The Montana Board of Crime Control. A light at the end of the tunnel...

Transcription

1 The Montana Board of Crime Control A light at the end of the tunnel... The Montana Adult Methamphetamine Treatment Coalition 2009

2 the high co$t of A new report prepared for Montana s Office of the Attorney General 1 put the 2008 price tag of methamphetamine abuse at more than $200 million. While this has declined since 2005 from a high of more than $300 million, this still reflects an appreciable cost burden to the State of Montana. Calculated into this cost were methamphetaminerelated crime ($80 million), work-related productivity losses ($65 million), health-care related expenses ($48.8 million) and treatment ($6 million). Other costs -- measurable and immeasurable -- were incurred as well. In 2008 alone, it cost Montana $11.9 million for foster care for children removed from homes where methamphetamine had preempted their parents ability to provide safe care. The total price in terms of pain, loss and community disruption cannot be calculated. The Office of National Drug Control Policy State of Montana Profile of Drug Indicators 2 published in July 2008 revealed that in 2006, there were 6,502 drug offenses reported by Montana police. Methamphetamine accounted for approximately 16 percent of those incidents; federal officers seized 3.4 kilograms of the drug in The report further indicates that while methamphetamine remains the most significant drug problem in Montana, availability may be shifting. There were just seven clandestine lab incidents in 2007, compared to 16 the year before, and 56 in According to this report 2, the majority of methamphetamine is currently trafficked by Mexican national groups, though numerous small labs continue to produce moderate quantities of the drug for personal use or local distribution. ndividual costs are well documented and include heart and kidney problems, brain damage, symptoms of mental illness, memory loss, convulsions, strokes and death. A landmark study 3 (Chang, et. al., 2009) released in April examined the effects of methamphetamine use during pregnancy. The results indicate that the drug causes abnormal brain development among children exposed to the drug in utero. Abnormal brain development may explain why some children with prenatal exposure reach developmental milestones later than others. Other studies have demonstrated that prenatal exposure can lead to increased stress and lethargy and poorer quality of movement for infants. It remains unknown whether the differences will normalize with age. 1 The Economic Cost of Methamphetamine Use in Montana. February Montana Department of Justice: A Report Prepared for the Attorney General. 2 Office of National Drug Control Policy State of Montana Profile of Drug Indicators. July American Academy of Neurology (2009, April 16). Prenatal Methamphetamine Exposure Linked To Abnormal Brain Development. ScienceDaily. Retrieved June 8, 2009, from /releases/2009/04/ htm 4 Montana Department of Corrections 2009 Biennial Report. Page 2...The Montana Adult Methamphetamine Treatment Coalition Methamphetamine in Montana he Department of Corrections (DOC) is responsible for supervising approximately 13,000 offenders at any given time; approximately 80 percent are managed outside of prison 4. Drug possession continues to be the most common crime among Montana offenders. Distribution of drugs ranks fourth among female and fifth among male offenders. The genders share eight of the ten most common offenses. In addition to drug crimes, the most common crimes for both genders include felony DUI, theft, burglary, criminal endangerment, assault with a weapon and issuing bad checks. These crimes all present significant direct and indirect costs to communities, and many - if not most - can be linked to addiction. During the past two years, the DOC developed two methamphetamine treatment programs believed to be the first of their kind in the nation to combat the threat posed by this drug. The DOC opened a 40-bed treatment center for female methamphetamine offenders in Boulder and an 80-bed treatment center for male meth offenders in Lewistown. Table of Contents Documenting Need 4 Addressing Abuse 6 Treatment Modalities 8 MAMTC Client Demographics 10 Living Arrangements 13 Health and Treatment History 14 Criminal Involvement 16 Family Disruption 17 Adverse Childhood Experiences 18 Gender-based Differences 20 Completers versus Non-completers 23 Indications of Success 24 Site Updates and Sustainability 28

3 G Montana Board of Crime Control eography All but 10 of Montana s counties can be classified as frontier, with less than 7 persons per square mile. Rural substance abuse treatment agencies typically serve vast areas with scarce resources and a great deal of windshield time. In 2005, the Montana Board of Crime Control (mbcc.mt.gov) was awarded a targeted capacity expansion grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). The intent was to provide evidence-based methamphetamine treatment to 16 rural and frontier counties. As a result of this grant, adult methamphetamine treatment services were delivered through regional treatment providers: Butte-Silver Bow Chemical Dependency Services; Eastern Montana Community Mental Health Center; Journey Recovery Program and the Fort Peck Reservation. Daniels Valley Phillips Sheridan Roosevelt Fort Peck Reservation Fergus Judith Basin Petroleum Garfield Rosebud Silver Bow Treasure Custer Powder River Fallon Carter The geographic areas served by the MAMTC have included: Butte/Silver Bow; Journey Recovery; Eastern Montana Community Mental Health Center and the Fort Peck Reservation. esearchers believe that each time a neurotransmitter (like dopamine) floods across a synapse, circuits that motivate action become hard wired in the brain. The neurochemistry of addiction is so powerful that people, objects and places associated with substance use are imprinted on the brain. Brain structures involved in memory and learning, including the dorsolateral prefrontal cortex, amygdala and cerebellum, have all been linked to cueinduced craving. I growing body of scientific research suggests that chronic use of stimulants affects dopaminergic neurons in limbic reward system structures. Researchers have also found evidence of changes in the structure and function of brain neurons after chronic stimulant use. Some propose that the changes come from dopamine depletion, changes in neurotransmitter receptors or other structures, or changes in other brain messenger pathways. As a result, the treatment needs of individuals addicted to methamphetamine are unique, complicated and significant. n all these years I have never come across a single drug-addicted person who told me [he or she] wanted to be addicted. - Nora Volkow, M.D., Director, National Institute on Drug Abuse The Montana Adult Methamphetamine Treatment Coalition...Page 3

