# Presentation: 087705

##  Gender Differences in Treatment Needs, Services, Utilization, and Outcomes

- Karol Kaltenbach, PhD
- Department of Pediatrics
- Jefferson Medical College
- Thomas Jefferson University

## APA Disclosure Statement

- This is to acknowledge I have no relationship with any manufacturer of a product or service I intend to discuss.

## Overview

- History of specialized services for women
- Assessing comprehensive needs of women
- Complexity of needs and treatment outcomes

## History of Specialized Services for Women

- NIDA 1974
-    Research demonstration projects for women’s treatment
- Women’s special needs and the delineation of gender specific treatment strategies were identified over 20 years ago
- Beschner, Reed, & Mondanaro (Eds) 1981
- 	Treatment services for drug dependent women

## History of Specialized Services for Women

- Federal grant programs, e.g. NIDA Perinatal 20 and CSAT pregnant and post-partum demonstration grants, provided support for development and enhancement of women’s treatment services in the late 80’s –’90’s

## Specialized Treatment Services for Women 

- Programs in US
- Residential:	 41% women-only
- 		  23% pregnant/postpartum women
-    (SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS) 2001)
- Of women who need treatment only 20% receive treatment
-          (SAMHSA, OAS 2002)

## Services: Models for Women’s Treatment

- Finnegan, Hagan, Kaltenbach (1991)
*Scientific foundation of clinical practice: Opiate use in pregnant women*
- Jansson, Svikis, et al (1996)
*Pregnancy and addiction: A comprehensive care model*
- Kaltenbach & Comfort (1996)
*Comprehensive treatment for pregnant substance abusing women*
- Finkelstein, Kennedy, Thomas, Kearns (1997) *Gender specific substance abuse treatment*

## Woman Centered Treatment Model

- Comprehensive treatment approach that addresses
- Addiction
- Medical/Psychiatric
- Psychosocial
- Parenting
- Educational/Vocational
- issues of both women and their children

## Specialized Programs

- Women-only programs more likely to provide:
- 	Pregnancy, pediatric and children’s services
- 	Client advocacy/case management
- 	Classes on social skills, practical skills,  parenting, anger management
- 	Assistance with housing and transportation
- 	Peer support groups and social outings
- (Grella et al., 1999)

## Effectiveness of  Specialized Treatment Services

- Residential
- Women in women-only programs had
- More time in treatment
- More likely to complete treatment
- (Grella, 1999)

## Effectiveness of Specialized  Treatment Services

- Women in gender-specialized programs
-  	Use more services throughout 	treatment than women in traditional 	coed program
-   Have higher rates of abstinence
-   More likely to see themselves as doing
-      well in treatment
- (Nelson-Zupko, 1997)

## Effectiveness of Woman Centered Treatment

- Treatment for Pregnant Women:
- Increased Gestational Age, Birth-weight, Apgar Scores
- Less likely to require NICU services
- Those admitted to NICU had shorter stays
- Average net savings for women in treatment of $4,644 per moth/infant pair
- (Svikis, et.al., 1997)

## Assessing Comprehensive Treatment Needs of Women

- Instruments
- Most assessment tools are based primarily on males
- Addiction Severity Index
- Most widely used standard data collection instrument
- Initially developed and tested solely on males
- Acceptable levels of reliability and validity with
-    a number of populations
**Limited in assessing critical areas for women**

## Assessing Comprehensive Needs of Women

- 	ASI limited in assessing
- Medical issues related to pregnancy
- Care-giving responsibilities
- Child and partner relationships
- Victimization

## Assessing Comprehensive Needs of Women

- Psychosocial History (PSH)
- Instrument that retains the fundamental structure of the ASI but expanded to include
- Family history and relationships
- Relationships with partner
- Responsibilities for children
- Pregnancy history
- History of violence and victimization
- Family legal issues
- Housing arrangements

## Complexity of Needs

- Personal and Family Characteristics
- 				Residential        Outpatient
- Age                             27.9                29.6
- Education                   11.8                10.8
- Employment              77%                94%
- Job training                48%                38%
- (Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999)

## Personal and Family Characteristics

- 					Residential     Outpatient
- Currently Receiving
- Public Assistance         84%                81%
- Relationship status
-    Married                        6%                17%
-    Not Married                84%                53%
-    Long-term
-      relationship              10%                30%

## Personal and Family Characteristics

- 						Residential    Outpatient
- Housing History
-   Homeless in past 3 yr.               68%                    21%
- Current Living arrangements
-   Family/Friends                           51%                    43%
-   Father of Baby                           10%                    29%
-   Shelter                                        26%                     7%
-   No Stable Housing                       6%                     7%
-   Other                                            6%                    14%

## Personal and Family Characteristics

- Substance Use by Partner
- No use				31%		33%
- Drug and/or alcohol use	42%		42%
- Recovery				27%		25%
- D/A Treatment
- Ever					41%		40%
- Currently				15%		25%

