Co-Occurring Methamphetamine Expanded Treatment COMET Program

Transcription

1 Co-Occurring Methamphetamine Expanded Treatment COMET Program Final Evaluation Report Prepared for Clark County Department of Community Services 12/30/2007 Prepared by: Regional Research Institute for Human Services Portland State University Evaluation Team Heidi Herinckx, Lead Evaluator Shane Ama, Research Assistant Sara Schwartz, Research Assistant Elisabeth Winter, Administrative Assistant In Collaboration with: Clark County Department of Community Services This evaluation was funded through a Targeted Capacity Expansion Grant from the Center for Mental Health Services, Substance Abuse and Mental Health Administration, U.S. Department of Health and Human Services (Grant No. CFDA93.243) Regional Research Institute for Human Services Portland State University P.O. Box 751 Portland, OR 97207

2 Table of Contents Executive Summary Introduction COMET Program Description Extent of the Methamphetamine Problem Overview of Evaluation Methodology Major Findings and Outcomes Section 1: COMET Consumer Interviews: GPRA and Assessment Data Section 2: Treatment Disposition and Factors Associated with Successful Completion of the COMET program Section 3: Consumer Perspectives of COMET: Qualitative Data Section 4: Service Utilization Section 5: Criminal Justice Activity Section 6: COMET Staff Interview Data Section 7: Fidelity to the PACT Model and the Matrix Model Conclusions References Table of Figures and Tables Figures Figure 1: Client Demographics, Age Figure 2: Client Demographics, Gender Figure 3: Client Demographics, Race Figure 4: Client Demographics, Diagnosis Figure 5: Marital Status Figure 6: Income Status at Enrollment Figure 7: Employment Status Figure 8: Illegal Drug Use Figure 9: Number of Individuals Who Used at Each Time Point Figure 10: Average Number Days of Use: Top Three Drugs Figure 11: Percentage with Psychiatric Symptoms Figure 12: GPRA Criminal Justice Involvement Figure 13: Housing Status at Baseline, 6 month and Discharge Figure 14: Employment at Baseline, 6 month and Discharge Figure 15: Treatment Disposition of COMET Clients at the End of Year Figure 16: Percentage of Total Service Utilization Disbursement Tables Table 1: Housing Status upon Enrollment in COMET Table 2: Number of COMET Clients who Ever Used Each Class of Drug and Used Each Class of Drug in the Past 30 Days Table 3: Age of First Use and First Meth Use

3 Table 4: Frequency of Meth use from Assessment Data: Use in Last 30 Days and Peak Use Table 5: Frequency of Marijuana use from Assessment Data: Use in Last 30 Days and Peak Use Table 6: Frequency of Cocaine use from Assessment Data: Use in Last 30 Days and Peak Use Table 7: Experienced Symptoms of Mental Illness in the Past 30 Days Table 8: Telesage Data Table 9: Income at Baseline, 6 Month and Discharge Table 10: Client Characteristics Table 11: Analysis of Client Characteristics Table 12: COMET Client Responses Kind of Help Needed from COMET Table 13: Client Responses to Single Most Important Part of Meth Recovery Table 14: COMET Client Responses COMET Help with Meth Recovery Table 15: Number of Individuals and Average Hours by Service Category Table 16: Number of Arrests in 12 months Pre-COMET compared to Post-COMET Enrollment Table 17: Number of Individuals Arrested by Housing Type and Arrest Category Table 18: COMET Staff Educational Level Table 19: Group Cohesion, COMET Staff

4 EXECUTIVE SUMMARY COMET Program Description The Co-Occurring Methamphetamine Expanded Treatment (COMET) program in Clark County Washington was established in October 2004 through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). This three-year project (funded from October 2004 through September 2007) was designed to expand Clark County, Washington s capacity to reduce methamphetamine abuse among seriously mentally ill people in the county. To promote integrated treatment within the system, a single PACT team (called the COMET team) was comprised of staff from three different organizations, Clark County Department of Community Services and two provider agencies Community Services Northwest and Lifeline Connections and all staff were housed at Lifeline Connections. A program manager/clinical supervisor and office assistant from the county worked side-by-side with the provider employees that included: two mental health case managers, two chemical dependency case managers, one registered nurse, one psychiatric nurse practitioner (ARNP), and two peer specialists, both of whom had a co-occurring disorder and were in recovery from methamphetamine dependence. COMET s target population were individuals who were not eligible for Medicaid funded mental health treatment but who were diagnosed with a co-occurring mental illness and methamphetamine dependency. Many were also homeless, parenting dependent children and involved in the criminal justice system. The County proposed to treat 180 individuals over the three year project period; this number was later reduced to 140 by the SAMHSA Federal Project Officer. Ultimately, the COMET program enrolled and served 120 clients over three years. The goals of the COMET program were: 1) to provide integrated mental health and substance abuse treatment; 2) to improve quality of life and level of functioning, increase physical health, and to reduce episodes of criminality, homelessness, and psychiatric crisis of COMET participants; 3) to expand Clark County s capacity to provide evidence based treatment approaches to treat the growing number of community members impacted by methamphetamine addiction. Over the grant period a number of factors within the county and State of Washington contributed to funding and sustaining COMET. Both the county and state recognized the need for more PACT teams, the magnitude of the Meth problem, and the importance of providing more co-occurring treatment. The Public Health Advisory Committee named Meth as the county s number one public health issue, and both the State Attorney General and Congressman Brian Baird visited the program. Washington State Senate Bill 5763 provided counties the option of adopting a one-tenth of 1 percent sales tax to fund new and expanded chemical dependency/mental health treatment. Clark County s Board of Commissioners established this tax and convened a task force to determine funding priorities. In November 2008 the task force recommended an additional three-years of funding for COMET. 1

