Treatment Works, Kentucky: An Overview of Substance Abuse Treatment Outcomes from KTOS

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1 Treatment Works, Kentucky: An Overview of Substance Abuse Treatment Outcomes from KTOS Robert Walker, M.S.W., L.C.S.W. University of Kentucky Center on Drug and Alcohol Research

2 Kentucky Substance Abuse Treatment Outcome Study (KTOS) Funded by the Division of Mental Health and Substance Abuse. Began in Uses all electronic data at intake (PDA). Also uses data from the client data set and event data set for services and costs.

3 Kentucky Substance Abuse Treatment Outcome Study (KTOS) Study Faculty and Staff Principal Investigator Robert Walker, M.S.W., L.C.S.W Co-investigator, Supervisor of Follow-ups TK Logan, Ph.D. Co-investigator Study Director Research Assistant Systems Administrator and Programmer Programmer Carl Leukefeld, D.S.W. Erin Stevenson, M.S.W. Gregory Bradshaw Tom Jackson, Ed.D. Jeb Messer Research Analyst Jennifer Cole, M.S.W. Research Assistant (Follow-up interviewer) Natalie Rambo Research Assistant (Follow-up interviewer) Megan Whitmer

4 Substance Abuse Treatment and Public Policy Policy makers in state government want to know: Does treatment for substance abuse really work? Is it worth what it costs? Program Directors and clinical providers want to know: Are we making a difference in people s s lives? Are we having a serious impact on the clinical problems that come into our clinics?

5 Treatment Outcomes and Public Policy Most substance abuse treatment outcome studies report that treatment results in reduced substance use and crime as well as improvement in employment (Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997; Simpson, Joe, Rowan-Szal Szal,, 1997). However, the question always comes up but is it effective here in Kentucky?

6 Block Grant Reporting Requirements SAMHSA has new requirements for the National Outcomes Measures (NOMS) By FY 2008 all states must comply in order to receive their Substance Abuse Prevention and Treatment Block Grant funding. The Block Grant represents the majority of funding for all the 14 CMHCs in the state.

7 DATA REQUIREMENTS Alcohol use the number of clients reporting abstinence Drug use the number of clients reporting abstinence Criminal justice involvement Living arrangements the number who are homeless Infectious disease risks (HIV) Supports for recovery (AA, NA, etc) Employment Retention in treatment

8 FY 2003 Follow-up Sample Demographics at Intake Intake question Breakdown N=1056 Gender Male 65.3% Mean age 34.0 Race 1 White Black Native Am. Asian Other 87.2% 11.1% 1.0% 0.2% 0.5% Ethnicity: 0.9% Hispanic / Latino 2 Marital status Current living arrangement Never married Married Divorced Separated Widowed Housed Institutionalized Shelter Street/Outdoors 38.7% 23.6% 26.7% 9.5% 1.4% 91.1% 7.2% 1.2% 0.5% 1 Percents do not add to 100 since clients can identify more than one race

9 Education and Employment at Intake Education Mean education (in years) Options N= years Less than 12 years education 43.8% GED (among those with less than 12 years education) Enrollment status for school or job training Not enrolled Full time Part time Other 36.7% 91.9% 4.3% 1.9% 2.0% Employment Full time Part time Retired Disabled Unemployed, looking Unemployed, volunteer Other 31.1% 7.2% 1.2% 14.1% 37.9% 0.7% 7.7%

10 Income at Intake Mean # days paid for working for those who work Received income from: 17.1 Wages 42.3% Public assistance 6.9% Retirement 1.1% Disability 11.6% Illegal source 0.5% Other 11.0% Mean monthly income for those receiving the following type of income: Wages $1041 Public assistance $325 Retirement $880 Disability $649 Illegal $1430 Other $599

11 Abuse and Mental Health Intake question Responses N=1056 Lifetime Abuse experience Abuse history Physical abuse 30.6% Sexual abuse 18.7% Past 12 months Mental health problem Psychological problems not directly a result of alcohol or drug use in the past 12 months Serious depression 42.0% Serious anxiety 46.7% Serious depression & serious anxiety 35.8% Hallucinations 6.8% Trouble remembering/concentrating Trouble controlling violent behavior 38.9% 14.8%

