Does gender-specific substance abuse treatment for women promote continuity of care?

Characteristics of clients entering women-only substance use treatment services in New South Wales

BACKGROUND

Women experiencing substance use disorders face barriers to treatment, including childcare, stigma and lack of gender/trauma-informed programming. Several non-government organizations in New South Wales run women-only treatment services to address these needs.

OBJECTIVES

We aim to assess characteristics of women entering treatment in these services.

DESIGN

Data on client characteristics from six women-only non-government organization substance use disorder treatment services in New South Wales between 2014 and 2018 were extracted from a database containing demographics, drug use and treatment characteristics and psychological distress (Kessler-10 scale) of women entering the services. Logistic regression models were used to estimate unadjusted odds ratio and adjusted odds ratio for treatment completion and different drugs on entry.

RESULTS

Data were available for 1357 women. Most (91%) episodes were for residential treatment. Women's mean age was 35.4 years (standard deviation = 9.8; range = 17-67). Residential clients tended to be younger than non-residential clients (35.1 vs 38.5 years, p < 0.001). Methamphetamine (43%) and alcohol (32%) were the most reported principal drug of concern. Women (89%) reported high levels of psychological distress (median Kessler-10 scale score = 27.5, range = 10-50), highest for women reporting alcohol as their principal drug. Overall, 43% of episodes resulted in treatment completion, most commonly for women entering residential treatment (45% vs 22%, p < 0.001) and for alcohol treatment (adjusted odds ratio = 1.42; confidence interval = 1.07-1.90; p < 0.001). Women with Kessler-10 scale scores indicating anxiety or depression at treatment entry were less likely to complete treatment than those with lower scores (adjusted odds ratio = 0.56; confidence interval = 0.38-0.80; p < 0.001).

CONCLUSION

Women entering women-only residential treatment tend to be younger and report methamphetamine as principal drug of concern. Women enter treatment with high degrees of psychological distress. Women's services need to ensure their programmes can respond to diverse needs of younger women presenting with methamphetamine use disorder and older women with alcohol use disorder experiencing high levels of psychological distress.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students

BACKGROUND

The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students.

METHODS

Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated.

RESULTS

Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students.

CONCLUSIONS

AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

A pilot randomized trial of CBT4CBT for women in residential treatment for substance use disorders

INTRODUCTION

Despite the effectiveness of cognitive behavioral therapy (CBT) for treatment of substance use disorder, dissemination to clinical practice is limited due to a range of barriers (e.g., time, cost). Computer-based training for cognitive behavioral therapy (CBT4CBT) offers a feasible and cost-effective opportunity to improve the quality and reach of SUD treatment. Research to date has supported the effectiveness of CBT4CBT in outpatient settings; however, research has not yet tested it in residential treatment.

METHODS

The current study evaluated the feasibility of CBT4CBT as an adjunct to residential treatment in a sample of women with SUDs using a two-arm pilot RCT comparing women randomized to either standard residential treatment plus access to the CBT4CBT program (N = 34) or residential treatment alone (TAU; N = 29). Assessments occurred at baseline, discharge from residential care, and at 4- and 12-weeks post-discharge. The study compared the two groups over the 12-week follow-up period on relapse to any substance (Y/N), relapse to primary substance (Y/N), and days of use using chi-square for categorical and t-tests for continuous measures. The study team also performed a Kaplan-Meier analysis to compare the two groups on time to relapse.

RESULTS

Demographically, the sample was predominantly African American (79.4%), with a mean age of 41.2 years (SD = 12.1). Although the current study was not powered for statistical significance, findings were in the predicted direction, with women in the CBT4CBT group reporting lower likelihood of relapse, longer time to relapse, and fewer days of substance use in the follow-up period compared to women in TAU.

CONCLUSIONS

This study expands the current literature supporting the use of CBT4CBT in outpatient settings. While a fully powered trial should confirm our findings, the current study provides benchmark data on the use of CBT4CBT in residential treatment for women with SUDs.

