Welcome

1. Welcome

2. Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs Module 13: TIP Chapter 14

3. Course Goals The goals of this training are to� Familiarize you with the content of TIP 43; and Increase your awareness of issues related to medication-assisted treatment of opioid addiction.

4. Module 13: Administrative Considerations in OTPs During this module, you will: Identify preferred staffing requirements for OTPs; Describe features of medication diversion control plans; Examine relationship issues between OTPs and local communities; Identify resources in the area of national community education; and Describe rationales and strategies for MAT program evaluation.

5. Staffing Chapter 14 describes policies, procedures, and considerations that make OTP administrators and managers more effective. Treatment outcomes are improved by providing leadership and staff management. OTP manager responsibilities include: Focusing on patient care and treatment outcomes; Setting clear guidelines; Supplying needed resources; and Nurturing staff growth and retention.

6. Staffing Interactions between staff and patients and staff attitude are the next most important determinant of treatment effectiveness, after adequate dose of methadone. Successful treatment outcomes depend on staff competence, values, and attitudes. Administrators should: Recruit qualified, capable, culturally competent people; Offer competitive benefit packages; and Provide supervision and ongoing training.

7. Staffing: Qualifications Treating opioid addicted patients requires highly trained caregivers to provide patient care and coordinate access to services. Hire individuals who are licensed or credentialed, and work effectively with the types of patients served by the OTP. Employ people with empathy, sensitivity, and flexibility to create a therapeutic milieu. Staff members should maintain appropriate professional boundaries.

8. Staffing: Qualifications Transference: Patients project feelings or emotions onto providers. Countertransference: Providers project feelings or emotions onto patients (e.g., displaying anger or disappointment with patients). Supervisors should ensure staff members avoid countertransference.

9. Staffing: Qualifications Knowledge of cross-cultural principles improved patient outcomes. Support staff should be willing to: Work with people from diverse backgrounds; Explore and accept other value systems; and Understand how culture and values relate to patient behavior. Recruit employees who reflect patient demographics, and consider hiring people in recovery.

10. Staffing: Qualifications Diversity also exists within cultures. Treatment staff should: Be sensitive to cultural differences but avoid acting on assumptions; Accept patients� cultural influences and individuality; and Be aware of factors that affect recovery (e.g. sexual orientation or age) but avoid generalizing.

11. Staffing: Qualifications Information on cultural competence and diversity is available at: National Association of Social Workers (www.socialworkers.org/diversity); Substance Abuse and Mental Health Services Administration (www.samhsa.gov/search/search.html); and �Cultural Competence for Social Workers� (Center for Substance Abuse Prevention 1995).

12. Staffing: Multicultural and Multilingual Representation No data demonstrating improved outcomes from ethnic matching of patients and providers. One study noted ��equivocal findings of the effect that therapist and patient similarity plays in treatment outcome" and concluded more research is needed. However, if program staff reflects the population served, patients are more likely to feel comfortable.

13. Staffing: Multicultural and Multilingual Representation When multicultural representation among staff is limited, OTPs should find ways to communicate acceptance of diversity. Federal and State resources are available for literature in languages other than English. Information about translation services are available online, at www.atanet.org/bin/view.fpl/52076.html.

14. Staffing: Flexibility Staff attitudes about MAT and opioid addiction can affect patient outcomes. Staff members should be free of rigid biases, non-judgmental, and should not have punitive attitudes toward patients. Therefore, managers should: Monitor staff attitudes; and Provide training to create or sustain appropriate attitudes.

15. Staffing: Flexibility Verbal expressions used by OTP staff members can reflect how they feel toward patients. Treatment staff members sometimes use countertherapeutic language. Avoid terms suggesting the criminal justice system to refer to patients doing poorly in treatment. Applying words derived from �toxin� to treatment medication suggests the medication is a toxin; �detoxification� should refer only to withdrawal from substances of abuse.

