Translating Research To Practice: SOCIAL WORKERS AS LEADERS IN BEHAVIORAL HEALTH AND ADDICTION TREATMENT

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1 Translating Research To Practice: SOCIAL WORKERS AS LEADERS IN BEHAVIORAL HEALTH AND ADDICTION TREATMENT Dr. Lena M. Lundgren, Presentation Prepared by: Dr. Ivy Krull. Post-Doctoral Fellow,.

2 Thank You

3 Social Work and Impact Privilege to Be a Social Worker Advocate for policies and practice that benefit the most vulnerable populations. Responsibility to work with our own colleagues and those from other disciplines to develop, test and implement the most effective, most just policies, programs and practices that reduce disparities in health, income, and in behavioral health including addiction treatment. 3

4 Social Work and Impact We have to keep asking ourselves: what is my impact in the field? 4

5 Behavioral Health One key area where we as social work need to take leadership in is behavioral health, including addiction treatment. I will now provide an argument for why and start with what may seem like an inconsistent example: my ongoing research in Sweden.

6 National population of those assessed for a substance use disorder in Sweden (n=12,833) 95% clustered in to three groups (cluster analysis) Lundgren et al.,

7 Example in Another Country National Swedish Studies: Mortality of those who have been deemed to be of danger to themselves and others due to their substance abuse and the use of Compulsory Care FINDINGS: Mortality rate 8-9 times higher than the general population (Lundgren et al. forthcoming). Average age of death 32 for narcotics users (55 alcohol). Alcohol/drug related causes of death primary reason for death. First and second generation immigrants disproportionally represented in compulsory care (Lundgren et al 2012). 7

8 Example in Another Country Continued Yet individuals in addiction treatment in Sweden Enter treatment earlier in their substance use careers, Receive more treatment than their US counterparts, The treatment is universal and free (Widthbrodt, & Romelsjo 2013, Trochio, Lundgren 2013). 8

9 The U.S. Treatment Gap No Treatment/or Inadequate Treatment Adequate Treatment Accessible 9

10 The Treatment Gap Continued An estimated 23 million individuals in the U.S., or 9% of the population aged 12 years and older, meet criteria for a diagnosis of substance abuse or dependence. (McCarty, McConnell & Schmidt, 2010; SAMHSA, 2011) 10

11 The Treatment Gap Continued Only 4 million or 17 % of those who need addiction treatment enter care for their substance use disorder each year: In 2008 of those who entered treatment, only 2.6 million entered into facilities that specialize in addiction treatment (McCarty, McConnell & Schmidt, 2009; SAMHSA, 2008) 11

12 Is there an Addiction Treatment System of Care? Our 2006 state-level study using MIS data suggested that the preferred system of care: detox, inpatient, outpatient, or detox-outpatient may not exist for many clients. For a sample of approximately 3,000 individuals new to treatment: The 10 most common patterns of care covering approximately 50 percent of clients were a range of detox entries followed by no entry to treatment (Lundgren et al, JSAT 2006). I.e. we need a system of treatment integrated with other care systems. 12

13 We Are Faced With Three Barriers: Disparate access Lack of trained workforce High-cost addiction treatment

14 Demographic Differences in Access to Addiction Treatment Treatment gap disproportionately large for young adults and for ethnic minority groups (Schmidt et al. 2007, McCarty, McConnell & Schmidt, 2010) 14

15 1. Adolescents and Young Adults Overall, there is a significant lack of addiction treatment slots for adolescents and young adults. (McLellan, & Meyers, 2004; Knudsen, H., 2009; Wong, J., Marshall, B., Kerr, T., Lai, C., Wood, E., 2009). Training for addiction treatment staff, the organization of treatment, and the testing/implementation of new treatment interventions only recently focused on adolescents and young adults (Mark et al.,2006; Knudsen, 2009). 15

