Best Practices : Substance Abuse Treatment and Rehabilitation

5. Perspectives on Service Delivery Systems

A review of the literature on substance abuse treatment delivery systems does not produce "landmark" reports on systems issues. Rather, there exists a patchwork of information from unpublished policy planning documents from various jurisdictions, limited discussion in the major reviews of treatment effectiveness and a few published articles. This mirrors the current state of substance abuse treatment "systems" which comprise a range of services, varied in type, scope and focus, and which are generally not well coordinated. There are a number of challenges to the research and development of treatment systems, not the least of which is an ongoing lack of clarity and agreement in the terms used to describe the components of treatment.

A great deal of research can be subsumed under systems research arising from disciplines as varied as social ecology, general systems theory and the study of public policy process (Rush, 1996). This discussion will be necessarily selective, focusing on broader issues that have particular application to the Canadian treatment context.

In Canada, most of the formal treatment of alcohol and drug problems occurs within specialized, "addiction-specific" services. However, over the past decade, there has been an increasing appreciation for the role that "non-specialized" services in the health, social and correctional fields can play in reducing alcohol and other drug problems. This appreciation has grown out of a view that substance abuse and other living problems are interrelated and accentuate each other, and that there can be an underlying basic problem of which substance abuse is a symptom. A significant proportion of these problems are less severe and respond well to minimal intervention provided by a non-specialist. These practitioners are also being seen as playing an important identification and referral function for more severe problems.

However, only a small proportion of people who experience problems with alcohol or other drugs intentionally seek help to deal with alcohol or drug use per se and fewer still seek help from services that specialize in the treatment of substance abuse.

So, a recurrent theme in systems discussions is the need to draw general human services more fully into substance abuse identification, counselling and referral activity. The Ontario Advisory Committee on Drug Treatment (Martin et al., 1990) envisioned a system in which practitioners within generic service contexts would be mandated, funded and trained to identify and address emerging drug and alcohol problems in the individuals they serve. Similarly, the US Institute of Medicine (1990) advocated a system wherein non-specialized services would help to broaden the base of treatment by serving those who would not otherwise come into contact with substance abuse services. The roles outlined in this report for the non-specialized sector were to: identify those individuals within the sector who have alcohol problems; provide a brief intervention for persons who have mild or moderate problems; and refer to specialized treatment those persons with substantial or severe alcohol problems or those for whom brief intervention was not successful.

a) Elements of a substance abuse treatment system

To assist in clarifying the roles that might be played by various agencies, both specialized and non-specialized, Martin and colleagues outlined the range of discrete functions required in a comprehensive response to drug and alcohol problems:

• information and referral
• outreach service
• case finding
• brief intervention
• walk-in and crisis service
• detoxification
• comprehensive assessment
• case management
• outpatient treatment
• day/evening treatment
• short-term residential treatment
• long-term residential treatment
• after-care/continuing care

These functions can be located in a variety of specialized and non-specialized settings, spanning health care, social service and criminal justice fields, but also including schools, workplaces and religious organizations.

At the centre of the envisioned systems is a comprehensive assessment that would match the individual with the most appropriate service. Eliany and Rush (1992) acknowledged that while treatment matching is a reasonable approach, the research in this area is very complex from a conceptual and methodological point of view. A distinction should be made between client matching to the most appropriate substance abuse intervention (e.g. social skills training or psychotherapy) and matching a client - who often presents a range of other problems - to related services (e.g. financial counselling or job training). While matching clients to other services is relatively straightforward, evidence on which to base client matching to the most effective intervention remains elusive. The recent large investigation into client/treatment matching reported by the US National Institute on Alcohol Abuse and Alcoholism (NIAAA) largely failed to identify matching criteria among three treatments and a large sample of clients (see Project MATCH in Section 2).

Perhaps anticipating this, a World Health Organization (1991) report suggests that matching guidelines will likely need to be developed at the local level based on local treatment outcome information. Recognizing that different people will be delivering treatment in differing circumstances, matching guidelines may need to vary from district to district. The report underscores the importance of programs and systems creating a feedback loop between outcomes and comprehensive assessment that will enable services to know how best to match their own people to local interventions.

