# Presentation: 126180

## Current Issues in Substance Abuse Treatment Research

**Current Issues in Substance Abuse Treatment Research**

**Christine Grella, Ph.D.**
*UCLA Integrated Substance Abuse Programs*

- December 10, 2003
- Washington, DC

## The Challenge

- What is the state of knowledge on the effectiveness of substance abuse treatment (SAT) and how does it relate to families who are involved with the child welfare system?
- What has been learned from large-scale evaluation studies and smaller-scale studies of specialized treatment for pregnant/parenting women?
- What are promising treatment/intervention models for blending/integrating services?
- What are the current critical issues on researchers’ agendas and future directions?

## National Studies on Effectiveness of Substance Abuse Treatment

|  |  | Intake |  |  |
| --- | --- | --- | --- | --- |
| Agency | Study | Years | Sample Size | No. of Programs/    Sites |
| NIDA | Drug Abuse Reporting Program (DARP) | 1969-72 | 44,000 | 139 programs |
| NIDA | Treatment Outcome Prospective Study (TOPS) | 1979-81 | 11,750 | 41 programs/
10 cities |
| NIDA | Drug Abuse Treatment Outcome Studies (DATOS) | 1991-93 | 10,100 | 96 programs/
11cities |
| NIAAA | Project MATCH | 1991-93 | 1,726
 | 9 clinical research units |
| CSAT | National Treatment Improvement Evaluation Study (NTIES) | 1993-95 | 6,593 | 78 service delivery units/
16 states |
| NIDA | Clinical Trials Network (CTN) | 1999 – Present | varies by protocol | 17 nodes/130 community treatment providers |

## Evidence-Based Treatment Model

**Sufficient**
**Retention**

**Behavioral**
**Strategies**

**Enhanced**
**Counseling**

**Social Skills**
**Training**

**Family &**
**Friends**

**Early **
**Engagement**

**Early **
**Recovery**

- Posttreatment

**Evidence-Based Treatment Model**

**Drug Use**

**Crime**

**Social Adj**

- Therapeutic
- Relationship

- Program
- Participation

- Behavioral
- Compliance

- Psychological
- Improvement

- Supportive
- Networks

**Induction**

- Health Services

- Social Support Services

- Source:  Simpson, 2003

## Development of State Outcome Monitoring Systems

| Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment | Years | No. of States |
| --- | --- | --- |
| Treatment Outcomes & Performance Pilot Studies (TOPPS) | 1997-1999 | 14 |
| Treatment Outcomes & Performance Pilot Studies Enhancement (TOPPS II) | 1999-2001 | 19 |
| Performance Partnership Grants (PPG) | Under Review | All |

## Findings from TOPPS II on Pregnancy and Status of Children

-   *Among women with children
- **Among women who had children removed from home
- Note:  Findings not controlled for sample attrition from follow-up and missing cases

## “Participation in Drug Treatment will Affect Child Custody” in DATOS*

- *Time frame is at treatment admission, 1991-93

## Characteristics of Individuals with Child Custody Issues in DATOS

- 	Having child custody issues was associated with:
- Being African American
- Having less than HS degree
- Being referred by community agency
- Receiving public assistance
- Having prior drug treatment
- Being unemployed
- Being on parole
- Having unstable shelter
- Reporting current physical and/or sexual abuse
- Having multiple psychiatric disorders
- Engaging in illegal activity

## Services Provided in Substance Abuse Treatment Programs

- Source:  Grella & Greenwell, 2003; Based on Uniform Facility Data Set, 1998

## Services Needed & Received Among Women in SAT and CWS (N = 183)

- Source:  Smith & Marsh, 2002

## Services Needed & Received Related to Treatment Outcomes

- Bivariate analyses showed that:
- Matched counseling services (i.e., domestic violence, family) were associated with less substance use at 24-month follow-up
- Matched ancillary services (i.e., housing, job training, legal) were associated with higher client satisfaction
- Multivariate analyses controlling for client characteristics showed that the total number of services received had a stronger impact on outcomes than degree of service matching

