Research Focused on Real Treatment
Presentation at “2007 National Association of Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are those of the authors and do not reflect official
positions of the association or government. Available on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]
2
The Panel Michael L. Dennis, Ph.D. Director, GAIN Coordinating
Center, Lighthouse Institute, Chestnut Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and Evaluation, Gateway Rehabilitation Center, Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook House , Seabrook, NJ
3
What do we mean by research? Management by objectives and milestones (budget, plans, internal funds) Performance Monitoring (e.g, Oryx, NOMS, GPRA, internal and external funds) Group problem solving to improve performance overal or for a subgroup (e.g, NIATX, Drug Courts) Program Development and Evaluation (e.g., Private, state or CSAT grants) Development and Replication of Evidenced Based Practices (e.g., CSAT, NIH grants) Quasi-Experiments and Randomized Experiments (e.g, NIH grants)
4
As you move down this list
It requires better and more consistent leadership, communications, and trust (particularly for a problem solving type approach)
Often requires patient or staff incentives as the burden goes up
Often requires building of infrastructure (workforce, equipment, systems) or changes in organizational culture that may take several years to be completed
The level of staff qualifications and experience goes up (typically from MA to Ph.D. with prior experience/grants)
The types of funding shifts (from direct service to state/foundation to CSAT to NIH)
The time to get funding gets longer and the likelihood of funding goes down (e.g., NIDA/NIAAA only fund the top 10-13% of applicants and that typically takes 1.5 to 2 years to get from the time the proposal is submitted)
May require collaboration with outside vendors (e.g. to help implement an evidenced based practice) or experts (e.g., in a specific analytic technique)
5
Cara Renzelli, Ph.D., Director of Research and Evaluation, Gateway Rehabilitation Center
Gateway Rehabilitation Center’s mission is to enable people affected by or at risk of addictive diseases and other mental and emotional disorders to lead healthy and productive lives through prevention, education, treatment, and research.
6
Gateway’s Range of Services
Genesis– Prevention– Evaluation– Detoxification– Inpatient– Outpatient
Extended Care– Halfway Houses
Corrections Ohio – Neil Kennedy Recovery Clinic
7
Research Activities - Internal Projects
Study of detoxification medicationExploration of gambling problems in our
treatment populationEvaluation of teen leadership instituteDevelopment and implementation of
outcomes monitoring systemAssists on performance improvement
initiatives
8
Research Activities - External Projects
Gateway has long history of collaboration with university-based research…recent endeavors include 1980s & 1990s – Washington and Jefferson College and
Indiana University of Pennsylvania: inpatient and outpatient treatment outcomes
1992 – today – University of Pittsburgh Medical Center, WPIC: Pittsburgh Adolescent Alcohol Research Center
2003 – 2005 – University of Pittsburgh, School of Social Work: study of adult outcomes and spirituality
2006 – present – Washington University, School of Medicine: prescription abuse study
9
Development and Implementation of Outcomes Monitoring System
Need for outcome data (Why measure?)
Domains (What to measure?)
Time points (When to measure?)
Staffing needs (Who will measure and where?)
Practical applications (How will we use the data?)
10
Outcomes Monitoring System
Why we decided to create this system
Time points– Data collected on ALL patients at 1, 3, 6, 12, and 24 months
after discharge from final level of care– Collected by phone, mail, or personal interview
Domains– Demographic – marital, employment, education– Criminal justice involvement– Additional post-discharge treatment– Relapse/abstinence– 12-step participation– Quality of life
11
Outcomes Monitoring System
Staffing needs - Currently have one research director, one research assistant (RA), and a team of volunteers– All volunteers trained on basic research principles,
data integrity, confidentiality– RA and volunteers collect data– RA manages collected data
Quiet, private space required
12
Outcomes Monitoring System
Practical applications
– Provides a picture of patients’ functioning after they leave our care
– Allows us to look for trends in the data that alert us to investigate further or take action
– Gives other departments within the Gateway system information that may meet a general or specific need
13
Future Directions of the Research Department Increase the number and breadth of our in-house
research and evaluation studies
Expand outcomes system to begin assessments at admission, during treatment, and at discharge
Expansion of survey domains Continue our work with university-affiliated researchers
Form collaborations with other treatment facilities to seek funding for multi-site projects
Extend dissemination efforts
14
Sigurd Zielke, D.Min. Clinical Specialist (Adolescents)Fairbanks
Fairbanks is a nonprofit organization focused on
recovery from alcohol and other drug problems,
serving as a resource to improve the well-being of individuals, families and communities by offering
hope and support through its programs and services.