A theory that has contributed to thinking around substance abuse treatment is Prochaska and DiClemente's (1983) transtheoretical model of change. First postulated as a tobacco cessation model, it organizes the treatment of addiction problems within a bio-psycho-social framework (Marlatt et al., 1988). This "stages-of-change" model describes a common pattern of behaviour change based on motivation or readiness to change:

• Precontemplation : not thinking about quitting
• Contemplation : seriously thinking about quitting
• Preparation : planning to stop in the next 30 days
• Action : having quit for less than 6 months
• Maintenance : the stage beginning 6 months after treatment
• Relapse : having re-adopted the problem behaviour

While clearly providing clinical guidance, this model also supports the configuration of a system suggested by Abrams et al., (1993) that incorporates stepped care and matching features. This model proposes that services be organized according to minimum, moderate and high levels of intensity.

In this model, clients are assessed according to level of motivation, self-efficacy, level of dependence, co-morbity and socio-cultural factors, and triaged into one of the three treatment levels. A guiding principle of this model is the use of the least intensive (and least expensive) level first and "stepping up" a client when a less intensive treatment has not been effective.

Overarching the clinical process is a public health approach which would focus on enhancing motivation levels through community action and public policy.

The scheme proposed by the World Health Organization (1991) outlines six "levels of cover" that form a logical implementation sequence, and together constitute a full system of substance abuse services:

• Level One: a systematic attempt is made to provide appropriate service to those who are intoxicated with alcohol or drugs, and to those who need assistance with detoxification.
  
• Level Two: provision is made for a period of generalized and non-specific rehabilitation (e.g. nutritional, medical, psychiatric) following the period of intoxication or detoxification.
  
• Level Three: all persons seeking basic human services in various areas (e.g. health care, criminal justice, welfare, educational and workplace services) are systematically evaluated for alcohol and other drug problems and an appropriate brief intervention is provided when evaluation is positive.
  
• Level Four: a case management function that provides continuity of care for all individuals with alcohol and drug problems is implemented.
  
• Level Five: one or more brief therapies is made available, to be utilized in selected cases in which follow-up through the continuity of care for all individuals with alcohol and drug problems is implemented.
  
• Level Six: multiple alternative complex interventions are made available, contingent on a thorough pre-treatment assessment function that gathers and evaluates data enabling the matching of specific individuals to the most suitable of these interventions.
  
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More recently, wishing to promote further research and systems development, Rush (1996) identified components of a substance abuse treatment system at two levels: a clinical level and community level.

At the clinical level, components of the system would be organized along a continuum similar to that proposed by Martin et al. (1990) and the Institute of Medicine (1990):

community membership → problem definition and help-seeking → entry and retention in the system → assessment, triage and case management → detoxification, stabilization and crisis intervention → treatment planning and goal selection → treatment, rehabilitation and relapse prevention → continuing care and evaluative follow-up.

At the community level, a series of steps is proposed in the development of a community treatment system, each of which might be the subject of investigation:

historical and contextual analysis → system description → need assessment → community development → coordination of services → system monitoring → system evaluation.

Rush goes on to suggest a number of ways a system could be characterized:

• the extent to which the components cover the "continuum of care";
  
• whether assessments are centralized or decentralized across the system;
  
• the extent to which, and the manner in which, case management occurs;
  
• role and contribution of self-help programs;
  
• the labour and other resources devoted to the system;
  
• training level of practitioners in the system;
  
• cost of the system and financing mechanisms;
  
• the role of coercive, mandatory measures in the system; and
  
• the relative coverage of different insurance plans.
  

b) Who seeks help for alcohol and other drug problems

How likely is it that someone who experiences problems involving alcohol or other drugs will intentionally seek help specifically for drinking or drug use, and how likely is it that they will seek help from a specialized treatment service? Estimates of the prevalence of such help-seeking vary with definitions of "help" and "problems." However, using broad definitions it appears that in North America most people who experience problems associated with their use of alcohol or other drugs do not intentionally seek help for drinking or drug use from either general or specialized services. Recent Canadian and US studies suggest that, among adults reporting ever having had alcohol problems, only 5%-28% say they have sought help for drinking from either informal sources (friends, family members, self-help groups) or from professionals, and only 1.2% to 9% report seeking help from specialized addiction services (Weisner, Greenfield and Room, 1995; Rush and Tyas, 1994). Of those who do seek help for alcohol problems, the majority (70%) report doing so from Alcoholics Anonymous or other mutual-aid groups. This may be due to addictions agencies having a relatively low profile within the general population, whereas more people are aware of AA.

Studies from the United States indicate a 3% to 6% increase in the number of problem drinkers seeking help during the 1980s, but it is not known if the percentage of problem drinkers in Canada who sought help also increased during this period.

In Canada, few (3%) users of illicit drugs, identified in a population survey, reported seeking any kind of help for drug problems (Rush and Tyas, 1994). No studies from the United States have generated estimates of the percentage of illicit drug users who seek help for drug problems.