Exploring Technology-Based Enhancements to Inpatient and Residential Treatment for Young Adult Women with Co-Occurring Substance Use

Young adults have the highest rates of substance use of any age group. Although men historically have higher rates of substance use disorders (SUDs) than women, research shows this gender gap is narrowing. Young adults with comorbid psychiatric disorders are at increased risk for developing a SUD. Co-occurring psychiatric disorders such as depression, anxiety, eating and post-traumatic stress disorders are more prevalent in women than men with SUDs, yet mental health treatment often does not adequately address substance use in patients receiving care for a comorbid psychiatric disorder. Tailored gender-responsive interventions for women with psychiatric disorders and co-occurring SUD have gained empirical support. Digital interventions tailored to young adult women with co-occurring disorders have the potential to overcome barriers to addressing substance use for young adult women in a psychiatric treatment setting. This study utilized a user-centered design process to better understand how technology could be used to address substance use in young adult women receiving inpatient and residential psychiatric care. Methods: Women (N = 15; age 18-25 years), recruited from five psychiatric treatment programs, engaged in a qualitative interview and completed self-report surveys on technology use and acceptability. Qualitative interviews were coded for salient themes. Results: Results showed that few participants were currently using mental health web-based applications (i.e., "apps"), but most participants expressed an interest in using apps as part of their mental health treatment. Participants identified several important topics salient to women their age including substance use and sexual assault, stigma and shame, difficulties abstaining from substance use while maintaining social relationships with peers, and negative emotions as a trigger for use. Conclusions: These data provide preliminary evidence that a digital intervention may be a feasible way to address co-occurring substance use problems in young adult women receiving care in a psychiatric setting.

Determinants and Prevention Strategies of Substance Abuse in Pacific Countries: A Systematic Review

Objectives

People abuse substances like drugs, alcohol, and tobacco for different reasons, including pleasure, improved performance and vigilance, relief of depression, curbing hunger, and weight control. In this review, we sought to identify the determinants and prevention strategies that have been undertaken to minimize the issue of substance abuse.

Methods

The systematic review was conducted following the Cochrane Library Guidelines and PRISMA checklist. We searched six online databases to identify studies from January 2000 to July 2017.

Results

Only peer-reviewed studies published in the English language that had full text accessible were included. We reviewed 19 studies; only one was quasi-experimental and the majority were descriptive studies. The determinants of substance abuse identified include personal, faciliatory/promotor, environmental, and social factors. The prevention strategies identified use culturally appropriate and gender-sensitive treatments, and identify sources of strength in families, community, individual, and even spiritual.

Conclusions

Substance abuse poses significant public health risks and therefore requires adequate interventions such as educating and informing individuals of the health risks associated with substance abuse and must be considered locally to promote the well-being of people.

Treatment Interventions for Women With Alcohol Use Disorder

Women with alcohol use disorder (AUD) experience more barriers to AUD treatment and are less likely to access treatment than men with AUD. A literature review identified several barriers to women seeking help: low perception of a need for treatment; guilt and shame; co-occurring disorders; employment, economic, and health insurance disparities; childcare responsibilities; and fear of child protective services. Women entering treatment present with more severe AUD and more complex psychological, social, and service needs than men. Treatment program elements that may reduce barriers to AUD treatment include provision of childcare, prenatal care, treatment for co-occurring psychological problems, and supplemental social services. Research has suggested that outcomes for women are best when treatment is provided in women-only programs that include female-specific content. To date, research on treatments tailored to the individual needs of women is limited, but research on mechanisms of change has suggested the importance of targeting anxiety and depression, affiliative statements in treatment, abstinence self-efficacy, coping skills, autonomy, and social support for abstinence. Future research should focus on early interventions, linkages between primary care or mental health clinics and AUD treatment settings, and integrated treatments for co-occurring AUD and other disorders. Further research should also explore novel treatment delivery approaches such as digital platforms and peer support groups.

Group therapy for women with substance use disorders: In-session affiliation predicts women's substance use treatment outcomes

In-session affiliation among members is a hypothesized mechanism of action of group therapy for women with substance use disorders (SUDs). We evaluated group affiliation as an independent predictor of SUD treatment outcome in women (n = 100), 18 years or older diagnosed with substance dependence, who were randomized to the single-gender Women's Recovery Group (WRG) or mixed-gender group therapy (Group Drug Counseling; GDC). Affiliative statements made by members in both groups were measured for 39 women in each treatment arm. We studied the relationship between frequency of affiliative statements categorized in quintiles and the trajectory of days of any drug use during 3 months treatment and 6 months post-treatment using a Poisson regression model with estimation via generalized estimating equations. Furthermore, we investigated whether the effect of affiliation on substance use was moderated by group therapy type. The relationship between amount of affiliation and substance use reduction was non-linear. At the end of the treatment phase (3 months), women who experienced the highest level of affiliation (>65 affiliative statements on average) were found to reduce substance use by about 1.75 days more (p-value = 0.02) than women who experienced the lowest level of affiliation (<26). The effects of affiliation persisted 6 months post-treatment and were moderated by therapy group, whereby women enrolled in the single-gender WRG appeared to benefit more from affiliation post-treatment. Training therapists to facilitate verbal affiliation may provide added therapeutic benefit to group therapy for women with SUDs.

