Journal Printed
of Substance Abuse Treatment, in the USA. All rights reserved.
Vol. 9,
pp. 177-181,
0740-5472/92
1992
$5.00
+ .@I
Copyright0 1992PergamonPressLtd.
IN THE SPOTLIGHT
A Multicomponent Model for Substance Abuse Treatment The Addiction
Research and Treatment Corporation
Abstract- This paper reviews the activities of the Addiction Research and Treatment Corporation (ARTC), a substance abuse treatment agency, located in Brooklyn, New York, which services approximately 2,300patients annually. ARTC’s history, treatment, and research activities are first described. We then proceed to detail the ARTC’s employee health maintenance and community relations programs. A multicomponent treatment model is then outlined, which emphasizes the interactive role of the above functions within an optimal treatment network. Keywords-substance lations; HIV.
abuse; employee assistance program (EAP); health program (HP); public re-
complex factors involving the subject population, the diversity of treatments, and imperfect assessment instruments. Additionally, issues such as subject dropouts and losses to the study, the unmeasured effects of the large range of treatment provider characteristics, and organizational dynamics make this research challenging. The Addiction Research and Treatment Corporation’s (ARTCs) approach to the treatment of substance abuse derives from our extensive history of providing treatment to a socially disadvantaged, opiate-dependent population, This paper: (a) reviews the history of ARTC, (b) describes treatment services and research activities at ARTC, (c) discusses the roles of our Employee Assistance (EAP) and Health Programs (HP), (d) reviews our community/public relations effort, both internal and external, and (e) presents a model for any agency providing full-spectrum services for low-income, opiate-dependent patients.
INTRODUCTION SUBSTANCE ABUSE TREATMENT RESEARCH has been charged with the tasks of developing effective means of treating drug abusing patients, both to reduce their use of intravenous substances, and to change needlesharing behaviors associated with HIV infection (Clayton, 1986; Drotman, 1987; Stimmel, 1987). The concern about IV drug use was potentiated by the recent epidemic of AIDS, although medical problems caused by IV use have been long-standing (Ball & Carl, 1970; Lowinson & Ruiz, 1981). Society’s search for effective treatments for opiate-addicted individuals has been underway for some time. The consensus of some investigators has been that, by and large, there have been some successes with different forms of treatment at various times (Ball, Lange, Myers, & Friedman, 1988). The conduct of effective treatment research is, in general, difficult because of
HISTORY OF ADDICTION RESEARCH AND TREATMENT CORPORATION (ARTC)
This research was supported by a grant from the National Institute on Drug Abuse (RlS-DA-060142). Requests for reprints should be addressed to Horace PhD, Addiction Research and Treatment Corporation, Street, Brooklyn, New York 11201.
The ARTC was organized in 1969 by Beny J. Primm, MD, to serve the unique needs of addicted minority group members. ARTC is a not-for-profit organiza-