12 Suicide and Medication Use in the Past 12 Months Suicidal thoughts were reported by 13.7% of the follow-up clients at intake Suicide attempts were reported by 5.4%. Almost 1/3 (31.3%) reported being prescribed medications for psychological problems in the past 12 months at intake

13 Referral from the Criminal Justice System Intake question Options N=1056 Admission/referral reasons Percent of sample referred by criminal justice system 64.0% Percent of overall sample referred following DUI a charge 33.5% Current legal status In Drug Court 7.6% On probation/parole 33.2%

14 Reported Arrests in the Past 12 Months at Intake Intake question Options Past 12 months Past 30 days Arrests Any charge Any drug arrest Drug arrests % of sample arrested on any charge Mean # arrests for those arrested % of sample arrested on drug charge Mean # for those arrested on drug charge % of sample of all those with any arrests whose arrests were for drug charges 60.3% % % 4.8% % 37.8%

15 Past 12 Month Substance Use at Intake Substance Past 12 months N=1056 Past 30 days N=1056 Alcohol 77.6% 43.6% Alcohol to Intoxication 64.0% 31.9% Marijuana/Hashish 49.1% 24.3% Tranquilizers 34.7% 19.7% Opiates 31.3% 17.2% Cocaine 29.4% 13.8% Stimulants 17.0% 6.2% Nonprescription methadone 8.4% 3.5% Hallucinogens 5.2% 0.9% Inhalants 2.2% 0.5% Any illegal substance 70.5% 44.3%

16 Percent of Clients Reporting Past 12 Month Substance Use at Intake by Substance Type (n=1,056) Inhalants Hallucinogens Nonprescription methadone 2.2% 5.2% 8.4% Stimulants 17.0% Cocaine Opiates Tranquilizers 29.4% 31.3% 34.7% Marijuana/Hashish 49.1% Alcohol to Intoxication 64.0% Alcohol 77.6%

17 Percent of time substance used in the past 30 days among those who report any use at intake (n=1,056) Opiates 55.1% Tranquilizers Hallucinogens 43.3% 48.8% Marijuana/Hashish Stimulants Alcohol to Intoxication Alcohol Cocaine 36.2% 35.4% 34.4% 33.7% 33.4% Nonprescription methadone Inhalants 16.3% 20.8%

18 Differences in days of use between clients with and without anxiety or depression at intake (n=971) No MH MH alcohol* marijuana* opiates* tranquilizers** cocaine max drug** Significance established using ANCOVA *p <.01. **p <.001

19 DUI versus other clients DUI clients more male (79% versus 58.3% for non- DUI). More DUI offenders are white (95.2% versus 85.4% for non-dui) 49.9% of DUI offenders are employed at intake compared to 33.2% of non-dui. DUI offenders make 1.5 times more income than non- DUI. DUI offenders have 1/3 the likelihood of having been arrested on a drug charge in the past 30 days compared to non-dui. DUIs report slightly higher alcohol use days and tranquilizer use days, but less than half the marijuana and opiate use compared to non-dui.

20 Percent of clients using services by service category from intake to follow-up All other 8.3 Percent Assessment 31.4 Case management 10.2 Wrap-around Transitional Residential 31.7 Outpatient 74.5 IOP & TRP 8.3 Detox/Stabilization 16.6 Percents do not add to 100 because clients can be in multiple modalities

21 Average number of services used from intake to follow-up Services All other Assessment Case management 10.2 Wrap-around Transitional Residential 27.6 Outpatient 11.3 IOP & TRP 29.3 Detox/Stabilization 6.8

22 Follow-up Changes Clients who consent to follow-up interviews are included in the pool of eligibles if they have face valid locator information. 3,280 clients gave informed consent at intake and had face valid contact information. UK CDAR follow-up sample generally includes 900 1,000 clients. Sampling is set up to match gender and basic distribution of services among residential and outpatient sites.

