1. 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 or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax: (309) ,

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 medication
Exploration of gambling problems in our treatment population
Evaluation of teen leadership institute
Development and implementation of outcomes monitoring system
Assists 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

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

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. Informed Clinical Culture for
Creating An Evidence -
Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents 1.
Identify/target 2.
Conduct 8.
Share results:
clinical issues of
field/grounded study
publication &
persistent concern
of targeted concern
training
to discern patterns
of functioning 7.
Use data to affirm, 3.
Identify strong lines
amend, or disregard
empirical evidence
models/ practice
that address
targeted concerns 4.
Synthesize findings 6.
Conduct quality 5.
Use models to
of 2 and 3 into field -
improvement and pilot
guide practice and
theory and models
studies with external
create tools
of practice
collaborators
Critical Cultural Elements •
Identify
“curious”
clinicians •
Keep multidisciplinary •
Carve -
out 1hr per week •
Provide readings •
Keep collegial •
Tie to writing and training

23. Valerie J. Slaymaker, Ph. D
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 Research Caron 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. 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 Schedule
Instrument
Admission
In-Treatment
Discharge
30-day Follow-Up
90-day Follow-up
GAIN
Initial
Tx Satisfaction
30 days
Substance Abuse
M90
ASI
DTCQ X
Pregnancy History
Full
Follow-up
SCL-90
90 days
PSI
TSPQ
UDS
60 days+

46. MatriArk Recruitment

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’s Direct Clinical Services
FY05 Admissions (n=9311) for Substance Abuse and Mental Health Services from 82 of Illinois 103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9

49. Chestnut Global Partners International Employee Assistance

50. Chestnut’s Lighthouse Institute (Research Division)
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
Major Study
Geog. Areas
LI-Research
Facilities

51. LI’s Global Appraisal of Individual Needs (GAIN) Coordinating Center (GCC)` NH WA VT MT ME ND MN OR MA ID NY SD WI WY MI RI IA PA NE CT OH NJ NV IL IN DC CA UT CO WV KS MO KY VA DE DC NC MD TN AZ OK NM AR SC
In addition, the GAIN is being used under NIH, State and private funds in all but six states for both adolescent and adult substance abuse treatment. GA
1 to 10 MS AL
11 to 25
26 to 130 TX LA
Statewide System* AK FL HI VI PR
* Also being considered in FL, GA, NC, SC, TN

52. It took a lot of time to get here…
Created GAIN Coordinating Center
Started going for External CSAT/ NIH Funding
Started by Bill White to do Training and Evaluation

53. Multiple Co-occurring Problems are Correlated with Severity and Contribute to Chronicity
Adolescents More likely to have externalizing disorders
20%
40%
60%
80%
100%
20%
40%
60%
80%
100% 0% 0%
Health Distress
Internal Disorders
Adults more likely to have internalizing disorders[
External Disorders
Crime/Violence
This figure shows the rates of co-occurring disorders among adolescents and adults in over 71 Treatment evaluation studies from 45 states in the U.S. who provide data to the GAIN coordinating Center that I run.
Multiple co-occurring problems are clearly the norm among both adolescents and adults presenting to substance abuse treatment in the U.S. This includes health distress, internal disorders (like somatic, depression, suicide, anxiety, trauma), external disorders (like ADHD, Conduct Disorder), and crime/violence (including physical violence, drug related crime, property crime, and interpersonal/violent crime).
Those reporting three or more past year symptoms of dependence at the time of treatment entry (shown in dark red) are generally more likely to have these problems than others with only abuse or dependence in partial remission.
1. One exception is that while the criminal justice system is likely to push adolescents with more severe substance use disorders into treatment, it is more likely to lock up adults who continue to use and offend.
These co-occurring problems increase the risk of relapse and make the long term management of substance use disorders more complicated.
Criminal Justice
System
Involvement
Adults
Adolescents
Dependent (n=3135)
Dependent (n=1221)
Abuse/Other (n=2617)
Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

54. Source: Dennis et al 2005 (n=1,271)
Substance Use Careers are Longer,
the Younger the Age of First Use
100%
90%
21+
80%
Percent in Recovery
15-20*
Age of 1st Use Groups
70%
60%
Years from first use to 1+ years abstinence
under 15*
50%
40%
30%
Substance use careers are longer the earlier the age of first use ---
20%
* p<.05 (different from 21+)
10% 0% 5 10 15 20 25 30
Source: Dennis et al 2005 (n=1,271)