16. Staffing: Terminology Judgmental Term Dirty urine Probationary Termination Clients Detox Preferred Expression Positive drug test Doing poorly in treatment Discharge Patients Dose tapering or medically supervised withdrawal

17. Staffing: Inclusion of Recovering Patients Employing treatment professionals and support staff who are in recovery adds valuable perspectives to treatment and provides role models for patients. OTP policies on hiring people who are in addiction recovery should be in writing and include procedures for addressing staff members who relapse. Hiring policies should comply with State and Federal laws prohibiting discrimination against people who are addicted. Staff members who are in recovery, and their colleagues who have no addiction history, should be treated similarly.

18. Staffing: Retention Retaining staff is important for several reasons: Stability of treatment staff may affect treatment outcomes. High staff turnover can undermine relations with community, funders, and others. Investment in recruitment and training is lost when staff members leave. Unfilled staff positions result in longer patient waiting lists. Reducing staff turnover minimizes disruption to patients� treatment. Accreditation standards place importance on stability of OTP staff.

19. Staffing: Retention Factors that contribute to high staff turnover include: Low salaries and benefits; Negative stereotypes of MAT and its patients; Job stress; Excessive counselor workload; Unreasonable operating hours; and Unsafe OTP locations. Staff members can experience burnout if they work in isolation with difficult patients, and receive inadequate support or feedback.

20. Staffing: Retention Managers should take concrete steps to retain staff, including the following: Establish, maintain, and apply consistent policies and procedures; Avoid excessive caseloads; Encourage team approach; Reduce intrastaff disagreements; Decrease �staff splitting�; Encourage mutual respect; Hold regular staff meetings; and Develop and annually review job descriptions that delineate roles, responsibilities, and lines of communication.

21. Staffing: Retention Managers should also establish: Performance standards with evaluations; Regular consulting sessions; Opportunities for training; Praise and recognition; and Caring personnel policies.

22. Staffing: Training Training should be offered for all staff. Accreditation standards require OTPs to provide continuing staff education, with many States requiring such education to maintain licensure. OTPs should help staff members by offering onsite training, collaboration with other training agencies, or paying for educational leave or tuition.

23. Staffing: Training Training should focus on the following: Facts about MAT and the health effects of treatment medications; Up-to-date information about medications; Up-to-date information about drugs of abuse; Up-to-date information about communicable diseases; Skills training (such as crisis management, communications, and problem solving); and Patient sensitivity training.

24. Staffing: Training Consistent inservice training can help staff members understand program's mission and the effects of MAT. OTP administrative staff may lack direct treatment responsibilities, but they are often the first to speak with patients. Orientation about MAT ensures understanding of how OTP operates and develops favorable attitudes about patients. If possible, all staff members should receive annual training in such areas as confidentiality requirements, cultural competence, prevention of workplace violence, and patient rights.

25. Medication Diversion Control Plans OTPs must maintain a current diversion control plan (DCP) to reduce the possibility of medication diversion and assign responsibility for control measures to medical and administrative staff members. A DCP should address diversion of medication both by patients, who might sell or give their take-home medication to others, and by staff, who might steal medication or spill or otherwise waste it.

26. Medication Diversion Control Plans: Patients Patients must meet Federal criteria for take-home medications. OTP�s medical director makes and documents decisions about take-home medications. Staff should ensure that patients store medications safely. All take-home medications must be labeled and packaged in a manner designed to reduce risk of accidental ingestion, including child-proof containers.

27. Medication Diversion Control Plans: Patients Callbacks help prevent patient diversion of take-home medication. OTPs select patients at random to return remaining take-home medication; random policy avoids patient complaints of being unfairly �picked on.� Programs can require patients to undergo drug tests when they bring in medications. Inform patients of responsibilities and consequences regarding callback policy. No-loitering policy part of an effective DCP.

