Research Focused on Real Treatment

1
Research Focused on Real Treatment

• Presentation at 2007 National Association of
  Addiction Treatment Providers (NAATP)
  Conference, May 20-23, 2007, San Diego, CA. The
  opinions are those of the authors and do not
  reflect official positions of the association or
  government. Available on line at
  www.chestnut.org/LI/Posters or by contacting Joan
  Unsicker at 720 West Chestnut, Bloomington, IL
  61701, phone [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
The Panel

• Michael L. Dennis, Ph.D. Director, GAIN
  Coordinating Center, Lighthouse Institute,
  Chestnut Health Systems, Bloomington, IL
• Cara Renzelli, Ph.D., Director of Research and
  Evaluation, Gateway Rehabilitation Center,
  Pittsburgh, PA
• Sigurd Zielke, Ph.D., Clinical Specialist
  (Adolescents), Fairbanks , Indianapolis, IN
• Valerie J. Slaymaker, Ph.D.,Director, Butler
  Center for Research, Hazelden, Center City, MN
• Erin Deneke, Ph.D., Director of Research, Caron
  Treatment Centers, Wernersville, PA
• Susan Gordon, Ph.D., Research Director, Seabrook
  House , Seabrook, NJ

3
What do we mean by research?

• Management by objectives and milestones (budget,
  plans, internal funds)
• Performance Monitoring (e.g, Oryx, NOMS, GPRA,
  internal and external funds)
• Group problem solving to improve performance
  overal or for a subgroup (e.g, NIATX, Drug
  Courts)
• Program Development and Evaluation (e.g.,
  Private, state or CSAT grants)
• Development and Replication of Evidenced Based
  Practices (e.g., CSAT, NIH grants)
• Quasi-Experiments and Randomized Experiments
  (e.g, NIH grants)

4
As you move down this list

• It requires better and more consistent
  leadership, communications, and trust
  (particularly for a problem solving type
  approach)
• Often requires patient or staff incentives as the
  burden goes up
• Often requires building of infrastructure
  (workforce, equipment, systems) or changes in
  organizational culture that may take several
  years to be completed
• The level of staff qualifications and experience
  goes up (typically from MA to Ph.D. with prior
  experience/grants)
• The types of funding shifts (from direct service
  to state/foundation to CSAT to NIH)
• The time to get funding gets longer and the
  likelihood of funding goes down (e.g., NIDA/NIAAA
  only fund the top 10-13 of applicants and that
  typically takes 1.5 to 2 years to get from the
  time the proposal is submitted)
• May require collaboration with outside vendors
  (e.g. to help implement an evidenced based
  practice) or experts (e.g., in a specific
  analytic technique)

5
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center
Gateway Rehabilitation Centers mission is to
enable people affected by or at risk of addictive
diseases and other mental and emotional disorders
to lead healthy and productive lives through
prevention, education, treatment, and research.
6
Gateways Range of Services

• Genesis
• Prevention
• Evaluation
• Detoxification
• Inpatient
• Outpatient
• Extended Care
• Halfway Houses
• Corrections
• Ohio Neil Kennedy Recovery Clinic

7
Research Activities - Internal Projects

• Study of detoxification medication
• Exploration of gambling problems in our treatment
  population
• Evaluation of teen leadership institute
• Development and implementation of outcomes
  monitoring system
• Assists on performance improvement initiatives

8
Research Activities - External Projects

• Gateway has long history of collaboration with
• university-based researchrecent endeavors
  include
• 1980s 1990s Washington and Jefferson College
  and Indiana University of Pennsylvania inpatient
  and outpatient treatment outcomes
• 1992 today University of Pittsburgh Medical
  Center, WPIC Pittsburgh Adolescent Alcohol
  Research Center
• 2003 2005 University of Pittsburgh, School of
  Social Work study of adult outcomes and
  spirituality
• 2006 present Washington University, School of
  Medicine prescription abuse study

9
Development and Implementation of Outcomes
Monitoring System

• Need for outcome data (Why measure?)
• Domains (What to measure?)
• Time points (When to measure?)
• Staffing needs (Who will measure and where?)
• Practical applications (How will we use the
  data?)

