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The Gold Standard
The Joint Commission bestows its prestigious Codman Award on Bayview’s Addiction Treatment Services.


In a field notorious for setbacks, Robert Brooner devised a novel program that has consistently improved addicts' success rates.

When Robert Brooner first took the job as director of Hopkins Bayview’s methadone treatment program in 1986, he was the sole faculty member as well as the program administrator. There were 160 patients and one treatment—methadone—and the only variation was the dose being given.

He thought this was unusual, but soon learned that the entire specialty used this same method to treat substance abuse—“a minimalist approach with a lot of hoping-for-the-best thinking,” according to Brooner. He also noticed that “there was relatively little expert review of the ongoing care of these patients, especially those not doing well.”

But over the years, he systematically built a program, now called Addiction Treatment Services, that he would test with controlled trials and evaluate meticulously. Last fall, the program garnered the Joint Commission’s Codman Award recognizing its effective use of outcome measurements. It was the first adult substance abuse treatment program ever to do so.

Brooner first began tweaking his patients’ treatment routine by beefing up counseling sessions. He added group therapy as a way to stretch his staff. He also took a harder look at the consequences of attendance. “I noticed if patients missed three consecutive days of medication dispensing, they were discharged,” he recalls. “If they missed their counseling sessions, nothing happened. We were unintentionally sending a clear but incorrect message that the medication was far more important than the verbal therapies.”

To create different intensities of care, Brooner devised a step-based approach gauged to each patient’s condition and added several behavioral contingencies to motivate good patient attendance. If a patient produced urine samples positive for cocaine, for example, more counseling was required. Good attendance and negative urine specimens were reinforced with a variety of clinic-based rewards, like more flexible and convenient medication times, take-home doses of methadone that reduced the number of times the patient had to come to the program and less intensive counseling schedules.

By the early 1990s, he was confident enough in the new treatment approach to conduct a controlled trial to test the model. After evaluating several hundred people over the past 12 years, the results were clear: Increased counseling was associated with decreased drug use and clinic-based incentives were highly effective in producing improved rates of counseling attendance. A mere 28 percent of patients in the control group came to therapy sessions, whereas 80 percent attended sessions in Brooner’s stepped-care model. “We’re absolutely convinced that the exposure to this treatment and the content of the counseling is quite therapeutic,” says Brooner. “It’s unquestionable.”

More than 12 years later, the model is still in use, although Brooner and his team have modified several aspects of the treatment. Today, patients are required to obtain jobs or community volunteer positions and increase their therapeutic social support network—both good prognostic indicators—and are provided more intensive services and support at the higher steps of care, if necessary, to accomplish these newer goals. The program now serves more than 500 people a day, many of whom have been patients for years. In addition, some aspects of the treatment model have been replicated in other programs in Baltimore.

Although ATS had historically done well in its Joint Commission site visits, “there was an added oomph” to the 2007 review, says Brooner. “They raved about the program and said they believed they had found the gold standard for treatment of these patients.” Not only had the program’s counseling attendance increased and positive urine tests decreased, but the improvement rates had been sustained over a dozen years. Furthermore, 70 percent of patients had been retained in the program after six months. “They loved our reliance upon comprehensive and continuous outcome measurement to develop and test a treatment and then guide movement through the treatment.”

Brooner says that how ATS differs from other programs is in its raised expectations of patients. “These patients are pretty bankrupt of faith and trust in themselves and others by the time they get here, and usually long before, but they hold out some small hope when they come into treatment,” explains Brooner. “What they really need in their doctor is somebody who believes he can help them. By lowering expectations to mirror those they come in with, I think we do a grave disservice to our field, and, more importantly, to our patients. We don’t expect people to act like they don’t have a disorder. We expect them to improve despite having it.”


—Mary Ellen Miller



Johns Hopkins Medicine

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