W. Batson, 22 Chapel
177
178
H. W. Batson et al.
tion funded for service by the New York State Division of Substance Abuse (DSAS). ARTC’s treatment program is designed to serve heroin-addicted individuals in the urban ghettos of New York City. The objective is to help patients become independent, responsible citizens engaged in a variety of meaningful activities. Since it was founded, ARTC has grown to be one of the country’s largest treatment programs. Six community-based clinics, handling a maximum of 2,300 patients annually, are in operation in both Brooklyn and Manhattan. To date, ARTC has provided over 20,000 patients with a full range of comprehensive health care and treatment services. In addition, ARTC’s Division of Medical Services, Evaluation, and Research contributes to research in the substance abuse field. The National Institute on Drug Abuse (NIDA), Centers for Disease Control (CDC), and the National Institute of Allergy and Infectious Disease (NIAID) funds various ARTC research projects. SERVICES PROVIDED AT ARTC Our patients are low-income and generally undereducated. Therefore, they come to treatment with a wide range of financial, educational, vocational, medical, and psychological needs, and so on. We fundamentally believe that the most effective way to treat this population is to treat the whole person. Our multifaceted, comprehensive treatment approach reflects this philosophy. Patients addicted to heroin or other opiates receive a dosage of methadone prescribed by a physician. Taken once a day, methadone is relatively effective in preventing addicted individuals from seeking a drugculture lifestyle. This lifestyle may include criminal activities and other antisocial behavior. Methadone maintenance helps opiate-dependent persons to avoid physical symptoms of withdrawal. They are enabled to engage in the pursuit of those specific activities and treatment objectives that constitute rehabilitation. Individual, group, and family counseling are also provided to help patients cope with the problems of daily living. Each patient has a counselor, who assesses and helps modify, where necessary, aspects of the patient’s behavior on social, economic, and personal levels. Narcotics Anonymous and other self-help groups are also available to serve as additional support systems. Comprehensive and ongoing medical care is provided at all clinics, provided by physicians, physician assistants, and nurses. A clinic vocational specialist assesses each patient’s educational/vocational strengths and aptitudes. This assessment helps patients to formulate their career goals. After this; they are referred to appropriate educational and vocational programs. Finally, patients are assisted with job placement. A mental health con-
sultant is responsible for the psychological evaluation of all patients. He or she evaluates and coordinates psychological services. Also, psychotherapy and/or psychiatric referrals are provided, as necessary. The clinic’s educational coordinator provides tutoring, remedial reading, and/or remedial math, testing, and evaluation of educational skills. This coordinator also makes referrals to programs offering GED preparation and vocational training. Also, referrals may be made to schools and colleges. Additionally, adult basic education classes are available to clinic patients. A women’s treatment coordinator helps to identify the special needs of women and coordinates the development of special projects and programs to meet these needs. Individual and group counseling are also provided directly by the women’s treatment coordinator. The pharmacy, located in one of ARTC’s Brooklyn clinics, fills medical prescriptions for patients as prescribed by the physician. Additionally, referrals are made to those programs that provide services that are not available within the clinic, or to those programs that augment existing programs within ARTC. We recognize that these services may be modified in the future, based on the acquisition of knowledge and the development of more effective treatment strategies. RESEARCH ACTIVITIES AT ARTC The ARTC recognizes that clinical research and evaluation are important tools in our efforts to provide the most effective treatments to our patients. Thus, ARTC has been totally committed to making research a vital component of this agency’s treatment modality. Basically, we believe that research/evaluation can help us to understand the problems that require treatment and the kinds of treatments that prove most effective for these problems. The ARTC is currently conducting studies in a number of areas. HIV Studies The ARTC currently participates in the new community-based clinical trials research program entitled, the “Community Programs for Clinical Research in AIDS” (CPCRA), funded by the National Institute of Allergy and Infectious Diseases (NIAID). This program is designed to provide access to research clinical trials for individuals who traditionally have been excluded from the testing of new AIDS drugs, such as African-Americans, Hispanics, intravenous drug abusers, and women. ARTC physicians actively prescribe AZT for clinic patients (the only drug so far proven effective against the AIDS virus). ARTC’s patients are among those getting “first crack” at promising new therapies. The first scheduled study is a two-drug comparison for the prophylaxis of toxoplasmosis encephalitis, a serious brain infection associated with AIDS. The sec-
A Multicomponent
Model for Substance Abuse Treatment
179
ond protocol is a comparison study of dideoxyinosine and dideoxycytidine, two promising new anti-retroviral drugs in patients who can no longer benefit from AZT. Additionally, ARTC is developing a statistical profile of our AIDS population as part of an observational data base. The goal of this database is to enable us to tailor better services to our patient population. Other therapies besides those offered by ARTC may also become available to our patients as we forge links with other AIDS clinical trials groups. Another HIV study consists of two components. The first component tests the hypothesis that HIV+ injecting drug users (IDUs) will sexually transmit the virus to their non-IDU sex partner. Both the index case (HIV-positive IDU) and the sex partner(s) (HIV-negative non-IDU) have their blood tested for the virus over a 3-year period at 3-month intervals to determine whether the HIV-negative sex partner seroconverts. A record of sexual practices is logged. Also, health education, sex education, AIDS education, condoms, and overall health care are provided to all participants. The second component of this study defines the natural history of HIV infection in the IDU population by plotting the course of disease of HIV-positive IDUs, starting with their asymptomatic baselines and continuing as they become progressively ill over time. We plot the progression of illness by examining changes in T-cell count and helper-suppressor T-cell ratios, and so on. As the patient becomes progressively sicker, we provide medical care and treatment as well as making the appropriate health care referrals for the needed tertiary care. In collaboration with the Pulmonary Division of the Department of Medicine at Harlem Hospital Center, the New York City Department of Health, and the Division of Tuberculosis Control of the Centers for Disease Control, ARTC is also conducting a prospective and longitudinal study of isoniazid (INH) therapy among IDUs who are enrolled in methadone maintenance.