10
Outcomes Monitoring System

• Why we decided to create this system
• Time points
• Data collected on ALL patients at 1, 3, 6, 12,
  and 24 months after discharge from final level of
  care
• Collected by phone, mail, or personal interview
• Domains
• Demographic marital, employment, education
• Criminal justice involvement
• Additional post-discharge treatment
• Relapse/abstinence
• 12-step participation
• Quality of life

11
Outcomes Monitoring System

• Staffing needs - Currently have one research
  director, one research assistant (RA), and a team
  of volunteers
• All volunteers trained on basic research
  principles, data integrity, confidentiality
• RA and volunteers collect data
• RA manages collected data
• Quiet, private space required

12
Outcomes Monitoring System

• Practical applications
• Provides a picture of patients functioning after
  they leave our care
• Allows us to look for trends in the data that
  alert us to investigate further or take action
• Gives other departments within the Gateway system
  information that may meet a general or specific
  need

13
Future Directions of the Research Department

• Increase the number and breadth of our in-house
  research and evaluation studies
• Expand outcomes system to begin assessments at
  admission, during treatment, and at discharge
• Expansion of survey domains
• Continue our work with university-affiliated
  researchers
• Form collaborations with other treatment
  facilities to seek funding for multi-site
  projects
• Extend dissemination efforts

14
Sigurd Zielke, D.Min. Clinical Specialist
(Adolescents)Fairbanks
Fairbanks is a nonprofit organization focused on
recovery from alcohol and other drug problems,
serving as a resource to improve the well-being
of individuals, families and communities by
offering hope and support through its programs
and services.
15
Objectives

• To construct empirically-informed models and
  generate methods to enhance adolescent treatment
  and recovery support
• To create an evidence-informed mindset among our
  clinicians i.e., an evidence-informed clinical
  culture
• To secure external partners for the measurement
  of models and methods generated

16
Full Range of Adolescent Services

• Discovery (education)
• Detoxification
• Rehabilitation
• Residential
• Transitional Living
• Partial Hospitalization
• Intensive Outpatient
• Recovery Management I II
• Hope Academy (Recovery High School)

17
Challenges to Adolescent Treatment Recovery
Support

• Historic application of adult models of treatment
  and recovery to adolescents
• Recent recognition by health services
  researchers that adolescence is different from
  adulthood, and that the methods to identify,
  treat, and prevent illness need to be different
  (Zucker, 2006)
• Emergence of the new field of developmental
  psychopathology
• Explosion of neurobehavioral research
• Lack of coherent adolescent treatment and
  recovery support models that integrate 12-step
  recovery processes with recent neurobehavioral
  and developmental findings
• Need for empirical study of updated models

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Research Needs (i.e., Targets)

• Need for grounded identification of adolescent
  treatment, relapse and recovery issues
  (affirmation of practitioner knowledge)
• Need for extensive professional literature
  reviews
• Need for rigorous theoretical researchresulting
  in grounded, empirically-informed models
• Need to develop methodologies to enact models
• Need for clinical staff to utilize
  models/methodologies
• Need to establish fidelity standards
• Need to secure academic partners to measure the
  efficacy of the models/methodologies generated

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Research Response Projects

• Grounded video study of student behavior over
  2000 classrooms in light of neurobehavioral
  literature
• Focus group narrative analysis study of educators
  experiences with young students coming to school
  SI
• Joint hospital and university 2 year professional
  study of the literature on SI children/youth,
  addiction brain studies, and pathway findings
• A field-based action research study to enhance
  the school behavior of SI elementary students
  grades one through fivetest of preliminary
  models
• Theoretical research---NBD White Paper (July
  2007)
• Generation and utilization of empirically-informed
  methods
• - 90 in 90 A Recovery Tool for School Success
• - Node link mapping of student relapses
• Establishing collaborations with
  academic/research partners

22
Creating An Evidence
-
Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents
1.
Identify/target
2.
Conduct
8.
Share results
clinical issues of
field/grounded study
publication
persistent concern
of targeted concern
training
to discern patterns
of functioning
3.
Identify strong lines
7.
Use data to affirm,
empirical evidence
amend, or disregard
that address
models/ practice
targeted concerns
4.
Synthesize findings
5.
Use models to
6.
Conduct quality
of 2 and 3 into field
-
guide practice and
improvement and pilot
theory and models
create tools
studies with external
of practice
collaborators
Critical Cultural Elements

Identify
curious
clinicians

Keep multidisciplinary

Carve
-
out 1hr per week

Provide readings

Keep collegial

Tie to writing and training
23
Valerie J. Slaymaker, Ph.D., Director of
Hazeldens Butler Center for Research (BCR)

• Dedicated to improving recovery from addiction by
  conducting clinical and institutional research,
  collaborating with other research centers, and
  communicating scientific findings. 

