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Current Status and Future Directions in Substance Abuse Treatment for Women

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Title: Current Status and Future Directions in Substance Abuse Treatment for Women


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 greater among 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 (N1,202 60
    female 89 African American)
  • Self-help participation was more strongly
    associated with transitions from
    using-to-recovery for women (ORs 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 (ORs 12.1
    vs. 1.03, respectively)

Grella, Scott, Foss, Dennis (in press).
Evaluation Review.
20
Treatment Outcomes are Improved with Services
that Address Womens 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 womens
    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 clients children
    (N427)

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 Womens Health Services in Outpatient
Programs, 1995 - 2000
  • Adoption of womens health services (gyn exams,
    contraceptive counseling, prenatal care, physical
    exams, MH care, HIV testing) was associated with
  • receipt of funding earmarked for womens
    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 womens 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 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 Womens 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 participants 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 Womens Access to
AOD Treatment
Criminal Justice System
AOD Treatment
Health/ Mental Health Providers
Child Protective Services
Welfare
42
Major Policy Initiatives Influence Womens 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 ERs
  • 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 long-term recovery based on chronic
disease model
Goal of timely resolution of case outcomes based
on ASFA
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
Comparison of Mothers Based on Child Welfare
Involvement in a Statewide Treatment Outcome Study
Child-Welfare Involved (N 1,939)
Not Involved w/Child Welfare (N 2,217)
  • 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)
  • 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)

Source Grella, Hser, Huang (2006). Child
Abuse Neglect
48
Multi-Level Model of Factors Associated with
Child Reunification Following Mothers
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)?

51
Program-Level Predictors of Reunification
Family/Child Services
Employment/Educational Services
p lt .10, p lt .05
52
Conclusion
  • Treatment for substance use disorders among women
    is most effective when it addresses the broad
    range of issues that accompany substance use
    among women (e.g., mental health, trauma,
    parenting, lack of economic self-sufficiency,
    relationships)
  • Current evidence-based treatment approaches have
    the potential to address the unique treatment
    needs issues of women, but evaluations of the
    efficacy of these gender-responsive approaches
    are still in the early stages
  • Referral and/or treatment for substance use
    disorders is increasingly embedded within other
    service systems (rather than in stand-alone
    programs) and necessitates a cross-system team
    approach
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