15
Objectives
To construct empirically-informed models and generate methods to enhance adolescent treatment and recovery support
To create an evidence-informed mindset among our clinicians i.e., an evidence-informed clinical culture
To secure external partners for the measurement of models and methods generated
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Full Range of Adolescent Services
Discovery (education) Detoxification Rehabilitation Residential Transitional Living Partial Hospitalization Intensive Outpatient Recovery Management I & II Hope Academy (Recovery High School)
17
Challenges to Adolescent Treatment & Recovery Support
Historic application of adult models of treatment and recovery to adolescents
Recent recognition by health services researchers… “that adolescence is different from adulthood, and that the methods to identify, treat, and prevent illness need to be different” (Zucker, 2006)
Emergence of the new field of developmental psychopathology Explosion of neurobehavioral research Lack of coherent adolescent treatment and recovery support
models that integrate 12-step recovery processes with recent neurobehavioral and developmental findings
Need for empirical study of updated models
18
Diathesis-Stress Model: Biopsychosocial-Developmental “A major premise…is that adult disorder does not emerge full-blown in adulthood, but rather is a process that emerges over time, and
for which childhood precursors are likely to be identifiable.” (Zucker, 2000; Developmental Psychopathology)
Primary Diagnostic Syndrome
Co-Occurring Diagnostic Syndrome
Co-Occurring Diagnostic Syndrome
Over Time
Risk Factor
Causal Links
Transactional Engagement
1. Must consider the multiple (cumulative) risk factors and causal links emerging over time.
© Copyright Zielke & Zielke, 2004
Protective Factor
2. Roots of later disorders can be found in earlier problems the individual may have had in resolving major developmental issues.
Gene Transcription PhenotypicGenotypic - Load
Protective Factor
Causal Links
Over Time
Diathesis Vulnerability.—a tendency to suffer from a certain condition
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Changing Developmental Pathway, Brain Organization & States of Consciousness
Zielke, 2005
Primary Diagnostic Syndrome
Co-Occurring Syndrome
Co-Occurring Syndrome
Over Time
Risk Factor
Causal Links
Over Time
Transactional Engagement
© Copyright Zielke & Zielke, 2004
Diathesis Vulnerability
Protective Factor
Alternative Pathway
1. Audit assets embedded in risk pathway.
2. “Reload” audited assets along an alternative prosocial pathway (this ameliorates resistance) and then bolster with additional assets.
Transactional Engagement
Over Time
Protective Factor
New Pathway
Our St r at egy
20
Research Needs (i.e., Targets)
Need for grounded identification of adolescent treatment, relapse and recovery issues (affirmation of practitioner knowledge)
Need for extensive professional literature reviews
Need for rigorous theoretical research—resulting in grounded, empirically-informed models
Need to develop methodologies to enact models
Need for clinical staff to utilize models/methodologies
Need to establish “fidelity standards”
Need to secure academic partners to measure the efficacy of the models/methodologies generated
21
Research Response: Projects Grounded video study of student behavior; over 2000 classrooms
in light of neurobehavioral literature Focus group narrative analysis study of educators experiences
with young students coming to school SI Joint hospital and university 2 year professional study of the
literature on SI children/youth, addiction brain studies, and pathway findings
A field-based action research study to enhance the school behavior of SI elementary students: grades one through five—test of preliminary models
Theoretical research---NBD White Paper (July 2007) Generation and utilization of empirically-informed methods:
- 90 in 90: A Recovery Tool for School Success- Node link mapping of student relapses
Establishing collaborations with academic/research partners
22
1. Identify/target clinical issues of persistent concern
2. Conduct field/grounded study of targeted concern to discern patterns of functioning
3. Identify strong lines empirical evidence that address targeted concerns
4. Synthesize findings of 2 and 3 into field-theory and models of practice
5. Use models to guide practice and create tools
6. Conduct quality improvement and pilot studies with external collaborators
7. Use data to affirm, amend, or disregard models/ practice
Creating An Evidence - Informed Clinical Culture for The Treatment And Recovery Support of Adolescents
8. Share results: publication & training
Critical Cultural Elements
• Identify “curious” clinicians
•Carve - out 1hr per week•Keep collegial
• Keep multidisciplinary
• Provide readings• Tie to writing and training
23
Valerie J. Slaymaker, Ph.D., Director of Hazelden’s Butler Center for Research (BCR)
Dedicated to improving recovery from addiction by conducting clinical
and institutional research, collaborating with other research
centers, and communicating scientific findings.