24
BCR Structure

• Two doctoral-level research staff
• One FT research assistant (others as funded)
• Data collections staff

25
BCR Activities

• Institutional research and evaluation
• Clinical research and collaboration
• Consultation
• Knowledge dissemination

26
Institutional Research Evaluation

• Outcomes data collection reporting
• 1, 6, and 12 month follow-ups
• Use and functional outcomes
• Special populations and reports
• BCBS
• Methamphetamine Outcomes Study
• Family Program
• Scale development

27
Clinical Research Collaboration

• Milestones of Recovery studies
• Phone-based Case Management
• Huss Research Chairs on Late Life Addiction
• Youth, AA and Treatment Processes study
• University of Minnesota Youth Neuroimaging study

28
Knowledge Dissemination

• Research Update
• Substance Abuse Research Forum
• Dan Anderson Research Award
• Conference presentations
• Published manuscripts

29
Erin Deneke, Ph.D., Director of ResearchCaron
Treatment Centers
?? Mission Or Logo
30
Range of Services

• Inpatient Care
• Mens Primary
• Womens Primary
• Adolescent
• Relapse
• Young Adult Male Program (YAMP)
• Extended Care
• Men, Women, and Adolescents
• Family Education Program
• Center for Self-Development
• Caron Outpatient Counseling

31
Current Research Activities

• Focused Continuing Care
• In collaboration with Treatment Research
  Institute
• Chronic Pain Study
• In collaboration with University of Pennsylvania
  and Reading Hospital
• Funded by NIDA
• Chronic Pain sub-study
• In collaboration with Reading Hospital
• Menstrual cycle and cravings study
• Menopause and addiction study

32
Caron Research Staffing

• Director of Research
• Design , develop, coordinate, and implement
  intramural and extramural research projects.
• Data analysis, reporting, publishing, and
  presentations
• Research Administrator
• Participant recruitment and data collection
• Data entry
• Assist with literature reviews
• Research Committee
• Review ongoing studies and outcomes
• Evaluation of new or proposed projects
  advantages/disadvantages both for internal as
  well as external studies
• Act as an informal Human Subjects Review Board
  all projects would be approved through committee
  for implementation at Caron.
• Physicians Advisory Committee
• Cutting edge treatment practices
• Best research methodology
• Members include Charles OBrien, M.D. David
  Mee-Lee, M.D. Hoover Adger, M.D. Sheila Blume,
  M.D., C.A.C.

33
Focused Continuing Care

• Available to all patients once leaving inpatient
  treatment
• Adult only at this time
• Will move to adolescent units
• Monthly follow-up contacts by phone for 12 months
  by focused continuing care specialists (5)
• Check in with patients to see how they are
  progressing in their recovery
• Data collection on such variables as AA
  attendance, sponsorship, mental health issues,
  follow-up care, and family issues
• Ability to analyze data at various points through
  1 year post treatment
• Outcome oriented
• Both quantitative and qualitative data
• Provide information on possible programmatic
  changes
• Unit specific data

34
Moving towards the Future

• Increase the number of intramural projects
  occurring at Caron
• Increase collaboration with other agencies and
  universities
• Encourage more extramural research activities
• Increase number of sources for outside funding of
  projects
• Improve dissemination of information through
  published articles, conferences, presentations,
  and information available to consumers
• Assist in marketing and public relation endeavors
  by providing media relevant information

35
Susan Gordon, Ph.D., Director of Research,
Seabrook House
To help families find the courage to recover.
36
Seabrook Research Goals

• Process and outcomes evaluation of two
  residential treatment programs
• Grant funding to increase/enhance clinical
  programs
• Participation in NIDA CTN

