current status and future directions in substance abuse treatment for women christine grella, ph.d....
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Current Status and Future Directions in Substance Abuse
Treatment for Women
Christine Grella, Ph.D.UCLA Integrated Substance Abuse Programs
Substance Abuse Research ConsortiumPasadena, CAMay 21, 2007
Topics
Data from California treatment system Epidemiological and health services
research Evolving treatment approaches Are current evidence-based treatments
gender responsive? System-level issues
Data from California Treatment System on Treatment Admissions
Annual Statewide Treatment Admissions in California
65
35
65
35
64
36
0%
10%
20%
30%
40%
50%
60%
70%
2002-03 2003-04 2004-05
Male Female
Female admissions represent 36% of total: National average = 31%
Source: California Alcohol and Drug Data System (CADDS). SFY 2004-2005
Racial/Ethnic Distribution of Treatment Admissions in California
by Gender
43
51
32
27
14 12
6 5 5 5
0%
10%
20%
30%
40%
50%
60%
White Hispanic AfricanAmerican
Asian/PacIslander
AmericanIndian
Male Female
Source: California Alcohol and Drug Data System (CADDS). SFY 2004-2005
Substance Use Among Treatment Admissions in California by Gender
21 19
12 11
2118
16
11
30
41
0%
10%
20%
30%
40%
50%
Alcohol Cocaine Heroin Marijuana Methamphetamine
Male Female
Source: California Alcohol and Drug Data System (CADDS). SFY 2004-2005
Perinatal Treatment Program in California
Approximately 300 publicly funded perinatal programs serve over 38,000 women annually in California
Perinatal State General Funds Perinatal Drug Medi-Cal Federal Block grant set-aside
Data from Epidemiological and Health Services Research
Prevalence of Lifetime Drug Use Disorders in U.S. Population by Gender
7.1
5.4
1.8
1.5
0.9
0.6
13.8
11.8
3.9
2.5
2.0
1.6
0 5 10 15
Any drug usedisorder
Marijuana
Cocaine
Amphetamines
Opioids
Sedatives
Percent
MalesFemales
Based on 2001-02 NESARC survey; includes both abuse and dependence, using DSM-IV criteria
Source: Conway et al. (2006)
Prevalence of Past-Year Substance Use Disorders in U.S. Population by Gender
6.2
4.1
1.3
0.8
12.2
8.5
1.9
1.8
0 5 10 15
Any illicit drug oralcohol disorder
Alcohol only
Any illicit drug only
Any illicit drug andalcohol
Percent
MalesFemales
Source: 2003 National Survey on Drug Use And Health (NSDUH); includes both abuse and dependence based on DSM-IV criteria
Treatment Access, Utilization, and Outcomes
Gender differences in: treatment utilization pathways to treatment retention outcomes
Treatment Admissions by Gender and Year: 1994 – 2004
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2,000,000
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Female
Male
Sources: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS). Highlights 2004; Treatment Episode Data Set (TEDS): 1993-2003.
Treatment Admissions by Gender and Primary Substance of Abuse: 2004
17%20%
13%
12%
6%
33%
Alcohol
Cocaine
Heroin/OtherOpiatesMarijuana
Meth/Stimulants
Other*/NoneSpecified
44%
12%
17%
17%
6%4%
Females Males
Source: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS). Highlights 2004
* Other substances includes: PCP, hallucinogens, tranquilizers, sedatives, inhalants and other
Treatment Admissions by Gender and Referral Source: 2004
33%
35%
40%
28%
8%
15%
10%12%
6%8%
1% 1% 1% 1%0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Self/Indiv Crim Just Sys Oth Community Sub Abuse CareProvider
Other HealthCare Provider
School Employer/EAP
Male Female
Source: Treatment Episode Data Set (TEDS) 2004 Computer File
Treatment Admissions by Gender and Type of Payment: 2004
26%
18%
33%31%
12%
26%
11%10%
8% 7%
10%
7%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Self-Pay Other Govt.Payment
Medicaid/ Medicare No Charge Private Insur Other
Male Female
Source: Treatment Episode Data Set (TEDS) 2004 Computer File
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
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)
Treatment Retention
Treatment Retention in Residential Programs by Program Characteristics
97
33
83
22
0
20
40
60
80
100
w/childcare
w/o childcare
women-only
mixed-gender
Days
Source: Brady & Ashley, 2005, SAMHSA Office of Applied Studies
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
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)
Grella, Scott, Foss, & Dennis (in press). Evaluation Review.
