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Current Status and Future Directions in Substance Abuse Treatment for Women

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

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  1. 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

  2. Martha Washington Home, 1869

  3. Federal Narcotics Farm, Lexington, KY, 1941 - 1965

  4. Women & Drug-Related Crime, 1936

  5. 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

  6. Epidemiological and Health Services Research Related to Gender

  7. 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)

  8. 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

  9. Treatment Access, Utilization, and Outcomes • Gender differences in: • treatment utilization • pathways to treatment • clinical profile • retention • outcomes

  10. 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.

  11. 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

  12. Treatment Admissions by Gender and Referral Source: 2004 Source: Treatment Episode Data Set (TEDS) 2004 Computer File

  13. Treatment Admissions by Gender and Type of Payment: 2004 Source: Treatment Episode Data Set (TEDS) 2004 Computer File

  14. 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

  15. 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

  16. 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)

  17. Treatment Retention in Residential Programs by Program Characteristics Source: Brady & Ashley, 2005, SAMHSA Office of Applied Studies

  18. 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

  19. 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.

  20. 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)

  21. 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

  22. To What Extent are “Specialized” Treatment Services/Programs for Women Available?

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. Services Needed & Received Among Women in AOD Treatment(N = 183) Source: Smith & Marsh, 2002

  29. 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)

  30. 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

  31. What are Evolving Treatment Approaches for Women?

  32. 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

  33. 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

  34. 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

  35. Are Current Evidence-Based Treatments Gender-Responsive? Cognitive Behavioral Therapy Motivational Interventions Contingency Management Trauma-Related Interventions Pharmacotherapy

  36. 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

  37. 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

  38. 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

  39. 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

  40. System-Level Challenges • Treatment access & utilization • Systems integration • Cross-system evaluation of outcomes

  41. Major Policy Initiatives Impact Women’s Access to AOD Treatment Criminal Justice System AOD Treatment Health/ Mental Health Providers Child Protective Services Welfare

  42. 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

  43. 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

  44. Child Welfare System

  45. 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

  46. 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)

  47. 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

  48. 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)

  49. 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)

  50. 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)

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