5 COMET Evaluation Methodology A comprehensive evaluation of the Clark County Co-Occurring Methamphetamine Expanded Treatment program (COMET) was conducted by the Regional Research Institute (RRI) at Portland State University. The evaluation design for COMET involved a mix of qualitative and quantitative methods to describe and evaluate the operation of the COMET program and to assess its impact on clients. The four main components were: 1) COMET client interviews conducted at baseline, 6 months and upon discharge from the COMET program; 2) COMET staff interviews; 3) secondary analysis of mental health service utilization, Telesage data, and Clark County jail data regarding COMET clients; and 4) program fidelity measurement to the MATRIX and the Assertive Community Treatment models. This report summarizes major findings of the COMET program. Major Findings Client Interviews: Of the 120 clients enrolled in the COMET program, 100% completed a baseline interview, 88 (73%) completed the 6 month follow-up interview, and 77 (64%) completed discharge interviews. Twenty-three clients were still in service at the end of the project. At six months and discharge, COMET clients reported higher level of functioning, higher quality of life, higher commitment to recovery and reduced methamphetamine use, and reduced mental health symptoms. However, COMET clients at 6 months and discharge did not demonstrate increased employment and were still dealing with issues of severe poverty with average personal incomes of $577 and $506 a month respectively. COMET clients spoke of the positive support they received from the COMET team and the benefits of being in a treatment program that addresses BOTH their mental health and methamphetamine addiction simultaneously. From the qualitative data collected from COMET clients it was clear that the COMET program provided individualized client-centered services. Clients reported that they worked with multiple members of the COMET team, felt valued and respected, and benefited from the information and support of their peers in group sessions. Service Utilization and Telesage data. COMET clients were engaged in treatment an average of 203 days and received an average of 38.6 hours of case management per person and 22.6 hours of Matrix groups per person. Telesage data was reported for 74 COMET clients with baseline, 6 month and 12 month data. Clients reported significant improvement in quality of life, commitment to recovery, level of functioning and reduced mental health symptoms. 2

6 Jail Data. For the entire sample of COMET clients, they did not have fewer arrests in the 12 months post-enrollment in COMET compared to 12 months pre-enrollment in COMET. However, those who successfully graduated from the COMET program DID have fewer arrests than those who did not successfully graduate. In fact, non-graduates accounted for 92% (1008 of 1094) of all jail days for COMET clients in the 12 months post-enrollment. COMET Staff Interviews. The COMET staff reported that they received adequate and ongoing training to meet the multiple and complex needs of COMET clients. The staff felt that the clinical supervision and support provided by the program director was of high quality. Staff believed the team functioned well and scored high on the Group Cohesion Scale. However, the team felt that the organizational structure of having some staff hired, supervised and managed by three separate organizations was confusing and resulted in inequitable pay, benefits, promotion/raises, and ultimately caused riffs within the team. PACT and Matrix Fidelity. The RRI evaluation staff measured PACT program fidelity at the beginning of the program and annually using the Dartmouth Fidelity Scale and attended 18 Matrix Groups and completed the Moment-Moment Elements MATRIX Fidelity Scale developed by the Matrix Institute. Overall, the COMET program consistently met fidelity to both models. The biggest challenge faced by the COMET program was how to meet the demand of 80% community service provision for PACT fidelity while meeting the demand of three (3) group sessions a week for MATRIX (which were often held in the COMET office). Ultimately, the COMET program provided 43% of case management services in the community. Conclusions Overall, the Clark County COMET program met the goals and objectives of the SAMHSA grant. The COMET program provided integrated Matrix and PACT services to 120 individuals with co-occurring mental illness and methamphetamine addiction. Forty-eight (48), 49% of the 97 consumers discharged had successfully completed the COMET program. The remaining 23 consumers were still enrolled in COMET at the end of the project. The average days in the COMET program were 203 days; longer than the average of 78 days found in a recent study of individuals in methamphetamine treatment in the California Alcohol and Drug Data System. Upon enrollment COMET clients were dealing with multiple and complex issues including personal histories of sexual, physical abuse and domestic violence, family histories of drug abuse, poverty, unstable housing, exacerbated mental health symptoms, a wide range of serious physical health problems, and criminal justice involvement. The COMET program had the most substantial impact in reducing both level of substance abuse and mental health symptoms, and in coordinating health care. At six months and 12 months, COMET clients reported higher level of functioning, higher quality of life, higher commitment to recovery and reduced methamphetamine use, and mental health symptoms. However, COMET clients at 6 months and discharge were still dealing with issues of severe poverty with average personal incomes of $506 a month. 3