16 2. Race/Ethnicity and Access to Addiction Treatment A number of studies in the past decade indicate that Whites are more likely to receive addiction treatment than their Hispanic/Latino and African-American counterparts and that they tend to receive more appropriate types of treatment. 16

17 Race/Ethnicity Examples Racial and ethnic differences in addiction treatment entry - Lundgren, Amodeo, Ferguson & Davis, 2001 Study compared patterns of treatment entry by African- American, Hispanic and white IDUs, with different patterns relative to three paths: entry into detoxification only, entry into residential treatment, or entry into methadone maintenance, N = 28,230 Latino IDUs were approximately a third less likely than white IDUs to enter residential treatment and African-American IDUs were half as likely as white IDUs to enter methadone. Presentation to NIDA, 2008 where we presented longitudinal data we found that after 5 years. these disparities had increased significantly. 17

18 Race/Ethnicity Continued Medication Availability within Addiction Treatment Organizations - Knudsen & Roman, 2010 Study examined whether the racial and ethnic composition of addiction treatment centers caseloads was associated with organizational offering of any prescription medications to treat addiction, psychiatric conditions, or pain, N=228 Organizations with a greater percentage of racial and ethnic minorities were less likely to have available medications. 18

19 Race/Ethnicity Continued Racial and ethnic differences in rates of completion from publicly funded alcohol treatment programs - Jacobson, Robinson & Bluthenthal, 2007 N= 10,591 African Americans were significantly less likely to complete outpatient and residential publically funded alcohol treatment 19

20 Follow-up After Care - Patient Treatment Episode by Race Mckay, Foltz, Leahy, et al., 2004 Study of disparities in continued drug abuse treatment access, N= 134 Participation in continued outpatient care after leaving inpatient care was significantly associated with being White African Americans were less likely to receive intensive outpatient care after leaving inpatient care, when compared to Whites 20

21 Disparities in Addiction Related Outcomes Despite similar rates of drug use by racial minorities when compared to Whites, the negative consequences of drug use are greater among African American and Hispanic than among White drug users (National Institute on Drug Abuse (NIDA), 2000; NIDA, 2003). Of the total number of new HIV infections among women in the United States in 2010, 64% occurred in African Americans, 18% were in whites, and 15% were in Hispanics/Latinas (CDC, March 2013). Drug use implicated in a host of health disparities between racial/ethnic groups such as incidence of HIV/AIDS, Hepatitis B and C, and tuberculosis, as well as homicide rates and cocaine-related deaths (NIDA, 2000; NIDA, 2003). At some point in their lifetimes, an estimated 1 in 32 African American women will be diagnosed with HIV infection, compared with 1 in 106 Hispanic/Latino women and 1 in 526 white women (CDC, March 2013). 21

22 We Are Faced With Three Barriers: Disparate access Lack of trained workforce High-cost addiction treatment

23 Lack of Trained Work-Force The shortage of health workers sufficiently trained in empiricallysupported alcohol and other drugs screening, assessment and treatment is acknowledged as a significant problem. (Institute of Medicine, 2006; DHHS, 2006; Lundgren et al., 2011; D Ippolito et al 2013; Krull et al, 2011; Martino, 2010; McCarty, Edmundson & Hartnett, 2006; McCarty et al., 2007; Warren & Hewitt, 2010) 23

24 The Addiction Treatment Work Force Continued The Institute on Medicine (2006) recommend both building and assuring the competency of the addiction treatment workforce. Also, in its report on the Fiscal Year (FY) 2006 budget for the Department of Health and Human Services (DHHS), the House Committee on Appropriations stated the following: The Committee has concerns that people who are seeking substance abuse treatment are unable to access services due to the lack of an adequate clinical treatment workforce. 24

25 Lack of Trained work force- Community Based Addiction Treatment In our national study of community based organizations: Clinical staff (n= 596) who reported that their program had greater program ad staff needs (needed improved staff assessment capacity, improved counseling capacity) and who reported high levels of organizational stress also reported greater barriers to implementing a new evidence based practice (Lundgren et. al 2012). 25

26 Lack of Trained work force in addiction treatment continued Multi-variate modeling also identified for a national sample of addiction treatment staff that those staff who reported greater level of barriers to EBP implementation, with less experience in implementing empirically supported treatments also reported lower levels of adherence to manuals and standard in EBP implementation (Lundgren, et al., 2013).