4 Documenting Need for Adult Methamphetamine Treatment Services Butte-Silver Bow Chemical Dependency Services Service area: Silver Bow County Service area size: 718 square miles Population: 32,803 Population density: 45.7 persons/square mile Silver Bow County, in Southwest Montana, is situated at the intersection of two major interstates (I-15 and I-90). According to a November 8, 2004 article in the Montana Standard, at that point in time, Butte/ Silver Bow had the highest crime rate in the state and second lowest per capita rate of law enforcement officers. Silver Bow County has a prerelease center that houses 166 adults, with another 80 in residence for 60-day in-patient treatment at the Connection Corrections facility, primarily for methamphetamine addiction. A number of other facts document the need for methamphetamine treatment services in this area. The population admitted for treatment by Butte/ Silver Bow Chemical Dependency Services (BSBCDS) jumped 294 percent between 2002 and 2004: 69 percent of those admitted were addicted to methamphetamine and 61 percent were intravenous users. The number of drug offenses in the Butte/Silver Bow area jumped 82.3 percent between 2000 and 2005, from 164 to 299. Between June and December 2004, 77.9 percent of the 109 children in foster care in Butte/Silver Bow County were in care for reasons directly tied to methamphetamine. In 2005, BSBCDS had the highest rates in Montana of women in treatment and women in treatment who had dependent children. Approximately 10.8 participants per 1,000 population were in alcohol and/or other treatment programs in Silver Bow County, compared to 7.12 per 1,000 in Montana (2005). Source: Project specific data was taken from the expansion grant application submitted to SAMHSA and funded in Page 4...The Montana Adult Methamphetamine Treatment Coalition Eastern Montana Community Mental Health Center Service area: Phillips, Valley, Daniels, Roosevelt, Sheridan, Garfield, Treasure, Rosebud, Custer, Fallon, Powder River and Carter counties; Northern Cheyenne and Fort Peck Indian Reservations Service area size: 38,217.2 square miles Population: 53,615 Population density: 1.4 persons/square mile (average) The communities in the Eastern Montana Community Mental Health Center (EMCMHC) service area are primarily agricultural. They are also economically depressed, partially because much of their economy is based on the amount of precipitation crops receive each year. The population is not only small, it is scattered, making it difficult for residents to access services. Many must travel to Miles City or Billings. This can require considerable effort, sometimes requiring residents to travel as many as 300 miles for services. Substance abuse treatment in this area is currently fragmented even though the methamphetamine problem has grown exponentially. Approximately 85 percent of those served by EMCMHC list methamphetamine as their primary or secondary drug of abuse. The top three substances of abuse for those served by EMCMHC are methamphetamine, alcohol and marijuana. The child welfare agency serving the 12 counties included in this service area indicates that approximately 75 percent of the children placed in foster care have parents who are addicted to methamphetamine. Most often, the primary client of the child welfare agency is the mother. The children placed in out-of-home care have suffered the serious neglect that frequently results from a caretaker s substance abuse. They tend to have special needs including developmental delays, mental health issues, lack of social development, academic failure, physical and nutritional problems. Methamphetamine has become a mind-boggling blight, to the point that about half of our inmates are in prison for meth-related crimes. - Mike Ferriter, Director of the Montana Department of Corrections

5 Spotted Bull Treatment Center Program Service area: Fort Peck Reservation Service area size: 1,456 square miles Population: 10,321 Population density: 7.1 persons/square mile The Fort Peck Reservation is home to two separate Indian nations, each comprised of numerous bands and divisions. The Sioux divisions of Sisseton/ Wahpetons, the Yanktonais, and the Teton Hunkpapa are represented, as are the Assiniboine bands of Canoe Paddler and Red Bottom. The Fort Peck Indian Reservation is the second largest reservation in Montana, covering more than two million acres in the northeast corner of Montana. The reservation is home to approximately half of the enrolled 11,755 Sioux and Assiniboine tribal members. The 2000 Census counted 10,321 persons living on the Fort Peck Reservation. Census data also indicated that 6,391 of the reservation residents (61.9 percent) described themselves as American Indian or Alaskan Native, alone or in combination with another race. Estimates of methamphetamine use rates on the Fort Peck Reservation range from 1.7 to 5 percent of the population. One survey found that 16 percent of adolescents and young adults reported using meth at least once. This is especially significant because nearly half of enrolled tribal members are younger than eighteen. Journey Recovery Program Service area: Fergus, Judith Basin and Petroleum counties Service area size: 7,862.9 square miles Population: 14,112 Population density: 1.8 persons/square mile (average) Fergus, Judith Basin and Petroleum counties are some of the most sparsely populated in Montana, with population densities ranging from 0.3 persons per square mile in Petroleum County to 2.6 persons per square mile in Fergus County. This service area is located in Central Montana. Major employment sectors in these counties are retail and wholesale trade, health care and social assistance. Educational attainment status is relatively low, with between 22.2 and 29.1 percent of the population holding at least an Associate of Arts degree, as compared to 31.3 percent statewide. Due to sparse populations, county residents have very limited access to addiction treatment, and often have little choice but to travel to Great Falls for services. During 2005, 100 Fort Peck children were placed in foster care. Tribal staff estimates indicate that about half of the placements were related to methamphetamine use by parents or guardians. When factoring in costs to the health care, foster care and criminal justice systems, addressing methamphetamine prorated out to about $370 for every person on the reservation (2005). Source of population and square mileage data: mt.gov population estimates used except in the case of the Fort Peck Reservation. In that instance, 2000 population data from the Census Bureau were used, as they were the most current available. Project specific data was taken from the expansion grant application submitted to SAMHSA and funded in The Montana Adult Methamphetamine Treatment Coalition...Page 5

