WHO collaborative project on drug dependence treatment and HIV/AIDS
Workshop Beijing 29.-31.05.2006

 

Monitoring and evaluation of methadone maintenance programs

 

•             Uchtenhagen

Research Institute for Public Health and Addiction

associated with Zurich University

 

 

Objectives of monitoring MMT

 

•Service utilisation corresponds to expectations

–Used by target population

–Optimal use of service capacity and resources

•Service quality corresponds to expectations

–Standards of care / good practice rules respected

–Qualified staff available

–Minimal adverse events

–Ethical guidelines respected

 

 

 

Schedules for the assessment of standards of care in substance abuse treatment
(WHO 1992)

•      Standards on access, availability and admission criteria (A1-11)

•      Standards on assessment (B1-12)

•      Standards on treatment content, provision and organisation (C1-18)

•      Standards on discharge, aftercare and referral (D1-7)

•      Standards on patient‘s rights (E1-6)

•      Standards on physical aspects of the treatment setting (F1-4)

•      Standards on staffing (G1-7)

 

 

Schedules for the assessment of standards of care in substance abuse treatment
(WHO 1992), contd.

•      The assessment is made in 3 steps :

–   Is the standard considered to be essential, advisable or not indicated

–   Is the indicated standard adequately met, inadequately met or not met at all

–   If inadequately or not met : why, how to improve

 

•      The assessment is made separately for :

–   Management of acute intoxication, of acute withdrawal, of drug dependence (including OST), of physical conditions, of psychiatric disorders, of psychosocial disability

 

 

 

13 principles of effective drug addiction treatment
A research based Guide (NIDA 1999)

•       Matching treatment to individual patient needs

•       Immediate availability and accessability

•       Address drug use and the associated medical, psychological, social, vocational and legal problems

•       Individual treatment plans must be continuously assessed and eventually modified

•       Minimal duration needed is 3 months, duration related to individual problems and needs

•       Counseling and other behavioural therapies are essential

•       Medications incl. replacement therapies are effective in combination with counseling and behavioral therapies

 

 

 

13 principles of effective drug addiction treatment
A research based Guide (NIDA 1999), contd.

 

•      Integrated treatment of psychiatric comorbidity

•      Sanctions / enticements can increase retention and outcome

•      Persisting drug use during treatment must be monitored

•      Prevention and treatment of blood born infections must be integrated

•      Multiple treatment episodes may be needed.

 

 

 

 

Voluntary Counseling and Testing VCT
(UNAIDS best practice collection 2000)

•      Voluntary counseling and testing for HIV : background, challenges, responses

–    Confidentiality

–    Counseling process (pre- & post-test)

–    HIV testing

–    Entry point to prevention and care

–    Expanding access, reducing costs

–    Improving education and awareness

–    Meeting the needs of specific groups

•      Tools for evaluating HIV voluntary counseling and testing (UNAIDS 2000)

 

Staff attitudes and satisfaction questionnaire
(Kang et al 1997)

•      Counselor attitudes, knowledge and satisfaction in methadone maintenance treatment

–Self-administered questionnaire

–2 domains, 96 resp. 51 items

•   Personal demographics, professional background, caseload characteristics, attitudes towards addiction / treatment policies / work environment / patients

•   Opinions on drug addiction / methadone programme policies / patients, medical knowledge about methadone, satisfaction with work environment

 

 

 

Ethical Guidelines
Adequacy in Drug Abuse Treatment and Care in Europe ADAT (WHO Euro office 2000)

•      Dimensions

–   Basic values and human rights

–   0rganisation of treatment and care

–   Responsibilities of services

–   Professional competence and behavior in general

–   Professional behavior towards clients

–   Bill of rights for clients

–   Procedure in case of infringement of guidelines

•      Checklist for the development of regional guidelines

 

 

 

  Outcome Evaluation in MMT

Outcome objectives
on the individual level (1)

•Health

–Somatic health improvements

–No acquisition /transmission of blood born infections

–Psychological health improvements

 