"They Gave Me Life": Motherhood and Recovery in a Tribal Community

OBJECTIVE

This study explored factors related to substance misuse and recovery among Native mothers in a Pacific Northwest tribe, focusing on motherhood as a motivating factor in seeking treatment and sustaining recovery.

METHOD

Using a community-based participatory research approach, we conducted a thematic analysis of 20 in-depth interviews and one focus group (N = 12) with Native women 18 years and older living on or near the reservation.

RESULTS

Qualitative findings highlighted challenges, motivations and strategies for seeking treatment and recovery in four major themes: (a) the close relationship between interpersonal violence and substance misuse; (b) traditional healing in recovery; (c) community-specific challenges to recovery; and (d) the motivating role of motherhood in seeking treatment and successful recovery.

CONCLUSIONS

A central finding of this work is that pregnancy and motherhood may be underexplored factors in Native women's substance use. Results support previous work suggesting that Native women are at high risk of interpersonal trauma and that trauma contributes to substance misuse. Findings offer several rich implications for treatment and recovery among Native mothers in tribal communities including the necessity of trauma-informed treatment, community and culturally-based interventions, more integration of treatment services with Child Protective Services, and drawing on motherhood as a motivation for seeking and succeeding in recovery.

Do women with complex alcohol and other drug use histories want women-only residential treatment?

BACKGROUND

Women-only addiction services tend to be provided on a poorly evidenced assumption that women want single-sex treatment. We draw upon women's expectations and experiences of women-only residential rehabilitation to stimulate debate on this issue.

METHODS

Semi-structured interviews were undertaken with 19 women aged 25-44 years [currently in treatment (n = 9), successfully completed treatment (n = 5), left treatment prematurely (n = 5)]. All had histories of physical or sexual abuse, and relapses linked to relationships with men. Interviews were audio-recorded, transcribed verbatim, coded and analysed inductively following Iterative Categorization.

FINDINGS

Women reported routinely that they had been concerned, anxious or scared about entering women-only treatment. They attributed these feelings to previous poor relationships with women, being more accustomed to male company and negative experiences of other women-only residential settings. Few women said that they had wanted women-only treatment, although many became more positive after entering the women-only service. Once in treatment, women often explained that they felt safe, supported, relaxed, understood and able to open up and develop relationships with other female residents. However, they also described tensions, conflicts, mistrust and social distancing that undermined their treatment experiences.

CONCLUSIONS

Women who have complex histories of alcohol and other drug use do not necessarily want or perceive benefit in women-only residential treatment.

Patient and program costs, and outcomes, of including gender-sensitive services in intensive inpatient programs for substance use

Gender-sensitive services (GSS) attempt to make substance use treatment better for women, but at what cost and with what results? We sought answers to these questions in a federally-funded study by measuring separately the patient and provider costs of adding GSS, outcomes, and cost-outcome relationships for 12 mixed-gender intensive inpatient programs (IIP) that varied in amounts and types of GSS. GSS costs to female inpatients included time devoted to GSS and expenses for care of dependents while in the IIP. GSS costs to providers included time spent with patients, indirect services, treatment facilities, equipment, and materials. Offering more GSS was expected to consume more patient and provider resources. Offering more GSS also was expected to enhance outcomes and cost-outcome relationships. We found that average GSS costs to patients at the IIPs were $585 ($515-$656) per patient. Average GSS costs to providers at the IIPs were $344 ($42-$544) per patient. GSS costs to patients significantly exceeded GSS costs to providers. Contrary to previous research, offering more GSS services to patients did not result in significantly higher costs to patients or providers. IIPs offering more GSS may have delivered fewer traditional services, but this did not significantly affect outcomes, i.e., days until returning to another substance use treatment. In fact, median cost-outcome for these IIPs was a promising 35 treatment-free days, i.e., over a month, per $100 of GSS resources used by patients and providers.

