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, CASeptember 18, 2007

Martha Washington Home, 1869

Federal Narcotics Farm, Lexington, KY, 1941 - 1965

Women & Drug-Related Crime, 1936

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

Epidemiological and Health Services Research

Related to Gender

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 clinical profile 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

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

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

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

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)

no significant cost difference for trauma-informed/integrated treatment (Domino et al., 2005)

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

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

1970s 1980s 1990s – 2000s

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?

Cognitive Behavioral Therapy

Motivational Interventions

Contingency Management

Trauma-Related Interventions

Pharmacotherapy

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

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

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

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

System-Level Challenges

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); dependency drug courts

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

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)

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%)

Child-Welfare Involved(N = 1,939)

Not Involved w/Child Welfare (N = 2,217)

Source: Grella, Hser, & Huang (2006). Child Abuse & Neglect

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

(OR = 0.4) 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

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