37
Seabrook Evaluation ProjectMatriArk Family
Program

• Residential treatment facility
• Low income women and children
• 10 short-term (28 days) patients
• 37 long-term (6 12 months) patients
• 12-step treatment approach
• Funded through state and local government

38
MatriArk Goals

• In-treatment
• Reunification of women with young children during
  treatment
• Increase healthy pregnancies and births
• Post-treatment
• Increase abstinence
• Increase 12-step participation
• Increase bio-psycho-social functioning

39
MatriArk Evaluation Goals

• Assess all eligible and willing patients
• Admission and in-treatment
• Discharge and one-year follow-up for treatment
  completers
• Assess grant funding objectives
• Identify strengths of the program
• Identify aspects of the program to improve

40
MatriArk Research Infrastructure

• PEOPLE Staffing
• Research Director
• Develop implement project
• Analyze results
• Research Assistant
• In-treatment data collection and data entry
• Aftercare Case Manager
• Post-treatment data collection
• Post-treatment needs assessment

41
MatriArk Research Infrastructure

• PLACES Facilities
• Private office space for patient interviews,
  follow-up calls
• THINGS Resources
• Computer, network and internet
• Locked filing cabinets
• Separate telephone line and stationery for
  follow-ups
• Appreciation gifts for patient follow-ups

42
MatriArk Research Infrastructure

• Protocols
• Consent procedures
• Post-treatment follow-up procedures
• Locating difficult participants
• Staff training and certification
• Research ethics
• Instrument administration
• Safety protocol for home visits

43
MatriArk Research Infrastructure

• Oversight
• Research and Education Advisory Committee
• 10 SBH 2 external members
• Recommend research projects
• Monitor ongoing research
• No I.R.B.
• Not Federally funded research
• Not clinical trial

44
MatriArk Assessments

• Evidence-based assessments
• Reliable and valid
• Measure goals and objectives
• Clinically-useful assessments
• Applicable for treatment
• Appropriate response burden
• Main task of patients is treatment not research!

45
MatriArk Assessment Schedule
46
MatriArk Recruitment
47
Michael Dennis, Ph.D., Director of the GAIN
Coordinating Center, Chestnut Health Systems

• Improving the quality of human service
  interventions through applied research,
  publications, and training.
• - Lighthouse Institute Mission
• Improving assessment to facilitate evidence-based
  practices.
• - GCC Mission

48
ChestnutsDirect Clinical Services
FY05 Admissions (n9311) for Substance Abuse and
Mental Health Services from 82 of Illinois 103
counties
49
Chestnut Global Partners International Employee
Assistance
50
Chestnuts Lighthouse Institute (Research
Division)

• Started in 1985 and grew to 90 full/part time
  staff grossing 9 Million a year in external
  funds (NIH, SAMHSA, Foundations)
• LI-Research Several major experiments,
  quasi-experiments and major surveys
• LI-Training and Publications 100s of training
  days and largest collection of evidence-based
  treatment manuals
• EBTx Coordinating Center---Supports training,
  certification, and coaching of clinicians and
  clinical supervisors learning A-CRA and ACC
• GAIN Coordinating Center supports training,
  certification and use of the GAIN to support
  diagnosis, placement, treatment planning, and
  research

