Assessing Baltimore's Treatment System

Baltimore’s current treatment capacity serves only one in three city residents addicted to alcohol and drugs.[244]  Wrap-around services, which increase treatment success, are lacking in Baltimore:  Of 20 programs surveyed in the city, only four offer on-site primary health care, two offer job training and one offers childcare.[245]  Despite these challenges, the city, with guidance from the Scientific Advisory Committee, is working to address shortcomings in its treatment system.  Increasing treatment availability while ensuring quality core treatment services is a top priority for city leaders.  Plans are underway to provide wrap-around services that address the myriad problems faced by people with addictions.  The city has also been expanding data collection within and across treatment programs to evaluate performance.

The Ingredients of Treatment Success
This chapter assesses the city’s treatment system according to three major criteria:  progress toward ready availability of high-quality treatment; progress toward providing a comprehensive continuum of treatment services; and capacity to evaluate program performance and ensure high standards.  These assessment criteria have been chosen based on research identifying the “active ingredients” of successful treatment.[246]

The National Institute on Drug Abuse (NIDA) recently compiled a list of thirteen factors that research has identified as crucial to successful treatment outcomes.[247]  Two factors in NIDA’s 1999 Principles of Drug Addiction Treatment stand out for assessing the performance of a treatment system as a whole:  “treatment needs to be readily available,” and “effective treatment attends to multiple needs of the individual, not just his or her drug use.”

System-wide treatment success depends on making progress toward these two goals.  The window of opportunity during which a person addicted to drugs is ready to enter treatment may open infrequently and briefly, and the opportunity is wasted if treatment is not immediately available.[248]  But success also depends on the comprehensiveness of the services actually provided.  Research shows that treatment outcomes improve when comprehensive services—varying intensities of weekly counseling and provision of a wide array of medications—are supplemented by “wrap-around” services that address the patient’s other needs, ranging from primary health care, psychiatric care and family services to education, employment and housing assistance.[249]  Failure to address such problems in conjunction with treatment leaves patients especially vulnerable to relapse.[250]

Although NIDA’s Principles leave it implied, a treatment system’s core services—addiction counseling and, in many cases, medication—must be adequate to reap the full benefits of ready availability and comprehensive wrap-around services.  If drug users have rapid access to treatment, but the core services are limited or of poor quality, then treatment’s ready availability will accomplish far less than it should.  Similarly, if services are provided to address a patient’s problems beyond addiction, but the core treatment services are themselves flawed, then the results will be less than anticipated.  The importance of adequate core services ties “ready availability” and “comprehensive wrap-around services” to the third criterion for assessing Baltimore’s treatment system: the capacity to evaluate program performance.

Baltimore’s challenge is to make high-quality treatment readily available, and to wrap comprehensive services that address a patient’s multiple needs around solid core treatment services.

The Historical Context: Facing the Legacy of Treatment’s Neglect
Decades of inadequate support for public treatment mean that NIDA’s research-based principles of effective treatment are far from being achieved in practice system-wide anywhere in the country.[251]  Scarce funding has left the field hard-pressed to attract and retain qualified counselors.  Salaries are not commensurate with the education and interpersonal skills required to be an effective counselor.[252]  As a result, many talented people who enter the field soon leave for other opportunities.  High staff turnover disrupts counselor-patient relationships, which take time to develop.  Maryland’s Treatment Task Force reports a shortage of qualified addictions counselors statewide, resulting in vacancies at treatment programs, including those in Baltimore.[253]

Cities like Baltimore that are now firmly committed to improving treatment confront the difficult legacy of years of inadequate investment.

In FY 2000, BSAS invested nearly $775,000 in salary enhancements to bring BSAS-funded program staff  in line with the state’s pay scale.  Still, the $27,500 average annual salary in the BSAS system for front-line counselors (whose work does not include supervising other counselors) falls $10,000 short of the average salary for all jobs in Baltimore;[254] the vast majority (88 percent) of BSAS-funded counselors, including those with supervisory responsibilities, earn less than the average Baltimore worker.[255]  (To keep pace with state-level salary increases, BSAS plans to devote a portion of the FY 2001 funding increase from the state to a 4.6 percent pay increase for staff at  BSAS-funded programs.)

Ready Availability of High-Quality Treatment
People addicted to drugs are often uncertain about entering treatment.  More than half of applicants on treatment waiting lists are less interested in entering treatment at the end of the waiting period than when they first enlisted.[256]  The length of time applicants spend on a waiting list is also associated with greater likelihood that a person addicted to drugs will resort to criminal activity in order to continue obtaining drugs.[257]

At least one in eight adults in Baltimore needs treatment.  Current treatment capacity is adequate for only about one-third of them.[258]  Although there is no wait for intensive outpatient treatment, the wait for admission ranges from one week to one month for methadone maintenance, detoxification and residential care.  With the exception of transitional living, no publicly-funded long-term residential treatment (beyond 30 days) is available in Baltimore.[259]

A survey of ten of the city’s methadone maintenance programs found that, on average, they receive over 50 telephone calls a week from people seeking to enter treatment, but are able to admit only about five new patients per week.