Hingson et al. (1980) conducted the first large-scale population survey comparing problem drinkers who had sought help from a treatment agency or professional with those who had not. The study was conducted in the Boston area. Among those reporting problems at the time of the survey, those who had recently sought help tended to drink more, to be older, less educated and were more likely to have a religious affiliation. However, there were no differences with respect to gender, employment status, income, race and several other socio-demographic characteristics. Among those who reported ever having alcohol problems, those who had sought help did not differ from those who had not, based on most of the socio-demographic characteristics considered. However, those who ever sought help were less likely to be separated or divorced and more likely to be unemployed, retired or disabled at the time of the interview. Given the cross-sectional design of this study, it is not possible to determine the influence of these differences on lifetime help seeking. However, a follow-up study (Hingson et al., 1982) showed that the decision to seek treatment was related to increased negative social and personal consequences rather than demographic characteristics or levels of drinking.

Weisner, Greenfield and Room (1995) used results from three national surveys in the United States to compare those who: ever sought help from an agency or professional for drinking problems; ever went to AA; and went to an alcoholism program, with those who had not sought help. Trends in help seeking and in the characteristics of those seeking help were also considered. Within the general population, and across all three surveys, help seeking, going to AA and going to alcoholism treatment programs were more common among males, and especially males between 18 and 49 years of age. Lifetime help-seeking was also related to lifetime levels of alcohol dependence and adverse social consequences. A measure of negative social consequences of drinking was the best predictor of help seeking. However, when lifetime social consequences and alcohol dependence were controlled, lifetime help seeking for alcohol problems was still more common among males, those who were not married and those in their middle years.

Rush and Tyas (1994) used data from Health Canada's 1989 National Alcohol and Other Drugs Survey to compare those seeking help for alcohol or other drug problems with others. In the general drinking population, those seeking help for alcohol problems were more likely than members of the general population to be male, aged 35 to 54, not to have completed high school, earning less than $20,000 a year, separated or divorced, living in the Prairies (Alberta, Saskatchewan, Manitoba) and not working. Among those using illegal drugs, help seekers were more likely than members of the general population to earn less than $20,000, not to have completed high school and to be divorced or separated.

Unpublished analyses using data from the mental health supplement of the 1990 Ontario Health Survey showed that help seeking was far more common among those with both a substance abuse and other mental health disorder (co-morbidity) than among those with only a substance abuse disorder. Among males with a substance abuse disorder, 10% had sought professional help in the past year, and 3.7% had sought help from hot-lines, self-help groups or vocational programs during the same period. The equivalent figures for co-morbid males were 29.2% and 15%. The same pattern of differences held for females. However, females with or without co-morbidities were almost twice as likely as males to have sought help from a professional.

Bardsley and Beckman (1988) compared alcoholics in treatment with others not in treatment who were recruited by the treated group and through publicity efforts. The results showed that the decision to enter treatment was predicted by perceptions of the severity of the drinking problem and by the number of "unusual" events in the previous month (e.g. conflicts with spouse, new physical symptoms, car accidents).

Only one study has compared opiate users in treatment with those not in treatment. This involved users treated at the Yale University Drug Dependency Unit in New Haven, Connecticut, and a companion sample constructed through "snow-ball" sampling, starting with untreated users known to those in treatment and ex-user therapists (Rounsaville and Kleber, 1985). Those in the treatment sample were similar to those in the non-treatment sample with respect to age, education and marital status. However, those in treatment were more likely to be non-white and female. Controlling for gender and race, Rounsaville and Kleber found that opiate users in treatment were similar to those in the community with respect to length and severity of opiate use and current intoxication-seeking behaviours. However, those not in treatment reported more adequate social functioning, fewer drug-related problems and lower rates of depression. Those who did not seek treatment seemed to underestimate the seriousness of their drug problems and the benefits of treatment.

Who seeks help from specialized services?

Room (1977) has characterized those seeking treatment from publicly funded alcoholism treatment services and those in the general population as inhabiting two different worlds. Those in publicly funded treatment agencies tend to be in the 35 to 60-year-old age group, to be unemployed and living outside a nuclear family. In contrast, those in the general population experiencing drinking problems are more likely to be 18 to 25 years old, employed and living in families (Armour, Polich and Stanbul, 1978).