Sex and gender differences in substance use disorders

The gender gap in substance use disorders (SUDs), characterized by greater prevalence in men, is narrowing, highlighting the importance of understanding sex and gender differences in SUD etiology and maintenance. In this critical review, we provide an overview of sex/gender differences in the biology, epidemiology and treatment of SUDs. Biological sex differences are evident across an array of systems, including brain structure and function, endocrine function, and metabolic function. Gender (i.e., environmentally and socioculturally defined roles for men and women) also contributes to the initiation and course of substance use and SUDs. Adverse medical, psychiatric, and functional consequences associated with SUDs are often more severe in women. However, men and women do not substantively differ with respect to SUD treatment outcomes. Although several trends are beginning to emerge in the literature, findings on sex and gender differences in SUDs are complicated by the interacting contributions of biological and environmental factors. Future research is needed to further elucidate sex and gender differences, especially focusing on hormonal factors in SUD course and treatment outcomes; research translating findings between animal and human models; and gender differences in understudied populations, such as those with co-occurring psychiatric disorders and gender-specific populations, such as pregnant women.

Gender Comparison in Referrals and Treatment Completion to Residential and Outpatient Alcohol Treatment

BACKGROUND

Residential treatment for alcoholism is associated with high completion rates for clients, yet there appear to be gender disparities in patient referrals and treatment completion rates. We studied whether (A) gender is associated with differential patient placement to outpatient vs. residential treatment facilities and (B) completion rates differ by gender.

METHODS

In this cross-sectional study, we analyzed the admission and discharge data from 185 publicly funded substance abuse treatment facilities across Los Angeles County between 2005 and 2010.

RESULTS

Among the 33,745 studied cases, women were referred to residential treatment facilities less frequently than men (75% vs. 66%). The adjusted results derived from logistic regression models confirmed that females were more likely to be referred to outpatient treatment than to residential treatment facilities (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.05–1.26). In addition, we observed that compared to White/Caucasian patients, all other races were associated with more referral to outpatient facilities (ie, less referral to residential facilities), indicating a racial disparity on the top of the observed gender disparity. However, there was no significant link between gender and treatment completion rates (OR: 0.93, 95% CI: 0.86–1.00).

CONCLUSIONS

Women seem to have treatment completion rates comparable to men, yet they are less likely to be referred to residential treatment facilities. Hence, there still remains a gender disparity in alcoholic patient referrals. Further studies should delineate which specific therapeutic aspects and programmatic components of women-focused treatments are essential to augment positive treatment outcomes.

Measuring affiliation in group therapy for substance use disorders in the Women's Recovery Group study: Does it matter whether the group is all-women or mixed-gender?

BACKGROUND AND OBJECTIVES

A Stage II, two-site randomized clinical trial compared the manualized, single-gender Women's Recovery Group (WRG) to mixed-gender group therapy (Group Drug Counseling; GDC) and demonstrated efficacy. Enhanced affiliation and support in the WRG is a hypothesized mechanism of efficacy. This study sought to extend results of the previous small Stage I trial that showed the rate of supportive affiliative statements occurred more frequently in WRG than GDC.

METHODS

Participants (N = 158; 100 women, 58 men) were 18 years or older, substance dependent, and had used substances within the past 60 days. Women were randomized to WRG (n = 52) or GDC (n = 48). Group therapy videos were coded by two independent raters; Rater 1 coded 20% of videos (n = 74); Rater 2 coded 25% of videos coded by Rater 1 (n = 19).

RESULTS

The number of affiliative statements made in WRG was 66% higher than in GDC. Three of eight affiliative statement categories occurred more frequently in WRG than GDC: supportive, shared experience, and strategy statements.

DISCUSSION AND CONCLUSIONS

This larger Stage II trial provided a greater number of group therapy tapes available for analysis. Results extended our previous findings, demonstrating both greater frequency of all affiliative statements, as well as specific categories of statements, made in single-gender WRG than mixed-gender GDC.

SCIENTIFIC SIGNIFICANCE

Greater frequency of affiliative statements among group members may be one mechanism of enhanced support and efficacy in women-only WRG compared with standard mixed-gender group therapy for substance use disorders. (Am J Addict 2016;25:573-580).

Barriers to Condom Use: Results for Men and Women Enrolled in HIV Risk Reduction Trials in Outpatient Drug Treatment

HIV transmission often occurs through heterosexual high-risk sex. Even in the era of HIV combination prevention, promoting condom use, and understanding condom barriers, remain priorities, especially among substance-dependent individuals. Men and women (N=729) in outpatient drug treatment participated in a five-session gender-specific risk reduction group or one-session HIV Education group. Condom barriers (Motivation, Partner-related, Access/Availability, Sexual experience) were assessed at baseline and 6-month follow-up. Completing either intervention was associated with fewer motivation and partner-related barriers. Among women, reductions in motivation and sexual experience barriers were associated with less sexual risk with primary partners. Condom barriers are important to gender-specific HIV prevention; given limited resources, brief interventions maximizing active components are needed.

