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Current Status and Future Directions in Substance Abuse Treatment for Women. Christine E. Grella, Ph.D. UCLA Integrated Substance Abuse Programs 36 th Semi-Annual Substance Abuse Research Consortium Meeting Sacramento, CA September 18, 2007. Martha Washington Home, 1869.
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Current Status and Future Directions in Substance Abuse Treatment for Women Christine E. Grella, Ph.D. UCLA Integrated Substance Abuse Programs 36th Semi-Annual Substance Abuse Research Consortium Meeting Sacramento, CA September 18, 2007
Topics • Epidemiological and health services research related to gender • Access to “special” services for women • Evolving treatment approaches for women • Evidence-based treatment approaches for women • System-level challenges
Epidemiological and Health Services Research Related to Gender
Prevalence of Lifetime Drug Use Disorders in U.S. Population by Gender Based on 2001-02 NESARC survey; includes both abuse and dependence, using DSM-IV criteria Source: Conway et al. (2006)
Prevalence of Past-Year Substance Use Disorders in U.S. Population by Gender Source: 2003 National Survey on Drug Use And Health (NSDUH); includes both abuse and dependence based on DSM-IV criteria
Treatment Access, Utilization, and Outcomes • Gender differences in: • treatment utilization • pathways to treatment • clinical profile • retention • outcomes
Treatment Admissions by Gender and Year: 1994 – 2004 Sources: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS). Highlights 2004; Treatment Episode Data Set (TEDS): 1993-2003.
Treatment Admissions by Gender and Primary Substance of Abuse: 2004 Females Males * Other substances includes: PCP, hallucinogens, tranquilizers, sedatives, inhalants and other Source: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS). Highlights 2004
Treatment Admissions by Gender and Referral Source: 2004 Source: Treatment Episode Data Set (TEDS) 2004 Computer File
Treatment Admissions by Gender and Type of Payment: 2004 Source: Treatment Episode Data Set (TEDS) 2004 Computer File
Factors Associated with Treatment Utilization in DATOS(N = 7,652) Men • spouse opposition to drug use • family assistance • referred by family, employer, or CJS Women • exchanged sex for drugs or money • self-initiation to treatment • referred by social worker • antisocial personality disorder • single mother Source: Grella & Joshi, 1999
Clinical Profile/Service Needs at Treatment Admission • Women tend to have greater severity in pre-treatment functioning: • addiction severity • co-occurring psychiatric disorders, especially mood & anxiety • lack of employment/vocational skills • childhood and adult trauma & abuse exposure • parenting responsibilities, involvement with child welfare • interpersonal problems, conflict with family
Treatment Retention • Treatment retention is greateramong women mandated to treatment by CPS or CJS (Chen et al., 2004) • Women are retained longer in women-only programs or in programs with higher concentrations of pregnant/ parenting women (Grella, 1999; Grella, Joshi, & Hser, 2000 ) • Longer time in residential treatment was related to better post-treatment outcomes in 3 large-scale national studies (Greenfield et al., 2004)
Treatment Retention in Residential Programs by Program Characteristics Source: Brady & Ashley, 2005, SAMHSA Office of Applied Studies
Gender Differences in Post-Treatment Outcomes • Research findings are mixed on the relationship of gender to treatment outcomes • Gender itself may not be a specific predictor of outcomes, however, several characteristics associated with treatment outcomes vary by gender and may have a greater impact on women: • Co-occurring psychiatric disorders • History of abuse or trauma • Socioeconomic status, employment • Parenting and childcare responsibilities
Gender Differences in Long-Term Outcomes: Transition Analysis • Women were 1/3 less likely than men to transition from recovery-to-using in a 6-year follow-up of a Chicago-based treatment cohort (N=1,202; 60% female; 89% African American) • Self-help participation was more strongly associated with transitions from using-to-recovery for women (OR’s: 1.9 vs. 1.5, respectively); similar to finding from a 16-year follow-up study of alcohol-dependent individuals (Timko, Finney, & Moos, 2005) • External mandate to treatment was 12 times stronger in predicting transitions from using-to-treatment for men than women (OR’s: 12.1 vs. 1.03, respectively) Grella, Scott, Foss, & Dennis (in press). Evaluation Review.
Treatment Outcomes are Improved with Services that Address Women’s Needs • Residential programs with “live-in” accommodations for children (Hughes et al., 1995) • Outpatient programs that provide comprehensive services, e.g., case management, family/parenting services, mental health services, vocational services (Zlotnick et al., 1996; Brindis et al., 1997; Howell et al. 1999; Volpicelli et al., 2000)
Treatment Components Associated with Better Outcomes for Women • Review of 38 studies with randomized and non-randomized comparison group designs: • child care • prenatal care • women-only admissions • supplemental services & workshops on women’s focused topics • mental health services • comprehensive programming Source: Ashley, Marsden, & Brady , 2003
To What Extent are “Specialized” Treatment Services/Programs for Women Available?
