1	Current Status and Future Directions in Substance Abuse Treatment for Women Christine E. Grella, Ph.D. UCLA Integrated Substance Abuse Programs ADPA Lecture Series December 14, 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 System-level challenges Findings from a study of child-welfare involved women in substance abuse treatment
6	Epidemiological and Health Services Research Related to Gender
7	Prevalence of Lifetime Drug Use Disorders in U.S. Population by Gender
8	Prevalence of Past-Year Substance Use Disorders in U.S. Population by Gender
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
11	Treatment Admissions by Gender and Primary Substance of Abuse: 2004
12	Treatment Admissions by Gender and Referral Source: 2004
13	Treatment Admissions by Gender and Type of Payment: 2004
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
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
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 (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)
20	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)
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 women’s focused topics mental health services comprehensive programming
22	To What Extent are “Specialized” Treatment Services/Programs for Women Available?
23	Special Services or Programs for Women
24	Transitional Services Offered by Whether Treatment Facilities Have a Women-Specific Program or Group: 2005
25	Other Services Offered by Whether Treatment Facilities Have a Women-Specific Program or Group: 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
27	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); note: these units decreased over the study period examined JACHO accreditation (for physical exams only)
28	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)
29	Summary Treatment services that address women’s specific needs improve: retention outcomes cost-benefits Yet most women with substance abuse problems are not treated in women-specific or “specialized” programs
30	What are Evolving Treatment Approaches for Women?
31
32	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
33
34	The Women’s Recovery Group Study: Stage I Behavioral Therapies Development Trial
35	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
36	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
37	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
38	System-Level Challenges Treatment access & utilization Systems integration Cross-system evaluation of outcomes
39
40	Major Policy Initiatives Influence Women’s 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 & ER’s 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
41	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
42	Child Welfare System
43
44	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
45	Comparison of Mothers Based on Child Welfare Involvement in a Statewide Treatment Outcome Study 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%) 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%)
46	Multi-Level Model of Factors Associated with Child Reunification Following Mother’s Participation in Treatment
47	Child Characteristics Associated with Reunification Older vs. younger ageÃ Non-kin placement (e.g., foster or group home) vs. kin placementÃ
48	Mother Characteristics Associated with Reunification Referral for AOD services in CWS records (OR = 1.50)Ã Treatment completion (OR = 1.95)Ã
49	Program-Level Predictors of Reunification
50	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