Differences between older and younger adults in residential treatment for co-occurring disorders

OBJECTIVE

The purpose of this study was to examine differences between older and younger adults who received integrated treatment for co-occurring substance use and mental disorders, including differences on demographic and baseline characteristics (e.g., substance use, readiness for change, mental health symptoms, and severity of problems associated with substance use), as well as predictors of retention in treatment.

METHODS

This study included 1400 adults who received integrated substance abuse and mental health treatment services at one of two private residential facilities offering residential and outpatient services. Initial analyses consisted of basic descriptive and bivariate analyses to examine differences between older (≥ 50 years old) and younger (< 50 years old) adults on baseline variables. Next, three ordinary least squares regression models were employed to examine the influence of baseline characteristics on length of stay.

RESULTS

Three main findings emerged. First, older adults differed from younger adults on pre-treatment characteristics. Older adults used more alcohol and experienced greater problem severity in the medical and alcohol domains, while younger adults used more illicit drugs (e.g., heroin, marijuana, and cocaine) and experienced problems in the drug, legal, and family/social domains. Second, while readiness to change did not differ between groups at baseline, older adults remained enrolled in treatment for a shorter period of time (nearly four days on average) than younger adults. Third, the pattern of variables that influenced length of stay in treatment for older adults differed from that of younger adults. Treatment retention for older adults was most influenced by internal factors, like psychological symptoms and problems, while younger adults seemed influenced primarily by external factors, like drug use, employment difficulties, and readiness for change.

CONCLUSIONS

The results of this study add to the limited knowledge base regarding older adults receiving integrated treatment for co-occurring substance use and mental health disorders by documenting that age-based differences exist in general and in the factors that are associated with the length of stay in residential treatment.

Continuity of Care in Dual Diagnosis Treatment: Definitions, Applications, and Implications

OBJECTIVE

The goal of this work is to review the current literature on continuity of care in the treatment of people with dual diagnosis. In particular, this review set out to clarify how continuity of care has been defined, applied, and assessed in treatment and to enhance its application in both research and clinical practice.

METHODS

To identify articles for review, the term "continuity" and combinations of "substance" and "treatment" were searched in electronic databases. The search was restricted to quantitative articles published in English after 1980. Papers were required to discuss "continuity" in treatment samples that included a proportion of patients with a dual diagnosis.

RESULTS

A total of 18 non-randomized studies met the inclusion criteria. Analysis revealed six core types of continuity in this treatment context: continuity of relationship with provider(s), continuity across services, continuity through transfer, continuity as regularity and intensity of care, continuity as responsive to changing patient need, and successful linkage of the patient. Patient age, ethnicity, medical status, living status, and the type of mental health and/or substance use disorder influenced the continuity of care experienced in treatment. Some evidence suggested that achieving continuity of care was associated with positive patient and treatment-related outcomes.

CONCLUSIONS

This review summarizes how continuity of care has been understood, applied, and assessed in the literature to date. Findings provide a platform for future researchers and service providers to implement and evaluate continuity of care in a consistent manner and to determine its significance in the treatment of people with a dual diagnosis.

Providers' constructions of pregnant and early parenting women who use substances

The research literature indicates that problematic substance use as a form of health behaviour is poorly understood, being sometimes viewed as deviance, at other times as a disease, and most often as a combination of these states. The use of substances by women who are pregnant or new parents is often conceptualised within an individualised framework. Yet drinking alcohol and using other drugs during pregnancy and early parenthood cuts across social divisions and is shaped by socio-structural contexts including health care. There is a growing body of literature that critically examines public health interventions that are aimed at implementing harm reduction and health promotion techniques in service delivery to help pregnant and early parenting women who are identified as problem substance users. We examine qualitative data from representatives of a recent harm reduction intervention, focusing, in particular, on providers' individual conceptualisations of the problematic behaviour. Our results show that most study participants regard any substance use during pregnancy, birth and the postpartum period as fundamentally unacceptable. This framing of problematic substance use is accomplished via gendered responsibilisation of women as foetal incubators and primary caregivers of infants. We discuss our results in light of the current literature and suggest policy implications.