Special Services or Programs for Women 41% (N = 4,747) • 41% provide domestic violence services (N = 1,946) • 17% provide services for pregnant or postpartum women (N = 807) • 18% provide childcare (N = 855) • 9% provide residential beds for client’s children (N=427) N = 11,578 treatment facilities that accept women clients Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2005
Transitional Services Offered by Whether Treatment Facilities Have a Women-Specific Program or Group: 2005 Source: National Survey of Substance Abuse Treatment Services (N-SSATS), 2005
Other Services Offered by Whether Treatment Facilities Have a Women-Specific Program or Group: 2005 Source: National Survey of Substance Abuse Treatment Services (N-SSATS), 2005
Characteristics of Private Programs With a Majority Female Caseload • National Treatment Center Study (N = 365) • provided childcare • had more families participating in treatment • treated psychiatric disorders • employed more counselors with MA degrees • received more referrals from mental health sources & fewer workplace referrals • accepted more clients with public insurance Source: Tinney et al., 2004
Adoption of Women’s Health Services in Outpatient Programs, 1995 - 2000 • Adoption of women’s health services (gyn exams, contraceptive counseling, prenatal care, physical exams, MH care, HIV testing) was associated with: • receipt of funding earmarked for women’s programming • provision of methadone treatment • greater percentage of staff trained to work with women (no effect of female staff or administrator) • private not-for-profit and public units (vs. private for-profit units) • JACHO accreditation (for physical exams only) Source: Campbell & Alexander, 2005
Services Needed & Received Among Women in AOD Treatment(N = 183) Source: Smith & Marsh, 2002
Cost-Benefits of Specialized Substance Abuse Treatment for Women • Higher costs due to more intensive services (primarily medical, MH) and longer duration • Greater benefit-to-cost ratios for pregnant/parenting women treated in: • residential vs. outpatient programs (Daley et al., 2000) • specialized vs. standard residential programs (French et al., 2002) • multi-disciplinary comprehensive treatment program vs. medical treatment-as-usual (Svikis et al., 1997) • no significant cost difference for trauma-informed/integrated treatment (Domino et al., 2005)
Summary • Treatment services that address women’s specific needs improve: • retention • outcomes • cost-benefits • Yet most women with substance abuse problems are not treated in women-specific or “specialized” programs
Evolving Treatment Approaches Gender Differences Gender Specific Gender Responsive biological parenting child-care or child live-in trauma sensitive separate facilities relational theory psycho- social strengths- based Special groups or services 1990s – 2000s 1970s 1980s
Gender-Responsive Treatment • Relationship of substance use and gender-specific experiences in: • family background • abuse history • mental health • physical health • marital/relationship status • children & parenting • education & employment • criminal involvement • sexuality
Dimensions Variables Treatment Orientation Women as priority or target population, program director’s gender, % women clients, treatment approach (e.g., non-confrontational, empowerment, strengths-based, relational, trauma-informed), % of female staff, staff training & education, cultural competency Women’s Services Prenatal/postnatal services, women-only groups (in mixed-gender settings), parenting training/counseling, trauma/abuse counseling and/or groups General Services Gender-specific assessment, psychiatric consult or on-site MH services, case management, medical, spiritual, educational, vocational, legal/CJS, social services, individual counseling, family therapy, HIV education/prevention, recreational/social, employment/ vocational, 2-step groups, transportation, after-care, housing Children’s Services On-site child care, live-in accommodations for children (in residential settings), age- & number rules regarding children’s participation, counseling services, psychoeducation, educational services, coordination with Child Welfare/Children’s Protective Services Physical Environment Program environment is safe & secure, child care area is clean and well designed, social/recreational spaces, community environment Dimensions of Gender-Responsive Treatment
Are Current Evidence-Based Treatments Gender-Responsive? Cognitive Behavioral Therapy Motivational Interventions Contingency Management Trauma-Related Interventions Pharmacotherapy
The Women’s Recovery Group Study: Stage I Behavioral Therapies Development Trial All women group composition Women-focused group content Increase group cohesiveness Education about antecedents of substance abuse that differentially affect women Enhanced outcomes for women in WRG Increase open discussion of triggers & relapse prevention Education about consequences of substance abuse that differentially affect women Increase comfort and support Source: Greenfield, S. F., et al. (2007). Drug and Alcohol Dependence