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)
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
Source: Ashley, Marsden, & Brady, 2003
To What Extent are “Specialized” Treatment Services/Programs for
Women Available?
Special Services or Programs for Women
59%Provide Special
Services or Programs for
Women
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
client’s children (N=427)
41% (N = 4,747)
N = 11,578 treatment facilities that accept women clients
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2005
Therapy/Counseling Services Offered by Whether Treatment Facilities Have a Women-
Specific Program or Group: 200597% 94% 95%
87%81%
74%
91%
74%
84%78%
0%
20%
40%
60%
80%
100%
IndividualTherapy
Group Therapy
FamilyCounseling
RelapsePrevention
Aftercare Counseling
Provide Women-Specific Program/ Group Do Not Provide Women-Specific Program/ Group
Source: National Survey of Substance Abuse Treatment Services (N-SSATS), 2005
Transitional Services Offered by Whether Treatment Facilities Have a Women-Specific
Program or Group: 2005
91%
80%
65%
46% 47%
26%
66%
47%
0%
20%
40%
60%
80%
100%
DischargePlanning
HousingAssistance
Employment Counseling/Training
Assistance w/Social Services
Provide Women-Specific Program/ Group Do Not Provide Women-Specific Program/ Group
Source: National Survey of Substance Abuse Treatment Services (N-SSATS), 2005
Other Services Offered by Whether Treatment Facilities Have a Women-Specific
Program or Group: 2005
41%
29%
18%
4%
9%
1%
0%
20%
40%
60%
DomesticViolence
Child Care Residential Beds for Children
Provide Women-Specific Program/ Group Do Not Provide Women-Specific Program/ Group
Source: National Survey of Substance Abuse Treatment Services (N-SSATS), 2005
Type of Treatment Provided by Whether Treatment Facilities Have a Women-Specific
Program or Group: 20051
30%
15%
6%10%
82%88%
0%
20%
40%
60%
80%
100%
Non-hospitalResidential
HospitalInpatient
Outpatient
Provide Women-Specific Program/ Group Do Not Provide Women-Specific Program/ Group
Source: National Survey of Substance Abuse Treatment Services (N-SSATS), 20051Facilities could offer more than 1 type of treatment
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
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) JACHO accreditation (for physical exams only)
Source: Campbell & Alexander, 2005
Services Needed & Received Among Women in AOD Treatment (N = 183)
45%
33%
56%62%
54%
32%
46%
16%
43%
7%6%
25%18%
27%
010203040506070
Childcare Domesticviolence
counseling
Familycounseling
Job training Housingassistance
Help withbenefits
Legal help
Service needed
Service received
Source: Smith & Marsh, 2002
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)
What are Evolving Treatment Approaches for Women?
Evolving Treatment Approaches
Gender Differences
biologicalpsycho-social
parenting
Gender Specific
separatefacilities Special
groupsor services
child-careor child live-in
Gender Responsive
traumasensitive strengths-
based
relationaltheory
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
Dimensions Variables
Treatment Orientation
Women as priority or target population, program director’s gender, % women clients, treatment approach (e.g., non-confrontational, empowerment, strengths-based, relational, trauma-informed), % of female staff, staff training & education, cultural competency
Women’s Services
Prenatal/postnatal services, women-only groups (in mixed-gender settings), parenting training/counseling, trauma/abuse counseling and/or groups
General Services Gender-specific assessment, psychiatric consult or on-site MH services, case management, medical, spiritual, educational, vocational, legal/CJS, social services, individual counseling, family therapy, HIV education/prevention, recreational/social, employment/ vocational, 2-step groups, transportation, after-care, housing
Children’s Services
On-site child care, live-in accommodations for children (in residential settings), age- & number rules regarding children’s participation, counseling services, psychoeducation, educational services, coordination with Child Welfare/Children’s Protective Services
Physical environment
Program environment is safe & secure, child care area is clean and well designed, social/recreational spaces, community environment
Dimensions of Gender-Responsive Treatment
Are Current Evidence-Based
Treatments Gender-Responsive?
Relapse Prevention
Motivational Interventions
Contingency Management
Trauma-Related Interventions
Gender Differences in Relapse to Substance Use
Women and men have similar rates of relapse to alcohol use; findings are mixed with regard to relapse to drug use
However, relapse is precipitated by different situations/factors for men and women
Source: Walitzer, K. S., and R. L. Dearing. (2006). Gender differences in alcohol and substance use relapse.