It is difficult to determine specific capacity shortfalls for each treatment modality; BSAS records the treatment needs of the 950 to 1,200 treatment inquiries it receives directly each month, but the calls drop off once word gets out around the city that treatment slots are filled.  As part of the city’s intensified enforcement efforts against ten open-air drug markets during the first half of 2000, health officials identified 612 people addicted to drugs near the designated areas.  Eighty-four of the 236 people identified as addicted to drugs who subsequently tried to enroll in treatment had to be turned away due to lack of space.[260]

Baltimore’s Approach

Baltimore’s health commissioner estimates that achieving treatment on request will require serving about 40,000 people per year—double the current number.[261]

Baltimore’s leaders know the city needs the state’s assistance in order to add treatment capacity, and in FY 2001 Baltimore will receive 46 percent more treatment funding from the state than the prior year.  Despite this considerable increase, the city’s overall treatment budget for FY 2001 will only be half of the $70 million in annual spending needed to add enough new capacity—about 4,000 slots—to provide treatment on request.[262]  BSAS has also estimated that some 1,900 new slots could be funded with an additional $15 million in spending per year, with the new capacity divided equally between court-ordered and voluntary slots, and emphasizing methadone maintenance (1,150 slots), the area of greatest need.8/[263]

In October 1999, the BSAS Scientific Advisory Committee submitted its first set of recommendations on how Baltimore should pursue its capacity expansion.[264]  Many of these recommendations are reflected in BSAS’s FY 2000-FY 2002 Operating Plan and are already underway:

Ø                  The Committee recommended integrating detoxification services into all adult outpatient programs, since detoxification increases patients’ ability to make good use of outpatient treatment.  In FY 2000, BSAS awarded grants creating 16 outpatient detoxification slots integrated into existing outpatient treatment programs, enough to serve 400 patients a year.  In FY 2001, BSAS plans to fund an additional 80 such slots (40 for court-ordered patients and 40 for voluntary entrants), projected to serve 2,000 patients.

Ø                  The Committee recommended introducing LAAM into opiate treatment programs, allowing the programs to serve more patients without requiring more space, and providing another option for patients who do not respond to methadone.  In FY 2000, the city added 70 new LAAM slots as part of the REACH Mobile Health Services project.  BSAS has also won funding through a CSAT capacity expansion grant that would partner mobile services with a fixed-site facility and expand LAAM slots by 100.

Ø                  The Committee recommended the creation of an interim methadone maintenance program to increase the number of people receiving treatment.  For people on methadone program waiting lists, federal regulations now allow “interim” treatment consisting of medical assessment and daily, supervised administration of medication while the patient waits for entry in full-service programs, which add counseling services.  BSAS and Maryland’s Alcohol and Drug Abuse Administration (ADAA) have collaborated with the Friends Research Institute in submitting a proposal to NIDA to fund a pilot interim methadone maintenance program.

Ø                  The Committee considered that every citywide treatment system must have at least one long-term residential program, which is essential to providing services to a young, difficult group of patients who do not respond well in outpatient settings.  A committee of the BSAS Board has been tasked with identifying the barriers to creating new residential programs in the city and formulating a strategy to overcome those barriers.

Ø                  The Committee recommended that BSAS engage in public education to deepen understanding of what makes an effective treatment system and sustain support for the level of investment necessary to achieve treatment on request.  In March 2000, BSAS hired an Advocacy and Public Information Coordinator to design and implement a public education strategy.

In addition to these initiatives, in FY 2000 BSAS funded 145 new methadone maintenance slots through a supplemental grant from ADAA.  Also beginning in FY 2000, capacity expansion funds were used to expand the early morning and evening hours of operation of certain programs to accommodate patients’ work schedules.  With the increased state funding provided for FY 2001, BSAS also plans to create an additional 945 methadone and LAAM maintenance slots.

Comprehensive Wrap-Around Services

Patients receiving wrap-around services are more likely to remain in treatment, stay abstinent for longer periods of time, and demonstrate improvements in psychiatric, vocational and personal functioning.[265]

Improved outcomes from wrap-around services outweigh the costs associated with providing these services.  A study of publicly-funded treatment in Philadelphia found that the economic benefits of outpatient treatment enhanced by wrap-around services outweighed the costs by a ratio of nearly seven to one.  For methadone maintenance, the benefits were even more pronounced:  Every dollar spent on treatment enhanced with comprehensive wrap-around services saved $18 in avoided costs, largely due to reductions in crime and psychiatric problems.[266]

A treatment system’s progress toward providing a comprehensive continuum of services will affect progress in related areas highlighted in NIDA’s Principles.  For example, research has demonstrated that providing treatment services appropriate to each patient’s particular needs (“treatment matching”) and ensuring that patients remain in treatment long enough to reap the benefits (“adequate length of stay”) are critical for treatment effectiveness.[267]  The longer patients remain in treatment, the greater their reductions in drug use and their improvement over time.[268]  For most patients, significant improvement begins after three months in treatment, and benefits increase beyond the three-month threshold.[269]

Treatment Matching
Once enrolled, whether patients stay in treatment long enough to reap the benefits depends in good measure on whether they are matched to services appropriate to their needs.  A patient who feels that the particular services being provided (including core treatment counseling and wrap-around services) are not helping him address his problems is not apt to remain in the program for long.