23 Kentucky Substance Abuse Treatment Outcome Study: FY 2003 Follow-up Findings Baseline data collected at intake by clinicians at over 150 sites. Baseline n=7,537 clients for FY 2003 Follow-up sample selected from consenting clients with face valid contact information 12 months after intake. Proportionate allocation sample (stratified by gender and treatment modality and then random within sample cells). Follow-up rate was 35.2% of the 3004 eligibles. Final follow-up n = 1,056

24 Follow-Up Follow-up interviews are conducted 12 months after treatment intake. UK Survey Research Center conducted the interviews for the FY 2003 sample. Participants are paid $20.00 to compensate for their time in the interview.

25 Percent of Increase in Past 30 day Alcohol Abstinence from Intake to Follow-up Remained abstinent Newly abstinent N % N % Total % alcohol abstinent at followup % of change a Alcohol Male (n = 690) Female (n = 366) Total (N = 1056) % 51.6% 44.5% % 24.9% 23.1% 62.9% 76.5% 67.6% 54.5%** 48.3%** 51.9%** Alcohol to Intoxication Male (n = 689) Female (n = 366) Total (N = 1055) % 68.0% 59.0% % 18.6% 20.9% 76.2% 86.6% 79.9% 40.9%** 27.4%** 35.4%** a Significance established using z test for proportions. *p <.01. **p <.001

26 Changes in the days of alcohol use intake to follow-up Mean proportion of days alcohol was used Percent reduction a Baseline Follow-up Alcohol Males (n = 629) Females (n = 342) Total (N = 971) 16.4% 13.6% 15.4% 9.5% 6.2% 8.4% 42.1%** 54.1%** 45.5%** Alcohol to Intoxication Males (n = 629) Females (n = 342) Total (N = 971) 12.3% 9.9% 11.4% 5.6% 3.0% 4.7% 54.5%** 69.7%** 58.8%** a Significance established using paired-samples t-tests. *p <.01. **p <.001.

27 Percent Increase in Abstinence from Any Illegal Drug from Intake to Follow-up N Remained abstinent % of the total sample Newly abstinent N % of the total sample Total % abstinent at followup % of change a Male (n = 690) % % 70.9% 51.5%** Female (n = 366) % % 71.3% 82.4%** Total (N = 1056) % % 71.0% 61.0%** a Significance established using z test for proportions. *p <.01. **p <.001

28 Changes in the days of use in the past 30 days of most-used illegal substance intake to follow-up Baseline Follow-Up Percent reduction a Males (n = 629) Females (n = 342) Total (N = 971) 22.9% 29.2% 25.1% 15.2% 15.2% 15.2% 33.6%** 47.9%** 39.4%** a Significance established using paired-samples t-tests. *p <.01. **p <.001.

29 Percent Increases in Abstinence by Type of Substance Cocaine 13.6% Opiates 17.4% Tranquilizers 20.6% Marijuana 23.6% Alcohol 51.9% All Illegal Drugs 61.0% Stimulants 97.9%

30 Changes in Employment Employment status, a N = 1050 Intake Follow-up Percent of change a Full time 31.1% 45.4% 23.0%** Part time 7.2% 11.5% 59.7%** Any employment (part + fulltime) 38.3% 56.9% 48.6%** Unemployed 37.9% 16.6% 56.2%** Disabled 14.1% 17.8% 26.2% Mean proportion days paid for working in the past 30 days b (n = 956) School/job training enrollment status a N = % 42.0% 53.3%** Full time 4.3% 5.9% 37.2% Part time 1.9% 4.5% 136.8%** Full or part time 6.2% 10.4% 67.1%**

31 Reductions in Criminal Justice Involvement from Intake to Follow-up Intake Follow-up N % N % Percent change a Arrested on any charge 12 months 30 days % 12.2% % 3.3% 51.9%** 73.0%** Arrested specifically on drug charge 12 months 30 days % 4.8% % 0.6% 53.0%** 87.5%** Spent at least 1 night in jail 12 months 30 days % 19.2% % 4.5% 52.0%** 76.6%** a Significance established using z test for proportions. *p <.01. **p <.001

32 Changes in the days of alcohol use intake to follow-up among those reporting self help or no self help Mean proportion of days alcohol was used Intake Follow-up Percent reduction a Self-help (n = 280) 17.4% 5.2% 70.1%** No Self-help (n = 691) 14.5% 10.2% 29.7%** Total (N = 971) 15.3% 8.8% 42.5%** a Significance established using paired-samples t-tests. *p <.01. **p <.001.