Clinical Psychology Review, 26 (2): 128-48.
Gender & Relapse to Alcohol Use
Women living with fewer
children (Saunders et al., 1993)
depression; negative affect (Zywiak et al., 2006)
“in presence of romantic partner” (Rubin et al., 1996)
Men when alone or
living alone social pressure
Gender & Relapse to Cocaine Use
Women “unpleasant affect”
and interpersonal problems
more impulsive quality (McKay et al., 1996)
group coping-skills training reduced relapse (Rohsenow et
al., 2004)
Men positive affect
Increase group cohesiveness
Increase opendiscussion of
triggers & relapseprevention
Increase comfort
and support
Education aboutantecedents of
substance abuse that differentially
affect women
Education aboutconsequences of substance abuse that differentially
affect women
Enhanced outcomes for women
in WRG
The Women’s Recovery Group Study: Stage I Behavioral Therapies
Development Trial
Source: Greenfield, S. F., et al. (2007). Drug and Alcohol Dependence
All women group composition Women-focused group content
Motivational Interventions
Meta Analysis of Brief Motivational Interventions For Heavy Drinking
12 of 15 studies reported the gender of the participants; only one study examined how gender interacts with treatment outcome (Marlatt et al., 1998)
Men reported higher quantity and frequency of drinking than women, but there was no interaction between gender and treatment outcome. Thus, brief MI was equally effective for both genders
However, it is possible that men and women benefit from different types of brief interventions, such as confrontational vs non-confrontational
Source: Vasilaki, Hosier, & Cox, 2006, Alcohol and Alcoholism, 41(3):328-335
Motivational Interviewing to Reduce Alcohol Use among Pregnant Women Focus on “health of the unborn baby” as a motivational theme Open-ended questions (e.g. , What do you know about the
effects of drinking during pregnancy? ) to evoke concerns related to the risks associated with FAE
Empathic reflections of the participant’s responses (e.g., You want your baby to have the best chance at life) to reinforce talk about change
Exploration of alternatives to drinking, especially for high-risk situations (e.g. , not drinking at a party); encourage participants to generate their own ideas about maintaining abstinence
Intervention had largest effect on women with heaviest drinking
Source: Handmaker et al., 1999
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
Contingency Management
Gender & Contingency Management CM and smoking cessation among low-
income pregnant women: $50 for 1st & $25 for successive months; $50 for final quit month at 2 months post-partum (Donatelle et al., 2004)
Pregnant and Clean Project: randomized, controlled trial of a CM program designed for cigarette-smoking pregnant, postpartum, and parenting drug users. Vouchers, contingent on reduced smoking, are redeemable at an on-site store (Amass & Kamien, 2004)
Donated Products Used as CM Vouchers for Pregnant Women
Trauma-Related Interventions
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
Beyond Trauma: A Healing Journey for Women (Covington): cognitive-behavioral, expressive arts, & relational theory; empowerment approach for offenders
SAMHSA Women, Co-occurring Disorders & Violence Multi-Site Study
Multi-site, quasi-experimental study; 1,023 women in comprehensive, trauma-informed, integrated treatment vs. 983 women in usual care
Individual characteristics, such as alcohol severity, mental health status, lifetime and current exposure to interpersonal abuse & other stressful events predicted outcomes independent of intervention condition
Sites where intervention condition provided more integrated counseling than comparison conditions demonstrated improved MH and AOD outcomes
Experimental condition (i.e., integrated, trauma-informed services) demonstrated improved PTSD symptoms as well as improved drug use severity
Pilot Study of Seeking Safety among Women in Prison
Sample of 17 incarcerated women with substance use disorder & PTSD
Nearly all had a history of sexual and physical abuse and repeated trauma
About half no longer met criteria for PTSD at a 3-month follow-up
About 1/3 returned to prison by 3 months
Source: Zlotnick et al., 2003
Pilot Study of A Gender-Responsive Treatment Protocol for Women
Offenders at VSPW S. Covington, Helping Women Recover Modules on:
Self Relationships Sexuality Spirituality “Beyond Trauma”
Random assignment of 100 women inmates to in-prison (TC) treatment as usual or experimental group