Matching patients to the appropriate services is a two-step process.  One step entails the accurate assessment of each patient’s particular needs.  Baltimore’s publicly-funded programs use two instruments designed for this purpose—the Addiction Severity Index (ASI)[270] and the American Society of Addiction Medicine’s Patient Placement Criteria (ASAM-PPC-2).[271]

The second step in matching depends on the necessary range of services being available.  The ability to accurately assess patients’ needs is moot if the proper services do not exist or are in too short supply.  This applies both to core treatment service modalities (for example, intensive counseling, alcohol and drug detoxification, and methadone maintenance) and wrap-around services (for example, psychiatric care and job training).

The existence of a comprehensive continuum of services may persuade many people addicted to drugs that treatment has something to offer.  Even when drug use has become compulsive, an addicted person may see other problems—such as lack of education, unemployment or depression—as the real causes for concern and view drugs as a way to cope with, if not solve, these problems.

Despite the evidence that wrap-around services improve treatment outcomes, research has shown a sharp decline in the availability of such services.  In Baltimore, research from 1989-1994 involving more than 700 heroin addicts in treatment found that nearly 50 percent suffered co-occurring psychiatric problems, with antisocial personality disorder and major depression the most common diagnoses.[272]  During NIDA’s 1991-1993 Drug Abuse Treatment Outcome Study (DATOS), 54 percent of methadone maintenance patients who needed psychological services did not receive them.  Medical, family and employment services were also significantly less available for methadone patients in DATOS than they were a decade earlier.  The same trends prevail in long-term residential and outpatient drug-free programs.[273]  Wrap-around services are rarely offered in public treatment settings.[274]

A December 1999 BSAS survey of 20 Baltimore treatment providers found that 90 percent have enough space at their facilities to expand or add wrap-around services if funding were available.[275]  The survey also found that Baltimore’s treatment providers consider their patients to be most in need of medical, vocational and housing services.  Currently, however, few programs offer these services.  Only four programs offer on-site primary health care, two programs offer on-site job training and six programs offer on-site housing assessment.  In addition, only one of the 20 programs reported providing on-site childcare.  A greater number of programs offer referrals to other services, but often with no assurances that their patient will receive these services promptly.  In the case of housing assessment, only seven of the 20 programs even provide referrals.

Baltimore’s Approach
In October 1999, the BSAS Scientific Advisory Committee recommended that BSAS tighten linkages between drug treatment and ancillary services.[276]  The Committee noted that the leadership of the agencies that provide these services is represented on the BSAS Board, which should facilitate close cooperation.  The Board’s Operating Plan Committee has identified five important ancillary services for patients in the BSAS system: medical, mental health, educational/vocational, housing and childcare.[277]  The city’s Department of Social Services will fund childcare for the children of patients in treatment.  In FY 2001, BSAS will test the feasibility of system-wide implementation of the other services through pilot programs at three sites:

Ø                  Nurse practitioners will provide on-site medical services, including HIV, tuberculosis and sexually transmitted disease (STD) testing; HIV risk assessment and education; physical examinations; family planning education; and referral to specialty care (primary and urgent care, gynecology and specialized HIV care) at community-based health organizations.  In addition, the Johns Hopkins University School of Hygiene and Public Health will provide HIV and hepatitis screening for patients enrolled in methadone maintenance.

Ø                  The mental health services pilot programs will include on-site psychiatric assessment and services.  BSAS and its mental health counterpart, Baltimore Mental Health Services (BMHS), also plan to provide training in the identification and treatment of dual-diagnosed patients for counselors in both systems.  (The possibility of merging BSAS and BMHS to create a single behavioral health entity has come under consideration in Baltimore.[278]  Regardless of the ultimate organizational structure chosen by city leaders, success in treating addictions and other mental health problems will require that the responsible entities be adequately funded and well managed.)  

Ø                  Vocational assessment, job readiness training and job placement services will be made available on-site.  BSAS is developing referral linkages to workforce development providers and agencies such as the city’s Office of Employment Development (OED).

Ø                  The services of community-based agencies specializing in housing will be made available to patients at each pilot program.  BSAS is also exploring the possibility of placing treatment counselors on-site at all city shelters and transitional living facilities.

Evaluation and Quality Assurance
Because research has shown that apparently similar treatment programs can actually vary widely in the range and quality of services provided as well as patient outcomes, the continual monitoring of program performance is crucial to building a strong treatment system.[279]  Performance evaluation has direct clinical value by offering insights into why certain programs excel while others may lag.  By providing objective information about the treatment outcomes achieved by individual programs within the system, evaluation results can guide funding decisions.  If weaker programs cannot improve their performance, then changes in funding or program management are in order.9  Perhaps most importantly, evaluation can provide evidence of treatment success in reducing drug use and other drug-related problems.

Sustaining public support for an aggressive treatment strategy will require that BSAS can provide scientifically valid evidence that treatment works in Baltimore.