33 Highlights Alcohol use Treatment programs in Kentucky show an increase in the number of clients reporting abstinence Drug use Treatment programs in Kentucky show an increase in the number of clients reporting abstinence Criminal justice involvement - Treatment programs in Kentucky show a decrease in the number of clients reporting arrests Living arrangements Treatment programs in Kentucky show a slight decrease in the number of clients reporting homelessness Supports for recovery (AA, NA, etc) appear related to better treatment outcomes Employment Treatment programs in Kentucky show an increase in the number of clients reporting employment Retention in treatment

34 Days of substance use intake to follow- up for clients with and without mental health problems intake follow-up alcohol* marijuana* opiates* tranquilizers** cocaine max drug** alcohol* marijuana* opiates* tranquilizers** cocaine max drug**

35 Reductions in days of use MH versus non-mh groups While clients reporting anxiety and depression as well as clients reporting no anxiety or depression made significant reductions in substance use 12 months after treatment, There are indications that the rate of improvement for those with mental health problems is less than those without MH problems.

36 Reductions in days of use MH versus non-mh groups Clients at follow-up reporting anxiety and depression still have times more days of alcohol use; 2 times more days of marijuana use; 4.5 times more days of opiate use; and 7.4 times more days of tranquilizer use Than clients who do not report anxiety or depression

37 Intake differences between follow-up and not-followed followed-up clients There are some differences between clients who are followed up versus those who are not in the follow-up study. Most of the differences relate to factors that can affect validity of locator information such as employment. They were more female (34.7 vs 30.4%) More white (88.7% vs 85.3%) More employed (31.1 vs 27.5%)

38 What can we learn from these data? Treatment results in - Significant increases in abstinence; Reduced use among those who continue to use; Reductions in criminal justice involvement; Increased employment; Reduced burden to taxpayers - The FY 2002 follow- up study found that for every $1.00 spent on treatment, there was a $4.03 cost offset for Kentuckians.

39 Kentucky Substance Abuse Treatment Outcome Study: FY 2002 Follow-up Findings Complete KTOS report available at: cdar.uky.edu/ktos Other annual KTOS reports available at the same web site and users can run their own crosstabs from baseline data at county, regional, and state levels.

40 Clients reporting NO substance use in the past 30 days Regional variations Region Percent of clients reporting no substance use Percent of these clients who are CJ referred ABC DEF LMN OPQ STATEWIDE

41 What do we need to pay closer attention to? Clients reporting depression and anxiety may need more focused treatment particularly in regard to opiate and tranquilizer use. Treatment may need to place even more emphasis on self-help. Intake assessment may need more training in facilitating substance use disclosures particularly regarding criminal justice referrals.

42 What s s Next? For FY 2004 follow-ups, there will be regional data for 12 of the 14 CMHCs. The follow-up rate jumped to 67% so confidence in the findings is increased. More data displays on the KTOS web site. We are working on ways to export the data to be used in CMHCs electronic medical records systems. Retention will be measured soon.

43 Retention a New Measure During FY 2006, retention will be measured in outpatient and residential modalities. Findings are to be reported as part of the Block Grant requirements. These data will come from the service event data.

44 Outpatient Substance Abuse Client Retention Rates in Kentucky, FY number of clients st visit clients 3rd event 8th event 20th event

45 Regional Variation 4 Selected Regions: Differences in retention rates to 3 rd and 8 th events 3rd 8th 80.0% 70.0% 60.0% 50.0% 48.3% 69.4% 53.5% 61.2% 40.0% 30.0% 28.1% 35.5% 34.0% 29.6% 20.0% 10.0% 0.0% Region X Region H Region M Region Z

46 The Bottom Line It works It s s cheap It works in urban areas It works in rural areas And - we can all learn from the data about how to improve treatment in Kentucky

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