6 The most effective treatments for methamphetamine addiction are behavioral therapies. For example, the Matrix Model, a comprehensive behavioral treatment approach that combines behavioral therapy, family education, individual counseling, 12-Step support, drug testing and encouragement for nondrugrelated activities, has been shown to be effective in reducing methamphetamine abuse. Contingency management interventions, which provide tangible incentives in exchange for engaging in treatment and maintaining abstinence, have also been shown to be effective. - National Institute on Drug Abuse: Methamphetamine and Addiction. Eastern Montana Community Mental Health Center (EMCMHC) County Population Area in Square Miles Population Density Carter 1, Custer 11, Daniels 1,643 1, Fallon 2,716 1, Garfield 1,184 4, Phillips 3,904 5, Powder River 1,694 3, Roosevelt 10,089 2, Rosebud 9,190 5, Sheridan 3,283 1, Treasure Valley 6,892 4, Totals EMCMHC 53,615 38, Butte/Silver Bow Chemical Dependency Services Silver Bow 32, Journey Recovery Program Fergus 11,195 4, Judith Basin 2,014 1, Petroleum 436 1, Totals 13,645 7, Spotted Bull Treatment Center Program Fort Peck Reservation 7,023 1, Data Source: 2008 population estimates, densities and square mileage: mt.gov; Fort Peck Reservation estimates from the 2005 American Indian Populations and Labor Reports: U.S. Department of the Interior, Bureau of Indian Affairs, Office of Tribal Services. C exhibit symptoms that can include anxiety, confusion, insomnia, mood disturbances, and violent behavior. They also can display a number of psychotic features, including paranoia, visual and auditory hallucinations and delusions (for example, the sensation of bugs creeping under the skin). Page 6...The Montana Adult Methamphetamine Treatment Coalition

7 Addressing dult Methamphetamine Abuse... the Montana Adult Methamphetamine Treatment Coalition (MAMTC) T arget Population The target population of the MAMTC project was methamphetamine-addicted adults who lived within the defined service areas. They were largely un- or underemployed and living on incomes below federal poverty levels. The population included a broad spectrum of pregnant women, adults with dependent children, families who had lost their children to the child welfare system, and men and women suffering from Post-Traumatic Stress Disorder (PTSD). Many had been involved with the criminal justice system; many more had co-occurring mental illnesses. Patients typically come to a treatment center or program because they have run out of money and cannot afford their next hit. They feel awful. Because of the significant dopamine depletion that rise from methamphetamine abuse, when a user first presents for treatment, mood disorders are common barriers that must be recognized and addressed. he served methamphetamineaddicted adults living in rural and frontier counties and one Native American Reservation where small agencies often serve vast areas and disproportionately large populations. Montana Board of Crime Control Risk Factors and Addiction Researchers have identified as many as 72 social risk factors for substance abuse and dependence (Leshner, 1998). These include poverty, racism, social dysfunction, dysfunctional families, poor education and substance-abusing peers. Many of these factors are discussed at length in this report, with specific risk factors quantified for MAMTC participants. Risk factors influence the initial decision to use substances. The substance use itself subsequently modifies mood, perception and the emotional state, all of which are modulated through the brain. Thus substance abuse and addiction must be understood as more than social problems or poor choices. Addiction is a chronic brain disease that causes compulsive drug seeking and use despite harmful consequences. Drug abuse leads to physical changes in the structure and function of the brain. Fortunately, treatment is available. Treatment approaches that have been individually tailored to provide strategies for addressing co-occurring medical, psychiatric and social problems can lead to sustained recovery. The strategies employed by the MAMTC project and documented in this report work, and as shown, can help counteract the effects of addiction. In the past 30 days (not due to your use of alcohol or drugs), how many have you experienced... Condition Number of Days 0 1 to 5 6 to to to Average # Trouble controlling violent behavior? 80.6% 11.2% 2.1% 2.8% 0.7% 2.8% 9 Serious depression? 43.1% 20.9% 7.7% 9.0% 3.5% 16.0% 14 Serious anxiety or tension? 29.9% 25.1% 11.2% 9.0% 3.5% 21.5% 14 Hallucinations? 91% 3.5% 2.1% 0.7% 1.4% 1.4% 12 Trouble understanding, concentrating or remembering? 46.5% 14.7% 9.0% 5.6% 3.5% 20.8% 17 The Montana Adult Methamphetamine Treatment Coalition...Page 7

8 Treatment M odalities Matrix Model The Matrix Model is the primary chemical dependency treatment modality used by the MAMTC. The approach emphasizes outpatient techniques with a focus on lifestyle changes, relapse prevention, education about dependencies and family involvement. Patients learn about issues critical to addiction and relapse, receive direction and support from trained therapists, become familiar with self-help programs, and are monitored for drug use through urine and saliva testing. The program includes education for family members affected by the addiction. The Matrix Model integrates elements from a number of treatment strategies, including motivational interviewing, psychoeducation, family therapy and 12-step programs. The outpatient Matrix Program offered groups during daytime and evening hours and consisted of Early Recovery Groups, Relapse Prevention Groups, Family Education Groups, Social Support Groups, 12-step meetings and other recovery activities. Early Recovery, Relapse Prevention, Family Education, Social Support Groups, 12-step meetings and other recovery activities were offered. Therapists would call when clients did not show. This was a 52-week program. The initial phase of intensive programming lasted four months, followed by eight months of continuing care. The Early Recovery Group lasted for the first four weeks; the Relapse Prevention Group ran from week one through week sixteen.. The last phase is the Social Support Group (weeks or longer, if needed). After a relapse, clients returned to the Early Recovery Group, but continued with the component they were in. The Family Education Group ran between weeks one and sixteen as well. This group was also fluid, and clients and families could choose to continue or return. All time frames were guidelines, but clients were required to complete specific topics, and there were goals and objectives they had to achieve before moving to the next treatment phase. Matrix Model Core Strategies 1. Create explicit structure and expectations 2. Establish positive, collaborative relationship with client 3. Teach and educate on recovery issues 4. Reinforce desired behavioral change 5. Provide corrective feedback (using motivational style) when necessary 6. Educate family regarding stimulant abuse recovery 7. Introduce and encourage self-help 8. Use drug testing to monitor use Fidelity to the Model In order to ensure fidelity to the Matrix Model, the MAMTC program looked at several treatment components. Model components On a weekly basis there were: Two relapse prevention groups; One family education group; Two early recovery skills groups (for the first four weeks of treatment); One social support group (starting with week 13); Urine and alcohol testing; and Three individual sessions (first 16 weeks). Group Characteristics The Relapse Prevention Group was limited to 7 15 clients, and a client served as co-leader. Staffing Group sessions took place with no more than a three day break, and clients had telephone access to a therapist between groups. Continuity of clinical staffing was considered important, and the programmatic goal was to keep annual staff turnover at a rate of 10 percent or less. 36 professionals had received 720 hours of training in the Matrix Model by the end of June Page 8...The Montana Adult Methamphetamine Treatment Coalition