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8 INTRODUCTION COMET (Co-occurring Methamphetamine Expanded Treatment) Program Description and Program Goals The Co-Occurring Methamphetamine Expanded Treatment (COMET) program in Clark County Washington was established in October 2004 through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). This three-year project (funded from October, 2004 through September, 2007) was designed to expand Clark County, Washington s capacity to reduce methamphetamine abuse among seriously mentally ill people in the county. Clark County Department of Community Health Services contracted with Community Services Northwest and Lifeline Connections to provide comprehensive mental health and methamphetamine treatment through a single multidisciplinary treatment team. The COMET program provided two evidence-based models of treatment: the Matrix Model of chemical dependency treatment and the Assertive Community Treatment model. All clients enrolled in the COMET program had an Axis I mental health diagnosis and a substance abuse diagnosis of methamphetamine dependency or abuse at admission. Extent of the Methamphetamine Problem Washington, Oregon and California has seen a rise in methamphetamine use, manufacturing and distribution for over 20 years. According to the SAMHSA Treatment Episodes Data System (TEDS) for Washington state, methamphetamine treatment admissions accounted for only 1% of all treatment admissions in 1992 and has steadily risen by 1% a year and now accounts for approximately 17% of all drug treatment admissions across all major drug categories. Treatment admissions for methamphetamine in Washington State have ranked third over the past three years (since 2004); only treatment admissions for alcohol and marijuana outnumber admissions for methamphetamine (SAMHSA TEDS, 2007). According to SAMHSA TEDS data, Oregon had the highest rate of Meth treatment admissions per capita in the nation in 1992 and In 1992, methamphetamine admissions were 72 per 100,000. In 2002, this rate rose to 324 per 100,000 in Oregon (SAMHSA, 2003). SAMHSA TEDS data for California showed that treatment admissions for methamphetamine have ranked number one (1) since 2002 with 36% of all drug abuse treatment admissions for methamphetamine in The COMET program was funded through a federal grant initiative specifically designed to treat methamphetamine addiction. In 2004, SAMHSA awarded six Targeted Capacity Expansion grants to develop service programs specifically for methamphetamine addiction. Clark County Washington was one recipient, along with Portland, Oregon; San Francisco and Oakland, California; Denver, Colorado; and Fort Worth, Texas. The target population served by the Clark County COMET program grant were adults age 18 and older who were Methamphetamine (Meth) dependent and also diagnosed with a serious mental health disorder in accordance with the DSM-IV. The overall goals of the COMET program were described in the grant as follows: The project s three central purposes are: 5

9 A. For the participants: to assist them to establish a clean and sober lifestyle, to improve the quality of their lives, to increase physical health, and to reduce episodes of criminality, homelessness, and psychiatric crisis; B. For the community: to increase the capacity for targeted culturally competent and genderspecific methamphetamine treatment by 60 slots each year (serving 180 over three years) and to develop provider capacity to effectively serve this population; C. For the treatment community: to develop an effective, evaluated, and manualized approach to treatment of methamphetamine users with co-occurring mental health disorders. A number of quality assurance and feedback processes were established as part of the COMET project to ensure that program goals were met. Monthly Planning and Oversight meetings were held among stakeholders to ensure that community partners interests were brought to the table and addressed by the COMET program. Systems linkages were enhanced by these problem-solving meetings. The Regional Research Institute at Portland State University conducted a comprehensive evaluation of the COMET project. The RRI conducted both a process and outcome evaluation - which measured the COMET program s fidelity to the PACT and MATRIX models over the project period, interviewing COMET participants and COMET staff about program operations and collecting administrative data such as COMET intake assessments, Telesage data, jail and service utilization data. This final evaluation report details the COMET project outcomes and results. This report focuses on data for 120 COMET clients served through the three-year grant period. The major findings presented in this report are organized into 7 Sections. Section 1 discusses the demographic and clinical characteristics of clients served by COMET. Section 2 provides treatment disposition and factors associated with successful completion of COMET. Section 3 discusses consumer perspectives of COMET. Section 4 provides service utilization data. Section 5 provides data on re-arrest rates and criminal justice activity. Section 6 presents COMET staff interview data. Finally, Section 7 summarizes COMET fidelity to the PACT and Matrix Model, followed by the evaluation conclusion. OVERVIEW OF EVALUATION METHODOLOGY Variables, Data Sources and Data Collection Methods 1) COMET Consumer Interviews GPRA data. The evaluation team from the RRI conducted personal interviews with COMET clients at baseline, 6 months and discharge from the program. In adherence to the Government Performance Results Act (GPRA), the primary method for the collection of quantitative data was the GPRA instrument. The GPRA instrument asks participants about his or her current substance use, housing, employment, education, criminal justice involvement, income and financial resources. The instrument is required for SAMHSA funded evaluations. 6