24
BCR Structure
Two doctoral-level research staff
One FT research assistant (others as funded)
Data collections staff
25
BCR Activities
Institutional research and evaluation
Clinical research and collaboration
Consultation
Knowledge dissemination
26
Institutional Research & Evaluation
Outcomes data collection & reporting– 1, 6, and 12 month follow-ups– Use and functional outcomes
Special populations and reports– BCBS– Methamphetamine Outcomes Study– Family Program– Scale development
27
Clinical Research & Collaboration
Milestones of Recovery studies
Phone-based Case Management
Huss Research Chairs on Late Life Addiction
Youth, AA and Treatment Processes study
University of Minnesota Youth & Neuroimaging study
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Knowledge Dissemination
Research Update
Substance Abuse Research Forum
Dan Anderson Research Award
Conference presentations
Published manuscripts
29
Erin Deneke, Ph.D., Director of ResearchCaron Treatment Centers
?? Mission
Or Logo
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Range of Services
Inpatient Care –– Men’s Primary– Women’s Primary– Adolescent – Relapse– Young Adult Male Program (YAMP)
Extended Care –– Men, Women, and Adolescents
Family Education Program
Center for Self-Development
Caron Outpatient Counseling
31
Current Research Activities
Focused Continuing Care– In collaboration with Treatment Research Institute
Chronic Pain Study– In collaboration with University of Pennsylvania and
Reading Hospital– Funded by NIDA
Chronic Pain sub-study– In collaboration with Reading Hospital
Menstrual cycle and cravings study
Menopause and addiction study
32
Caron Research Staffing Director of Research –
– Design , develop, coordinate, and implement intramural and extramural research projects.
– Data analysis, reporting, publishing, and presentations
Research Administrator –– Participant recruitment and data collection– Data entry– Assist with literature reviews
Research Committee –– Review ongoing studies and outcomes– Evaluation of new or proposed projects – advantages/disadvantages both for
internal as well as external studies– Act as an informal Human Subjects Review Board – all projects would be
approved through committee for implementation at Caron.
Physician’s Advisory Committee –– Cutting edge treatment practices– Best research methodology– Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.; Hoover Adger,
M.D.; Sheila Blume, M.D., C.A.C.
33
Focused Continuing Care Available to all patients once leaving inpatient treatment
– Adult only at this time– Will move to adolescent units
Monthly follow-up contacts by phone for 12 months by focused continuing care specialists (5)
– Check in with patients to see how they are progressing in their recovery
– Data collection on such variables as AA attendance, sponsorship, mental health issues, follow-up care, and family issues
Ability to analyze data at various points through 1 year post treatment
Outcome oriented– Both quantitative and qualitative data
Provide information on possible programmatic changes
Unit specific data
34
Moving towards the Future
Increase the number of intramural projects occurring at Caron
Increase collaboration with other agencies and universities
Encourage more extramural research activities
Increase number of sources for outside funding of projects
Improve dissemination of information through published articles, conferences, presentations, and information available to consumers
Assist in marketing and public relation endeavors by providing media relevant information
35
Susan Gordon, Ph.D., Director of Research, Seabrook House
“To help families find the courage to recover.”