27 Social Work Training Yet National study of MSW programs (N = 210) examined prevalence of addiction courses and specializations. Web-based analyses showed that only 14% of accredited schools offered specialization in substance use; only 5% of accredited schools had one or more required courses related to substance abuse. Social work education has not met addiction workforce development needs; there is little evidence this pattern will change (Wilkey, C., Lundgren, L., Amodeo, M., 2013). 27

28 We Are Faced With Three Barriers: Disparate access Lack of trained workforce High-cost addiction treatment

29 Is Income a Determinant to Accessing Treatment? Public payers dominate and account for about 78% of the total expenditures on treatments for alcohol and drug dependence (Mark et al. 2007). 29

30 How Do Individuals Pay for Addiction Treatment? 30

31 Our Three Tiered Addiction Treatment System 1. Highly comprehensive, residential treatment services ranging from 3 months to a year increasingly available to those who pay a large percentage of cost out of pocket. Approximate cost per person for a 28 day in-patient stay is $11,000 (Guide to Drug and Alcohol Addiction Recovery, 2012) 31

32 Our Three-Tiered Addiction Treatment System Continued 2. Addiction treatment funded through private insurance. Currently, significant variation in coverage for addiction treatment by insurance. Some insurance companies may cover a highly limited time of inpatient treatment and/or weekly or bi-monthly outpatient visits depending on insurance. 32

33 Our Three-Tiered Addiction Treatment System Continued 3. Publicly funded treatment: Medicaid, Medicare and a range and federal/state level specific program efforts. The federal/state program efforts often target community based addiction treatment programs and highly vulnerable populations groups, they range dramatically with respect to type of care, length of program funding. 33

34 PPACA Patient Protection and Affordable Care Act The PPACA includes health insurance coverage for addiction treatment which will likely and hopefully increase access to outpatient treatment A Fee-For-Service (FFS) model is increasingly being utilized in reimbursing addiction treatment providers (National Institute of Mental Health, The Economics of Health Care Reform, 2011). 34

35 New Funding Models - Potential Impact on Vulnerable Populations Over the past 20 years, federal agencies like SAMHSA and CDC enhanced the capacity of community based organizations (CBO S) to better serve these groups. The advent of PPACA should not in my opinion be coupled with a trend towards decreased federal funding of community based organizations (CBO s) that treat vulnerable populations 35

36 PPACA and Vulnerable Populations Continued Whether due to the advent of PPACA or the need to decrease federal government spending, federal spending on community based addiction treatment has been significantly reduced in the past years. This includes funding for: Those with co-morbid mental health conditions Those at risk of HIV The homeless Racially and ethnically diverse populations 36

37 PPACA Continued Under PPACA primary care physicians are to be the center for all care. Historically, these health care providers, for a number of reasons, have not been the primary source of referral to addiction treatment for those with severe substance use disorder including homeless populations. 37

38 Key Challenges in PCP-Led Addiction Detection and Treatment Lack of clinical skills and training Feelings of professional incompetence Underdiagnoses Patient perception of physician awareness 38

39 Lack of PCP Clinical Skills & Training Studies conducted by those in the medical/health profession report that physicians receive little training in treatment of addictions and lack the clinical skills necessary to identify and intervene effectively with substance users (Kahan, 2009). Medical School students lack role models, instruction and experiences in addiction medicine throughout their years of medical education (Miller, 2001). 39

40 PCPs and Feelings of Incompetence Most primary care physicians do not feel competent to treat alcohol- and drug-related disorders, they are trained that diagnosis and treatment of such disorders are separate from medical matters (Miller 2001). 40

