1. Gender Differences in Treatment Needs, Services, Utilization, and Outcomes Karol Kaltenbach, PhD Department of Pediatrics Jefferson Medical College Thomas Jefferson University

2. APA Disclosure Statement n This is to acknowledge I have no relationship with any manufacturer of a product or service I intend to discuss.

3. Overview n History of specialized services for women n Assessing comprehensive needs of women n Complexity of needs and treatment outcomes

4. History of Specialized Services for Women n NIDA 1974 Research demonstration projects for women’s treatment n Women’s special needs and the delineation of gender specific treatment strategies were identified over 20 years ago n Beschner, Reed, & Mondanaro (Eds) 1981 Treatment services for drug dependent women

5. History of Specialized Services for Women n Federal grant programs, e.g. NIDA Perinatal 20 and CSAT pregnant and post-partum demonstration grants, provided support for development and enhancement of women’s treatment services in the late 80’s –’90’s

6. Specialized Treatment Services for Women n Programs in US –Residential: 41% women-only 23% pregnant/postpartum women (SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS) 2001) n Of women who need treatment only 20% receive treatment (SAMHSA, OAS 2002)

7. Services: Models for Women’s Treatment Finnegan, Hagan, Kaltenbach (1991) Scientific foundation of clinical practice: Opiate use in pregnant women Jansson, Svikis, et al (1996) Pregnancy and addiction: A comprehensive care model Kaltenbach & Comfort (1996) Comprehensive treatment for pregnant substance abusing women Finkelstein, Kennedy, Thomas, Kearns (1997) Gender specific substance abuse treatment

8. Woman Centered Treatment Model Comprehensive treatment approach that addresses –Addiction –Medical/Psychiatric –Psychosocial –Parenting –Educational/Vocational issues of both women and their children

9. Specialized Programs Women-only programs more likely to provide: Pregnancy, pediatric and children’s services Client advocacy/case management Classes on social skills, practical skills, parenting, anger management Assistance with housing and transportation Peer support groups and social outings (Grella et al., 1999)

10. Effectiveness of Specialized Treatment Services n Residential –Women in women-only programs had More time in treatment More likely to complete treatment (Grella, 1999)

11. Effectiveness of Specialized Treatment Services n Women in gender-specialized programs – Use more services throughout treatment than women in traditional coed program – Have higher rates of abstinence – More likely to see themselves as doing well in treatment ( Nelson-Zupko, 1997)

12. Effectiveness of Woman Centered Treatment n Treatment for Pregnant Women: –Increased Gestational Age, Birth-weight, Apgar Scores –Less likely to require NICU services –Those admitted to NICU had shorter stays –Average net savings for women in treatment of $4,644 per moth/infant pair (Svikis, et.al., 1997)

13. Assessing Comprehensive Treatment Needs of Women n Instruments –Most assessment tools are based primarily on males –Addiction Severity Index Most widely used standard data collection instrument Initially developed and tested solely on males Acceptable levels of reliability and validity with a number of populations Limited in assessing critical areas for women

14. Assessing Comprehensive Needs of Women ASI limited in assessing  Medical issues related to pregnancy  Care-giving responsibilities  Child and partner relationships  Victimization

15. Assessing Comprehensive Needs of Women n Psychosocial History (PSH) –Instrument that retains the fundamental structure of the ASI but expanded to include Family history and relationships Relationships with partner Responsibilities for children Pregnancy history History of violence and victimization Family legal issues Housing arrangements

16. Complexity of Needs Personal and Family Characteristics Residential Outpatient Age 27.9 29.6 Education 11.8 10.8 Employment 77% 94% Job training 48% 38% (Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999)

17. Personal and Family Characteristics Residential Outpatient Currently Receiving Public Assistance 84% 81% Relationship status Married 6% 17% Not Married 84% 53% Long-term relationship 10% 30%

18. Personal and Family Characteristics Residential Outpatient Housing History Homeless in past 3 yr. 68% 21% Current Living arrangements Family/Friends 51% 43% Father of Baby 10% 29% Shelter 26% 7% No Stable Housing 6% 7% Other 6% 14%

19. Personal and Family Characteristics n Substance Use by Partner No use31%33% Drug and/or alcohol use42%42% Recovery27%25% D/A Treatment Ever41%40% Currently15%25%