10 The COMET evaluation protocols including the interview questions were reviewed and approved by Portland State University s Human Subjects Internal Review Board (IRB). Participation in this project was voluntary and all participants signed informed consent prior to participation. Over the three year grant period, the evaluation team interviewed 120 COMET clients. Interviews were scheduled with consenting COMET clients at a time and location determined by the client. Most interviews were conducted face-to-face in the client s homes, at the COMET office, or somewhere in the community (i.e., in a restaurant, coffee shop, or community social service agency). Interview length generally ranged from forty to sixty minutes. 2) Telesage Data. Administrative Data. Client Status Measures. The evaluation team analyzed the Telesage data collected on COMET clients at regular intervals by COMET program staff. Washington State developed this standardized measure called the Washington State Consumer Outcomes Survey (Telesage, 2004), to measure outcomes for all mental health and substance abuse consumers in treatment programs in the state. It measures six outcome domains drawn from standardized assessments: quality of life (Lehman Quality of Life, 1993), functioning (Multnomah County Ability Scale, Barker, Barron, McFarland, & Bigelow, 1994; Barker, Barron, McFarland, Bigelow, & Carnahan, 1994), recovery (Recovery Assessment Scale, Giffort, Schmook, Woody, Vollendorf, & Gervain, 1995), symptoms (Symptoms Checklist 10-R Rosen, et al, 2000.) and substance abuse (Addiction Severity Index, McLellan, Luborski, Woody & O Brien, 1984) (see Appendix 2). Service providers collect this instrument at baseline, 3 months, 6 months and every following 6-month period. Clark County Department of Community Services provided these data for all COMET clients periodically throughout the grant period. 3) Mental Health and Substance Abuse Service Utilization. Administrative level data was collected from the Clark County Department of Community Services for all COMET clients. The Regional Services Network (RSN) data set captures all mental health services delivered by agencies within Clark County. Service utilization data recorded the type of service activity, minutes, whether the service was provided in the office or out of the office each work day. The type of activities tracked included: assessment, case management, medication management, crisis related services, intake, employment, other outpatient services, and inpatient services. RSN data was acquired for services provided to COMET clients from April 2004 through September ) Demographic and assessment data. In addition to the GPRA instrument, the evaluation team collected initial assessment and service utilization data from the program files. These data were entered into an SPSS database developed by the evaluation team. To gain insight into individual experiences of treatment and recovery, the COMET treatment team developed a comprehensive assessment to gather data on an individual s family history of substance use, personal history of substance abuse, mental health symptomology, and several need domains such as basic needs, food and shelter, medical and dental needs, education and 7

11 employment, assistance with resolving legal issues, and information about factors and services that have helped or not helped the participants achieve a period of sobriety. Demographic information on all COMET clients served (e.g. age, race/ethnicity, gender, marital status, highest education) was extracted from clinical assessment records and the GPRA tool. These data were used to describe the number of clients served by age, race, gender, and diagnostic categories. 5) Jail Data for COMET Clients. Arrest data were provided by the Clark County Department of Community Corrections. The Corrections Management Information System (MIS) tracks all charges brought against an offender on the date that he/she is booked in jail, the court case number, and the status of the offense. From these data, the number of arrests, the type of crime, parole and probation violation variables were created. 6) COMET Service Provider Interview Data. The evaluation team from the RRI conducted personal interviews with all COMET staff members. The goal of the interviews were to measure providers experience implementing and providing both the MATRIX model of services and the PACT model of services, the challenges and successes of their job, assess level of staff burnout and level of administrative support the team experienced from the two service agencies participating in the COMET project. 7) Fidelity to the PACT model and the MATRIX model. Fidelity to the PACT model was assessed using the Dartmouth Fidelity Scale (Teague, Bond, & Drake, 1998) to ensure all essential elements of the PACT program are maintained over the program period. Fidelity was measured at the beginning of the project and annually in Year 2 and Year 3. Fidelity to the MATRIX model was assessed using the Moment to Moment scale developed by the MATRIX Institute. The Dartmouth Fidelity Scale was completed by the program director. The Matrix fidelity scale was completed by the evaluation staff after observing MATRIX group sessions. Matrix fidelity was captured once a year by observing 6-8 group sessions over four consecutive weeks and calculating an average rating over the sessions. Analytical Techniques Paired t-tests, Analysis of Variance, Chi-square and other descriptive statistics were conducted to determine client difference in outcomes over time. Logistic regression was used to explore the factors associated with successful completion of the COMET program. MAJOR FINDINGS AND OUTCOMES Section 1: COMET Consumer Interviews: GPRA and Assessment Data Client Demographics and Clinical Characteristics Data reported in this section came from GPRA baseline interviews and COMET clinical assessments. The target population served by the COMET program was adults age 18 and older who were Methamphetamine (Meth) dependent and also diagnosed with a serious 8