through the Department of Health/AIDS Research Unit. This study involves an evaluation of a skillsbased, educational intervention-teaching AIDS awareness; contraception use; drug, health, and nutrition information. In addition, a standardized quantitative questionnaire is administered. This instrument consists of a series of pretest/posttest comparisons measuring knowledge, attitudes, and behaviors related to HIV. An unstructured, ethnographic interview, is also administered to assess community norms related to HIV, reproduction, and contraception.
Perinatal Studies This collaborative project attempts to increase the use of and compliance with family planning methods in women at high risk for perinatal transmission of HIV. Research participants will be provided with individualized education concerning HIV and family planning. The study is being conducted with women attending four of the six ARTC methadone maintenance programs. It is expected that this intervention will reduce the incidence of pregnancy in the research participants. The seropositive rate for women attending ARTC is 61%. A sister project to the aforementioned study is funded by the Centers for Disease Control (CDC)
National Institute of Drug Abuse (NIDA) Treatment Research Unit Study (TRU) The Treatment Research Unit of the ARTC has recently received funding from the National Institute on Drug Abuse (NIDA). The TRU’s objectives are threefold: 1. To increase enrollment in drug treatment of 210 persons dependent upon psychoactive substances that are associated with parenteral routes of administration or that are associated with disinhibiting behaviors that place these persons at risk of HIV infection. 2. To evaluate the efficacy of various pharmacologic and nonpharmacologic interventions that will reduce drug/sex behaviors associated with HIV transmission or HIV disease progression among persons enrolled in drug treatment, and 3. To identify factors (demographic, behavioral, and biomedical) associated with the success of various interventions to reduce HIV-associated transmission behaviors. Toward addressing these objectives, we are implementing a series of studies. The first involves an assessment of the relationships among patient characteristics and treatment response. We are administering several psychosocial instruments to patients (ie., those who remain in treatment and dropouts) at intake into the study and at 3,6, 9, and 12 months. This investigation will allow us to ascertain the relationships between patient characteristics and treatment responses. The second study measures the effectiveness of several drugs for the treatment of cocaine and opiate abuse - desipramine and buprenorphine. The ARTC is collaborating in a NIDA-sponsored multicenter trial of the latter drug. The third investigation assesses the effectiveness of enhanced primary care for several disorders that are common in our population-HIV disease, diabetes, hypertension, and so forth. EFFORTS TO MAINTAIN STAFF HEALTH Constant exposure to demands and challenges of the work environment (without employee motivational/ health programs) is believed to accelerate staff burn