41 Diagnostic Impact on Patients with Drug Use Disorders Multiple studies found that a significant number of Substance Use Disorders (SUDs) were underdiagnosed by Primary Care Physicians For example, nearly half of patients seeking addiction treatment from their PCP were not recognized as having a disorder by their PCP (Reif, 2011). 41

42 Additional Implications Access barriers for vulnerable populations: These individuals need a comprehensive range of services. It is not evident that weekly or bi-monthly outpatient services can address these needs. Hence, as federal treatment funding may continue to decrease funds for community based addiction treatment, a concern is that the most vulnerable population groups will experience reduced access to treatment, whereas those with higher incomes will continue to access the most comprehensive treatment. 42

43 Recommendations 1. Hopefully, PPACA will reduce the gap between those in need of addiction treatment and those who receive treatment. 2. However, we need to increase research and training by and of all healthcare professionals including social workers to better respond to the treatment needs/options for addicted patients, especially highly vulnerable population groups. 43

44 Recommendations Continued 3. Expand research on implementation of empirically tested, culturally adapted, screening, assessment and treatment methods. 4. Support the use of extensive range of health services by those with a substance use disorder. 44

45 Recommendations Continued Promote the development of government policies and programs that ensure that implementation of PPACA does not result in decreased access to a comprehensive range of treatment options for those most in need, including access to behavioral interventions, medications, social support services, as well as both inpatient and outpatient treatment options. 45

46 And What About Social Work Social work as a profession is based on an integrated care model. (Think about the old case-management model, which has now been newly found ). We train our students to understand their clients and their life from a bio/psycho/social perspective and to have a strong social justice perspective. We should be the leaders, the researchers and trainers of: integrated behavioral health, of efforts to reduce disparities in access, and of new workforce development. This at a policy, national, community and agency level.

47 Role of Social Work in Addiction Treatment Example: Effectiveness of addiction treatment medications such as Subutex and Methadone are most effective IF used in combination with a range of empirically tested therapeutic, family and economic support services. (McLellan et al. 2004, 2012) Those are the services we social workers provide We are at the forefront of implementation research in community based organizations- we work in community based organization that serve the most vulnerable and diverse populations. We already are trained in a bio/psycho/social framework, it is not new to us. We reach the most hard to reach population who do not access primary care.

48 I.e. We do not need to beg, plead or argue about whether or not Social Work should be a participant in new policy, program and practice efforts providing integrated care models to vulnerable populations such as those in need of integrated care associated with a substance use disorder, We should simply acknowledge our leadership and promote every opportunity to interdisciplinary collaboration.

49 Addictions Health Services Research Conference 2014 The, Center for Addictions Research and Services, in collaboration with The Boston University Schools of Medicine and Public Health. Hosts: Lena Lundgren, Ph.D., Jeffrey Samet, M.D., M.A., M.P.H.,, Richard Saitz, M.D. M.P.H., Ivy Krull, M.S.W., M.P.H., Ph.D. Boston, Massachusetts - Wednesday, October 15 Friday, October 17, 2014 For more information, please visit