- Source:  Smith & Marsh, 2002

## Development of Specialized Treatment Programs for Women

- Interest in specialized substance abuse treatment for women was stimulated in the 1970s by feminism – how women’s AOD use differs from men’s
- Etiology
- Epidemiology
- Social influences
- Barriers to treatment participation
- Treatment needs
- In the 1980s, public concern over crack epidemic lead to increased policy attention and funding for women’s drug treatment
- National Pregnancy and Health Survey (1996), sponsored by NIDA

## Development of Specialized Treatment Programs for Women, Cont.

- Demonstration programs of specialized SAT for pregnant/parenting women
- NIDA “Perinatal-20”
- CSAT Residential Women and Children/Pregnant & Parenting Women (RWC/PPW) Program (Clark, 2001)
- Federal block grant funds include 5% - 10% “women’s set-aside” for specialized programs/services
- States are “encouraged” (not mandated) to use set-aside to fund women’s services
- GAO Report (1991) showed inconsistent implementation of set-aside across states

## Findings from Studies of Specialized Substance Abuse Treatment for Women

- Treatment retention is greater:
- In women-only programs or in programs with higher concentrations of pregnant/parenting women (Grella, 1999)
- Longer retention is related to better post-treatment outcomes (Grella, Joshi, & Hser, 2000)
- Treatment outcomes (i.e., abstinence) are improved:
- In residential programs with “live-in” accommodations for children (Hughes et al., 1995)
- In 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)

## Meta Analysis of the Effectiveness of Women’s Substance Abuse Treatment Programs

- 34 studies; 3 types of comparisons:
- Treatment vs. no treatment
- Women-only vs. mixed-gender treatment
- Enhanced vs. standard treatment for women
- Positive treatment effects were found for:
- Alcohol use, other drug use, criminal activity
- Pregnancy outcomes, psychiatric problems
- Psychological well-being, attitudes/beliefs, HIV risk reduction

- Source:  Orwin, Francisco, & Bernichon, 2001

## Changes in Child Custody Status Among Participants in CSAT RWC/PPW Programs

- *Time frame is 6 months following treatment discharge
- ** Time frame is ever

- **

## Longer Treatment Retention is Associated with Better Outcomes in RWC/PPW Programs*

- *Time frame is 6 months following treatment discharge

## Comparison of Pregnant Women in Substance Abuse Treatment by CWS Status

- Among pregnant women (N = 678) in SAT in a large, California county:
- 46% were white, 24% were African American, 26% were Hispanic
- 59% were under legal supervision
- 50% = methamphetamine is primary drug; 22% = alcohol, 13% = cocaine/crack, 7% = heroin
- 15% were involved with CPS

- Source:  Hohman, Shillington, & Barter, 2003

## Comparison of Pregnant Women in Substance Abuse Treatment by CWS Status, Cont.

- Those involved with CPS were more likely to:
- Report marijuana (14% vs. 6%), less likely to report cocaine/crack (5% vs. 14%) as primary drug
- Be mandated to treatment (65% vs. 24%)
- Be treated in day treatment (36% vs. 20%) rather than outpatient (28% vs. 43%)
- Have an unsatisfactory treatment discharge (43% vs. 27%)

- Source:  Hohman, Shillington, & Barter, 2003

## Options for Recovery:  Collaborative Project for PPW in CA

- Collaboration among state agencies:  AOD, CPS, health services, social services
- Comprehensive case management, residential and intensive outpatient treatment, perinatal medical care, foster care
- Key evaluation findings (1991-93):
- 1/3 of participants mandated to treatment by CJS or CPS
- Mandated participants had higher treatment completion vs. voluntary (28% vs. 16%)
- Decreased involvement with CPS after treatment (59% to 32%)
- Increases in children who lived with mothers (+4%) and reunified with families after foster placement (40%)
- Decreased length of time children were in foster placement
- Cost savings due to reductions in neonatal care, incarceration, and foster care