Evaluation and quality assurance require putting two distinct systems in place.  First, there must be a management information system (MIS) with the capacity to support program-specific and system-wide performance monitoring and evaluation.  The MIS must incorporate data for key performance measures, and procedures must be established to ensure that programs can provide the data on a routine basis.  Funding must be available to support evaluation research and retain personnel with the expertise to use the MIS to its full potential.  Second, formal decision-making processes must be in place to ensure that the information derived from performance evaluation guides program funding decisions.

Baltimore’s Approach
Baltimore began developing its Centralized Intake Referral and Management Information System (CIRMIS) in 1990 as part of the federally-funded Target Cities project.  CIRMIS now links more than 60 treatment programs, other social service providers and criminal justice agencies.  CIRMIS performs two major functions, monitoring slot availability and collecting demographic and treatment data as the basis for performance evaluation.

To improve performance monitoring of individual programs and the treatment system as a whole, the Scientific Advisory Committee recommended in its October 1999 report that BSAS track data for five key outcome measures:  treatment retention rates; reductions in alcohol and drug use (verified by frequent, random drug testing); kept appointment rates; program utilization rates; and repeated measurement of a subset of patients’ Addiction Severity Index (ASI) scores.[280]

Ø                  Although research has demonstrated the validity of patient self-reports in measuring alcohol and drug use, breathalyzer readings and urinalysis have become standard practice in measuring treatment outcomes.[281]  Negative urine or breath results support the success of treatment, while positive results indicate some drug use.  Drug tests are also clinically valuable for many patients, for whom the prospect of a drug test provides additional motivation to sustain recovery.[282]  The Scientific Advisory Committee recommended random weekly drug testing for patients in outpatient programs during the first three months of treatment, and twice monthly afterwards (depending on a patient’s progress).  The Committee’s recommendation represented a significant increase in testing by BSAS programs, and would therefore increase costs. 

Ø                  The rate of kept appointments is a crucial measure of treatment participation.  If counseling has been shown to work, but patients miss counseling sessions and are not adequately motivated to participate by program staff, then successful outcomes should not be expected.

Ø                  Program utilization rates provide a measure of the treatment system’s efficiency.  For example, if a significant proportion of funded capacity in a certain modality is consistently unused, then funding should probably be switched to treatment modalities that are operating at full capacity but still unable to meet demand.

Ø                  Repeating the administration of a subset of ASI questions at regular intervals in the treatment process will provide a fine-grain picture of patients’ progress in treatment over time.  The Committee recommended that questions be asked of all patients monthly for the first three months of treatment, and every other month for the first year of treatment, if applicable.  The information derived should help counselors assess the effectiveness of treatment services, and determine whether mid-course modifications are needed.  ASI data will also constitute an important source of information on the benefits of treatment as it occurs.  Outcome evaluations typically study a patient’s behavior after treatment, and therefore fail to capture the benefits to society generated during treatment.  For example, one of the ASI questions recommended for repeat administration by the Scientific Advisory Committee asks how many days in the past month a patient has engaged in illegal activities for profit.

Steep reductions in illegal activities and other measures compared to a patient’s Addiction Severity Index  scores at admission to treatment would indicate that the patient’s participation in treatment is of tangible benefit to society, apart from any consideration of how the patient does after leaving treatment.

CIRMIS is already capable of tracking retention rates, drug test results and program utilization rates.  The subset of ASI questions recommended by the Scientific Advisory Committee was piloted at one of the city’s treatment programs.  The clinical and performance evaluation benefits of regularly administering the ASI subset will likely be significant.  Like any new data-gathering task, though, it will take staff time and training to be done properly, which will add to the cost of treatment.

The ASI subset provides a good illustration of the fact that improving performance evaluation capabilities carries a price, and cannot be done well on the cheap.  Tracking kept appointment rates presents a similar issue. While tracking kept appointments rates is a straightforward task in terms of CIRMIS’ software, the data collection and reporting burden would currently be too heavy for many BSAS-funded programs unless a specific allowance is made in the BSAS budget to hire and train staff responsible for collecting and reporting data to BSAS.

BSAS is standardizing the administration of urinalysis and the recording of the results across all of the system’s programs.  Since July 2000, a single laboratory has conducted all of the tests for BSAS programs and electronically posts the results to BSAS.  This relieves program staff of the significant burden of urine test data entry, and makes the results available more quickly in a form suitable for CIRMIS.  BSAS plans to devote more than $500,000 of the increased state funding for FY 2001 to increase the frequency of drug testing across the system, with the minimum goal of randomly administering drug tests to every patient twice a month for the first three months in treatment, and once a month thereafter, with more frequent testing indicated where relapse appears likely.  This schedule does not yet meet the Scientific Advisory Committee’s recommended level of testing—once per week for the first three months of treatment, and twice per month thereafter.  Increasing the volume of tests again will require another increase in funding.

In pursuing the Scientific Advisory Committee’s recommendations, BSAS is building a management information system with considerable capacity to support ongoing program evaluation and research.  To take advantage of the system, BSAS created the new staff position of Director of Research and Evaluation, and filled the position in February 2000.  Beginning with the FY 2001 round of funding decisions, which took place in February 2000, the BSAS Board incorporated retention rates, utilization rates and drug test results in its grant review process.    