180
H. W. Batson et al.
out (Carol1 1979; Daley, 1979; Edelwich & Brodsky, 1980; Glicken, 1983; Maslach, C., 1978). This situation exists for substance abuse treatment staff. These employees experience a great deal of stress in their jobs. Stressors result from various sources, such as crowded working conditions, increased patient loads, a multiplicity of personnel needs, such as housing, financial, medical, and psychiatric issues. These stressors mount, often compromising staff members’ ability to function at their best on their job. Such negative experiences can result in poor staff morale, excessive absenteeism, attrition, illness, and low productivity. Additionally, clinical staff bear the burden not only of providing treatment, but, also of experiencing the suffering and eventual death of their patients from AIDS, other diseases, and natural or unnatural causes. Finally, it is worth noting that staff often experience some of the same life problems as their patients. For example, financial, legal, vocational, health, and so on-which may be helped by the availability and provision of specialized services at the workplace. ARTC is beginning to develop two approaches to reducing the impact of these negative stress factors on employee health and productivity, the Employee Assistance Program (EAP) and Health Program (HP). Employee
Assistance
Program (EAP)
The EAP, a service offered by ARTC, is designed to offer confidential, free, or low-cost counseling and/or referral services - on a voluntary basis -to all agency personnel. A social worker serves as EAP coordinator and brings first-rate professional help to assist employees in coping with such problems as alcoholism, marital discord, stress, a troubled child, the difficulty of identifying appropriate child-care resources, or caring for an aging parent. The focus of short-term counseling provided by the social worker is always to help the employee come to grips with his or her problems as quickly as possible. The EAP has only one purpose-to help the employee’s immediate family and the employee cope with personal problems. The existence of the EAP is an indication that management wants to protect its most valuable resource-the employee of ARTC. Health Program
stein, 1983; Brewer 8z Dubnicki, 1983; Glicken, 1983; Matteson & Ivancevich, 1982). These programs differ from EAPs in that they are specifically designed to improve or prevent worker problems or difficulties stemming from health-related disorders. HPs (Health Programs) offer practical help through workshops on stress management, ways to deal with depression, dealing with death and dying, weight loss, stopping smoking, staying healthy, and other important health-oriented workshops. Management offers these programs free to ARTC staff, and they are allowed to attend on company time. To be sure, maintaining employee health is important for facilitating treatment delivery. Also, of importance to the health of both the staff and the agency is a high agency profile vis-a-vis the community. These efforts serve to promote agency-community harmony and foster a more positive company image. We describe below the development of ARTC’s Public Relations program. COMMUNITY/PUBLIC RELATIONSINTERNAL AND EXTERNAL
As discussed earlier in this paper, working with substance abusers is a difficult and challenging task. This work becomes even more troublesome if the community has negative views about the treatment agency (i.e., ARTC). To prevent this from occurring, we envision a public relations division, whose objective is to inform the community of our activities. ARTC develops and maintains relationships with residents, community, and business leaders. We also educate the community about substance abuse and program services. ARTC staff members attend various social functions as a part of its general outreach efforts. ARTC is formalizing the following programs to maintain close ties to its continually growing number of employees and to foster a greater “team” spirit: corporate management makes personal visits to clinical, medical, and research staff; personalized letters of congratulations are sent to each member of the clinical and medical team for recognition of their efforts; holiday and birthday cards are sent to each member in a timely manner, and time off is given to staff members to participate in training/conferences and Health Programs, to name just a few!
(HP)
The ARTC recognizes the particular difficulties experienced by our employees. We are also making a concerted effort to provide and improve upon our employee health maintenance system. In addition to our EAP, ARTC is developing its Health Program (HP). Evidence suggests that maintaining employee health through health-promotion programs and services can improve job performance and prevent burn out (Bern-
A MULTICOMPONENT SERVICE MODEL
DELIVERY
In overview, our treatment system is depicted in the model shown in Figure 1. ARTC believes that it is important to provide a full range of comprehensive, multidisciplinary, multifaceted services to our patients. This approach is designed to address the full range of financial, drug, educational, employee, housing, fam-
A Multicomponent
Model for Substance Abuse Treatment
CL/Patlents
of Substance Abuse Treatment, in the USA. All rights reserved.
