Current Status and Future Directions in Substance Abuse Treatment for Women

1. Current Status and Future Directions in Substance Abuse Treatment for Women Christine Grella, Ph.D. UCLA Integrated Substance Abuse Programs Substance Abuse Research Consortium Pasadena, CA May 21, 2007

2. Topics • Data from California treatment system • Epidemiological and health services research • Evolving treatment approaches • Are current evidence-based treatments gender responsive? • System-level issues

3. Data from California Treatment System on Treatment Admissions

4. Annual Statewide Treatment Admissions in California Female admissions represent 36% of total: National average = 31% Source: California Alcohol and Drug Data System (CADDS). SFY 2004-2005

5. Racial/Ethnic Distribution of Treatment Admissions in California by Gender Source: California Alcohol and Drug Data System (CADDS). SFY 2004-2005

6. Substance Use Among Treatment Admissions in California by Gender Source: California Alcohol and Drug Data System (CADDS). SFY 2004-2005

7. Perinatal Treatment Program in California • Approximately 300 publicly funded perinatal programs serve over 38,000 women annually in California • Perinatal State General Funds • Perinatal Drug Medi-Cal • Federal Block grant set-aside

8. Data from Epidemiological and Health Services Research

9. 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)

10. 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

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

12. 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.

13. 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

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

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

16. 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

17. 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)

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

19. 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

20. 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.

21. 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)

22. 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

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

24. 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

25. Therapy/Counseling 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. 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

27. 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

28. Type of Treatment Provided by Whether Treatment Facilities Have a Women-Specific Program or Group: 20051 Source: National Survey of Substance Abuse Treatment Services (N-SSATS), 2005 1Facilities could offer more than 1 type of treatment

29. 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

30. 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

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

32. 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)

33. What are Evolving Treatment Approaches for Women?

34. 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

35. 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

36. 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

37. Are Current Evidence-Based Treatments Gender-Responsive? Relapse Prevention Motivational Interventions Contingency Management Trauma-Related Interventions

38. Gender Differences in Relapse to Substance Use • Women and men have similar rates of relapse to alcohol use; findings are mixed with regard to relapse to drug use • However, relapse is precipitated by different situations/factors for men and women Source: Walitzer, K. S., and R. L. Dearing. (2006). Gender differences in alcohol and substance use relapse. Clinical Psychology Review, 26(2): 128-48.

39. Women living with fewer children (Saunders et al., 1993) depression; negative affect (Zywiak et al., 2006) “in presence of romantic partner” (Rubin et al., 1996) Men when alone or living alone social pressure Gender & Relapse to Alcohol Use

40. Women “unpleasant affect” and interpersonal problems more impulsive quality (McKay et al., 1996) group coping-skills training reduced relapse (Rohsenow et al., 2004) Men positive affect Gender & Relapse to Cocaine Use

41. 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

42. Motivational Interventions

43. Meta Analysis of Brief Motivational Interventions For Heavy Drinking • 12 of 15 studies reported the gender of the participants; only one study examined how gender interacts with treatment outcome (Marlatt et al., 1998) • Men reported higher quantity and frequency of drinking than women, but there was no interaction between gender and treatment outcome. Thus, brief MI was equally effective for both genders • However, it is possible that men and women benefit from different types of brief interventions, such as confrontational vs non-confrontational Source: Vasilaki, Hosier, & Cox, 2006, Alcohol and Alcoholism, 41(3):328-335

44. Motivational Interviewing to Reduce Alcohol Use among Pregnant Women • Focus on “health of the unborn baby” as a motivational theme • Open-ended questions (e.g. , What do you know about the effects of drinking during pregnancy? ) to evoke concerns related to the risks associated with FAE • Empathic reflections of the participant’s responses (e.g., You want your baby to have the best chance at life) to reinforce talk about change • Exploration of alternatives to drinking, especially for high-risk situations (e.g. , not drinking at a party); encourage participants to generate their own ideas about maintaining abstinence • Intervention had largest effect on women with heaviest drinking Source: Handmaker et al., 1999

45. 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

46. Contingency Management

47. Gender & Contingency Management • CM and smoking cessation among low-income pregnant women: $50 for 1st & $25 for successive months; $50 for final quit month at 2 months post-partum (Donatelle et al., 2004) • Pregnant and Clean Project: randomized, controlled trial of a CM program designed for cigarette-smoking pregnant, postpartum, and parenting drug users. Vouchers, contingent on reduced smoking, are redeemable at an on-site store (Amass & Kamien, 2004)

48. Donated Products Used as CM Vouchers for Pregnant Women

49. Trauma-Related Interventions

50. 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 • Beyond Trauma: A Healing Journey for Women (Covington): cognitive-behavioral, expressive arts, & relational theory; empowerment approach for offenders