In addition to enhancing its own evaluation capabilities, BSAS and its component programs have been involved in several major treatment outcome studies.  When the city’s treatment expansion was launched, funding for evaluation was incorporated into the budget for city-funded slots known as the Mayor’s Initiative.  The results of a three-year evaluation of the Mayor’s Initiative are due in Spring 2001.  BSAS and individual treatment providers in the city are also participating in two important statewide studies of treatment effectiveness, known as the Treatment Outcome Performance Pilot Studies (TOPPS), and a federal network of clinical trials designed to test the effectiveness of innovative treatment techniques.

Mayor’s Initiative Evaluation
Established under Mayor Schmoke, the Mayor’s Initiative funds 860 treatment slots in detoxification, methadone and outpatient programs.  The University of Maryland, the Johns Hopkins University and Morgan State University are conducting a three-year evaluation of the Mayor’s Initiative, including the impact of the treatment expansion on program operations, treatment retention, service utilization, and drug use during and after treatment.[283]  Although final results are not due until Spring 2001, preliminary findings—based on ASI scores for 806 study participants in outpatient and methadone maintenance programs—underscore the effectiveness of  treatment and its benefits for Baltimore.  Compared to their behavior in the period before treatment, six months after entering treatment, participants (on average) had reduced the number of days in which they used heroin from 21 out of the previous 30 to 6 of 30.  Participants also reduced the number of days in which they engaged in illegal activity for profit from 41 out of the previous 180 to 17 of 180, while cutting their past-month spending on illicit drugs from $714 to $220.

Mayor’s Initiative researchers will also be testing the feasibility of conducting outcome research by linking to other public systems’ databases for information that will allow for objective follow-up research on the behavior of patients after they leave treatment.  For example, patient information in CIRMIS is being linked to criminal justice information in state databases. The Scientific Advisory Committee endorsed this line of research for its potential to cost-effectively expand the scope of the city’s treatment outcome research.

Treatment Outcomes and Performance Pilot Studies
Conducted by ADAA and CESAR with funding from CSAT, the study’s first phase (TOPPS-1) piloted a methodology to assess the performance of outpatient treatment programs statewide based on information collected through ADAA’s Substance Abuse Management Information System (SAMIS).[284]  TOPPS-1 ranked 58 programs in the state among five tiers (quintiles) according to their performance along seven measures at discharge, based on SAMIS data for FY 1997.  ADAA has stressed that the study was only the first step in exploring the feasibility of using SAMIS (an administrative database) to conduct program evaluation research, and that the results cannot be interpreted as conclusive evidence about the performance of the participating programs.

Although TOPPS-1 controlled for the severity of clients’ problems across programs (as measured by the ASI), it did not take into account the varied neighborhoods in which the outpatient participants lived.  A treatment client returning to a Baltimore neighborhood characterized by poverty and open-air drug markets, for example, might find less support for staying in treatment than a client who goes home to a more stable neighborhood.  Despite this potential disadvantage, several Baltimore programs were ranked among the best performing programs in the state; others were ranked in the middle, and some near the bottom.  However, given the exploratory nature of the research  and the limited value of the TOPPS-1 rankings themselves, ADAA and CESAR are following-up TOPPS-1 with a more in-depth study of the Baltimore programs that participated in the original research.  Known as Community Research on Effective Substance Abuse Treatment (CREST), the study will interview program administrators, staff and clients to ascertain which particular program characteristics are most associated with the strongest treatment outcomes and which are associated with weaker results.[285]

TOPPS-2 is exploring on a statewide basis the feasibility of linking treatment patients to data in other public databases.  SAMIS, the state’s treatment information system, only records the last four digits of each patient’s Social Security number.  Baltimore’s CIRMIS—which collects full Social Security numbers—will be used to help test whether the state’s four-digit Social Security number and date of birth records will be adequate to make the linkages to other databases.[286]

Clinical Trials Network
Bridging the gap between research and practice is crucial to achieving the full benefits of treatment.[287]  In 1998, the Institute of Medicine recommended that NIDA create a Clinical Trials Network (CTN) that would link community-based providers with researchers to test the effectiveness of promising new treatment techniques in real-world settings with diverse patient populations.

NIDA envisions a network consisting of 20 to 30 regional research centers; the first six regional centers were established in 1999, including a Mid-Atlantic Node anchored by  Baltimore’s Johns Hopkins University and by Virginia Commonwealth University.  Six of the nine treatment programs participating in the Mid-Atlantic Node are located in Baltimore. 

Participation in NIDA’s Clinical Trials Network by members of the BSAS Scientific Advisory Committee and local treatment programs ensures that the most promising treatment techniques from across the country will be infused into Baltimore’s public system.

Within each CTN node, researchers team with treatment program directors to propose which promising techniques should be tested among community-based programs throughout the network.  By spanning multiple sites, populations and geographic regions, CTN research findings will be more generalizable than is typically the case for research carried out in only one location and in a limited set of circumstances.  Among the research concepts already approved for implementation is a test of the effectiveness of buprenorphene/naloxone as an alternative to other medication for short-term opioid detoxification.  Successful detoxification in short-term outpatient settings and through mobile services would represent a major step forward, especially for cities such as Baltimore, where heroin is a major drug of abuse.