36
Seabrook Research Goals
Process and outcomes evaluation of two residential treatment programs
Grant funding to increase/enhance clinical programs
Participation in NIDA CTN
37
Seabrook Evaluation Project:MatriArk Family Program
Residential treatment facility
Low income women and children
10 short-term (28 days) patients
37 long-term (6 – 12 months) patients
12-step treatment approach
Funded through state and local government
38
MatriArk Goals
In-treatment
Reunification of women with young children during treatment
Increase healthy pregnancies and births
Post-treatment
Increase abstinence
Increase 12-step participation
Increase bio-psycho-social functioning
39
MatriArk Evaluation Goals
Assess all eligible and willing patients– Admission and in-treatment– Discharge and one-year follow-up for treatment
completers
Assess grant funding objectives
Identify strengths of the program
Identify aspects of the program to improve
40
MatriArk Research Infrastructure
PEOPLE: Staffing
Research Director– Develop & implement project– Analyze results
Research Assistant– In-treatment data collection and data entry
Aftercare Case Manager– Post-treatment data collection– Post-treatment needs assessment
41
MatriArk Research Infrastructure
PLACES: Facilities Private office space for patient interviews, follow-up calls
THINGS: Resources Computer, network and internet Locked filing cabinets Separate telephone line and stationery for follow-ups Appreciation gifts for patient follow-ups
42
MatriArk Research Infrastructure
Protocols
Consent procedures
Post-treatment follow-up procedures– Locating difficult participants
Staff training and certification– Research ethics– Instrument administration
Safety protocol for home visits
43
MatriArk Research Infrastructure
Oversight
Research and Education Advisory Committee– 10 SBH; 2 external members– Recommend research projects– Monitor ongoing research
No I.R.B.– Not Federally funded research– Not clinical trial
44
MatriArk Assessments
Evidence-based assessments– Reliable and valid– Measure goals and objectives
Clinically-useful assessments– Applicable for treatment
Appropriate “response burden”– Main task of patients is treatment – not research!
45
MatriArk Assessment ScheduleInstrument Admission In-Treatment Discharge 30-day
Follow-Up90-day
Follow-up
GAIN Initial Tx Satisfaction
30 days
Substance Abuse
M90
ASI Initial
DTCQ X 30 days X XPregnancy
HistoryFull Follow-up Follow-up
SCL-90 X 90 days X
PSI X X X
TSPQ X X X
UDS X 60 days+ X
46
MatriArk Recruitment
Completed Follow-ups
96100
8591
87
0
20
40
60
80
100
Admission(55/57)
Discharge(22/22)
1 month (17/20) 2 month (10/11) 3 month (7/8)
% E
lig
ible
Par
tici
pan
ts
47
Michael Dennis, Ph.D., Director of the GAIN Coordinating Center, Chestnut Health Systems
Improving the quality of human service interventions through applied research, publications, and training.
- Lighthouse Institute Mission
Improving assessment to facilitate evidence-based practices.
- GCC Mission
48
Chestnut’sDirect Clinical Services
FY05 Admissions
1,000 to 9,999100 to 99910 to 991 to 9
FY05 Admissions (n=9311) for Substance Abuse and Mental Health Services from 82 of Illinois 103 counties
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Chestnut Global Partners International Employee Assistance
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Major Study Geog. Areas
LI-Research
Facilities
Started in 1985 and grew to 90 full/part time staff grossing $9 Million a year in external funds (NIH, SAMHSA, Foundations)
LI-Research: Several major experiments, quasi-experiments and major surveys
LI-Training and Publications: 100s of training days and largest collection of evidence-based treatment manuals
EBTx Coordinating Center---Supports training, certification, and coaching of clinicians and clinical supervisors learning A-CRA and ACC
GAIN Coordinating Center – supports training, certification and use of the GAIN to support diagnosis, placement, treatment planning, and research
Chestnut’s Lighthouse Institute (Research Division)
51
LI’s Global Appraisal of Individual Needs (GAIN) Coordinating Center (GCC)
VI
01 to 1011 to 2526 to 130
IN
KS
ME
MS
MT ND
NE
NV
PR
HI
NM
SD
AL
AR
IA
OK
RI
SC
DC
TN
UT
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WV
MN
NC
NJ
AK
MD
PA
GA
ID
KY VA
MI
NY
OR
CO
CT
TX
NH
IL
MO
AZ
FL
OH
VT
MA
CA
WY
Statewide System*
WA
DE
WI
* Also being considered in FL, GA, NC, SC, TN
DC
`
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It took a lot of time to get here…
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ouse
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ute
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nu
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even
ue
.
