Research Focused on Real Treatment Presentation at 2007 National Association of Addiction Treatment...

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


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


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

16

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


© 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.


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

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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

28

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

30

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


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


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


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

49

Chestnut Global Partners International Employee Assistance

50

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

LA

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

`

52

It took a lot of time to get here…

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

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ute

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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%


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%


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:

[email protected] )

mailto:[email protected]





Research Focused on Real Treatment Presentation at 2007 National Association of Addiction Treatment...

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