9 M echanisms GAIN (Global Appraisal of Individual Needs) The Global Appraisal of Individual Needs (GAIN) is a comprehensive biopsychosocial assessment tool that was administered to MAMTC clients. It supports a number of treatment practices and can be used to assist with clinical assessments for diagnosis, placement and treatment planning, and for monitoring change in clinical status, service utilization, and costs to society. The GAIN is evidence-based and can be used in a variety of settings, from outpatient to corrections. The GAIN has eight core sections: Background; Substance Use; Physical Health, Risk Behaviors and Disease Prevention; Mental and Emotional Health; Environment and Living Situation; Legal; and Vocational. Each section contains questions on the recency of problems, breadth of symptoms and recent prevalence as well as lifetime and recent service utilization and frequency. By the end of June 2008, 42 professionals had received 820 hours of training on the GAIN assessment tool. Moral Reconation Therapy Moral Reconation Therapy (MRT ) has been described by its authors (Kenneth Robinson, Gregory Little, and their colleagues at Correctional Counseling, Inc.) as a cognitive behavioral approach with a strong moral reasoning emphasis*. During the MRT process, clients move through steps aimed at identifying and changing destructive patterns of thought and behavior. MRT helps participants assess their beliefs, attitudes and behaviors and subject themselves to criticism from themselves and others. Participants formulate strategies for confronting their problems, ending negative relationships and repairing those that are valuable. As treatment progresses, participants evaluate their goals and determine what is needed to achieve those goals. They learn to expect delayed gratification and that ends must be evaluated not only in and of themselves, but in terms of how they were achieved. The MRT program utilizes nine personality stages loosely based on the developmental paradigms of Kohlberg and Piaget. It can be completed in 12 or 16 sequential steps. Participants must behave in particular ways to progress from step to step. To improve their moral reasoning, participants must be morally accountable on all levels of functioning: beliefs, attitudes and behavior. The program relies on confrontation of cognitions and behaviors, and uses verbal and behavioral interventions (i.e., penalties for failure to comply and reinforcement for progress). The effectiveness can be evaluated through behavior and prosocial modeling. By the end of June 2008, 5 professionals had been certified in MRT. C ontingency management is a well-known behavioral intervention designed to increase desired behaviors and decrease undesired behaviors through immediate consequences (positive or negative). It has been effective in treating a variety of substance use disorders. Contingency management is useful for treatment planning because it sets concrete short- and long-term goals and emphasizes positive behavioral changes. - CSAT TIP #33: Treatment of Stimulant Use Disorders *Source: Brame, et. al. Moral Reconation Therapy and Problem Behavior in the Oklahoma Department of Corrections. The Montana Adult Methamphetamine Treatment Coalition...Page 9

10 M ore M echanisms Integrated Dual Disorder Treatment More than half of the adults with severe mental illness in public mental health systems are further impaired by co-occurring substance use disorders. Consumers with dual disorders have high rates of recovery when provided integrated dual disorder treatment, which means combining mental health and substance abuse treatment within the same team or program. Integrated dual disorders treatment blends mental health and substance abuse treatments, so that one practitioner or team in one agency provides mental health and substance abuse treatments. Effective integrated dual disorders treatment includes the following characteristics: Co-occurring capable clinicians know the effects of alcohol and drugs and their interactions with mental illness. Services for mental illness and substance use are provided at the same time. Integrated dual disorder treatment is stagewise, meaning that people go through a recovery process over time and that different services are helpful at different stages of recovery. Consumers collaborate with clinicians to develop individualized treatment plans. Clinicians use specific listening and counseling skills to help consumers develop awareness, hopefulness and motivation for recovery. This motivational treatment is important for consumers who are demoralized and not ready for substance abuse treatment. Substance abuse counseling helps people with dual disorders develop the skills and find the supports needed to pursue recovery from substance use disorder. By the end of June 2008, 30 professionals had received 439 hours of training on Dual Disorder Treatment. S have I ntensive Case Management refers to the coordination of services and provision of individualized and on-going supports needed to help patients achieve their goals, stabilize and improve their quality of life. The direct involvement of the consumer and development of a caring, supportive relationship between the case manager and the consumer are integral components of the intensive case management process. This process is responsive to the individual s multiple and changing needs, and plays a pivotal role in coordinating services across multiple systems (e.g., mental health, substance abuse treatment, primary health, criminal justice and other social services ). Case managers work with consumers to help them realize personal recovery goals. By the end of June 2008, 23 professionals had received 248 hours of training on Intensive Case Management. Telemedicine There are numerous barriers to chemical dependency treatment in rural areas, including limited availability of services and long distances between small towns and treatment centers. Despite the growing body of knowledge about drug abuse and co-occurring disorders, interventions may not reach those who need them in rural and frontier areas of Montana. Telemedicine utilizes technology to link patients in one location with appropriate clinicians in another. They can see and hear one another in real time. Improved access is important, but equally so is the potential for continued relationships between providers and patients. now shown that a treatment known as the Matrix Model can be used successfully for the treatment of methamphetamine addiction. Nora Volkow, M.D., Director, National Institute on Drug Abuse Page 10...The Montana Adult Methamphetamine Treatment Coalition

11 Who did the MAMTC serve? Demographics at Intake Between August 2006 and August 2009, the Montana Adult Methamphetamine Treatment Coalition (MAMTC) served 144 individuals. The majority were from Butte (87 clients) and Miles City (32 clients), with 19 served by the Spotted Bull Treatment Center on the Fort Peck Reservation and six by Journey Recovery in Lewistown. 87 (60%) were female and 57 (40%) were male; 104 (72%) were White; 33 (23%) were American Indian; 4 (3%) were Hispanic; 1 was Asian (1%) and 1 was multi-racial (1%); 6 (7%) women were pregnant : 9.1% Age of MAMTC Participants 35-44: 23.8% 18-24: 24% 25-34: 45% The largest age group at intake was 25-34, with nearly half of MAMTC participants falling into that category. The largest percentage had a high school education (47.2%), but the majority had a high school education or less (75%). Just under one percent (0.7%) had a Bachelors Degree, though 25% had attended college or vocational school for at least one year. 47.2% Montana Board of Crime Control The typical MAMTC client is a White female between the ages of 25 and 34. She has a high school education, and had no wages in the 30 days prior to intake. Educational Attainment Status (Highest Educational Level Achieved) 4.2% 9.0% 6.3% 8.3% 9.0% 7.6% 3.5% 0.7% 2.1% 2.1% 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade or GED 1 year of college 2 years of college or AA 3 years of college Bachelors Degree Some Vo Tech - no certificate Vo Tech Certificate The Montana Adult Methamphetamine Treatment Coalition...Page 11