12 mental health disorder in accordance with the DSM-IV. The COMET program served 120 clients over the three year grant period. Figures 1-4 provide demographic information for all 120 COMET clients enrolled. Most clients (88%) served by the COMET program were Caucasian, almost two-thirds of COMET clients were women (64%) and the average age was 36 years old, with 72% of all clients between the ages of 24 and 44. Figures 1-4: Demographics of COMET Program Participants Demographics: Age Demographics: Gender % % % % Male 45% % Female 55% Demographics: Race Demographics: Diagnosis Hispanic 2% Other 9% PTSD/ Anxiety 8% Other 2% Schizoaffect 5% No A xis I 12% African American 1% Depression 18% White 88% Psychotic/ Schizophre nia 7% Bipolar 48% *Other includes: American Indian and White and other mixed racial heritage Diagnoses. All COMET clients had a substance abuse diagnosis of Methamphetamine Abuse or Dependence AND a mental health diagnosis upon intake into the COMET program. However, diagnoses were reassessed after clients were stabilized and firmly in recovery. The diagnoses presented in Figure 4 are discharge diagnoses, and reflect the fact that after treatment, it was found that 12% of those exhibiting a mental health diagnosis at intake did not exhibit these symptoms at discharge. In all, 88% were found to truly have a co-occurring 9

13 mental health disorder. Most COMET clients were diagnosed with Bipolar Disorder (48%) followed by Depression (18%), Schizophrenia or other psychotic disorder (7%), Schizoaffective disorder (5%), and Anxiety or PTSD (8%) or other Axis I disorder (2%), and 12% did not have an Axis I mental illness (See Figure 4). Marital Status. Almost one quarter of the COMET clients were single, and almost one quarter were married or living with a domestic partner. Half of COMET clients were divorced or separated and only one client was widowed. Figure 5: Marital Status Marital Status Separated 20% Widow ed 1% Married or Dom e stic Partner 23% Divorce d 30% Single 26% Additionally, 76 of 120 (63%) COMET clients had children. Of the 76 clients with children, 27 (36%) had lost custody of one or more of their children. Only 5 (4%) clients were pregnant when enrolled in the COMET program. Income. Upon entry into the COMET program, the average income for clients was 484 dollars per month. The monthly income ranged from 0 to 2,210 dollars. Fifty-four percent (n=65) of participants were receiving public assistance whereas 15% (n=18) earned their income via wages; and 23 people (19%) received income from disability. Figure 6: Income Status at Enrollment $484 AVERAGE MONTHLY INCOME 54% RECEIVES PUBLIC ASSISTANCE 15% EARNS INCOME VIA WAGES 19% RECEIVES DISABILITY 10

14 Employment at Enrollment. At baseline, eighteen clients (15%) were employed (5 full-time and 13 part-time), 29 (24%) were looking for work, 58 (48%) people were not looking for work, and 13 (11%) were disabled. Figure 7: Employment Status Number of Clients Employed - Full-time 5 13 Employment Status Employed - Part-time 29 Looking for Work 58 Not Looking for Work 13 Disabled Employment Category Housing Status at Enrollment. A total of 52 (43%) clients were in temporary housing such as a shelter or transitional housing. Eleven (11) clients were homeless and on the street at enrollment; 10 were in an institution; and 47 (39%) participants were in permanent housing, living independently. Table 1: Housing Status upon Enrollment in Comet Housing Status upon Enrollment in COMET n % Shelter/transitional Street Institution Housed TOTAL

15 Profile of COMET clients from Clinical Assessment Data at Enrollment Medical Issues. In addition to a clinical diagnosis of methamphetamine addiction or dependence and an Axis I mental health diagnosis, COMET clients had multiple medical issues upon enrollment in the program. Ten percent (10%) of clients were HIV positive and an additional 13% had other STDs (Herpes, Chlamydia, Gonorrhea). Fourteen percent (14%) had Hepatitis C and 10% had liver disease or Cirrhosis. Twenty-six percent had asthma. Twelve percent had high blood pressure and 11% had heart disease; 2% had Cancer; and 7% had Diabetes. The most prevalent health need was dental care; 56% needed dental care upon entry into the program, but did not have access to it. Domestic Violence. The majority of COMET clients (82%) had been involved in domestic violence as an adult. In addition, 22% had a protective order in place. More than half, (62%) had been physically abused in their life time, and 53% had been sexually abused in their lifetime; 20% had a history of self mutilation or self-harm. Mental Health and Suicidality. More than half (63%) of COMET clients had a family history of mental illness. Almost half of COMET clients (43%) had at least one prior psychiatric hospitalization. Half (50%) had at least one suicide attempt in their life time. Five clients had tried to commit suicide in the past 30 days. At the time of enrollment, 50% had a low suicide risk, 9% had a moderately high level of suicide risk and 19% had a high level of suicide risk as rated by the MINI Suicide Assessment at intake. The remaining 22% had missing data. Criminal Justice Involvement from Assessment Data. In the intake assessment, 65% of COMET clients reported that they had been arrested and charged with a crime in their life time; and 51% had served time in jail. In addition, 36% of clients reported that they currently were in legal trouble because of their methamphetamine use. Drugs of Choice. One-hundred COMET clients completed the COMET comprehensive substance abuse assessment. According to the clinical intake assessment, the top three illegal drugs of choice were methamphetamine, marijuana and cocaine. Seventy-four percent (74%) of COMET clients used Meth in the 30 days prior to enrolling in COMET, second was marijuana (35%) and cocaine (14%). However, the vast majority of COMET clients had used a variety of drugs over their life time (see Table 2) and as well in the thirty days prior to enrollment. While Meth, marijuana and cocaine were the most commonly reported drugs, small numbers of COMET clients also used heroin or morphine (7%), hallucinogens (5%), opiates (6%), sedatives (4%) and other illegal drugs. In addition, 82% of COMET clients smoked nicotine in the past 30 days, with 73% smoking on a daily basis. An additional, 40% drank alcohol in the past 30 days; and 16% drank alcohol heavily (defined as 3 or more drinks in a sitting more than 12 times in one month). 12