NIDA Clinical Trials Network: Motivational Enhancement Therapy (MET) for Pregnant Substance Users • Experimental study of MET vs. standard treatment to improve treatment engagement and outcomes • 3 brief sessions focus on: • Developing rapport • Exploring pros and cons of using • Reviewing participant’s feedback on the consequences of substance use & the status of her pregnancy • Developing a change plan or strengthening commitment to change
Manual-Based Interventions that Address PTSD & Trauma Exposure • Seeking Safety (Najavits): 25-session cognitive, behavioral training, case management, & social support to address PTSD & substance abuse concurrently; focus on coping skills • Beyond Trauma: A Healing Journey for Women (Covington): cognitive-behavioral, expressive arts, & relational theory; empowerment approach for offenders
Implementation Challenges • Moving beyond one-size-fits all approach • differences by age, ethnicity, culture, sexual orientation • Treatment as a longitudinal process (e.g., chronic disease/long-term care model) • what is time frame for measuring change? • External constraints/realities (e.g., labor market & economic conditions, bureaucratic inertia, system-level mandates) • How to demonstrate change/progress? • internal evaluation capacity • treatment outcomes • performance indicators
System-Level Challenges • Treatment access & utilization • Systems integration • Cross-system evaluation of outcomes
Major Policy Initiatives Impact Women’s Access to AOD Treatment Criminal Justice System AOD Treatment Health/ Mental Health Providers Child Protective Services Welfare
Major Policy Initiatives Influence Women’s Access to AOD Treatment • Criminal justice: changes in drug laws and sentencing policies have increased arrest and incarceration rates of women; drug courts; Prop 36 • Health services: cost-containment initiatives have reduced length of stay in treatment and service intensity; screening & brief motivational interventions in primary care & ER’s • Welfare: mandated screening for AOD abuse and referral for treatment participation; time table for benefits; restrictions on entitlements • Child welfare: increased emphasis on screening and assessment and coordinated treatment; time table for permanent placement (ASFA); dependency drug courts
Structural Barriers to Drug Treatment • Level of impairment must be high to reach treatment through institutional channels • Lack of treatment availability, particularly in residential programs with capacity for child “live-in” and outpatient programs that provide child-care or family-related services • Lack of co-ordination among substance abuse, health care, mental health, criminal justice, and child welfare systems
Intersection of Child Welfare and Substance Abuse Treatment Systems Substance Abuse Treatment Recovery of substance- involved parent; health and social functioning of the parent Child Welfare Developmental needs of child; safety, permanency & well-being of child Goal of timely resolution of case outcomes based on ASFA Goal of long-term “recovery” based on chronic disease model
Relationship of Treatment Participation and Child Welfare Outcomes • A recent study comparing placement outcomes of children of substance-abusing mothers, pre- and post-ASFA, showed that they: • spent less time in foster care • were placed more quickly into permanent placements • were more likely to be adopted than to remain in long-term foster care • however, the proportion of children who were reunified remained the same Source: Rockhill, Green, & Furrer (2007)
Younger (31.6 vs. 34.4) More children (2.93 vs. 2.09) More methamphetamine use (47% vs. 37%) More likely to have history of physical abuse More economic instability: higher ASI Employment Score less likely to have HS degree (50% vs. 66%) less likely to be in labor force (18% vs. 26%) more likely to depend on others for support (45% vs. 39%) Higher scores on ASI Alcohol Score More polysubstance use (61% vs. 53%) More likely to be referred by self or family (35% vs. 25%) and less likely to be referred by a service provider (15% vs. 28%) Comparison of Mothers Based on Child Welfare Involvement in a Statewide Treatment Outcome Study Not Involved w/Child Welfare (N = 2,217) Child-Welfare Involved (N = 1,939) Source: Grella, Hser, & Huang (2006). Child Abuse & Neglect
Multi-Level Model of Factors Associated with Child Reunification Following Mother’s Participation in Treatment Programs (N = 43) Mothers (N = 1,115) Children (N = 2,299)
Child Characteristics Associated with Reunification • Older vs. younger age • Non-kin placement (e.g., foster or group home) vs. kin placement • Prior placement episode (OR = 0.6) • 4 or more moves within current placement episode (OR = 0.4) • Placement duration (months) (OR = 0.95)
Mother Characteristics Associated with Reunification • Referral for AOD services in CWS records (OR = 1.50) • Treatment completion (OR = 1.95) • Higher employment or psychiatric problem severity • Primary drug is heroin/other opioids vs. alcohol (OR = 0.4) • Self-referral vs. provider referral (OR = 0.5)