Assessments at baseline, 3-months, 6-month phone follow-up, & 12-month face-to-face follow-up
Outcomes: drug use, recidivism, self-efficacy, psychological status
System-Level Issues
Treatment access & utilization Systems integration Cross-system evaluation of outcomes
AODAODTreatmentTreatment
WelfareWelfareWelfareWelfare
Criminal Criminal JusticeJustice SystemSystem
Criminal Criminal JusticeJustice SystemSystem
Child Child Protective Protective ServicesServices
Child Child Protective Protective ServicesServices
Health/ Health/ Mental Health Mental Health
ProvidersProviders
Health/ Health/ Mental Health Mental Health
ProvidersProviders
Major Policy Initiatives Impact Women’s Access to AOD Treatment
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)
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
Child Welfare System
Goal of long-term“recovery” based on
chronic disease model
Goal of long-term“recovery” based on
chronic disease model
Goal of timely resolution of case outcomes
based on ASFA
Goal of timely resolution of case outcomes
based on ASFA
SubstanceAbuse Treatment Recovery of substance-
involved parent; health and social functioning of
the parent
ChildWelfare
Developmental needs of child; safety,
permanency & well-being of child
Intersection of Child Welfare and Substance Abuse Treatment Systems
Comparison of Child-Welfare Involved Mothers and Other Mothers 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%)
Higher scores on ASI Alcohol Score
More polysubstance use (61% vs. 53%)
More likely to be referred by self or family (35% vs. 25%)
Child-Welfare Involved(N = 1,939)
Not Involved w/Child Welfare (N = 2,217)
Source: Grella, Hser, & Huang, 2006
Multi-Level Model of Factors Associated with Child Reunification Following Mother’s Participation in
Treatment
Children(N = 2,299)
Mothers(N = 1,115)
Programs(N = 43)
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 Placement duration (months) (OR = 0.95)
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)
Program-Level Predictors of Reunification
1.0
1.94
2.25
1.0
1.72
1.96
0.0
0.5
1.0
1.5
2.0
2.5
Odds
Low Medium* High** Low Medium** High**
*p < .10, **p < .05
Family/Child Services Employment/Educational Services
Criminal Justice System
California Inmate Population by Gender, 1985 - 2005
150,000
100,000
50,000
10,000
8,000
6,000
4,000
2,000
47,205
156,573
2,906
11,462
1985 2005 1985 2005Males Females
No. of inmates
Source: CDCR (2006). Historical Trends 1985-2005.
3.3 increase
3.9 increase
Proportion of Offenders in California Incarcerated for Drug-Related
Offenses by Gender, 1985-2005
0
10
20
30
40
50
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Per
cen
t
Source: CDCR (2006). Historical Trends 1985-2005. SACPA
Females
Males
Intervention Points for Women in CJSGirls in JJS have higher rates of drug use, trauma exposure, HIV risk, STD’s, family disruption & co-occurring disorders
Screening & referral to treatment, health services, prevention
Alternative sentencing for non-violent offenders (e.g., community prisoner mother programs)
Treatment diversion while on probation (e.g., drug court, California’s Prop. 36)
Dependency drug court (coordination with child welfare system)
In-prison treatment (primarily therapeutic communities)
Community correctional facilities
Early release/work programs
Re-entry/aftercare programs
Integrate evidence-based practices with supervision (e.g., contingency management, case management, relapse prevention, cognitive-behavioral, trauma-focused)
Target those at high risk for relapse & recidivism
Juvenile Justice
Arrest
Conviction
Incarceration
Parole
Recidivism
Female Offender Treatment and Employment Project (FOTEP)
Residential treatment is provided for 5-15 months in 10 community programs in 8 counties in California
Core services:
Case management
Vocational training/job preparation
Parenting skills training and family services
Trauma-related and mental health services
Co-residence with up to two children (< 12 years old)
Predictors of Return to Prison within 12 Months of FOTEP Discharge
0.98** 0.95*
1.28*
1.82***
1.26** 1.25*
0.31***
0.00.2
0.40.60.8
1.01.2
1.41.61.8
2.0
Odds
Age(years)
Education(years)
AfricanAmerican
(vs. White)
Mental HealthStatus
No. ofIncarcerations
EnteredFOTEP fromcommunity(vs. parole)
CompletedFOTEP
*p < .05, **p < .01, ***p < .001
Implications
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)
Referral and/or treatment for substance use disorders is increasingly embedded within other service systems (rather than in stand-alone programs)
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