All Things Considered: Assessing Baltimore’s Priorities and Progress
BSAS has described its top priorities to Maryland’s Treatment Task Force as supporting the current treatment system, expanding treatment system capacity, and improving treatment outcomes through enhancement of treatment services.  In light of the  research that underscores adequate core services and performance evaluation, ready availability of treatment and comprehensive wrap-around services as keys to successful treatment, BSAS’s priorities are in good order.

Baltimore, however, does not have the luxury of resources to fully address all of these priorities at the same time.  Nor can BSAS afford to focus all of its resources in one area before moving on to the next.  The scope and urgency of the city’s drug problems require that BSAS move on all fronts at once, and BSAS has been doing so.  Given the city’s unmet demand for treatment services, capacity expansion cannot be delayed.  Yet simply expanding capacity without shoring up the foundations of existing programs would be of limited benefit, as would enhancing treatment with wrap-around services without being able to evaluate whether such enhancements improve treatment outcomes.

BSAS has therefore rightly invested time and resources in upgrading its capacity to evaluate program performance and to identify areas of the system that need to be strengthened.  It bears emphasis that proper evaluation and quality assurance cannot be done on the cheap.  For example, simply repeating a subset of Addiction Severity Index questions at determined intervals during treatment will make significant new demands on program staff time, in terms of training, administering the questions on a regular basis, and entering the data in a way useful to BSAS.

Making such improvements to BSAS’s own infrastructure has meant that expansion of the system’s treatment services has not happened as rapidly as it might have.  The higher expenses entailed by more frequent drug testing within BSAS-funded programs, for example, mean that fewer resources are available for other priorities, including capacity expansion.  In addition to its clinical value, more frequent drug testing plays an important role in performance evaluation.  BSAS has also chosen to invest in intensifying outpatient services and in upgrading  counselors’ salaries, balancing these priorities with the goal of creating new capacity.  Even if Baltimore has significantly more treatment funding at its disposal in the future, BSAS will need to continue striking a balance between fortifying the existing system and creating new capacity.

Despite the urgent need for greater capacity, BSAS has in practice adopted a more deliberate pace—so as not to neglect shoring up the existing system, and in order to begin the process of providing patients with the comprehensive range of high-quality services they need.  This more deliberate pace of expansion, with close attention to the quality and comprehensiveness of services offered, should serve Baltimore well.

---

8           Securing the funding to add capacity is merely the first step in what is necessarily a painstaking process.  Before even one additional patient can receive treatment, proposals must be requested and reviewed, contracts awarded, space secured, and staff hired and trained.  So even when new funding can be devoted to expansion, adding new capacity takes time.

9           In evaluating performance, it is essential to take into account differences in the severity of patients’ problems across programs.   Failure to control for patient differences exaggerates the effectiveness of programs treating less impaired patients and understates the effectiveness of programs treating patients with more severe problems.  

---

[245]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Service Enhancements Treatment Survey.  December 1999.

[246]           A. McLellan et al.  “Evaluating the effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons.”  The Milbank Quarterly, 74(1):51-85, 1996.  The same research that has shown that treatment works has also made it clear that not all treatment programs are equally effective.  Successful treatment depends to a great degree on the nature and extent of a patient’s problems and on the patient’s degree of engagement in the treatment process.  But success also depends on the strength of the particular program in which the patient is enrolled.  Research controlling for patient characteristics has found remarkable variation across programs in the nature and amount of services provided during treatment—even when the programs appear similar in terms of their goals, rehabilitation philosophies, and counseling techniques.  In general, programs that provide more services, especially services targeted at patients’ particular problems, produce superior outcomes, while programs providing fewer and less well-targeted services produce inferior outcomes.

[247]           National Institute on Drug Abuse (NIDA).  Principles of Drug Addiction Treatment:  A Research-Based Guide.  October 1999.

[248]           National Institute on Drug Abuse (NIDA).  Principles of Drug Addiction Treatment:  A Research-Based Guide.  October 1999.  Principle 2: “Treatment Needs to Be Readily Available.  Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial.  Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible.”

[249].            A. McLellan et al.  “Supplemental social services improve outcomes in public addiction treatment.”  Addiction, 93(10):1489-1499, October 1998.

[250]           National Institute on Drug Abuse (NIDA).  Principles of Drug Addiction Treatment:  A Research-Based Guide.  October 1999.  Principle 3: “Effective Treatment Attends to Multiple Needs of the Individual, Not Just His or Her Drug Use.  To be effective, treatment must address the individual’s drug use and any associated medical, psychological, social, vocational, and legal problems.”