- Source:  Brindis, Clayson, & Berkowitz, 1994

## Cost-Benefits of Specialized Substance Abuse Treatment for Women

- Higher costs due to more intensive services (primarily medical, mental health) and longer treatment duration
- Recent studies have shown 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)

## Summary of Substance Abuse Treatment Effectiveness Research

- Large-scale treatment effectiveness research shows reductions in AOD use and improvements in functioning post-treatment
- Outcomes for pregnant/parenting women and children are improved with longer time in treatment and more intensive services
- Women involved with child welfare present a different profile at intake; mixed findings on rates of treatment completion for clients mandated to treatment; few studies examine child custody/parental status outcomes

## Service System Issues

- Access to treatment
- Service system co-ordination
- Treatment/intervention models

## Drug 

**Drug **
**Treatment**

**Welfare**

**Criminal **
**Justice**
** ****System**

**Child **
**Protective **
**Services**

**Health **
**Care **
**Providers**

**Pregnant and Parenting Women:  Access to Substance Abuse Treatment**

## Major Policy Initiatives Have Influenced the Provision of Treatment to Women

- Criminal justice:  changes in drug laws and sentencing policies have increased arrest and incarceration rates of women
- Health services:  managed care and cost-containment initiatives have reduced length of stay in treatment and service intensity
- Welfare reform:  mandated screening for AOD abuse and referral for treatment participation
- Child welfare:  increased emphasis on screening and assessment and coordinated treatment

## Structural Barriers to 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, criminal justice, and child welfare systems

## Parenting Capacity vs. Parenting Behavior of Substance-Abusing Women

- Addicted women have similar capacities for parenting compared with non-addicted women of similar circumstances:
- Poverty
- History of abuse and trauma
- Psychological problems
- Addiction compromises parenting capacities
- Preoccupation with use
- Allocation of money and resources
- Physical and mental health problems
- Lack of structure and effective parental authority
- Interventions to strengthen parenting capacities

## Model of Community-Based Care for Drug-Dependent Mothers and Children

- 	Basic Survival Services
- 	Medical Substance 	Abuse Services
- 	Mental Health Services

- 	Substance Abuse 	Treatment Services
- 	Domestic Violence/ 	Trauma  Services
- 	Family Services
- 	Legal Services

- 	Substance Abuse 	Treatment Services
- 	Recreational/Social 	Activities
- 	Relapse Prevention

- 	Family Services
- 	Educational and 	Vocational Services

- 	Aftercare Services
- 	Educational and 	Vocational Services
- 	Ongoing Recovery 	Activities

- Basic Psychological Needs

- Safety and Security

- Affection and Social Activity

- Esteem and Status

- Self-Realization and Fulfillment

**Model of Community-Based Care for ****Drug-Dependent Mothers and Children**

- Source:  Haack, 1997

## Combining Child Welfare and Substance Abuse Services:  A Blended Model of Intervention

- Co-operative, interagency task force between child welfare and substance abuse services in Montgomery County, MD
- Framework:  stages of change model (Prochaska & Diclemente, 1982) and motivational interventions (Miller & Rollnick, 1991) applied to organizational change
- Structured Response:  blended intervention model using graduated sanctions or levels of intensity in providing services, engaging client participation, and engendering motivation; co-location of AOD staff
- 4 components:
- Philosophy shift
- Skills building
- Standards and protocols for assessment, referral, and follow-up
- Quality assurance in order to achieve treatment and service objectives within designated time frames

- Source:  McAlpine, Marshall, & Doran, 2001

## Current “Hot” Topics in Substance Abuse Treatment Research

- Shift from focus on prenatal substance abuse and birth outcomes to the “caregiving environment” after birth
- Abuse & neglect
- Parenting behaviors, attitudes toward parental role
- Passive exposure/child endangerment from drug labs
- Systems linkage:  CPS, CJS, welfare, health services, mental health
- Screening for AOD use across systems
- Linkage and referral
- Coordination of services
- Child placement outcomes in relation to treatment participation, compliance, and completion