12 I ncome During Past 30 Days (at Intake) Patients were asked at intake if they d had income from any of a number of sources during the past 30 days. In each case, the majority had not had any income from the listed sources. Among those who reported income, wages were the most common source, even though more than half (58%) of participants hadn t had wages in the 30 days prior to intake. Among those who had earned wages during the 30 days prior to intake, 41 percent had earned between $1 and $4,999 and one person reported wages between $5,000 and $9,999. Retirement: 0.7% % of Patients with Income, by Source Disability: 3.5% Non-legal Income: 7.6% Public Assistance: 14.0% Family: 21.8% Wages: 41.7% Employment Status at Intake Fewer than half (40.3%) of MAMTC participants were employed full- or part-time at the time of intake. Another 27.1 percent were unemployed but looking for work, while 7.7 percent were enrolled in school or job training either part- or full-time. One person was unemployed, but volunteering. Seven (4.9%) were unemployed but disabled and 20.8% were unemployed and not looking for work 30% 25% 20% 15% 10% 5% 0% Employed, Full-time Looking for Work NOT Looking for Work Employed, Part-time Other Disabled Volunteering Page 12...The Montana Adult Methamphetamine Treatment Coalition

13 Living Arrangements n the past 30 days, where have you been living most of the I time? In response to this question: 7 (4.9%) clients stated that they had been living in a shelter; 2 (1.4%) had been living on the streets or outdoors; 20 (13.9%) had been in an institution; and 115 (79.9%) were housed. When asked, In the past 30 days, did you receive inpatient treatment for alcohol or drugs? 17 clients (11.8%) responded that they had received inpatient treatment. f you have been living in a house, where have you been Iliving most of the time? Of the 115 clients who had been housed in the 30 days prior to intake, living arrangements included: 71/115 clients (61.7%) had owned or rented an apartment, house or room; 37/115 (32.2%) had been living in someone else s apartment, room or house; 2/115 (1.7%) had been living in residential treatment; and 5/115 clients (4.3%) had been living in other. n the past 30 days, how many nights have you spent in jail/ Iprison? Of the 144 clients served by MAMTC, 110 had not spent any time in jail or prison during the past 30 days, and data was missing for one client. Among the 33 persons who had spent time in jail or prison, the average length of stay was 15 days. Cumulatively, the 33 persons spent a total of 485 nights incarcerated. Eight were there for the entire 30 days prior. According to estimates published in The Economic Cost of Methamphetamine Use in Montana, released in February 2009, the cost of meth associated crime and criminal justice costs for sheriffs departments and local jails came to more than $6 million in 2007 alone. This was down substantially from $11.5 million in The Economic Cost of Methamphetamine Use in Montana: a Report Prepared for the Office of the Attorney General. Montana Department of Justice. February P. 10. Risk B ehaviors n the past 30 days, have you I injected drugs? Yes: 31 (21.5%) No: 113 (78.5%) n the past 30 days, how Imany unprotected sexual contacts did you have? Twelve (12) MAMTC clients stated that they had not had unprotected sex in the past 30 days, 51 stated that the question was Not applicable, two refused to answer ad one stated that s/he did not know. Fifty-seven (57) clients had between one and ten unprotected sexual encounters, 18 reported between 11 and 30 unprotected encounters, and 3 reported more than 30 unprotected sexual contacts. Among those who had engaged in unprotected sexual contact during the past 30 days, 29 had sexual contact with an individual who is or was an injection drug user. Among those who had engaged in unprotected sexual contact during the past 30 days, 33 had unprotected sexual contact with an individual who was high on some substance. n the past 30 days (not I due to your use of alcohol or drugs), how many days have you attempted suicide? Have not attempted suicide: 137 One day: 5 MAMTC clients Two days: 1 MAMTC client Three days: 1 MAMTC client The Montana Adult Methamphetamine Treatment Coalition...Page 13

14 Health at Intake Just 29.5 percent of clients rated their health as excellent or very good at intake. More than a third (39.4%) ranked their health as good, and about a third (30.8%) rated their health as fair or poor. 40% 30% 20% 10% 0% M Excellent Very Good Good Fair Poor ental Health in the past 30 days Clients of the MAMTC project were troubled by a number of mental health conditions. As illustrated in the table below, the majority experienced symptoms of depression, anxiety, tension or trouble understanding, concentrating or remembering during the prior 30 days. Just over one in five (21.5%) experienced serious anxiety or tension during all 30 of the past 30 days, and almost one in five experienced serious depression and/or trouble understanding, concentrating or remembering on all 30 days. n the past 30 days, how stressful have things been Ifor you because of your alcohol or other drug use? Not at all: 26 (18.2%) Somewhat: 26 (18.2%) Considerably: 24 (16.8%) Extremely: 47 (32.9%) Not applicable: 20 (14.0%) Don t know: 1 respondent Health at Intake 56.9% of MAMTC clients responding to an additional questionnaire had a valid driver s license Page 14...The Montana Adult Methamphetamine Treatment Coalition Clients who received Emergency Room treatment during the past 30 days for: For mental or emotional difficulties: 4 For alcohol or substance abuse: 6 For physical complaint: 17 n the past 30 days, how many days I(not due to your use of alcohol or drugs) have you been prescribed medication for psychological/emotional problems? 0 days: 89 (61.8%) 1-5 days: 6 (4.2%) days: 5 (3.2%) 30 days: 44 (30.6%) ow much have you been Hbothered by psychological or emotional problems in the past 30 days? Extremely: 14.6% Considerably: 25.7% Moderately: 24.8% Not applicable: 12.5% In the past 30 days (not due to your use of alcohol or drugs), how many have you experienced... Slightly: 16% Condition Number of Days 0 1 to 5 6 to to to Average # Trouble controlling violent behavior? 80.6% 11.2% 2.1% 2.8% 0.7% 2.8% 9 Serious depression? 43.1% 20.9% 7.7% 9.0% 3.5% 16.0% 14 Serious anxiety or tension? 29.9% 25.1% 11.2% 9.0% 3.5% 21.5% 14 Hallucinations? 91% 3.5% 2.1% 0.7% 1.4% 1.4% 12 Trouble understanding, concentrating or remembering? 46.5% 14.7% 9.0% 5.6% 3.5% 20.8% 17 Not at all: 6.9%