Started going for External CSAT/ NIH
Funding
Created GAIN
Coordinating Center
Started by Bill White to do Training and Evaluation
53
Multiple Co-occurring Problems are Correlated with Severity and Contribute to Chronicity
0% 20%
40%
60%
80%
100%
Health Distress
Internal Disorders
External Disorders
Crime/Violence
Criminal JusticeSystem
Involvement
Dependent (n=1221)
Abuse/Other (n=385)
0% 20%
40%
60%
80%
100%
Dependent (n=3135)
Abuse/Other (n=2617)
Adolescents Adults
Source: GAIN Coordinating Center Data Set
Adolescents More likely to have externalizing
disorders
Adults more likely to have internalizing
disorders[
54
Substance Use Careers are Longer, the Younger the Age of First Use
Per
cen
t in
Rec
over
y
Years from first use to 1+ years abstinence
302520151050
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Dennis et al 2005 (n=1,271)
under 15*
21+
15-20*
Age
of
1st U
se G
rou
ps
* p<.05 (different from 21+)
55
Substance Use Careers are Shorter the Sooner People get to Treatment
Per
cen
t in
Rec
over
y
Years from first use to 1+ years abstinence
302520151050
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Dennis et al 2005 (n=1,271)
20+
0-9*
10-19*
Yea
rs t
o 1st
Tx
Gro
up
s
* p<.05 (different from 20+)
56
It Takes Decades and Multiple Episodes of Treatment
Years from first Tx to 1+ years abstinence
2520151050
Median duration of 9 years
(IQR: 3 to 23) and 3 to 4
episodes of care
Per
cen
t in
Rec
over
y
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Dennis et al 2005 (n=1,271)
57
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Using(N=661)
1 to 12 ms(N=232)
1 to 3 yrs(N=127)
3 to 5 yrs(N=65)
5 to 8 yrs(N=77)
% Days of Psych Prob (of 30 days)
% Above Poverty Line
% Days Worked For Pay (of 22)
% of Clean and Sober Friens
% Days of Illegal Activity (of 30 days)
Other Aspects of Recovery by Duration of Abstinence of 8 Years1-12 Months:
Immediate increase in clean and sober friend
1-3 Years: Decrease in
Illegal Activity; Increase in
Psych Problems
3-5 Years: Improved
Vocational and Financial Status
5-8 Years: Improved
Psychological Status
Source: Dennis, Foss & Scott (under review)
58
The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adults
In the Community
Using (53% stable)
In Treatment (21% stable)
In Recovery (58% stable)
Incarcerated(37% stable)
6%
13%
8%
30%
8%
25%
31%
4%
44%7%
29%
7%
Treatment is the most likely path
to recovery
P not the same in both directions
Source: Scott et al 2005
Avg of 32% change status each quarter
59
RMC’s Impact on Time to Treatment Re-Entry
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0% 0 90 18
0270 36
0450
540
630
Days to Re-Admission (from 3 month interview)
Percent Readmitted 1+ Times
55% ERI-2 RMC* (n=221)
37% ERI-2 OM (n=224)
*Cohen's d=+0.41 Wilcoxon-Gehen
Statistic (df=1)=16.56, p <.0001
630-246 = -384 days
The size of the effect is growing every quarter
Source: Dennis & Scott, in press; Scott & Dennis, under review
60
RMC’s Impact on Adult Outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
of 630 DaysAbstinent (d=0.29)*
of 7 SubsequentQuarters in Need
(d= -0.32) *
of 90 DaysAbstinent(d= 0.23)*
of 11 Sx ofAbuse/Dependence
(d= -0.23)*
Still in need of Tx
(d= -0.24) *
Per
cent
age
OM RMC
* p<.05
68%
49%
68%
27%
57%
76%
37%
76%
19%
46%
Months 4-24 Final Interview
Significant Increase in Abstinence
RMC Broke the
Run
Less Likely to be in Need of Treatment
Less Symptoms
Source: Dennis & Scott, in press; Scott & Dennis, under review
61
Contact Information Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems (720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li) Cara Renzelli, Ph.D., Director of Research and Evaluation, Gateway
Rehabilitation Center (100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; E-mail:
[email protected]) Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents), Fairbanks (8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] ) Valerie J. Slaymaker, Ph.D.,Director, Butler Center for Research,
Hazelden (P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] ) Erin Deneke, Ph.D., Director of Research, Caron Treatment Centers (Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242, E-mail:
[email protected]) Susan Gordon, Ph.D., Research Director, Seabrook House (133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail: