Take 40 drug addicts, slot them into an experimental treatment program and measure the results. Sounds simple, right?
A pilot program to test an experimental drug treatment protocol called Prometa has roiled Pierce County government, pitting skeptics against program advocates.
Last month, a preliminary report by two county auditors threw cold water on the Prometa program, undercutting months of glowing testimonials by the nonprofit Pierce County Alliance that praised Prometa as a dream come true for drug treatment.
Auditors took a hard look at the numbers behind the claims, and concluded Prometa wasn’t as successful as advertised.
The report prompted County Council members to suspend funding for the program, and sent alliance leaders into orbit. Disclosures that elected leaders and alliance administrators owned stock in Hythiam Inc., Prometa’s parent company in Santa Monica, Calif., added a layer of controversy.
At the moment, the program sits in limbo. County Council members are waiting for alliance leaders to explain how the report by the auditors differs so sharply from their own findings. The council will hear the answers Wednesday.
An independent analysis by The News Tribune examined the auditors’ report and compared it to numbers provided by alliance leaders. Both sides explained the basis for their statistics, and how they were calculated.
The debate starts with the number of Prometa clients included in the analysis. When the pilot program started in March 2006, it was 40. Since then, alliance statements and Hythiam promotional materials have listed 37, 35 and 33.
Alliance leaders now say 35 clients should be counted in the official Prometa pool. Two were dismissed from the program for mental health issues. Three more didn’t complete the treatment, and couldn’t be compared to those who did, alliance leaders said.
Auditors counted their findings both ways – with the 40 original clients, and the 35 listed by the alliance.
The statistics from both sides cover 14-month periods, but the time frames are slightly different. The alliance measured a 14-month span between March 20, 2006, when the pilot program began, and May 20, 2007, when 14-month results were announced to the County Council.
Auditors also used a 14-month range, but they counted each Prometa client separately. Individual clients started the Prometa program on different dates between March 20, 2006, and June 5, 2006. The auditors reasoned that each client’s progress should be measured over the same amount of time; in other words, 14 months per person.
WHAT’S A CLEAN DRUG TEST?
Alliance leaders have cited clean drug tests as a measure of Prometa’s success. Auditors found reasons to question their findings.
The debate starts with a number: 98 percent.
In multiple public statements, alliance leaders have said 98 percent represents the total number of clean urinalysis results among more than 1,180 tests of Prometa clients taken over 14 months.
The statements didn’t mention three factors that were excluded from the alliance tally: unexcused absences, diluted drug tests and positive tests for prescription drugs.
In drug court parlance, an unexcused absence is a “no-show” – it means the client didn’t appear for a scheduled urinalysis appointment. Using figures supplied by the alliance, county auditors found that 17 of 35 official Prometa clients racked up a total of 85 unexcused absences. Several clients listed as graduates of the Prometa program missed multiple drug-test appointments.
The alliance didn’t count those results as failures – but South Sound drug courts do. In Pierce, King, Thurston and Snohomish counties, no-shows count as positive drug tests, and serve as one basis for legal sanctions.
The same holds true for “dilutes.” Urinalysis tests measure the levels of certain bodily byproducts. A diluted result reflects an abnormally low level. In the drug-testing world, a “dilute” means one of two things: kidney failure, or someone trying to beat a drug test by drinking loads of fluids.
Among the 35 official Prometa clients, eight people generated a total of nine diluted results. At least two are listed by the alliance as graduates of the Prometa program.
The alliance didn’t count dilutes as failures – but drug courts do.
Jim Boyle, deputy director of the alliance, said Friday that the alliance reports unexcused absences and diluted test results to the Pierce County drug court, where a judge can decide whether to impose sanctions.
“We do acknowledge that those are failures,” Boyle said. “But they’re not positive UAs.”
When auditors crunched the alliance urinalysis data, they counted it two ways. Excluding unexcused absences and dilutes, they found that 95 percent of the urinalysis results were clean. When unexcused absences and dilutes were included as failures, the number slipped to 87 percent.
Still, 95 percent isn’t 98 percent. The last shavings of difference come from a third exclusion: positive tests for prescription drugs.
Among the 40 original Prometa clients, nine tested positive for prescription drugs on 35 individual tests, according to alliance figures.
Alliance leaders didn’t count those results in the tally of failed tests. Drug courts treat such results the same way, but they expect clients to provide proof of a doctor’s prescription.
County auditors aren’t disputing test results that point to prescriptions, but they say they want to verify the underlying medical information to make sure the prescribed drugs really were prescribed.
WHAT DOES ‘DRUG-FREE’ MEAN?
The single biggest difference between the two sides hinges on a simple-sounding phrase: “drug-free.”
According to the multiple public statements by the alliance, 86 percent of the Prometa clients “remained drug-free” at the end of the 14-month program.
According to county auditors, the number was 50 percent.
The gulf between the two sides reflects a difference in definition. To the auditors, “drug-free” meant a clean score: no positive drug tests during the 14-month pilot program.
Alliance leaders took a different approach.
“That’s not the way we looked at it,” said Lisa Daheim, director of alliance drug-court programs, and keeper of the group’s drug-testing data.
Drug addiction is a disease, alliance leaders argue. Treatment is an inexact science. Recovery comes in fits and starts, not letter-perfect results from beginning to end.
With that in mind, the alliance measured success by progress, not clean scores. Clients were “drug-free” if they had no positive drug tests in the final 60 days of the 14-month program. By that measure, earlier positive drug tests – no matter how many – didn’t count.
“They needed to be successfully engaged in treatment by the end,” Daheim said.
During interviews with The News Tribune, alliance leaders agreed that “remained drug-free,” their favored phrase, sounds like a clean score.
“Of course I understand that,” Daheim said. “I totally get that.”
John Neiswender, the alliance’s chief financial officer, said the words could have been chosen more carefully.
“We didn’t clarify what we meant,” he said.
Auditors and alliance leaders met last week to compare their findings. In a concession to the alliance, auditors agreed to adjust their numbers to reflect clients who tested positive for doctor-prescribed drugs.
On Wednesday, alliance leaders released a revised definition of “drug-free.” It appears in a letter to County Council Chairman Terry Lee, signed by Neiswender and Boyle, the deputy director.
The letter states that 86 percent of the Prometa clients “remained engaged in treatment over the first 14 months of the Prometa treatment program.”
The letter adds that 57 percent of the clients were “completely drug-free,” while 43 percent “engaged in episodic drug use but were nevertheless drug-free at the end of the period and continued the treatment regimen.”
Auditors have raised a new question since filing their report last month: What about active Prometa clients who are still in drug court, but not taking tests?
At least two Prometa clients included in the 35-person alliance list have had active bench warrants since February, auditors found. The clients’ whereabouts are unknown, and no recent drug tests have been provided.
Can clients qualify as drug-free if they’re not around to test?
On Friday, alliance leaders said they didn’t know. They acknowledged that two Prometa clients on the list have active bench warrants. One has called the alliance and reported continuing drug-free progress – but there are no drug tests to back up those claims.
A client with an active warrant is a fugitive in the eyes of the law.
“We do tell them, ‘You need to come in – we can try to quash the warrant,’” Boyle said.
WHAT IS SUCCESS?
The alliance defined success in the Prometa program as 60 or more days of clean drug tests. That standard differs from that used in drug courts in Pierce County and neighboring jurisdictions where Prometa isn’t a factor.
Drug-court clients typically go through three phases of treatment, moving ahead based on clean tests. In Pierce County, drug-court clients must show 90 days of clean drug tests before they graduate. In Snohomish and Thurston counties, drug court clients must show six months – 180 days – of clean drug tests. King County requires 90 days in its final phase.
In response to the alliance’s 60-day standard, auditors have raised a new question: How many Prometa clients were drug-free for more than 60 days before they started the program?
Auditors found that information for 19 of the 35 Prometa clients. The results showed that 12 clients were drug-free for between 61 and 270 days before starting Prometa.
Alliance leaders said progress in drug treatment covers more than drug tests. Clients need to attend therapy sessions, hold steady jobs and stabilize their lives. Prometa helps in that respect, they said.
“They’re doing things they need to be doing besides being drug-free,” Boyle said. “They’re involved in their treatment.”
DO CRAVINGS MATTER?
Auditors and alliance leaders remain divided on the worth of findings regarding drug cravings. Alliance numbers show a significant drop in cravings for all Prometa clients.
Auditors argue that the cravings data is irrelevant, because some of the Prometa clients tested positive for drugs despite reporting no cravings.
The alliance sees it differently. Some clients in treatment relapse because they continue to see friends or lovers who use drugs, they said.
“Cravings are a factor – but that’s not the only reason addicts continue to use drugs,” Daheim said.
Neiswender offered a similar point.
“Prometa does not solve all the problems that have brought an addict to drug court – we never said it did,” he said. “To dismiss cravings data as meaningless simply because it was consistent across all clients points to lack of understanding of drug users, drug courts and substance-abuse treatment.”
The alliance will present its response to the auditors’ report at Wednesday’s County Council meeting. Auditors will provide a memo – an addendum to their earlier report that addresses concerns raised by the alliance.
Sean Robinson: 253-597-8486