51
LIs Global Appraisal of Individual Needs (GAIN)
Coordinating Center (GCC)
NH
WA
VT
ME
MT
ND
MN
OR
MA
ID
NY
SD
WI
WY
MI
RI
PA
IA
CT
NE
OH
NJ
NV
DC
IL
IN
UT
CA
CO
WV
DE
VA
MO
KS
KY
DC
MD
NC
TN
OK
AZ
NM
AR
SC
0
1 to 10
GA
AL
MS
11 to 25
26 to 130
TX
LA
Statewide System
AK
FL
HI
VI
PR
Also being considered in FL, GA, NC, SC, TN
52
It took a lot of time to get here
Created GAIN Coordinating Center
Started going for External CSAT/ NIH Funding
Started by Bill White to do Training and
Evaluation
53
Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity
Adolescents More likely to have externalizing
disorders
100
100
20
40
60
80
20
40
60
80
0
0
Health Distress
Internal Disorders
Adults more likely to have internalizing
disorders
External Disorders
Crime/Violence
Criminal Justice System Involvement
Adults
Adolescents
Dependent (n1221)
Dependent (n3135)
Abuse/Other (n385)
Abuse/Other (n2617)
Source GAIN Coordinating Center Data Set
54
Substance Use Careers are Longer, the Younger
the Age of First Use
100
90
21
80
Percent in Recovery
15-20
Age of 1st Use Groups
70
Years from first use to 1 years abstinence
60
under 15
50
40
30
20
plt.05 (different from 21)
10
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
55
Substance Use Careers are Shorter the Sooner
People get to Treatment
100
0-9
90
80
10-19
Years to 1st Tx Groups
Percent in Recovery
70
Years from first use to 1 years abstinence
60
50
40
20
30
20
10
plt.05 (different from 20)
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
56
It Takes Decades and Multiple Episodes of
Treatment
100
90
80
Percent in Recovery
70
Median duration of 9 years (IQR 3 to 23) and 3
to 4 episodes of care
Years from first Tx to 1 years abstinence
60
50
40
30
20
10
0
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
57
Other Aspects of Recovery by Duration of
Abstinence of 8 Years
100
90
80
70
60
50
40
30
20
10
0
Using
1 to 12 ms
1 to 3 yrs
3 to 5 yrs
5 to 8 yrs
(N661)
(N232)
(N127)
(N65)
(N77)
Source Dennis, Foss Scott (under review)
58
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adults

Avg of 32 change status each quarter

Incarcerated

(37 stable)
In the

In Recovery
Community

(58 stable)
Using


(53 stable)






In Treatment

(21 stable)

Source Scott et al 2005
59
RMCs Impact on Time to Treatment Re-Entry
Percent Readmitted 1 Times
(n221)
55 ERI-2 RMC
37 ERI-2 OM
(n224)
Cohen's d0.41
Wilcoxon-Gehen
Statistic (df1)
16.56, p lt.0001
Days to Re-Admission (from 3 month interview)
Source Dennis Scott, in press Scott
Dennis, under review
60
RMCs Impact on Adult Outcomes
Months 4-24
Final Interview
100
RMC
90
OM
RMC Broke the Run
76
76
80
Less Likely to be in Need of Treatment
68
68
70
57
60
Less Symptoms
49
Percentage
46
50
37
40
27
30
19
20
10
0
of 630 Days
of 7 Subsequent
of 90 Days
of 11 Sx of
Still in need of Tx
Abstinent
Quarters in Need
Abstinent
Abuse/Dependence
(d0.29)
(d -0.32)
(d 0.23)
(d -0.23)
(d -0.24)
plt.05
Source Dennis Scott, in press Scott
Dennis, under review
61
Contact Information

• Michael L. Dennis, Ph.D. Director, GAIN
  Coordinating Center, Lighthouse Institute,
  Chestnut Health Systems
• (720 West Chestnut, Bloomington, IL 61701,
  Phone [phone], E-mail mdennis_at_chestnut.or
  g , Web www.chestnut.org/li)
• Cara Renzelli, Ph.D., Director of Research and
  Evaluation, Gateway Rehabilitation Center
• (100 Moffett Run Road, Aliquippa, PA, 15001
  Phone [phone] x1104 E-mail
  cara.renzelli_at_gatewayrehab.org)
• Sigurd Zielke, Ph.D., Clinical Specialist
  (Adolescents), Fairbanks
• (8102 Clearvista Parkway,. Indianapolis, IN
  4625, Phone [phone], E-mail
  szielke_at_fairbankscd.org )
• Valerie J. Slaymaker, Ph.D.,Director, Butler
  Center for Research, Hazelden
• (P O Box 11 (BC 4) , Center City, MN
  55012-0011 Phone [phone] E-mail
  vslaymaker_at_hazelden.org )
• Erin Deneke, Ph.D., Director of Research, Caron
  Treatment Centers
• (Galen Hall Road, P.O. Box 150,
  Wernersville, PA 19565, Phone [phone],
  E-mail edeneke_at_caron.org)
• Susan Gordon, Ph.D., Research Director, Seabrook
  House
• (133 Polk Lane, Seabrook, NJ 08302, Phone
  856-455-7575, ext. 5803, E-mail
  sgordon_at_seabrookhouse.org )