20. Personal and Family Characteristics n Substance Use by Family RT OP No Yes No Yes Biological mother53% 37% 37% 53% Biological father 27% 67% 28% 72% Female caregiver 89% 11% 67% 33% Male caregiver 100% 20% 80% Maternal grandmother 58% 42% 72% 21% Maternal grandfather 43% 50% 45% 55%

21. Personal Characteristics n Victimization Residential Outpatient n One/more types of victimization 73% 89% n Domestic violence 45% 65% n Rape 43% 54% n Childhood abuse/neglect 32% 39%

22. Personal Characteristics n Legal Status Residential Outpatient n Family legal problems45%31% n Requested order of protection22%23% n Ever arrested32%23% n Ever incarcerated23%13%

23. Treatment Outcomes n What are the factors that result in successful outcomes? –Literature reflects a variety of conceptual frameworks that are ‘gender neutral” Patient-treatment matching Motivation to change Treatment process Retention in treatment

24. Treatment Outcomes We know relatively little of the relationship between women’s characteristics/needs and treatment outcome.

25. Treatment Outcomes n Retrospective study of 133 pregnant women enrolled in comprehensive gender specific outpatient treatment to identify factors that predict retention, abstinence, and service utilization (Comfort & Kaltenbach, Substance Abuse, 2000)

26. Treatment Outcomes n Measures –PSH Factor analyses procedures reduced set of predictors to 27 variables organized into five factors –Personal Stability –Opiate Dependence –Psychiatric and Medical problems –Multiple family problems –High-risk lifestyle

27. Treatment Outcomes n Summary of Findings Retention predicted by Personal Stability Opiate Dependence Fewer Psychiatric and Medical Problems Multiple Family Problems (multiple R 2 =.153, p<.0001)

28. Treatment Outcomes n Summary of Findings Abstinence predicted by Lower scores on High-Risk Lifestyle (trend) (multiple R 2 =.035, p=.059)

29. Treatment Outcomes n Summary of Findings Utilization of Required Services Lower scores on Multiple Family Problems (multiple R 2 =.069, p=.021) Utilization of Specialized Services Psychiatric and Medical Services (trend) (multiple R 2 =.045, p=.061)

30. Treatment Outcomes n Prospective Longitudinal Study –Women (95) enrolled for a minimum of 3 months with 12 month follow-up data Outpatient (60) Residential (35) (Comfort & Kaltenbach, Addictive Behaviors, 2003)

31. Treatment Outcomes n Treatment Outcome Variables –Treatment duration –Intensity of service utilization –Engagement in treatment –Satisfaction with treatment services –Substance use during treatment

32. Treatment Outcomes n Summary: n Outpatient –The most noteworthy predictors for women in outpatient treatment were differing combinations of Social support Life stressors Levels of past substance abuse Chronic medical conditions

33. Treatment Outcomes n Summary: n Residential –The most significant predictors for women in residential treatment reflected lower levels of personal risk factors Partner abuse Prostitution Homelessness Depression

34. Treatment Outcomes –More responsibilities Care-giving responsibilities Less financial assistance from family

35. Treatment Outcomes n Conclusion –No simple predictors of women’s substance abuse treatment outcomes –Assessment areas of particular value Social supportChronic medical problems Daily stressorsChildbirth history Life satisfactionChildcare responsibilities Partner abuseEngagement in treatment Psychiatric history

36. Predictors of Program Completion for Women in Residential Treatment n Five domains of patient characteristics to predict completion of treatment: Socio-demographics Substance use Legal involvement Psychological functioning Social relations (Knight et.al. Am J Drug Alcohol Abuse, 2001)

37. Predictors of Program Completion for Women in Residential Treatment n Predictors of treatment completion –Education –Recent arrests –Peer deviance (Knight et. al. 2001)

38. Predictors of Program Completion for Women in Residential Treatment n Noteworthy trends Women who were not married Women who had two or more children Women who had an open child welfare case Women who had psychological problems Appeared to be at greater risk for non- completion (Knight et. al. 2001)

39. Treatment for Women n In summary, limited research on gender specific treatment Biopsychosocial characteristics of women Treatment utilization and retention Psychiatric co-morbidity

40. Treatment for Women n Need for continued research –Development of assessments that reflect the complex issues of pregnant and parenting drug dependent women –Systematic investigations of barriers to treatment –Pharmacological treatment and pregnancy –Treatment outcomes for mother and child