Vol. 9,
pp. 177-181,
0740-5472/92
1992
$5.00
+ .@I
Copyright0 1992PergamonPressLtd.
IN THE SPOTLIGHT
A Multicomponent Model for Substance Abuse Treatment The Addiction
Research and Treatment Corporation
Abstract- This paper reviews the activities of the Addiction Research and Treatment Corporation (ARTC), a substance abuse treatment agency, located in Brooklyn, New York, which services approximately 2,300patients annually. ARTC’s history, treatment, and research activities are first described. We then proceed to detail the ARTC’s employee health maintenance and community relations programs. A multicomponent treatment model is then outlined, which emphasizes the interactive role of the above functions within an optimal treatment network. Keywords-substance lations; HIV.
abuse; employee assistance program (EAP); health program (HP); public re-
complex factors involving the subject population, the diversity of treatments, and imperfect assessment instruments. Additionally, issues such as subject dropouts and losses to the study, the unmeasured effects of the large range of treatment provider characteristics, and organizational dynamics make this research challenging. The Addiction Research and Treatment Corporation’s (ARTCs) approach to the treatment of substance abuse derives from our extensive history of providing treatment to a socially disadvantaged, opiate-dependent population, This paper: (a) reviews the history of ARTC, (b) describes treatment services and research activities at ARTC, (c) discusses the roles of our Employee Assistance (EAP) and Health Programs (HP), (d) reviews our community/public relations effort, both internal and external, and (e) presents a model for any agency providing full-spectrum services for low-income, opiate-dependent patients.
INTRODUCTION SUBSTANCE ABUSE TREATMENT RESEARCH has been charged with the tasks of developing effective means of treating drug abusing patients, both to reduce their use of intravenous substances, and to change needlesharing behaviors associated with HIV infection (Clayton, 1986; Drotman, 1987; Stimmel, 1987). The concern about IV drug use was potentiated by the recent epidemic of AIDS, although medical problems caused by IV use have been long-standing (Ball & Carl, 1970; Lowinson & Ruiz, 1981). Society’s search for effective treatments for opiate-addicted individuals has been underway for some time. The consensus of some investigators has been that, by and large, there have been some successes with different forms of treatment at various times (Ball, Lange, Myers, & Friedman, 1988). The conduct of effective treatment research is, in general, difficult because of
HISTORY OF ADDICTION RESEARCH AND TREATMENT CORPORATION (ARTC)
This research was supported by a grant from the National Institute on Drug Abuse (RlS-DA-060142). Requests for reprints should be addressed to Horace PhD, Addiction Research and Treatment Corporation, Street, Brooklyn, New York 11201.
The ARTC was organized in 1969 by Beny J. Primm, MD, to serve the unique needs of addicted minority group members. ARTC is a not-for-profit organiza-
W. Batson, 22 Chapel
177
178
H. W. Batson et al.
tion funded for service by the New York State Division of Substance Abuse (DSAS). ARTC’s treatment program is designed to serve heroin-addicted individuals in the urban ghettos of New York City. The objective is to help patients become independent, responsible citizens engaged in a variety of meaningful activities. Since it was founded, ARTC has grown to be one of the country’s largest treatment programs. Six community-based clinics, handling a maximum of 2,300 patients annually, are in operation in both Brooklyn and Manhattan. To date, ARTC has provided over 20,000 patients with a full range of comprehensive health care and treatment services. In addition, ARTC’s Division of Medical Services, Evaluation, and Research contributes to research in the substance abuse field. The National Institute on Drug Abuse (NIDA), Centers for Disease Control (CDC), and the National Institute of Allergy and Infectious Disease (NIAID) funds various ARTC research projects. SERVICES PROVIDED AT ARTC Our patients are low-income and generally undereducated. Therefore, they come to treatment with a wide range of financial, educational, vocational, medical, and psychological needs, and so on. We fundamentally believe that the most effective way to treat this population is to treat the whole person. Our multifaceted, comprehensive treatment approach reflects this philosophy. Patients addicted to heroin or other opiates receive a dosage of methadone prescribed by a physician. Taken once a day, methadone is relatively effective in preventing addicted individuals from seeking a drugculture lifestyle. This lifestyle may include criminal activities and other antisocial behavior. Methadone maintenance helps opiate-dependent persons to avoid physical symptoms of withdrawal. They are enabled to engage in the pursuit of those specific activities and treatment objectives that constitute rehabilitation. Individual, group, and family counseling are also provided to help patients cope with the problems of daily living. Each patient has a counselor, who assesses and helps modify, where necessary, aspects of the patient’s behavior on social, economic, and personal levels. Narcotics Anonymous and other self-help groups are also available to serve as additional support systems. Comprehensive and ongoing medical care is provided at all clinics, provided by physicians, physician assistants, and nurses. A clinic vocational specialist assesses each patient’s educational/vocational strengths and aptitudes. This assessment helps patients to formulate their career goals. After this; they are referred to appropriate educational and vocational programs. Finally, patients are assisted with job placement. A mental health con-
sultant is responsible for the psychological evaluation of all patients. He or she evaluates and coordinates psychological services. Also, psychotherapy and/or psychiatric referrals are provided, as necessary. The clinic’s educational coordinator provides tutoring, remedial reading, and/or remedial math, testing, and evaluation of educational skills. This coordinator also makes referrals to programs offering GED preparation and vocational training. Also, referrals may be made to schools and colleges. Additionally, adult basic education classes are available to clinic patients. A women’s treatment coordinator helps to identify the special needs of women and coordinates the development of special projects and programs to meet these needs. Individual and group counseling are also provided directly by the women’s treatment coordinator. The pharmacy, located in one of ARTC’s Brooklyn clinics, fills medical prescriptions for patients as prescribed by the physician. Additionally, referrals are made to those programs that provide services that are not available within the clinic, or to those programs that augment existing programs within ARTC. We recognize that these services may be modified in the future, based on the acquisition of knowledge and the development of more effective treatment strategies. RESEARCH ACTIVITIES AT ARTC The ARTC recognizes that clinical research and evaluation are important tools in our efforts to provide the most effective treatments to our patients. Thus, ARTC has been totally committed to making research a vital component of this agency’s treatment modality. Basically, we believe that research/evaluation can help us to understand the problems that require treatment and the kinds of treatments that prove most effective for these problems. The ARTC is currently conducting studies in a number of areas. HIV Studies The ARTC currently participates in the new community-based clinical trials research program entitled, the “Community Programs for Clinical Research in AIDS” (CPCRA), funded by the National Institute of Allergy and Infectious Diseases (NIAID). This program is designed to provide access to research clinical trials for individuals who traditionally have been excluded from the testing of new AIDS drugs, such as African-Americans, Hispanics, intravenous drug abusers, and women. ARTC physicians actively prescribe AZT for clinic patients (the only drug so far proven effective against the AIDS virus). ARTC’s patients are among those getting “first crack” at promising new therapies. The first scheduled study is a two-drug comparison for the prophylaxis of toxoplasmosis encephalitis, a serious brain infection associated with AIDS. The sec-
A Multicomponent
Model for Substance Abuse Treatment
179
ond protocol is a comparison study of dideoxyinosine and dideoxycytidine, two promising new anti-retroviral drugs in patients who can no longer benefit from AZT. Additionally, ARTC is developing a statistical profile of our AIDS population as part of an observational data base. The goal of this database is to enable us to tailor better services to our patient population. Other therapies besides those offered by ARTC may also become available to our patients as we forge links with other AIDS clinical trials groups. Another HIV study consists of two components. The first component tests the hypothesis that HIV+ injecting drug users (IDUs) will sexually transmit the virus to their non-IDU sex partner. Both the index case (HIV-positive IDU) and the sex partner(s) (HIV-negative non-IDU) have their blood tested for the virus over a 3-year period at 3-month intervals to determine whether the HIV-negative sex partner seroconverts. A record of sexual practices is logged. Also, health education, sex education, AIDS education, condoms, and overall health care are provided to all participants. The second component of this study defines the natural history of HIV infection in the IDU population by plotting the course of disease of HIV-positive IDUs, starting with their asymptomatic baselines and continuing as they become progressively ill over time. We plot the progression of illness by examining changes in T-cell count and helper-suppressor T-cell ratios, and so on. As the patient becomes progressively sicker, we provide medical care and treatment as well as making the appropriate health care referrals for the needed tertiary care. In collaboration with the Pulmonary Division of the Department of Medicine at Harlem Hospital Center, the New York City Department of Health, and the Division of Tuberculosis Control of the Centers for Disease Control, ARTC is also conducting a prospective and longitudinal study of isoniazid (INH) therapy among IDUs who are enrolled in methadone maintenance.
through the Department of Health/AIDS Research Unit. This study involves an evaluation of a skillsbased, educational intervention-teaching AIDS awareness; contraception use; drug, health, and nutrition information. In addition, a standardized quantitative questionnaire is administered. This instrument consists of a series of pretest/posttest comparisons measuring knowledge, attitudes, and behaviors related to HIV. An unstructured, ethnographic interview, is also administered to assess community norms related to HIV, reproduction, and contraception.
Perinatal Studies This collaborative project attempts to increase the use of and compliance with family planning methods in women at high risk for perinatal transmission of HIV. Research participants will be provided with individualized education concerning HIV and family planning. The study is being conducted with women attending four of the six ARTC methadone maintenance programs. It is expected that this intervention will reduce the incidence of pregnancy in the research participants. The seropositive rate for women attending ARTC is 61%. A sister project to the aforementioned study is funded by the Centers for Disease Control (CDC)
National Institute of Drug Abuse (NIDA) Treatment Research Unit Study (TRU) The Treatment Research Unit of the ARTC has recently received funding from the National Institute on Drug Abuse (NIDA). The TRU’s objectives are threefold: 1. To increase enrollment in drug treatment of 210 persons dependent upon psychoactive substances that are associated with parenteral routes of administration or that are associated with disinhibiting behaviors that place these persons at risk of HIV infection. 2. To evaluate the efficacy of various pharmacologic and nonpharmacologic interventions that will reduce drug/sex behaviors associated with HIV transmission or HIV disease progression among persons enrolled in drug treatment, and 3. To identify factors (demographic, behavioral, and biomedical) associated with the success of various interventions to reduce HIV-associated transmission behaviors. Toward addressing these objectives, we are implementing a series of studies. The first involves an assessment of the relationships among patient characteristics and treatment response. We are administering several psychosocial instruments to patients (ie., those who remain in treatment and dropouts) at intake into the study and at 3,6, 9, and 12 months. This investigation will allow us to ascertain the relationships between patient characteristics and treatment responses. The second study measures the effectiveness of several drugs for the treatment of cocaine and opiate abuse - desipramine and buprenorphine. The ARTC is collaborating in a NIDA-sponsored multicenter trial of the latter drug. The third investigation assesses the effectiveness of enhanced primary care for several disorders that are common in our population-HIV disease, diabetes, hypertension, and so forth. EFFORTS TO MAINTAIN STAFF HEALTH Constant exposure to demands and challenges of the work environment (without employee motivational/ health programs) is believed to accelerate staff burn
180
H. W. Batson et al.
out (Carol1 1979; Daley, 1979; Edelwich & Brodsky, 1980; Glicken, 1983; Maslach, C., 1978). This situation exists for substance abuse treatment staff. These employees experience a great deal of stress in their jobs. Stressors result from various sources, such as crowded working conditions, increased patient loads, a multiplicity of personnel needs, such as housing, financial, medical, and psychiatric issues. These stressors mount, often compromising staff members’ ability to function at their best on their job. Such negative experiences can result in poor staff morale, excessive absenteeism, attrition, illness, and low productivity. Additionally, clinical staff bear the burden not only of providing treatment, but, also of experiencing the suffering and eventual death of their patients from AIDS, other diseases, and natural or unnatural causes. Finally, it is worth noting that staff often experience some of the same life problems as their patients. For example, financial, legal, vocational, health, and so on-which may be helped by the availability and provision of specialized services at the workplace. ARTC is beginning to develop two approaches to reducing the impact of these negative stress factors on employee health and productivity, the Employee Assistance Program (EAP) and Health Program (HP). Employee
Assistance
Program (EAP)
The EAP, a service offered by ARTC, is designed to offer confidential, free, or low-cost counseling and/or referral services - on a voluntary basis -to all agency personnel. A social worker serves as EAP coordinator and brings first-rate professional help to assist employees in coping with such problems as alcoholism, marital discord, stress, a troubled child, the difficulty of identifying appropriate child-care resources, or caring for an aging parent. The focus of short-term counseling provided by the social worker is always to help the employee come to grips with his or her problems as quickly as possible. The EAP has only one purpose-to help the employee’s immediate family and the employee cope with personal problems. The existence of the EAP is an indication that management wants to protect its most valuable resource-the employee of ARTC. Health Program
stein, 1983; Brewer 8z Dubnicki, 1983; Glicken, 1983; Matteson & Ivancevich, 1982). These programs differ from EAPs in that they are specifically designed to improve or prevent worker problems or difficulties stemming from health-related disorders. HPs (Health Programs) offer practical help through workshops on stress management, ways to deal with depression, dealing with death and dying, weight loss, stopping smoking, staying healthy, and other important health-oriented workshops. Management offers these programs free to ARTC staff, and they are allowed to attend on company time. To be sure, maintaining employee health is important for facilitating treatment delivery. Also, of importance to the health of both the staff and the agency is a high agency profile vis-a-vis the community. These efforts serve to promote agency-community harmony and foster a more positive company image. We describe below the development of ARTC’s Public Relations program. COMMUNITY/PUBLIC RELATIONSINTERNAL AND EXTERNAL
As discussed earlier in this paper, working with substance abusers is a difficult and challenging task. This work becomes even more troublesome if the community has negative views about the treatment agency (i.e., ARTC). To prevent this from occurring, we envision a public relations division, whose objective is to inform the community of our activities. ARTC develops and maintains relationships with residents, community, and business leaders. We also educate the community about substance abuse and program services. ARTC staff members attend various social functions as a part of its general outreach efforts. ARTC is formalizing the following programs to maintain close ties to its continually growing number of employees and to foster a greater “team” spirit: corporate management makes personal visits to clinical, medical, and research staff; personalized letters of congratulations are sent to each member of the clinical and medical team for recognition of their efforts; holiday and birthday cards are sent to each member in a timely manner, and time off is given to staff members to participate in training/conferences and Health Programs, to name just a few!
(HP)
The ARTC recognizes the particular difficulties experienced by our employees. We are also making a concerted effort to provide and improve upon our employee health maintenance system. In addition to our EAP, ARTC is developing its Health Program (HP). Evidence suggests that maintaining employee health through health-promotion programs and services can improve job performance and prevent burn out (Bern-
A MULTICOMPONENT SERVICE MODEL
DELIVERY
In overview, our treatment system is depicted in the model shown in Figure 1. ARTC believes that it is important to provide a full range of comprehensive, multidisciplinary, multifaceted services to our patients. This approach is designed to address the full range of financial, drug, educational, employee, housing, fam-
A Multicomponent
Model for Substance Abuse Treatment
CL/Patlents