## Personal and Family Characteristics

- Substance Use by Family
- 					         RT                     OP
- 					 No       Yes         No       Yes
- Biological mother		53%     37%       37%     53%
- Biological father                  27%     67%       28%     72%
- Female caregiver                89%     11%       67%     33%
- Male caregiver                               100%       20%     80%
- Maternal grandmother        58%      42%       72%     21%
- Maternal grandfather          43%      50%       45%     55%

## Personal Characteristics

**Victimization**
- 						Residential        Outpatient
- One/more types of victimization    73%             89%
- Domestic violence                          45%             65%
- Rape                                               43%             54%
- Childhood abuse/neglect	      32%             39%

## Personal Characteristics

- Legal Status
- 	 			    Residential	     Outpatient
- Family legal problems		45%		31%
- Requested order of protection	22%		23%
- Ever arrested			32%		23%
- Ever incarcerated			23%		13%

## Treatment Outcomes

-  What are the factors that result in successful outcomes?
- Literature reflects a variety of conceptual frameworks that are ‘gender neutral”
- Patient-treatment matching
- Motivation to change
- Treatment process
- Retention in treatment

## Treatment Outcomes

- 	We know relatively little of the relationship between women’s characteristics/needs and treatment outcome.

## Treatment Outcomes

- Retrospective study of 133 pregnant women enrolled in comprehensive gender specific outpatient treatment to identify factors that predict retention, abstinence, and service utilization
- (Comfort & Kaltenbach, Substance Abuse, 2000)

## Treatment Outcomes

- Measures
- PSH
-    Factor analyses procedures reduced set of predictors to 27 variables organized into five factors
- Personal Stability
- Opiate Dependence
- Psychiatric and Medical problems
- Multiple family problems
- High-risk lifestyle

## Treatment Outcomes

- Summary of Findings
- Retention predicted by
- Personal Stability
- Opiate Dependence
- Fewer Psychiatric and Medical Problems
- Multiple Family Problems
- (multiple R2=.153, p<.0001)

## Treatment Outcomes

- Summary of Findings
- 	Abstinence predicted by
- Lower scores on High-Risk Lifestyle (trend)
- (multiple R2=.035, p=.059)

## Treatment Outcomes

- Summary of Findings
**	****	****Utilization of Required Services**
- Lower scores on Multiple Family Problems
- (multiple R2=.069, p=.021)
**Utilization of Specialized Services**
-  Psychiatric and Medical Services (trend)
- (multiple R2=.045, p=.061)

## Treatment Outcomes

- Prospective Longitudinal Study
- Women (95) enrolled for a minimum of 3 months with 12 month follow-up data
- Outpatient     (60)
- Residential    (35)
- (Comfort & Kaltenbach, Addictive Behaviors, 2003)

## Treatment Outcomes

- Treatment Outcome Variables
- Treatment duration
- Intensity of service utilization
- Engagement in treatment
- Satisfaction with treatment services
- Substance use during treatment

## Treatment Outcomes

- Summary:
- Outpatient
- The most noteworthy predictors for women in outpatient treatment were differing combinations of
- Social support
- Life stressors
- Levels of past substance abuse
- Chronic medical conditions

## Treatment Outcomes

- Summary:
- Residential
- The most significant predictors for women in residential treatment reflected lower levels of personal risk factors
- Partner abuse
- Prostitution
- Homelessness
- Depression

## Treatment Outcomes

- More responsibilities
- Care-giving responsibilities
- Less financial assistance from family

## Treatment Outcomes

- Conclusion
- No simple predictors of women’s substance abuse treatment outcomes
- Assessment areas of particular value
- Social support	Chronic medical problems
- Daily stressors	Childbirth history
- Life satisfaction	Childcare responsibilities
- Partner abuse	Engagement in treatment
- Psychiatric history

## Predictors of Program Completion for Women in Residential Treatment

- Five domains of patient characteristics to predict completion of treatment:
- Socio-demographics
- Substance use
- Legal involvement
- Psychological functioning
- Social relations
- (Knight et.al. Am J Drug Alcohol Abuse, 2001)

## Predictors of Program Completion for Women in Residential Treatment  

- Predictors of treatment completion
- Education
- Recent arrests
- Peer deviance
- (Knight et. al. 2001)

## Predictors of Program Completion for Women in Residential Treatment

- Noteworthy trends
- Women who were not married
- Women who had two or more children
- Women who had an open child welfare case
- Women who had psychological problems
- Appeared to be at greater risk for non-completion
- (Knight et. al. 2001)

## Treatment for Women

- In summary, limited research on gender specific treatment
- Biopsychosocial characteristics of women
- Treatment utilization and retention
- Psychiatric co-morbidity

## Treatment for Women

- Need for continued research
- Development of assessments that reflect the complex issues of pregnant and parenting drug dependent women
- Systematic investigations of barriers to treatment
- Pharmacological treatment and pregnancy
- Treatment outcomes for mother and child