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: junsicker@Chestnut.Org

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

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)

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)

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.

Gateway’s Range of Services Genesis Prevention Evaluation Detoxification Inpatient Outpatient Extended Care Halfway Houses Corrections Ohio – Neil Kennedy Recovery Clinic

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

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

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?)

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

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

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

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

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.

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

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)

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

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

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

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

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. 

BCR Structure Two doctoral-level research staff One FT research assistant (others as funded) Data collections staff

BCR Activities Institutional research and evaluation Clinical research and collaboration Consultation Knowledge dissemination

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

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

Knowledge Dissemination Research Update Substance Abuse Research Forum Dan Anderson Research Award Conference presentations Published manuscripts

Erin Deneke, Ph.D., Director of Research Caron Treatment Centers ?? Mission Or Logo

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

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

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.

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

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

Susan Gordon, Ph.D., Director of Research, Seabrook House “To help families find the courage to recover.”

Seabrook Research Goals Process and outcomes evaluation of two residential treatment programs Grant funding to increase/enhance clinical programs Participation in NIDA CTN

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

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

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

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

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

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

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

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!

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+

MatriArk Recruitment

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

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

Chestnut Global Partners International Employee Assistance

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

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

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

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

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)

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)

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)

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)

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. 45% stayed in the same status for 12 months and 55% changed. 1,2,3,4 ---- 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

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 630-246 = -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

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

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: mdennis@chestnut.org , 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: cara.renzelli@gatewayrehab.org) Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents), Fairbanks (8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail: szielke@fairbankscd.org ) 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: vslaymaker@hazelden.org ) 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: edeneke@caron.org) Susan Gordon, Ph.D., Research Director, Seabrook House (133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail: sgordon@seabrookhouse.org )