Many studies have indicated that after controlling for gender-related differences in rates of drinking and drinking problems, women are less likely than men to use specialized services (Weisner and Schmidt, 1993). This has been attributed to a lack of services tailored to the needs of women and to female-specific barriers to treatment (e.g. financial, need to provide child care). However, there are differences in the ways men and women interpret symptoms of illness and this may influence help-seeking behaviour. Compared with men, female problem drinkers are more likely to see themselves as suffering from depression or anxiety and less likely to describe their problems as explicitly related to alcohol (Fillmore, 1984; Beckman and Amaro, 1986; Blume, 1982). This may be due to the greater stigmatization of women's abuse of alcohol and a tendency for women problem drinkers to seek help from services that do not specialize in alcoholism treatment. This was confirmed in the study by Weisner and Schmidt (1993). This study showed that women with drinking problems were more likely than men to use non-alcohol-specific health care services, particularly mental health services, and also to report greater symptom severity. This latter result indicates that women may delay seeking help until their problems become quite serious. Weisner, Greenfield and Room (1995) also found that women with drinking problems in the general population, unlike men, reported more use of health and mental health programs than alcohol treatment programs.

In addition to many descriptive studies of those seeking help from specific sources, a few studies have compared those seeking help from different sources. Pattison, Coe and Rhodes (1969) compared clients of an aversion-conditioning hospital, a halfway house and an outpatient psychotherapy clinic. Compared with those in the halfway house, clients in the other programs had, on intake, significantly lower scores on a scale of drinking problems and higher scores on a scale of interpersonal health. Those attending the aversion hospital also had significantly higher scores than those in both other programs on a scale of vocational health.

Beckman and Kocel (1982) studied structural characteristics of 53 alcohol treatment facilities in California and found that women were more likely found in agencies that hire more professionals, provide treatment for children and provide after-care services.

Ogborne (1995a) found that in a sample of young people (aged 12-25) seeking help for substance use, those preferring residential treatment had more mental health and addiction problems than those preferring non-residential treatment. Those seeking residential treatment were also more likely to have had previous treatment experience. This suggests that clients do not seek residential treatment capriciously or because they are unaware of alternatives, and it reinforces the need to consider client preferences in treatment planning.

Early studies indicated that alcoholics who affiliated with AA were mostly males who differed from others with respect to drinking experiences, socio-demographic and personality characteristics, and belief systems (Ogborne and Glaser, 1981). However, AA groups are now quite diverse and seem to attract a more heterogeneous population (Montgomery, Miller and Tonigan, 1993). AA has also become an important resource for women (Weisner, Greenfield and Room, 1995).

Best Practice Guideline (No. 20)

The majority of those who have problems with alcohol or other drugs do not seek help, especially not from specialized addictions services. More efforts may therefore be required to increase awareness of specialized services among the general population and among social and health service providers.

c) Coordination issues in a substance abuse treatment system

Coordination, an issue for all human services, has been defined as the degree to which collaboration and exchange exist within an aggregation of service providers (Baker, 1991). Coordination is seen as reducing the fragmentation, discontinuity, inaccessibility and lack of accountability of specialized services, with the result that clients will be less likely to fall through the gaps between services (Anderson, Frieden and Murphy, 1977).

A number of particular challenges to coordination in the context of Canadian substance abuse treatment have been identified (Ogborne and Rush, 1983):

• The unsystematic manner in which services have been planned and funded.
  
• Conflicting ideologies and perspectives on the nature of alcohol and other drug problems, and the optimal assessment and treatment approaches.
  
• Lack of a common framework or language to describe clients and their problems, coupled with diverse and non-standardized training requirements in addictions, for personnel working in specialized agencies as well as professionals in more general health and social services.
  
• The wide network of health, social and correctional services with which clients may be involved and the potential for poor communication across such a diverse network.
  
• The complex, multi-dimensional nature of alcohol and other drug problems and the difficulty of matching clients to appropriate services when the full range of required services is not available and the criteria for matching to existing resources lack a strong empirical base.
  
• The referral process itself, when it involves only a "passive" recommendation to seek assistance rather than the active provision of assistance and advocacy that may be required to link clients with the various services that are needed.
  
• Record keeping and other dimensions of quality assurance that are non-standardized and/or of poor quality, and therefore impede the accountability and evaluation of community-wide treatment systems issues.

The current reforms within health and social services systems are compounding these issues by requiring providers to sustain and perhaps redefine their present relationships, while forging new ones in the community. Though no standardized measures of coordination among services have been developed, Ogborne et al. (1997), in a review of the literature, suggested that coordination among service providers could be characterized in the following ways:

• Mutual awareness: do staff know about each other and their respective programs?
  