15 More on Health Almost one in three participants in MAMTC (30.9%) rated their health as fair or poor at intake, and the 135 MAMTC participants who complete optional additional intake questionnaires at intake described a number of healthrelated issues and behaviors. A number noted that they d been disagnosed with mental health disorders, which is to be expected because co-occurring chemical dependency and mental health disorders are the expectation, not the exception. The data bears this out: 62.5 percent of questionnaire respondents had been in treatment for mental health issues at some point in their lives. Health Issue Respiratory problems 23.3% Hepatitis C 22.6% Gynecological problems 22.5% Digestive system problems 22.0% Bone or muscle problems 17.8% STD 15.8% Heart problems 15.0% Physical disability 7.5% Cirrhosis 6.7% Diabetes 4.2% Mental Health Issue Percent reporting Percent reporting Depression 63.3% Anxiety 45.0% Bipolar disorder 22.5% Antisocial personality disorder 10.8% Eating disorder 10.0% Schizophrenia 5.1% Cognitive delay 5.1% Paranoid psychosis 4.2% Behavioral Issues Percent reporting Have been a cigarette smoker 89.9% Have tried suicide at least once 34.3% 83% of MAMTC participants had no health insurance. Given the prevalence of serious health conditions, the lack of access to health care puts them at high risk of further degradation of their health. Montana Board of Crime Control Treatment History The 135 MAMTC participants who filled out the supplemental questionnaire provided additional information about prior treatment episodes. Relapses are a common symptom of chemical dependency disorders, so the multiple treatment episodes reported by participants are not surprising. Though just over one in three participants reported not having had any prior treatment, 25.7 percent reported having been in treatment at least three times prior to MAMTC project participation, and about 10 percent had at least six prior episodes. Percent Reporting: Number of Prior Treatment Episodes by Treatment Type Prior Treatment Episodes Prior Outpatient Programs Prior In paitent Treatment During MAMTC Participation None 34.1% % % 3 9.1% 4 3.0% 5 3.8% 6 to % None 74.7% % % 3 6.9% 4 to 8 6.8% None 22.6% % 2 to % Percent reporting Tested for HIV 91.7% Attended AA/NA/GA 60.1% Had a physical examination 26.6% Had new criminal charges 13.6% Had at least one drink of alcohol 10.0% Were incarcerated 6.8% Had at least 5 drinks in one sitting 6.3% Used illegal drugs 4.7% Were hospitalized for physical medical problems 3.8% Referred for inpatient treatment 2.8% The Montana Adult Methamphetamine Treatment Coalition...Page 15

16 C riminal Involvement A rrests During the 30 days prior to enrolling in MAMTC, 21 clients had been arrested between one and three times. Of the 21 who had been arrested, 11 had been arrested for drug-related offenses. Crimes Committed Arrest rates were far lower than they could have been. Of the 144 clients, 57 (40%) stated that they had not committed a crime; one refused to answer, and the data was missing for one client. Most (60%) had committed at least one crime during the past 30 days, and 24 people (17%) reported that they had committed between 21 and 30 crimes in the 30 days prior to admission to the MAMTC program. Of 144 MAMTC clients, 135 completed intake questionnaires beyond those required. Some of the data provided insight into past criminal involvement. For example, 91 percent had been in jail at least one time, and 89.6 percent had been arrested at some time in their lives. More than half (53.5 percent) had been in jail at least once during the past six months. Nearly half (46.5%) had been charged with at least one DWI or for use of illegal drugs. More than one in three had been charged at least once for theft (37.5%) or violence against another person (34.9%). Status offenses pertain only to juveniles, and include such offenses as runaway, curfew violations, ungovernable youth and liquor violations; 39 percent of MAMTC participants completing the additional questionnaire had been charged with a status offense at least once, which could be evidence of a longterm pattern of antisocial behavior. Family Disruption Loss of Parental Rights 73 children have been affected by MAMTC participants loss of parental rights. Most clients of the MAMTC (87.4% of women and 61.4% of men) had children. When asked, Are any of your children living with someone else due to child protection court orders? 34.2% of women with children and 22.9% of men said yes. When asked, For how many children have you lost parental rights? 18% of women and 25% of men stated that they had lost their parental rights to one or more children. How many times have you committed a crime in the past 30 days? 21 to % None 40.1% Among the 144 persons participating, 34 (23.6%) were awaiting charges, trial or sentencing and 59 (41.5%) were on parole or probation. Page 16...The Montana Adult Methamphetamine Treatment Coalition % % %