•Social Integration and life style

–Social contacts outside drug scene

–Gainful employment, adequate housing

–No illegal activities

 

Outcome objectives
on the individual level (2)  

•Substance use

–Reduction of illicit / unprescribed use

–Abstaining from high-risk use patterns

–Phasing-out facilitated

 

•Quality of life

–Subjective life quality improved

–Patients are mainly satisfied and stay in treatment

–Positive perspectives for the future

 

Outcome objectives
on the population level  

•Public Health

–Reduced rate of illicit drug use 

–Reduced rate of blood born infections (HIV, Hep.)

–Reduced mortality by accident, overdose & suicide 

•Public order

–Reduced rate of acquisitive crime

–Reduced extent of nuisance

•Economy

–savings through effective treatment 

 

 

Blood born virus transmission risk assessment questionnaire BBV-TRAQ
(Fry et al 1998)

•      Measuring risk-taking and protecting behavior for acquiring / transmitting HIV / Hepatitis

•      Self-administered questionnaire, 10-15 min.

•      Domains

–  Injecting risk behavior (20 items)

–  Sexual risk behavior (8 items)

–  Other skin penetration risk behavior (6 items)

•      Output

–  Total risk score, 3 sub-scores

Measuring patient satisfaction :
Treatment perception questionnaire TPQ (Marsden et al 1998)

 

•      Self-administred questionnaire

•      10 questions (agreement rating 1-5)

–5 questions regarding the service

–5 questions regarding staff attitudes & behaviour

•      3 additional questions (on gender, age, duration of treatment)

 

WHO Quality of Life Questionnaire WHOQOL-BREF 1997

•      Definition

–   „“the individuals‘ perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards, concerns“

•      Questionnaire

–   4 domains, 26 items : physical health (7 items), psychological health (6 items), social relationships (3 items), environment (8 items)

–   Short form of the WHOQOL-100

–   19 languages, international field tested

–   Self-administered or interviewer-administered, standardised instructions, provides a quality-of-life profile, SPSS syntax file available

–   For national adaptations consult WHO

Measuring economic outcome in MMT

•      Cost-effectiveness analysis

–  Comparing costs in terms of outcome

•      Cost-utility analysis

–  Comparing costs in terms of quality-adjusted life-years QALY‘s

•      Cost-benefit analysis

–  Comparing costs in relation to economic benefits

   (CALDATA study, Gerstein et al 1994)

   (WHO/UNDCP/EMCDDA Workbooks on Evaluation of Treatment nr. 8, 2000 )

 Evaluating availability
and affordability 
of MMT

 

Needs assessment evaluation
WHO/UNDCP/EMCDDA
Workbooks on Evaluation of Treatment  nr. 3, 2000

 

•      Question 1 : how many people in the region or the community need treatment ?

–   Mortality-based models, population surveys, capture-recapture models

 

•      Question 2 : what is the relative need for treatment across regions or communities ?

–   No satisfactory assessment methods available

 

 

Needs assessment evaluation 2 WHO/UNDCP/EMCDDA
Workbooks on Evaluation of Treatment  nr. 3, 2000

•      Question 3 : what types of services are needed and what is the necessary capacity ?

–   Questionnaire on availability and accessability of services, exploring the perception of needed treatment by patients/clients (is the intervention you need available, accessible ?) CCCNA Client Centered Community Needs Assessment (Di Villaer 1996)

•      Question 4 : are existing services co-ordinated, what is needed to improve system functioning ?

–   No reliable and valid instrument available

 

DATCAP
Drug Abuse Treatment Cost Analysis Program
(French 1998 6th ed.)

•      Structured interview and manual

–  Public domain, duration 8-16 hours

•      Domains

–  Program revenue, client information, personnel, supplies & materials, contracted services,buildings and facilities, equipment, miscellaneous costs and resources

•      Outputs

–  Total annual costs estimates for each cost category, for the program as a whole, per average client and per treatment episode

 

 Conclusions