## Study of Child Placement Outcomes Among Substance-Involved Parents (N = 159) in Cook County Placement Outcomes of Children* (N = 498)

- *Time frame is 21-30 months
- Source:  Smith, 2003

## Predictors of Family Reunification Using Cox Regression Models

- Control Variables
- Longer time case had been open, placement when child is    < 1 year old, and poverty increased time-to-reunification (TTR)
- Prior reunifications (RR = 1.9) and non-relative-only placement (vs. mixed) (RR=2.9) reduced TTR
- Drug Use History
- Substance-exposed infant (SEI) allegation reduced TTR (vs. other allegation) (RR = 2.4)
- Treatment Compliance
- Drug dependent & completed treatment reduced TTR (vs. dependent and quit or no treatment (RR = 6.6)
- Ongoing Drug Use by Parent
- Increased TTR (RR = .43)

## Predictors of Family Reunification Using Cox Regression Models, Cont.

- Parenting Behavior
- Subsequent SEI allegation or other allegation increased TTR (RRs = .38, .35)
- Parenting scale = NS
- Conclusion:  Completing SAT substantially increased rate of reunification independent of ongoing drug use and indicators of high-risk parenting
- Study Strengths:  multiple data sources (client survey, case records), child & parent measures, multivariate model with control variables, standardized measures (DSM-III-R for dependence, AAPI, CAPI), intersection of substance abuse treatment and child welfare

- Source:  Smith, 2003

## Intersection of Child Welfare and Substance Abuse Treatment Systems

**“****recovery” based on **
**chronic disease model**

**Goal of timely **
**resolution of case outcomes**
**based on ASFA**

**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

**Intersection of Child Welfare and Substance Abuse Treatment Systems**

## Methodological Issues in Substance Abuse Treatment/Child Welfare Research

- Use of common assessments and definitions of problem severity (i.e., use, abuse, dependence)
- Outcomes
- Definition (e.g., abstinence vs. decreased use)
- Range (parent, child, family)
- Source of info (i.e., self-report, drug tests, arrests, administrative records)
- Time frame
- Limitations of pre/post research designs, need for controlled studies
- Study attrition due to cases lost to follow-up

## Integration of Child Welfare and Substance Abuse Treatment:  Future Treatment & Research Issues

- Dual focus on needs of parents (i.e., recovery) and children (i.e., safety, placement)
- Expand definition of “outcomes” to include family functioning
- Examine outcomes in relation to services needed (i.e., medical, parenting, legal, mental health) and received across service systems
- Expand time frame for evaluating outcomes

## References 

- Brindis, C.D., Berkowitz, G., Clayson, Z., & Lamb, B. (1997).  California's approach to perinatal substance abuse: Toward a model of comprehensive care.  *Journal of Psychoactive Drugs, 29*(1), 113-122.
- Brindis, C.D., Clayson, Z., & Berkowitz, G. (1994).  *Options for recovery:  Final evaluation report:  Executive Summary.  *San Francisco, CA: UCSF, Center for Reproductive Health Policy Research, Institute for Health Policy Studies.
- Clark, H.W. (2001). Residential substance abuse treatment for pregnant and postpartum women and their children: Treatment and policy implications. *Child Welfare, 80*(2), 179-198.
- Daley, M., Argeriou, M., McCarty, D., Callahan, J.J., Shepard, D.S., & Williams, C.N. (2000).  The costs of crime and the benefits of substance abuse treatment for pregnant women. *Journal of Substance Abuse Treatment, *19, 445-458.
- French, M.T., McCollister, K.E., Cacciola, J., Durell, J., & Stephens, R.L**. **(2002).  Benefit-cost analysis of addiction treatment in Arkansas: Specialty and standard residential programs for pregnant and parenting women. *Substance Abuse, *23(1), 31-51.
- General Accounting Office. (1991).  *ADMS Block Grant: Women’s set-aside does not assure drug treatment for pregnant women.* (Report No. GAO-T-HRD 91-37). Washington, DC: Author.