[251]           L. Koenig et al.  The Costs and Benefits of Substance Abuse Treatment: Findings from the National Treatment Improvement Evaluation Study (NTIES).  Fairfax, VA: National Evaluation Data Services, August 1999.  To be sure, public-sector treatment has been able to deliver major benefits.  For example, NIDA’s sample population for the 1993-1995 National Treatment Improvement Evaluation Study (NTIES) emphasized low-income clients—individuals who are more likely to receive treatment through publicly-supported programs—and still found that every dollar invested in treatment yielded $3 in benefits for society.  Nonetheless, scarce funding has left public-sector treatment in the United States struggling to realize its full potential.

[252]           A. McLellan et al.  “Is the counselor an ‘active ingredient’ in substance abuse rehabilitation?  An examination of treatment success among four counselors.”  Journal of Nervous and Mental Disorders, 176(7):423-430, July 1988.

[253]           Maryland Task Force to Study Increasing the Availability of Substance Abuse Programs. Interim Report by the Committee on Availability and the Committee on Effectiveness.  December 1999.

[254]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Not including hospital-based programs (which have different salary scales), the 54 full-time level I, II and III addictions counselors at BSAS-funded programs earned an average salary of $27,491 in FY 2000.

Maryland Office of Planning, Planning Data Services.  In 1998, the average wage and salary for a job in Baltimore totaled $34,457.  Based on the 8.85 percent wage and salary increase experienced between 1996 and 1998, the average wage and salary for a job in Baltimore in 2000 can be estimated at $37,506, or $10,015 more than the average addictions counselor’s salary.

[255]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Not including hospital-based programs (which have different salary scales), 82 of 93 (88.2 percent) full-time counselors in BSAS-funded programs earn less than the $37,506 average wage and salary for a job in Baltimore.  The total of 93 full-time counselors includes 54 without supervisory responsibilities and 39 with supervisory responsibilities.

[256]           B. Brown et al.  “The functioning of individuals on a drug abuse treatment waiting list.” American Journal of Drug and Alcohol Abuse, 15(3):261-274, 1989.

[257]           B. Brown et al.  “The functioning of individuals on a drug abuse treatment waiting list.” American Journal of Drug and Alcohol Abuse, 15(3):261-274, 1989.

[258]           Maryland Department of Health and Mental Hygiene, Alcohol and Drug Abuse Administration (ADAA).  Based on treatment admissions data for fiscal year (FY) 1998, ADAA estimated 60,375 Baltimore residents to be in need of treatment for alcohol or other drug abuse—amounting to 12.8 percent of the city’s 471,147 adults in 1999, or one in eight adults.  ADAA acknowledges that this estimate is conservative, particularly in accounting for alcohol treatment need and for the number of drug abusers among the city’s criminal offenders.  The true number of Baltimore residents needing treatment may be in the range of 75,000 to 80,000.   For FY 1999, ADAA calculates that 18,738 individuals received treatment in BSAS-funded programs (unduplicated count), and that 20,445 Baltimore residents received treatment at state-certified treatment programs, in and beyond Baltimore.  Therefore, Baltimore’s public-sector programs serve only one-third of city residents in need of treatment.

[259]           Maryland Task Force to Study Increasing the Availability of Substance Abuse Programs. Filling in the Gaps:  Statewide Needs Assessment of County Alcohol and Drug Treatment Systems.  February 2000.

[260]           P. Hermann.  “Drug crackdown works, mayor says.”  The Baltimore Sun, June 8, 2000.

[261]           P. Beilenson.  “How $40 million more can aid addicts.”  The Baltimore Sun, March 6, 2000.

[262]           Baltimore Substance Abuse Systems, Inc. (BSAS).  System Overview.  February 2000.

[263]           Baltimore Substance Abuse Systems, Inc. (BSAS).  System Overview.  February 2000.

[264]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Scientific Advisory Committee Report and Recommendations.  October 1999.

[265]           A. McLellan et al.  “Supplemental social services improve outcomes in public addiction treatment.”  Addiction, 93(10):1489-1499, October 1998.  

[266]           M. French et al.  “Benefit-cost analysis of ancillary social services in publicly supported addiction treatment.”  Draft paper based on the Philadelphia Target Cities Project, submitted for publication May 1999.

[267]           National Institute on Drug Abuse (NIDA).  Principles of Drug Addiction Treatment: A Research-Based Guide.  October 1999.  Principle 4:  “An Individual’s Treatment and Service Plan Must Be Assessed Continually and Modified as Necessary to Ensure that the Plan Meets the Person’s Changing Needs.”  Principle 5:  “Remaining in Treatment for an Adequate Period of Time is Critical for Treatment Effectiveness.”

Y. Hser et al.  “Matching Clients’ Needs With Drug Treatment Services.”  Journal of Substance Abuse Treatment, 16(4):299-305, 1999.

[268]           A. McLellan et al.  “Evaluating the effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons.”  The Milbank Quarterly, 74(1):51-85, 1996.

[269]           R. Hubbard et al.  “Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcomes Study (DATOS).” Psychology of Addictive Behaviors, 11(4):261-278, 1997.

[270]           A. McLellan et al.  “The fifth edition of the Addiction Severity Index.”  Journal of Substance Abuse Treatment, 9:199-213, 1992.