28. Medication Diversion Control Plans: Staff Members Protocols should be in place to reduce risk of staff diversion. Scheduled substances should be accounted for rigorously and inventoried continuously. Working stocks should be logged and tracked from receipt through dispensing, and measured at the beginning and end of each workday.

29. Medication Diversion Control Plans: Staff Members Measurements and daily reconciliations should be monitored by supervisors and dispensary managers. Significant discrepancy should prompt an investigation, with dispensary manager, executive director, and medical director following up on investigation findings. In matters of medication dispensing, OTPs must consult and comply with DEA regulations.

30. Community Relations

31. Community Relations: Groups Group 1: Community Opposition and Good Community Relations (pp. 231-232). Group 2: Overcoming Negative Community Reactions and Community Relations and Education (pp. 232-233). Group 3: Delineating Roles, Initiating and Maintaining Contacts (p. 233), and Establishing Effective Media Relations (p. 235). Group 4: Educating and Serving the Community (pp. 233-235). Group 5: Developing Policies and Documenting Community Contacts (pp. 235-236).

32. National Education OTPs should be aware of and involved in the national dialog and efforts to promote MAT. OTPs should build on and contribute to these national initiatives within their communities.

33. National Education Numerous resources are available to educate the public about MAT and assist OTPs with public relations. National organizations such as American Association for the Treatment of Opioid Dependence (AATOD) and the American Society of Addiction Medicine (ASAM) hold national and regional conferences. More detailed information on publications and other resources may be found on page 237 in TIP 43.

34. Evaluating Program Performance Federal regulations and guidelines require OTPs to establish performance improvement programs. OTPs must demonstrate effectiveness and efficiency. Program evaluation contributes to improved treatment. For information on evaluation details, refer to Demystifying Evaluation: A Manual for Evaluating Your Substance Abuse Treatment Program�Volume 1 (CSAT 1997a).

35. Evaluating Program Performance: Background MAT is one of the most frequently studied addiction therapies, but evaluating program performance based on patient outcomes is relatively new. Many OTPs appear to be on their own in conducting program evaluations that comply with accreditation and State mandates.

36. Evaluating Program Performance: Outcome vs. Process Evaluation Earlier regulations stressed process evaluation, based on compliance with recommended treatment procedures. Process evaluation does not ask whether a recommended process has worked, only whether it has been followed. Outcome evaluation focuses on patients and their progress during or after participation in MAT.

37. Evaluating Program Performance: Outcome Evaluation Outcome evaluation focuses on patients and their progress during or after MAT. Evaluation should focus on progress markers and behavioral improvements. Such study can set a baseline and provide a benchmark to evaluate the effects of changes in program practices. Measures selected for evaluation by an OTP should agree with target behaviors specified in program goals and objectives.

38. Evaluating Program Performance: SAMHSA Accreditation SAMHSA�s accreditation guidelines list the following treatment outcomes as examples of what might be measured by OTPs: Reduce or eliminate use of illicit and problematic drugs; Reduce or eliminate associated criminal activities; Reduce behaviors contributing to the spread of diseases; and Improved quality of life by restoring physical and mental health and function.

39. Evaluating Program Performance: Process Evaluation Process evaluation describes what is happening in the treatment program. For example, a process evaluation can document what actually happens during an intervention. Process evaluation also may describe what is happening within the �black box� of the treatment program. (Black box, a commonly used term in this context, refers to the unknown quality of some treatment programs).

40. Evaluating Program Performance: Process Evaluation Permits others to replicate methods. Can lead to development of a manual. Can assess program strengths and weaknesses to improve operations. May help administrators understand program resources, leading to improved allocation.

41. Evaluating Program Performance: Resources for Evaluation CSAT: Demystifying Evaluation. NIDA: Measuring and Improving Costs, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs. Institute of Behavioral Research at Texas Christian University: core evaluation instruments. United Way of America: Outcome Measurement Resource Network. National (ATTC): The Change Book. Further details on page 240 of TIP 43.

42.

43. Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs Module 13: TIP Chapter 14