## References, Cont. 

- Grella, C.E. (1999). Women in residential drug treatment: Differences by program type and pregnancy. *Journal of Health Care for the Poor and Underserved, *10(2), 216-229.
- Grella, C.E. & Greenwell, L. (2003).*  Substance abuse treatment for women:  Changes in settings where women received treatment and types of services provided, 1987-1998.  *Manuscript under review.
- Grella, C.E., Joshi, V., & Hser, Y.-I. (2000). Program variation in treatment outcomes among women in residential drug treatment. *Evaluation Review*, *24*(4), 364-383.
- Haack, M.R. (1997).  Comprehensive community-based care:  The link between public policy and public health.  In M.R. Haack (Ed.), *Drug-dependent mothers and their children:  Issues in public policy and public health* (pp. 1-28).  New York:  Springer.
- Hohman, M.M., Shillington, A.M., & Baxter, H.G. (2003).  A comparison of pregnant women presenting for alcohol and other drug treatment by CPS status. *Child Abuse & Neglect, 27*(3), 303-317.
- Howell, E.M., Heiser, N., & Harrington, M.(1999).  A review of recent findings on substance abuse treatment for pregnant women. *Journal of Substance Abuse Treatment, 16*(3), 195-219.
- Hughes, P.H., Coletti, S.D., Neri, R.L., Urmann, C.F., Stahl, S., Sicilian, D.M., & Anthony, J.C. (1995).  Retaining cocaine-abusing women in a therapeutic community:  The effect of a child live-in program.  *American Journal of Public Health, 85*, 1149-1152.

## References, Cont. 

- McAlpine, C., Marshall, C. C., & Doran, N. H. (2001).  Combining child welfare and substance abuse services:  A blended model of intervention.  *Child Welfare, 80*(2), 129-149.
- National Institute on Drug Abuse (1996).  *National pregnancy & health survey:  Drug use among women delivering livebirths:  1992* (NIH Publication No. 96-3819).  Washington, DC:  U.S. Department of Health and Human Services.
- Orwin, R., Francisco, L., & Bernichon, T. (2001).  *Effectiveness of women’s substance abuse treatment programs:  A meta-analysis *(NEDS Analytic Summary Series No. 21).  Fairfax, VA:  Caliber Associates.
- Simpson, D.D. (2003).  *A conceptual framework for drug treatment process and outcomes:  Applications for improving treatment effectiveness.*  Manuscript under review.
- Smith, B.D. (2003).  How parental drug use and drug treatment compliance relate to family reunification.  *Child Welfare, 82*(3), 335-365
- Smith, B. D., & Marsh, J.C. (2002).  Client-service matching in substance abuse treatment for women with children.  *Journal of Substance Abuse Treatment, 22,* 161-168.
- Svikis, D. S., Golden, A. S., Huggins, G. R., Pickens, R. W., McCaul, M. E., Velez, M. L., Rosendale, C. T., Brooner, R. K., Gazaway, P. M., Stitzer, M. L., & Ball, C. E. (1997). Cost-effectiveness of treatment for drug-abusing pregnant women. *Drug and Alcohol Dependence, *45(1-2), 105-113.

## References, Cont. 

- Volpicelli, J. R., Markman, I., Monterosso, J., Filing, J., & O'Brien C P. (2000).  Psychosocially enhanced treatment for cocaine-dependent mothers: Evidence of efficacy.  *Journal of Substance Abuse Treatment, 18*(1), 41-49.
- Zlotnick, C., Franchino, K., St. Claire, N., Cox, K., & St. John, M. (1996)*.  *The impact of outpatient drug services on abstinence among pregnant and parenting women*.  Journal of Substance Abuse Treatment, 13*(3), 195-202.