16 Table 2: Number of Comet Clients Who Ever Used Each Class of Drug and Use of Each Class of Drug in the Past 30 Days at Enrollment (n=100) Drug Category Number of COMET clients ever used Number of COMET clients used in past 30 days Methamphetamine Marijuana Cocaine Hallucinogens 71 5 Opiates 46 6 Heroine/Methadone* unknown 7 Speed 27 1 Ecstasy 26 1 Inhalants 14 1 Sedatives 13 4 Other 12 2 Alcohol Nicotine (73 smoked daily) *n=100 so percentage is the same as n, data taken from assessment data except heroine use which was added from the GPRA interview and did not measure number who ever used heroine/methadone- only use in past 30 days. Data for the top three drugs of choice, frequency of methamphetamine, marijuana and cocaine use at COMET enrollment is reported below. Methamphetamine. The average age of first Meth use was age 23. Over half of COMET clients first used Meth before age 20 (See table 3). Most COMET clients smoked Meth (59%), however at the intake interview 36% injected Meth, the remaining 5% snorted, inhaled or took it orally. Table 3: Age of First Use and First Meth Use Age of first Use Number of COMET clients who first started Meth Regarding frequency of Meth use in the past 30 days prior to enrolling in COMET, 18% of COMET clients used Meth on a daily basis; 15% used Meth from days in the last 30; 13

17 17% used Meth from 4-12 days in the last 30; 18% used Meth between 1-3 days, and 26% had not used Meth within the last 30. At peak Meth use, 62% of COMET clients reported that they used Meth on a daily basis, an additional 18% used between times a month, 9% from 4-12 times a month, 8% 1-3 times a month and 3 reported that they did not know how much they used. Table 4: Frequency of Meth use from Assessment Data: Use in Last 30 days and Peak Use (n=100) Use Category Meth Use in Last 30 days Meth Use During Peak Use Daily Use times a Month times a Month times a Month 18 8 No Use 26 Don t Know 3 Prior to coming to the COMET program, clients report attempting to quit Meth an average of 4.9 times, (range was 0 times to 100 times). Marijuana. The second most commonly used illegal drug was marijuana; 35% of COMET clients used marijuana; 18% using marijuana daily in the 30 days prior to enrollment in COMET. Table 5: Frequency of Marijuana use from Assessment Data: Use in Last 30 days and Peak Use (n=100) Use Category Marijuana Use in Last 30 Days Marijuana Use During Peak Use Daily Use times a Month times a Month times a Month No Use Don t Know 4 4 Cocaine. The third most commonly used illegal drug was cocaine; 14% of COMET clients used cocaine. 14

18 Table 6: Frequency of Cocaine use from Assessment Data: Use in Last 30 days and Peak Use (n=100) Use Category Cocaine Use in Last 30 Days Cocaine Use During Peak Use Daily Use times a Month times a Month times a Month No Use Don t Know 3 The comprehensive assessments collected at intake on COMET clients revealed that COMET clients had multiple health and social service needs. In addition to both methamphetamine addiction and mental illness, COMET clients had a wide array of medical health problems, needed help finding stable housing, employment, access to financial resources and benefits, help resolving legal issues and help working with child protective services. The following sections of this report focus on client outcomes at 6 months and program discharge compared to baseline measures. GPRA Outcomes Measured over Time: Baseline, 6 Months And Discharge The data presented in this section compared COMET client s interview data at baseline, sixmonths and discharge. 120 clients completed baseline interviews; 88 completed the 6 month follow-up interview, representing 73% of the original sample and 77 (64%) completed discharge interviews. The analyses that follow include only the 77 COMET clients that completed all three interview time points. The main outcome domains measured by GPRA were: Illegal drug use and alcohol use, psychiatric symptoms, criminal justice involvement, residential status, education and employment status, and income. These data will be provided below. Illegal Drug Use Overall, both the number of COMET clients who used illegal drugs and the frequency of use declined at 6 months post-enrollment in COMET and remained low at program discharge. Figure 8, illustrates the percentage of COMET clients who used illegal drugs in the 30 days prior to enrollment in COMET. At baseline, only 29% had not used illegal drugs at all in the past 30 days. However at 6 months and discharge, the number of COMET clients who DID NOT USE ANY illegal drugs jumped to 64% and 67% respectively. On the high end of use, at baseline, 14% of COMET clients used illegal drugs days out of the month, 27% used illegal drugs days out of the month, and 31% used illegal drugs 1-10 days out of the month. However, at 6 months and 12 months the frequency of drug use declined significantly. Approximately one-quarter used illegal drugs between 1-10 days and a 15