[271]           American Society of Addiction Medicine (ASAM).  Patient Placement Criteria for the Treatment of Substance Related Disorders (ASAM-PPC-2), 2nd Edition.  Chevy Chase, MD:  ASAM, 1996.  The ASAM-PPC-2 assesses patients in six domains and offers criteria by which patients can be matched to the appropriate level of treatment.  The six domains are (1) acute intoxication and withdrawal, (2) biomedical condition, (3) emotional behavioral conditions, (4) acceptance of treatment, (5) relapse potential, and (6) recovery environment.

[272]           R. Brooner et al.  “Psychiatric and substance use comorbidity among treatment seeking opioid users.”  Archives of General Psychiatry, 54:71-80, January 1997.

[273]           “DATOS documents dramatic decline in drug abuse treatment services.”  NIDA Notes, 12(5), September/October 1997.  In addition to the example in the text, the following reductions in the availability of wrap-around services were found by DATOS researchers.

Methadone maintenance patients who needed but did not receive medical services: TOPS, 17.8 percent; DATOS, 39.6 percent.
Methadone maintenance patients who needed but did not receive family services: TOPS, 17.0 percent; DATOS, 52.8 percent.
Methadone maintenance patients who needed but did not receive employment  services: TOPS, 33.1 percent; DATOS, 54.1 percent.

Long-term residential patients who needed but did not receive medical services: TOPS, 5.6 percent; DATOS, 24.8 percent.
Long-term residential patients who needed but did not receive family services: TOPS, 23.7 percent; DATOS, 59.6 percent.
Long-term residential patients who needed but did not receive employment  services: TOPS, 43.8 percent; DATOS, 62.0 percent.
Long-term residential patients who needed but did not receive psychological  services: TOPS, 10.0 percent; DATOS, 57.3 percent.

Outpatient drug-free patients who needed but did not receive medical services: TOPS, 9.2 percent; DATOS, 32.0 percent.
Outpatient drug-free patients who needed but did not receive family services: TOPS, 8.1 percent; DATOS, 63.0 percent.
Outpatient drug-free patients who needed but did not receive employment  services: TOPS, 21.0 percent; DATOS, 54.5 percent.
Outpatient drug-free patients who needed but did not receive psychological  services: TOPS, 6.6 percent; DATOS, 57.2 percent.

[274]           M. French et al.  “Benefit-cost analysis of ancillary social services in publicly supported addiction treatment.”  Draft paper based on the Philadelphia Target Cities Project, submitted for publication May 1999.

[275]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Service Enhancements Treatment Survey.  December 1999.

[276]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Scientific Advisory Committee Report and Recommendations.  October 1999.

[277]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Service Enhancements Report and Recommendations.  April 2000.

[278]           Greater Baltimore Committee (GBC) & the Presidents’ Roundtable.  Managing for Success.  July 2000.  The report called for combining BSAS and Baltimore Mental Health Systems (BMHS) “to create a unified organization to oversee and direct the City’s behavioral health spending.”

G. Shields.  “Mayor targets excess costs.”  The Baltimore Sun, November 7, 2000.  Mayor Martin O’Malley reportedly accepted the recommendation to combine BSAS with BMHS and plans to do so by 2002.   

[279]           A. McLellan et al.  “Evaluating the effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons.”  The Milbank Quarterly, 74(1):51-85, 1996.

[280]           Baltimore Substance Abuse Systems, Inc. (BSAS).  Scientific Advisory Committee Report and Recommendations.  October 1999.

[281]           A. McLellan et al.  “Evaluating the effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons.”  The Milbank Quarterly, 74(1):51-85, 1996.

[282]           A. Washton.  “Structured Outpatient Group Therapy,” in J. Lowinson et al. (eds.), Substance Abuse: A Comprehensive Textbook, 3rd Edition.  Baltimore, MD: Williams and Wilkins, 1997.

[283]           University of Maryland, the Johns Hopkins University and Morgan State University.  Overview of the Mayor’s Initiative for Substance Abuse Treatment Evaluation in the City of Baltimore.  August 2000.

[284]           M. Hsu et al.  Results from Maryland’s Treatment Outcomes and Performance Pilot Study (TOPPS-1): Executive Summary.  College Park, MD: Center for Substance Abuse Research (CESAR), September 1999.

[285]           Center for Substance Abuse Research (CESAR).  Proposal:  The Influence of Program Characteristics on Drug Treatment Outcomes in Baltimore City.  Funded in December 1999 as Community Research on Substance Abuse Treatment (CREST) by the Abell Foundation and the Open Society Institute-Baltimore.   

[286]           Maryland Alcohol and Drug Abuse Administration (ADAA) and Center for Substance Abuse Research (CESAR).  Study Protocol—Treatment Outcomes and Performance Pilot Study II (TOPPS II): Establishment of a Statewide Outcomes Monitoring System in Maryland.  May 1999.

[287]           Institute of Medicine.  Bridging the Gap between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment.  Washington, D.C.:  National Academy Press, 1998.  On one hand, community-based treatment providers underutilize much of what research has shown can improve treatment services.  At the same time, researchers often ignore issues of great concern to community-based service providers.  For both reasons, new treatment techniques tend to be only slowly adopted on a wide scale in community settings.