• Frequency of interaction: do key staff meet to discuss work-related issues?
  
• Frequency and direction of referrals: how often or how many clients are referred to and from different services in the network?
  
• Frequency and direction of information exchange: do services exchange information about programs, services and clients?
  
• Frequency and direction of staff sharing or exchange: are staff of different services permanently or temporarily shared or loaned?
  
• Frequency and direction of other resource exchanges: do services share funds, meeting rooms, materials or other resources?
  
• Joint activities: are there jointly held consultations, case conferences, staff training, intake and assessment, data collection, program design and operations, program evaluation or mergers?
  
• Overlapping boards: are there members in common to community boards from different services?
  
• Formalization of agreements: have services developed formal agreements to coordinate their activities?

Martin et al. (1990) suggest that formal, organized methods of networking should be considered to enhance informal activities. While noting regular workshops, newsletters or formal associations of service providers as mechanisms for networking, they also recommend that funding bodies formally include a certain percentage of time for participation in a local planning or coordinating committee in the job description of a program manager.

d) Case management

With the size and complexity of current treatment services, an arrangement for case management is viewed as a crucial element in a treatment system. While the other elements of a system, such as assessment, matching and treatment, occur in more or less sequential order, case management needs to cut across these other elements, providing a coherent experience for the individual (Institute of Medicine, 1990). Martin et al., (1990) define case management as a process involving:

• Ongoing assessment of current strengths, weaknesses and needs.
  
• Ongoing planning to identify services appropriate to the particular needs of the client.
  
• Linking clients to needed services and ensuring that these linkages are maintained.
  
• Continuous monitoring and evaluation of progress.
  
• Interceding on behalf of the client to ensure that the treatment system responds equitably and effectively to the needs of the client.
  
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A variety of case management mechanisms exists, such as creating highly structured relationships among components of a system, or having some clients take responsibility for their continuity of care, or most often, assigning the function to an individual within a service agency (Institute of Medicine, 1990). Martin et al., (1990) emphasize that, regardless of who is responsible or how it is handled, all organizations need to regard case management as a discrete function based on policy and procedures. The Institute of Medicine (1990) suggests that the lay public may be able to play a role, because the literature on case management emphasizes the importance of personal traits such as perseverance, flexibility and thoroughness.

Best Practice Guideline (No. 21)

Research on effective configurations for service systems is limited. However, there is consensus in the literature that clients are better served when they can access a range of flexible and individualized services spanning the specialized and non-specialized sectors, linked through some form of coordination and case management, and accounting for the needs of special populations.

e) The role of self-help/mutual aid groups

Although they do not consider themselves formal treatment programs, self-help/mutual aid groups such as AA and Narcotics Anonymous (NA) play a vital role in many substance abuse treatment systems. Particularly in large urban areas, a wide range of different AA groups is available to address specific needs e.g. women only, non-smokers, gay men and lesbians. In addition, there are now a wide range of self-help/mutual aid groups beyond AA and NA addressing different needs and philosophies. These include Women for Sobriety, Moderation Management, Rational Recovery, Secular Organizations for Sobriety, and Self Management and Recovery Training, though AA and NA still remain the most widely available, particularly in Canada (Youngson, 1997).

Over the years, the philosophy of the AA/NA fellowships has guided the design of programs and for many treatment programs the groups constitute the continuing care component. As well, many programs make participation at AA or NA a requirement. As sponsors, members often play a crucial role in supporting and advocating for an individual through detoxification and treatment and in maintaining recovery. Many individuals utilize only these fellowships, without becoming involved with the formal treatment system.

While many people benefit from involvement with self-help groups, others do not and the issue is not "does self-help work?," but rather "for whom and under what conditions might a referral to self-help be most beneficial?" While more research is needed to answer this question, some attempts to link substance users with self-help groups may be appropriate unless clearly contraindicated by personal preference or local conditions. Self-help groups, and especially AA, are low cost, and readily available in both the short and long term.

Professionals need to be aware of local self-help groups and to provide relevant information to their clients and, where appropriate, seek to ensure that client concerns about attending self-help groups are addressed, but also to recognize that such groups are not suitable for all clients. Mandatory attendance at AA or other self-help groups seems contrary to the nature of self-help and is not supported by research.

Best Practice Guideline (No 22)

Though by its nature it is difficult to evaluate the efficacy of attendance at AA or other mutual aid groups, many people find such groups of benefit, and clinicians should make themselves familiar with AA and other mutual aid groups and provide information and support to their clients in the use of these resources.