Gender-sensitive substance abuse treatment and arrest outcomes for women

The present study links an empirically-developed quantitative measure of gender-sensitive (GS) substance abuse treatment to arrest outcomes among 5109 substance abusing women in mixed-gender short-term residential programs in Washington State. Frailty models of survival analysis and three-level hierarchical linear models were conducted to test the beneficial effects of GS treatment on decreasing criminal justice involvement. Propensity scores were used to control for the pre-existing differences among women due to the quasi-experimental nature of the study. Men's arrest outcomes were used to control for confounding at the program level. Results show that women in more GS treatment programs had a lower risk of drug-related arrests, and women in more GS treatment programs who also completed treatment had a significant reduction in overall arrests from 2 years before- to 2 years after treatment, above and beyond the reduction in arrests due to treatment alone. Implications and directions for future research are discussed.

Explaining long-term outcomes among drug dependent mothers treated in women-only versus mixed-gender programs

Specialized substance abuse treatment for parenting women is thought to improve outcomes, but long-term impacts and how they occur are poorly understood. Utilizing a sample of 789 California mothers followed for 10 years after admission to women-only (WO) or mixed-gender (MG) drug treatment, we examine the relationship between WO treatment and outcomes and whether it is mediated by post-treatment exposures to criminal justice and health services systems. At follow-up, 48% of mothers had a successful outcome (i.e., no use of illicit drugs, not involved with the criminal justice system, alive). Controlling for patient characteristics, WO (vs. MG) treatment increased the odds of successful outcome by 44%. In the structural equation model WO treatment was associated with fewer post-treatment arrests, which was associated with better outcomes. Women-only substance abuse treatment has long-term benefits for drug-dependent mothers, a relationship that may be partially explained by post-treatment exposure to the criminal justice system. Findings underscore additional leverage points for relapse prevention and recovery-supportive efforts for drug-dependent mothers.

Women-specific HIV/AIDS services: identifying and defining the components of holistic service delivery for women living with HIV/AIDS

Introduction

The increasing proportion of women living with HIV has evoked calls for tailored services that respond to women's specific needs. The objective of this investigation was to explore the concept of women-specific HIV/AIDS services to identify and define what key elements underlie this approach to care.

Methods

A comprehensive review was conducted using online databases (CSA Social Service Abstracts, OvidSP, Proquest, Psycinfo, PubMed, CINAHL), augmented with a search for grey literature. In total, 84 articles were retrieved and 30 were included for a full review. Of these 30, 15 were specific to HIV/AIDS, 11 for mental health and addictions and four stemmed from other disciplines.

Results and discussion

The review demonstrated the absence of a consensual definition of women-specific HIV/AIDS services in the literature. We distilled this concept into its defining features and 12 additional dimensions (1) creating an atmosphere of safety, respect and acceptance; (2) facilitating communication and interaction among peers; (3) involving women in the planning, delivery and evaluation of services; (4) providing self-determination opportunities; (5) providing tailored programming for women; (6) facilitating meaningful access to care through the provision of social and supportive services; (7) facilitating access to women-specific and culturally sensitive information; (8) considering family as the unit of intervention; (9) providing multidisciplinary integration and coordination of a comprehensive array of services; (10) meeting women “where they are”; (11) providing gender-, culture- and HIV-sensitive training to health and social care providers; and (12) conducting gendered HIV/AIDS research.

Conclusions

This review highlights that the concept of women-specific HIV/AIDS services is a complex and multidimensional one that has been shaped by diverse theoretical perspectives. Further research is needed to better understand this emerging concept and ultimately assess the effectiveness of women-specific services on HIV-positive women's health outcomes.

Measurement of gender-sensitive treatment for women in mixed-gender substance abuse treatment programs

BACKGROUND

Gender-sensitive (GS) substance abuse treatment services have emerged in response to the multidimensional profile of problems that women display upon admission to substance abuse treatment. The present study examines the extent to which treatment programs vary in GS programming for women in real-world mixed-gender treatment settings, where most women are treated.

METHODS

Data were collected through site visits using semi-structured interviews with program directors, clinical directors, and counselors in 13 mixed-gender treatment programs from Washington State. Rasch modeling techniques were used to analyze the data.

RESULTS

Naturally occurring variation was revealed within and across the treatment programs, and demonstrated that reliable measures of three GS domains (Grella, 2008) can be constructed despite a small number of programs.