17 Family Disruption The 135 MAMTC clients who completed intake questionnaires beyond those required provided additional more insight into family dynamics and living arrangements. When asked where their children were living, participants indicated the following: 15.4% of children were in foster care; 22.2% of children were with the other parent; 31.1% of children were with other relatives; 14.4% of children were in other living arrangement; and 16.9% of children were living with MAMTC participants. Participants who had children living outside the home were asked, Have you visited your children in the last 30 days? Just over half (55.6%) said that they had. Participants were also asked, Have any of your children ever been removed from your care by Child and Family Services (CFS)? Over half (60.3%) answered affirmatively. Of those who had children removed from their care, 76.5 percent had their children removed once and 23.5 percent had their children removed twice. L iving Arrangements 6 Months Prior to Entering MAMTC Living Arrangements 40% of MAMTC participants had lived with their parents during the six months prior to entering the program; 22.3% had lived with other relatives; and 28.3% had lived with friends. MAMTC Clients: Parental Histories The 135 MAMTC clients who completed additional intake questionnaires were asked about specific parental examples relative to prison or jail time, breaking the law, use drugs or get drunk. Far more fathers than mothers (24.4% versus 11.4%) spent some time in jail or prison, got drunk (42.8% versus 28.1%), or used drugs (19.0% versus 12.9%). Currently, far more MAMTC clients had almost daily contact with their mothers than their fathers (55.9% versus 31.5%), while fewer never had contact with their mothers than their fathers (6.3% versus 31.5%). 25.2% Mothers Fathers Always or often Never or rarely Always or often Never or rarely Spend time in prison or jail* Do things against the law Montana Board of Crime Control Growing up, did your parents...? Use drugs Get drunk *Time in prison or jail categories: often/ sometimes/rarely or never. 0% 10% 20% 30% 40% 50% 60% 70% 80% of participants had been homeless during the 2 years prior to entering the MAMTC. 88.1% 69.7% 18.1% 21.2% Parent is still living Father Mother 29.4% 26.4% Parent has received addiction treatment Parent is in recovery 55.9% 31.5% 6.3% 31.5% MAMTC client has almost DAILY contact with MAMTC client NEVER has contact with The Montana Adult Methamphetamine Treatment Coalition...Page 17

18 Childhood Trauma and Adverse Adult Outcomes According to The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold into Lead, a growing body of research indicates that childhood trauma is a significant risk factor for the development of adult substance abuse disorders. Research reveals that traumatic childhood experiences can lead to a higher risk of adult alcohol or substance addiction. Adult survivors of childhood physical, emotional, or sexual abuse are not only at increased risk for addiction, but likely to suffer from other physical and mental health disorders, including depression, heart disease and obesity. The Adverse Childhood Experiences (ACE) Study was carried out in Kaiser Permanente s Department of Preventive Medicine in San Diego. Twenty-six thousand (26,000) consecutive adults coming through the Department were asked if they would participate in a study to demonstrate how childhood events affect adult health status: 71 percent (18,000 volunteers) agreed. Volunteers were asked about eight categories of childhood abuse and household dysfunction. The abuse categories were: recurrent physical abuse, recurrent emotional abuse and sexual abuse. The five categories of household dysfunction were: growing up in a household where someone was in prison; where the mother was treated violently; with an alcoholic or a drug user; where someone was chronically depressed, mentally ill, or suicidal; and where at least one biological parent was lost to the patient during childhood regardless of the cause. An individual exposed to none of the categories had an ACE Score of 0; an individual exposed to any four had an ACE Score of 4. In addition, a prospective arm of the Study is following the cohort for at least 5 years to compare distant childhood experiences against current emergency room use, doctor office visits, medication costs, hospitalization and death. The ACE Study revealed an epidemilogical correlation between the ACE Score and likelihood of later becoming an IV drug user. For example, a male child with an ACE Score of 6 has a 4,600 percent increase in the likelihood of later becoming an IV drug user as compared to a male child with an ACE Score of 0. In addition to these examples, many other measures of adult health were found to have a strong, graded relationship to what happened in childhood: heart disease, fractures, diabetes, obesity, unintended pregnancy, sexually transmitted diseases and alcoholism were all more frequent. Source: The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold into Lead. Page 18...The Montana Adult Methamphetamine Treatment Coalition Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study This study by Dube, S.R, et. al., examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) with the total number of ACEs (ACE score). A retrospective cohort study of 8,613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction, illicit drug use and other health-related issues. The main outcomes measured were selfreported use of illicit drugs, including initiation during 3 age categories: 14 or younger, 15 to 18, or as an adult aged 19 or older. The study revealed that each Adverse Childhood Experience (ACE) increased the likelihood for early initiation of illicit drug use by two to four times. The ACE score had a strong graded relationship to initiation of drug use in all three age categories as well as to drug use problems, drug addiction and parental drug use. Compared with people who had no ACEs, people with five or more were seven to ten times more likely to report illicit drug use problems, addiction to illicit drugs and parental drug use. Source: Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Division of Adult and Community Health, Atlanta, Georgia. pubmed/ ?dopt=abstract

19 Adverse Childhood Experiences (ACEs) Among MAMTC Participants A CEs The 135 MAMTC clients who completed additional intake questionnaires provided data that suggests highly disproportionate rates of childhood trauma. Number of ACEs by Percentage of Total Participants: MAMTC Compared to CDC ACE Study Number of Adverse Childhood Experiences 69.7% had been a witness to domestic violence as a child; 66.7% indicated their parents were divorced or separated; 56.9% had been emotionally abused as a child; 45.4% had been physically abused as a child; 42% had been abandoned by one or more parents; 33.1% had been sexually abused as a child; 30.5% had been sexually abused by a non-relative; and 11.7% reported being a victim of incest. Total Percentage of MAMTC Participants Total Percentage of CDC ACE Study Sample (normative data) 0 5.9% 36.1% 1 9.6% 26.0% % 15.9% 3 9.6% 9.5% 4 or more 60% 12.5% Source: Prevalence of Individual Adverse Childhood Experiences (ACEs): Data and Statistics. Centers for Disease Control and Prevention (CDC) Per responses to the supplemental questionnaire, many MAMTC participants continued to be victimized as adults: 67.5% of MAMTC participants had been emotionally abused as adults; 62.2% had been emotionally abused at some point in their lives; and 52% had been physically abused as an adult. 36.3% of MAMTC clients (49 of 135 answering the supplemental questionnaire) had Post Traumatic Stress Syndrome (PTSD). Household Dysfunction Neglect Abuse Incarcerated parent** Separation/divorce Household mental illness Household substance abuse Mother was abused* 33.3% 66.7% 37.0% 37.0% 61.5% 4.7% Percent with Histories of Adverse Childhood Experiences (ACEs): MAMTC Clients Compared to CDC ACE Study Sample Physical 42.2% 9.9% Emotional 54.8% 14.8% Sexual 31.9% 20.7% Physical MAMTC CDC ACE 43.7% 28.3% Clients Study Emotional Sample 54.8% 10.6% * Mother was abused MAMTC language, as opposed to Mother treated violently CDC language ** Incarcerated Parent MAMTC language, as opposed to Incarcerated Household Member CDC language 19.4% 26.9% 12.7% 23.3% The Montana Adult Methamphetamine Treatment Coalition...Page 19