55. Source: Dennis et al 2005 (n=1,271)
Substance Use Careers are Shorter
the Sooner People get to Treatment
100%
0-9*
90%
80%
10-19*
Percent in Recovery
Years to 1st Tx Groups
70%
60%
Years from first use to 1+ years abstinence
50%
40%
20+
30%
1- However, entering treatment in the first decade of use was associated with reducing the lifetime substance use career by over half.
It does not take long to realize that the potential saving in societal costs justifies more research on to improve participation in and the effectiveness of adolescent substance abuse treatment.
20%
10%
* p<.05 (different from 20+) 0% 5 10 15 20 25 30
Source: Dennis et al 2005 (n=1,271)

56. Multiple Episodes of Treatment
It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%
Percent in Recovery
70%
Median duration of 9 years
(IQR: 3 to 23) and 3 to 4 episodes of care
Years from first Tx to 1+ years abstinence
60%
50%
40%
30%
Note that one episode of treatment is rarely sufficient once someone has a chronic substance use disorder with multiple co-occurring problems. This figure shows the time from 1st treatment to 1+ years of abstinence, the median was 9 years with an inter-quartile range of 3 to 23 years. Moreover the average person did not have 1+ years of abstinence until then had been in treatment 3 to 4 times.
The traditional acute care model focusing on 1-12 sessions or even 90 days of treatment and 6 month outcomes are simply not sufficient for treating or studying the treatment of this kind of chronic substance use disorders.
20%
10% 0% 5 10 15 20 25
Source: Dennis et al 2005 (n=1,271)

57. Other Aspects of Recovery by Duration of Abstinence of 8 Years
1-12 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
100%
% of Clean and
Sober Friens
90%
80%
70%
60%
% Days Worked
For Pay (of 22)
50%
% Above
Poverty Line
40%
30%
This figure classifies people at year 8 of the study based on how long they have been abstinent (if at all) to examine how the duration of abstinence is related to other aspects of recovery
20%
% Days of Illegal
Activity (of 30 days)
% Days of Psych
Prob (of 30 days)
10% 0%
Using
1 to 12 ms
1 to 3 yrs
3 to 5 yrs
5 to 8 yrs
(N=661)
(N=232)
(N=127)
(N=65)
(N=77)
Source: Dennis, Foss & Scott (under review)

58. Avg of 32% change status each quarter
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change status each quarter
P not the same in both directions
Incarcerated
(37% stable) 6%
13% 8% 7%
29%
30% 8%
25%
Treatment is the most likely path to recovery
31% 4%
44%
In the
Community
In Recovery
Using
(58% stable)
(53% stable)
To shift to a chronic condition management paradigm it is necessary to start by recognizing that most people are typically cycling through multiple periods of being in the community using, incarceration, treatment and being in the community in recovery for a month or more. The circles in this figure show the average percent staying in each condition between two annual interviews for this same large sample % stayed in the same status for 12 months and 55% changed.
1,2,3, these arrows show the percent moving along each pathway from one state to another.
5- Notice that the percentages are not the same in both directions.
6- Also notice that the probability of moving from the three states on the left to recovery on the right are not the same --- with treatment being the most likely pathway to recovery over a 12 month period.
In Treatment
(21% stable)
Source: Scott et al 2005

59. RMC’s Impact on Time to Treatment Re-Entry
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
The size of the effect is growing every quarter
= -384 days
Percent Readmitted 1+ Times
55% ERI-2 RMC*
(n=221)
37% ERI-2 OM
(n=224)
*Cohen's d=+0.41
Wilcoxon-Gehen 0% 90
180
270
360
450
540
630
Statistic (df=1)
=16.56, p <.0001
Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

60. RMC’s Impact on Adult Outcomes
Months 4-24
Final Interview
100%
Significant Increase in Abstinence
90% OM
RMC
RMC Broke the Run
80%
76%
76%
Less Likely to be in Need of Treatment
68%
68%
70%
57%
60%
Less Symptoms
49%
Percentage
50%
46%
40%
37%
27%
30%
19%
20%
What this figures shows is the total number of days --- green RMC, red control….. Keep in mind that the control group did not get any help. The right….literature
10% 0%
of 630 Days
of 7 Subsequent
of 90 Days
of 11 Sx of
Still in need
of Tx
Abstinent
Quarters in Need
Abstinent
Abuse/Dependence
(d=0.29)*
(d= -0.32) *
(d= 0.23)*
(d= -0.23)*
(d= -0.24) *
Source: Dennis & Scott, in press; Scott & Dennis, under review
* p<.05

61. Contact Information
Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center, Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: , , Web:
Cara Renzelli, Ph.D., Director of Research and Evaluation, Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: x1104;
Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents), Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: , )
Valerie J. Slaymaker, Ph.D.,Director, Butler Center for Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN ; Phone: ; )
Erin Deneke, Ph.D., Director of Research, Caron Treatment Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA , Phone: ,
Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: , ext. 5803, )