19 very small percentage (9% and 10% respectively) used illegal drugs more than 11 days out of the past 30, at the 6 months and discharge time points (See Figure 8). Figure 8: Illegal Drug Use Illegal Drug Use 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline Six-Months Discharge days days 1-10 days ZERO days Drug Use by Class of Drug: Of the 77 COMET clients with all three data points, the number of individuals who used methamphetamine in the 30 days prior to the baseline as reported in the GPRA interview was 47. However, the number of individuals who used meth at 6 months and discharge interviews dropped by 47%. The number of COMET clients who used marijuana also decreased from 16 at baseline to 5 at six months and 8 at discharge. The base rates for cocaine and other drugs as reported by clients from the GPRA interview was low at baseline, 6 months and discharge, but the trend also illustrated a decrease in number of clients who used these drugs. As would be expected, COMET clients used methamphetamine on more days than any other drug. At baseline, COMET clients used methamphetamine 8.6 days out of the last 30 on average. This number declined to 5.5 days at 6 months and 4.9 days at discharge. The frequency of marijuana use also declined at 6 months and discharge compared to baseline. This graph appears to increase for cocaine use, however, this is misleading as the number of individuals who used cocaine was only 3 at baseline, 2 at 6 months and 1 at discharge (see Figure 9 below) so represents the behavior of only a few COMET clients and is not a statistically significant change. 16

20 Figure 9: Number of Individuals who Used at Each Time Point Number of Individuals who Used at each Time Point Baseline 6 mo Discharge Cocaine Marijuana Meth Other Figure 10: Average Number Days of Use: Top Three Drugs Average Days of Use at Each Data Point Days Baseline 6 mo Discharge Cocaine Marijuana Meth Other Psychiatric Symptoms: Reductions in the percentage of COMET clients who experienced psychiatric symptoms were observed for ALL psychiatric symptoms. At baseline, the majority of COMET clients reported experiencing depression and anxiety (88% for each category). More than half also experienced trouble with brain function (64%). At 6 months 17

21 and discharge, the percentage of clients who experienced these symptoms was statistically lower (see Figure 11). Figure 11: Percentage with Psychiatric Symptoms Percentage with Psychiatric Symptoms 100% 80% 60% 40% 20% 0% Anxiety Depression Trouble with Brain Function Hallucinations Violent Behavior Suicide Baseline Six-Month Discharge Table 7: Experienced Symptoms of Mental Illness in the Past 30 Days Baseline Six Months Discharge Number of Clients n (%) Average number of days in last 30 days Number of Clients n (%) Average number of days in last 30 days Number of Clients n (%) Average number of days in last 30 days Depression (68%) 9.4 (88%) (78%) Anxiety (75%) 11.7 (88%) (78%) Hallucinations (7%).86 (16%) (7%) Brain Function (45%) 9.5 (64%) (48%) Violent (6%) 0.37 Behavior (21%) (4%) Suicide 5 (7%) (1%) 0 Telesage Data. Mental health symptomology, quality of life, level of functioning, the recovery assessment scale were additional client outcome measures used by the COMET 18

22 program collected from the Telesage data system. Baseline, 6 month and 12 month Telesage data points were collected on 74 COMET clients and these data are reported in the table below. Overall COMET clients reported statistically significant improvements in quality of life, increased level of functioning, increased commitment to recovery and decreased mental health symptoms (See Table 8). Table 8: Telesage Data Domain Instrument Mean Total Score Baseline Mean Total Score 6 Mo Mean Total Score 12 Mo Level of Multnomah Functioning* County Ability Scale Quality of Life* Lehman Quality of Life Recovery* Recovery Assessment Scale Mental Health Symptoms Symptoms* Checklist *= statistically significant improvement overtime at.05 level Criminal Justice Involvement The GPRA interview measures criminal justice involvement by asking clients if they have been arrested in the past thirty days, whether they are currently on parole or probation and whether they are awaiting trial. Overall, there are no statistically significant changes in criminal justice involvement overtime as measured by GPRA. The number of persons arrested in the past thirty days was 10 at program entry and was eight (8) at both 6 month and discharge. The percentage of clients on parole/probation decreased slightly from 35 to 33 at 6 months and 32 at discharge. The number of individuals awaiting trial also decreased from 18 at baseline, to 12 at 6 months and 8 at discharge (see Figure 12 below). A detailed account of criminal justice involvement in the 12 months prior to enrolling in COMET and 12 months post enrollment in COMET using booking data from the Clark County jail is provided in Section 4. 19

23 Figure 12: GPRA Criminal Justice Involvement Number of Clients Criminal Justice Involvement Arrested in the last 30 days Parole/Probation Awaiting Trial 5 0 Baseline Six-Month Discharge Residential Status There was a slight increase in the number of individuals in permanent housing at 6 months and discharge compared to baseline; 29 were in independent housing at baseline compared to 34 at six months and discharge. There is a corresponding decrease in the number of individuals on the street and in temporary housing. However, there is a slight increase in the number of individuals in an institution at 6 months and 12 months (see figure 13). Figure 13: Housing Status at Baseline, 6 Month and Discharge Housing Status at Baseline, 6 Month and Discharge Independent Housing Temp Institution Street 0 Baseline Six-Month Discharge 20

