provided in residential or outpatient settings. Everyone attends the same groups whether or not they have an identified need for the content. Usually few individual or family sessions are provided. When people return to use of alcohol and other drugs following discharge and again seek assistance, they are put into the same services previously provided. The majority of persons entering treatment have been in treatment before, many for multiple episodes.

Albert Einstein defined insanity as doing the same thing over and over and expecting different results. I will explore how we may do some different “things” in the treatment of substance use disorders and how these approaches may impact the need for future staffing of these services.

The National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-based Treatment Practices endorsed by the National Quality Forum (NQF) in 2006 may serve as starting model. These standards were developed by a committee of national experts.

The first five of these standards are directed towards primary care practices regarding screening, assessment, brief interventions and engaging those in need into treatment. Thus, primary care is envisioned as a crucial resource in addressing substance use problems. Under this scenario, the treatment “field” is expanded and integration of the current substance abuse treatment system and primary care will be necessary for successful implementation of these standards.

The involvement of medical specialists is also essential to implement standards 6, 8, 9 and 10. These state that pharmacotherapy be provided to manage withdrawal and offered to all persons who are dependent on opiates, alcohol or nicotine. Further, literally dozens of research studies are underway within the pharmaceutical industry to develop new medications that target other drugs of abuse. Some of these show considerable promise to be more effective than current medications with treating alcohol, opiate or nicotine dependence. Implementation of medication use requires that all providers employ medical personnel. The 2004-2006 National Treatment Center Study conducted by the Institute for Behavioral Research at the University of Georgia found that only 60% of addiction treatment programs had a physician employed or on contract and 36.5% employed nurses.

In a time of shortage of both primary care and nursing staff, more of this medical expertise will needed within the substance abuse treatment field. An opportunity that should be explored is collaboration with Federally Qualified Health Centers that receive greatly enhanced reimbursement rates from Medicaid and Medicare. A question yet to be answered is whether these enhanced reimbursement rates will also apply under some form of national health insurance.

The NQF’s 6th standard is that empirically validated psychosocial treatments be utilized in substance abuse treatment. These practices would replace the didactic lectures, educational videos and open-ended “process” groups that dominate the approaches commonly utilized today. Achieving this standard will require more persons with advanced degrees in the addiction treatment settings to provide training, supervision and direct provision of evidence based practices. While some of these practices are manualized and persons without advanced education can be taught to effectively implement the techniques, many require a high level of clinical sophistication.

The last standard is provision of continuing care following active treatment. This implies that we move into actual practice our rhetoric regarding alcoholism and drug addiction as chronic disorders. A new National Quality Forum committee has been created to define what constitutes an episode of continuing care. The work of this committee may guide what workforce talents will be required for models of continuing care.

There are a couple of very important terms that need to be addressed in the fore-mentioned “voluntary standards” of the NQF. First, a standard is very different from a guideline. A guideline is a recommendation that may or may not be followed based on clinical judgment. A standard establishes a process that must be implemented to meet a defined quality measurement. While the word “voluntary” is utilized, the goal of many involved in this process is that the adoption and utilization of these standards will become the basis for funding and purchasing by governmental organizations and by insurance providers. The addiction treatment field would be wise to plan to implement these standards. Those who do not comply may be voluntarily giving up their funding sources in the future.

Beyond the NQF standards, I believe we need to explore whether our treatment focus is far too narrow. Most people entering the public funded addiction treatment system have multiple problems in addition to the most severe alcohol or drug dependency problems. They commonly lack employment, education, housing and positive family or social support. Yet, the focus of treatment is often only on the addiction with the assumption that other problems will eventually be resolved if abstinence is achieved. Further, the answer when someone relapses is often more of the same treatment with a longer length of stay – literally more of the same. And following longer treatment, they are once again discharged without a job and perhaps homeless. And we expect different results?

These people often have nothing left to lose and nothing on the near horizon to gain from abstinence except avoiding punishment such as imprisonment or loss of children to the child welfare system. We should attend to assisting people to obtain employment and/or begin GED or community college classes while in treatment. Building the positive side of their personal ledger may give an incentive for continued abstinence that provides reasons to use the skills acquired in treatment.

As an example, my organization has established computer labs in our residential programs that assist people to gain skills that can be applied in the “real world”. Utilization of the labs ranges from basic computer use, developing resumes, learning knowledge to obtain a GED to beginning on-line college courses. An hour spent gaining skills on a computer may be more beneficial than hearing the same lecture on the impact of drugs on the brain for the third time. Employment specialists have begun using supportive employment techniques (developed for working with persons with psychiatric problems) with persons with addictions who have difficulty obtaining employment. Assisting people to develop recovery capital as a component of treatment requires different skill sets that may not be present in the existing workforce.

To end on a provocative note, perhaps we will need less rather than more counselors to provide treatment in the future. On the average, staff salaries and benefits constitute 76% of addiction treatment costs. In comparison, the staffing component of building a Toyota is less than 10% of the costs of the automobile. A major reason for the difference is the use of technology.

When the term technology is used in behavioral health care, it usually limited to the idea of an electronic medical record. How about treatment and recovery supports delivered through telephonic and computerized systems? Existing research has demonstrated the effectiveness of virtual counselors delivered through computerized systems. Will nanotechnology someday allow the just-in-time release of a blocking agent to be released when the presence of a specific drug is detected? And, will that “someday” be far sooner than we expect?

Dave Gustafson, Director of NIATx, believes the addiction treatment field, characterized by low salaries and high turnover, is unsustainable. He believes the answer is in the development and use of technologies that can lead to less staffing demands and thus higher pay. Dr. Gustafson has secured National Institute on Alcohol Abuse and Alcoholism research funding to conduct a randomized clinical trial using smart phones to provide recovery support for persons following residential treatment. An overview of some of the technologies that will be provided in this research can be accessed at www.innovationsforrecovery.com. If new technologies are to be developed and utilized, researchers in these domains must be solicited to become partners, and persons with skills to implement these technologies must become part of, the treatment team. Can the substance abuse treatment field of today embrace these changes?



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