20 G ender-based Differences at Intake There were some interesting gender-based differences in the percent of MAMTC participants who used specific substances in the 30 days prior to entering the program, and in the number of average days a drug was used. For example, 61.4 percent of men used methampetamine/amphetamine in the 30 days prior, as compared to 40.7 percent of women. Though the percentages of those using other drugs were lower, women were more likely than men to use tranquilizers (2.3 percent of women versus 0% of men), and among the women who used tranquilzers, on average, they used them 16 of the 30 days prior to entrance to the program. Similar percentages of women and men reported using other illegal drugs in the past 30 days (3.4% of women as compared to 3.5% of men), but women reported far more days of use (16 versus 6). This is also true of Codeine: 2.3 percent of women reported use, as compared to 3.5 percent of men, but the women who used Codiene reported 16 days of use, compared to one day for men. of women and 91.2% of men participating in MAMTC reported interaction with family members and/or friends who were supportive of their recovery during the previous 30 days. 94.3% Substances Used at Intake by Gender in Females Males Past 30 Days Prior to Entering MAMTC Percent Average days used Percent Average days used Hallucinogens 1.1% 1 day 5.3% 9 days Methamphetamine / Amphetamine 40.7% 8 days 61.4 % 9 days Benzodiazepines 10.3% 4 days 3.5% 6 days Tranquilizers 2.3% 16 days 0% -- Inhalants 0% % 3 days Other Illegal Drugs 3.4% 16 days 3.5% 6 days Cocaine/Crack 10.3% 2 days 3.5% 9 days Marijuana 36.8% 9 days 40.4% 9 days Heroin 1.1% 1 day 0% -- Morphine 8% 9 days 7% 16 days Demerol 1.1% 7 days 1.8% 5 days Percocet 2.3% 6 days 7% 8 days Codeine 2.3% 16 days 3.5% 1 day Tylenol 2, 3, 4 3.4% 13 days 1.8% 3 days Oxycontin/Oxycodone 6.9% 8 days 8.8% 4 days Non-prescription Methadone 3.4% 2 days 5.3% 14 days Gender-based Differences: Drugs in Order by Average Number of Days Abused Top 10 Drugs of Abuse by Average Number of Days Used Females Males 1 Codeine 16 Morphine 16 2 Other Illegal Drugs 16 Non-prescription Methadone 14 3 Tranquilizers 16 Marijuana 9 4 Tylenol 2, 3, 4 13 Methamphetamine / Amphetamine 9 5 Marijuana 9 Cocaine/Crack 9 6 Morphine 9 Hallucinogens 9 7 Oxycontin/Oxycodone 8 Percocet 8 8 Methamphetamine / Amphetamine 8 Other Illegal Drugs 6 9 Demerol 7 Benzodiazepines 6 10 Percocet 6 Demerol 5 Page 20...The Montana Adult Methamphetamine Treatment Coalition

21 G ender-based Differences at Intake M W omen There were several additional gender-based differences at intake. For example, women reported more in- and out-patient treatment for physical complaints, substance abuse, and mental health in the past 30 days than men did, and utilized the Emergency Room more frequently. In the 30 days prior to intake, women were also more likely to have: Been prescribed medication for psychological/ emotional problems (46% versus 26.3%); Lived in a shelter (8.0% versus 0%); Received public assistance (18.6% versus 7%); Received money from family and friends (25.6% versus 16.1%); Experienced serious depression (61.9% versus 52.9%); and Experienced serious anxiety or tension (72.4% versus 66.7%). While a nearly equal percentage of women and men reported hallucinations in the past 30 days (9.2% versus 8.8%), women who experienced hallucinations reported a higher frequency of days (on average, 15 of the past 30 days versus an average of 6 days for men). While a nearly equal percentage of women and men reported trouble controlling violent behavior in the past 30 days (19.5 versus 19.3%), women who experienced trouble controlling their violent behavior reported a higher frequency of days (11 of the past 30 days, on average, versus men at an average of 6 of the past 30 days). A greater number of women reported that they had not been arrested in the past 30 days (92% versus 75.4%), and that they hadn t spent any nights in jail (82.6% versus 68.4%). Women who did spend time in jail during the past 30 days, spent more time there than their male counterparts (16 versus 13 days). Montana Board of Crime Control en The differences between genders were also evident in terms of substance use, illegal activity and emotional ill effects. For example, among MAMTC participants who d had an arrest in the past 30 days, men were more likely to have been charged for a drug offense than their female counterparts (57.1% compared to 42.9%). During the 30 days prior to intake, men were also more likely to have: Used alcohol than their female counterparts (40.4% to 27.6%); Used illegal drugs (62.7% to 54.7%); Used alcohol and drugs on the same day (51.6% as compared to 40%); Injected drugs (28.1% versus 17.2%); Reported illegal income (14% versus 3.4%); Been on parole or probation (54.4% to 32.9%); and Lived in an institution (19.3% versus 10.3%). While fewer men reported experiencing serious depression in the past 30 days, those who did reported the same number of days as their female counterparts, with men reporting 15 of the past 30 days and women reporting 14 days. Men were considerably more likely to report that because of their alcohol or drug use, things had been extremely stressful during the past 30 days (43.9% versus 25.6%). Men also reported being extremely bothered by psychological or emotional problems more frequently than their female counterparts (28.1% to 19.5%). W ho do you turn to when you are having trouble? Friends Other Family member Although women were less likely to have used alcohol during the past 30 days (27.6% versus 40.4%), those who had were more likely to have used it to the point of intoxication (82.6% versus 60.9%). Clergy No one Women Men 0% 10% 20% 30% 40% 50% 60% The Montana Adult Methamphetamine Treatment Coalition...Page 21