CONCLUSIONS

This is the first study to quantify GS treatment for substance abusing women. The identified treatment services and practices and the way they clustered together to form scales have practical implications for researchers, service providers, clinicians, and policy makers. The scales can be used to study treatment outcomes and to evaluate the effectiveness, cost-effectiveness, and cost-benefit of GS programming for women.

Mortality among substance-using mothers in California: a 10-year prospective study

AIMS

To examine mortality rates and causes of death among a cohort of substance-using mothers and to identify risk factors that predict mortality.

DESIGN, SETTING, PARTICIPANTS

This is a prospective study of a cohort of 4447 substance-using mothers (pregnant or parenting) who were enrolled during 2000-02 in 40 drug abuse treatment programs across California.

METHODS

All mothers were assessed at baseline using the Addiction Severity Index. Mortality data were obtained from the National Death Index and causes of death were coded using ICD-10. Standardized mortality ratios (SMR) were calculated relative to women in the general population adjusted for age. Proportional hazard (Cox) regression was used to identify risk factors predicting death.

RESULTS

At the end of 2010, 194 deaths were confirmed, corresponding to a crude mortality rate of 4.47 per 1000 person-years and SMR of 8.4 (95% confidence interval: 7.2-9.6). Drug overdose (28.8%), cardiovascular disease (10%), and alcohol or drug disorders (8.9%) were the leading causes of death. Baseline factors associated with higher mortality included older age, being white (relative to African American or Hispanic), heroin, alcohol, cocaine or marijuana (relative to methamphetamine) as the primary drug problem, drug injection and greater severity of employment, medical/health and psychiatric problems.

CONCLUSIONS

Substance-using mothers have 8.4 times the mortality than that observed among US women of similar age. Greater severity of employment, medical/health and psychiatric problems contributed to the elevated mortality.

Long-term outcomes among drug-dependent mothers treated in women-only versus mixed-gender programs

This study examined the long-term outcomes of women who were pregnant or parenting at admission to women-only (WO; n = 500) versus mixed-gender (MG; a matched sample of 500) substance abuse treatment programs. Administrative records on arrests, incarcerations, mental health services utilization, and drug treatment participation were collected, covering 3 years preadmission and 8 years postadmission. Women treated in WO programs had lower levels of arrest, mental health services utilization rates, and drug treatment participation during the first year after drug treatment. No differences were found between the two groups in the long-term trajectories except that the WO program participants had lower incarceration rates during the third year after treatment. The study findings suggest a positive short-term impact of WO versus MG programs with regard to arrest and mental health services utilization. Limited long-term gain is shown in the reductions in posttreatment incarceration. The study findings suggest the added value of specialized WO programs and begin to address the gap in knowledge regarding long-term outcomes for substance-abusing women.

A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting

BACKGROUND

The objectives of this study were to examine the determinants of using a peer-led mobile outreach program (the Mobile Access Project [MAP]) among a sample of street-based female sex workers (FSWs) who use drugs in an urban Canadian setting and evaluate the relationship between program exposure and utilizing addiction treatment services.

METHODS

A detailed questionnaire was administered at baseline and bi-annual follow-up visits over 18 months (2006-2008) to 242 FSWs in Vancouver, Canada. We used bivariate and multivariate logistic regression with generalized estimating equations for both objectives, reporting unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

RESULTS

Over 18 months, 42.2% (202) reports of peer-led mobile outreach program use were made. High-risk women, including those servicing a higher weekly client volume (10+ compared to <10; AOR: 1.7, 95%CIs: 1.1-2.6) and those soliciting clients in deserted, isolated settings (AOR: 1.7, 95%CIs: 1.1-2.7) were more likely to use the program. In total, 9.4% (45) reports of using inpatient addiction treatment services were made (7.5% detoxification; 4.0% residential drug treatment), and 33.6% (161) using outpatient treatment (28.8% methadone; 9.6% alcohol/drug counsellor). Women who used the peer-led mobile outreach were more likely to use inpatient addiction treatment (AOR: 4.2, 95%CIs: 2.1-8.1), even after adjusting for drug use, environmental-structural factors, and outpatient drug treatment.

DISCUSSION

Our findings demonstrate that FSWs at higher risk for sexually transmitted infections and violence are more likely to access this peer-led mobile outreach program and suggest that the program plays a critical role in facilitating utilization of detoxification and residential drug treatment.