24 Employment And Income At baseline, 11% of clients were employed (full-time or part-time), but at six-month followup, 24% of clients had found employment and at discharge 26% were employed. At baseline, 20% of clients were looking for work, but six months later, 15% were searching for jobs and similarly 17% were looking for work at discharge. Figure 14: Employment at Baseline, 6 Month and Discharge Employment Number of Clients Full or Part-time Looking for work Not Looking for work Disabled Baseline 6 Month Discharge Total average income increased modestly at 6 months after enrollment in COMET compared to baseline but then dropped slightly at discharge. At baseline, average income was $460 and rose to $577 at 6 months and decreased slightly to $506 at discharge. The increase in total income was accounted for by increased income from wages. Income from wages increased significantly at six months and discharge compared to baseline income (see Table 9). However, there were no statistically significant changes in income from public assistance or disability at six months or discharge. 21

25 Table 9: Income at Baseline, 6 Month and Discharge Income at Baseline, 6 Month and Discharge (n=75) Baseline 6 Month Discharge Follow-Up Average income from wages* Average income from public assistance Average income from disability Average total income* Section 2: Treatment Disposition and Factors Associated with Successful Completion of the COMET program Figure 15: Treatment Disposition of COMET Clients at the end of Year clients enrolled in the COMET program 48 clients were successfully discharged meeting most of the requirements of the COMET program Of these forty-eight clients, 29 were considered graduates of the program meeting all completion requirements of the program 9 COMET clients were jailed, 4 for old warrants 5 for new offenses and did not return to treatment. 4 failed to engage in treatment. 12 dropped out of treatment, left against medical advice. 11 refused to go to inpatient or failed to re-engage with COMET after receiving inpatient. 5 were non-compliant, MIA. 9 were discharged for other reasons. 23 clients were still in treatment when the grant ended. Criteria for graduation" were: 1) clean of Meth for at least 2 months (and most graduates were clean much longer); 2) stabilized on medication and have a means to acquire and afford medication after exiting COMET; 3) stably housing and a means to pay for housing, 4) completion of 80% of treatment plan goals; 4) no longer needed PACT level of services. Successfully discharged individuals were those who did not meet graduation criteria but were: 1) stabilized and no longer required an PACT team; 2) were transferred to another agency for reasons including housing needs, inpatient treatment, request by consumer for transfer because COMET did not provide a specific service they wanted (e.g., Dialectic Behavioral 22

26 Therapy (DBT) treatment) AND person had made satisfactory progress; 3) individual had made significant progress in the program but did not meet all the criteria for graduation. Factors Associated with Successful Completion of Treatment Numerous demographic and clinical characteristics have been found to contribute to an individual s willingness or ability to successfully adhere to treatment. These factors include employment, race, gender, age and education. Specifically, being older, non-hispanic white, employed, and male with more years of education and stable housing are most likely to participate in treatment (McCaul, Svikis, Moore, 2001). Traditionally, individuals with cooccurring mental illness have poorer treatment outcomes (Broome, KM, Flynn, PM, Simpson, DD, 1999; McLellan, AT, Luborsky, L, Woody, GE, et al. 1983; Selzer, JA, Lieberman, JA, 1993). Studies also generally have found that those with better pretreatment psychosocial adjustment (lower severity of drug use, less criminal involvement) stay in treatment longer (Anglin & Hser, 1990). Studies have found a positive relationship between level of drug use (Kleinman, et al.1992; Stark, 1992), and number of different drugs used (Gainey, et al. 1993). Conversely, an older study by Taylor (1970) found no differences in retention for multiple drug users, alcoholics, or heroin-only users. There is a strong relationship between legal mandates and retention in drug treatment. Most studies have found that when clients are admitted to treatment on an involuntary basis (as a condition of parole or with criminal charges pending, as part of drug court) they stay longer in treatment than those who enter treatment voluntarily (Condelli & De Leon, 1993). Evaluation studies have also shown that some individuals are able to sustain long-term positive behavioral changes after a single treatment while others require multiple treatment episodes (Hser et al. 1998). Means and colleagues (1989) found that outpatient cocaine users with prior treatment experience were more likely to complete treatment and remain abstinent. The national Treatment Outcome Prospective Study (TOPS) reported that more than 50% of patients in residential and outpatient drug-free programs remain in treatment less than three months. Furthermore, the Drug Service Research Survey (DSRS) found that 40% of a nationally representative sample of admissions to drug treatment did not complete their treatment plan (National Institute on Drug Abuse 1992). In an analysis of treatment retention among Meth users in California, using the California Alcohol and Drug Data System (CADDS), it was found that Meth users typically remain in outpatient drug-free treatment programs for an average of 78.2 days. Anglin and colleagues (1997) found significant differences in treatment retention when comparing Meth users to users of any other drugs, upon comparing a cohort of 500 Meth users to a cohort of 224 cocaine users. However, Huber and colleagues (1997) also compared Meth users to cocaine users and DID NOT find any differences in retention. In the Huber study, both cohorts were treated in the same outpatient clinic using the identical manualized treatment. 23