Client and service characteristics associated with addiction treatment completion of clients with co-occurring disorders

The study examines client and service characteristics of addiction treatment completers and non-completers with co-occurring disorders (COD). On demographic variables, completers were more likely to be male and homeless. In the psychiatric domain, a greater proportion of completers received diagnoses of depression and generalized anxiety disorder, whereas non-completers were more often diagnosed with bipolar disorder and posttraumatic stress disorder. No group differences were found in client-reported psychiatric symptom severity; however, non-completers were rated by clinicians as having more severe symptoms in the areas of interpersonal sensitivity, depression, and hostility. In the area of substance use patterns, no differences were found in primary substance of abuse but completers reported more days of use during the month prior to treatment. Completers also had a greater history of both prior detox and non-detox treatment. At discharge, completers achieved higher rates of past month abstinence and AA attendance, but no differences were found in length of stay in treatment. Examination of recovery support services utilization revealed that completers more often received peer mentoring services. Greater proportions of the non-completer group received educational support, clothing, medical care, and employment assistance. These results suggest that future studies are needed in examining possible differential treatment response by diagnostic category and the potential role of peer mentoring in enhancing addiction treatment completion of COD clients.

Organizational determinants of outpatient substance abuse treatment duration in women

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored women's programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and women's treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to external influences.

Using administrative data for longitudinal substance abuse research

The utilization of administrative data in substance abuse research has become more widespread than ever. This selective review synthesizes recent extant research from 31 articles to consider what has been learned from using administrative data to conduct longitudinal substance abuse research in four overlapping areas: (1) service access and utilization, (2) underrepresented populations, (3) treatment outcomes, and (4) cost analysis. Despite several notable limitations, administrative data contribute valuable information, particularly in the investigation of service system interactions and outcomes among substance abusers as they unfold and influence each other over the long term. This critical assessment of the advantages and disadvantages of using existing administrative data within a longitudinal framework should stimulate innovative thinking regarding future applications of administrative data for longitudinal substance abuse research purposes.

Cross-system data linkage for treatment outcome evaluation: lessons learned from the California Treatment Outcome Project

Using administrative data to evaluate health care outcomes has become increasingly common, but the reliability and validity of outcome measures based on cross-system data linkage have been little scrutinized. Applying a deterministic data matching methodology, we linked 6545 Californians admitted to 43 substance abuse treatment programs between 2000 and 2001 to administrative data acquired from three state agency databases. We compared self-reported treatment outcome measures to equivalent measures derived from official records on motor vehicle driving incidents, criminal history, and mental health services utilization. Administrative data provided analogous results in some measures (e.g., percent of people using mental health services, percent ever arrested) and more accurate results in others (e.g., frequency of service utilization, and frequency of arrests). Similar to findings based on the interview data, the administrative data also revealed improvements in several domains 1-year post-treatment compared to 1-year pre-treatment. Experiences with data linkage procedures and strategies for enhancing record linkage accuracy are discussed. Findings illustrate the value of using administrative records for substance abuse treatment outcome evaluation, while highlighting areas for improvement for future cross-system data linkage efforts.

Tailoring of outpatient substance abuse treatment to women, 1995-2005

BACKGROUND

Tailoring substance abuse treatment to women often leads to better outcomes. Previous evidence, however, suggests limited availability of such options.

OBJECTIVES

This investigation sought to depict recent changes in outpatient substance abuse treatment (OSAT) tailoring to women and to identify unit and contextual factors associated with these practices.

RESEARCH DESIGN

Data were from 2 waves of a national OSAT unit survey (N = 618 in 1995, N = 566 in 2005). Comparisons of weighted means between waves indicate which practices changed over time. Multiple logistic regressions with generalized estimating equations test associations between unit and contextual attributes and tailoring to women.

MEASURES

Tailoring to women was measured as availability of prenatal care, child care, single sex therapy, and same sex therapists, and the percentage of staff trained to meet female clients' needs.

RESULTS

Two measures of tailoring to women declined significantly between 1995 and 2005: availability of single sex therapy (from 66% to 44% of units) and percent of staff trained to work with women (from 42% to 32% of units). No aspect of tailoring to women became more common. Proportion of female clients, total number of clients, methadone status, and private and government managed care were associated with higher odds of tailoring to women. For-profit facilities, which became more prevalent during the study period, had lower odds than other units of tailoring treatment to women.

CONCLUSIONS

Some key aspects of OSAT tailoring to women decreased significantly in the last decade. Managed care contracts may offer 1 mechanism for counteracting these trends.