50 Additional Resources Barber (1995). Working with resistant drug abusers. Social Work, 40(1), Bureau of Labor Statistics. (2009). United States department of labor, occupational outlook handbook, edition. Retrieved January 10, 2012 from Conway, K., Compton, W., Stinson, F. et al. (2006). Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drugs. Journal of Clinical Psychiatry; 67: Dohm, A. & Shniper, L. (2007). Occupational employment projection to Monthly Lab.Rev., 130, 86. Ettner, S., Huang, D., Evans, E., Ash, D., Hardy, M., Jourabchi, M. et al. (2006). Benefit-cost in the California Treatment Outcome Project: Does substance abuse treatment pay for itself? Health Services Research, 41(1): Grella, C., Hser, Y., Hsieh, S. (2003). Predictors of drug treatment re-entry following relapse to cocaine use in DATOS. Journal of Substance Abuse Treatment, 25 (3): Hser, Y., Huang, D., Teruya, C. & Anglin, M. (2003). Gender comparisons of drug abuse treatment outcomes and predictors. Drug and Alcohol Dependence, 72, Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Kahan (2009). Short-term outcomes in patients attending a primary care based addiction shared care program. Can Fam Physician. November; 2009, 55(11): e5. Knudsen, H. & Roman, P. (2004). Modeling the use of innovations in private treatment organizations: The role of absorptive capacity. Journal of Substance Abuse Treatment, 26, Open Societies Foundation (2010). Defining the addiction treatment gap: Data summary. Baltimore, Maryland. Patient Protection and Affordable Care Act. (2010). Pub. L. No , 2702, 124 Stat. 119, Saitz, R., Mulvey, K., Plough, A., & Samet, J. (1997). Physician unawareness of serious substance abuse. The American Journal of Drug and Alcohol Abuse, 23(3), Trocchio, S. Chassler, D., Storbjörk, J., DeLucchi, K., Witbrodt, J., Lundgren, L. (2013). The association between self-reported mental health status and alcohol and drug abstinence 5 years post-assessment for an addiction disorder in US and Swedish samples. Journal of Addictive Diseases, 32:2, PMID: / NIMHS

51 References D Ippolito, M., Lundgren, L., Amodeo, M., Beltrame, L., Lim, L., Chassler, D. (2013). Addiction treatment staff perceptions of training as a facilitator or barrier to implementing evidence-based practices: A national qualitative research study. Substance Abuse. Institute of Medicine. (2006). Improving the quality of health care for mental and substance-use disorders: Quality Chasm Series. Washington, DC: National Academy Press. Jacobson, J., Robinson, R., Bluthenthal, R. (2007). A multilevel decomposition approach to estimate the role of program location and neighborhood disadvantage in racial disparities in alcohol treatment completion. Social Science and Medicine, 64(2), Knudsen, H. (2009). Adolescent-only substance abuse treatment: Availability and adoption of components of quality. Journal of Substance Abuse Treatment, 36, Krull, I., Lundgren, L., Zerden, L. (2011). Attitudes toward evidence-based pharmacological treatments among community-based addiction treatment programs targeting vulnerable population groups. Journal of Addictive Diseases, 30(4), Lundgren, L., Wilkey, C., Chassler, D., Sandlund, M., Armelius, B., Armelius, K., Brännström, J. (2014). Integrating addiction and mental health treatment within a national addiction treatment system: Using multiple statistical methods to analyze client and interviewer assessment of co-occurring mental health problems. Nordic Studies on Alcohol and Drugs. Lundgren, L., Amodeo, M., Chassler, D., Krull, I., & Sullivan, L. (2013). Organizational readiness for change in community-based addiction treatment programs and adherence in implementing evidence-based practices: a national study. Journal of Substance Abuse Treatment, 45(5), PMID: Lundgren, L., Brännström, J., Chassler, D., Wilkey, C., Sullivan, L., Nordström, A. (2013) Mental health, substance use, and criminal justice characteristics of males with a history of abuse in a Swedish national sample assessed for a substance use disorder through the Swedish welfare system. Journal of Dual Diagnosis, 9:1, 47. Lundgren, L., Chassler, D., Amodeo, M., D Ippolito, M., Sullivan, L. (2012). Barriers to Implementation of evidence-based addiction treatment: A national study. Journal of Substance Abuse Treatment, 42, Lundgren, L., Brännström, J., Armelius, B-A., Chassler, D., Moren, S., & Trocchio, S. (2012). Association between immigrant status and history of compulsory addiction treatment in a national sample of individuals assessed for addiction disorders through the Swedish public welfare system. Substance Use and Misuse, 47:1, Lundgren, L., Amodeo, M., Krull, I., Chassler, D., Weidenfeld, R., Zerden, L., Gowler, R., Lederer, J., Cohen, A. & Beltrame, C. (2011). Addiction treatment provider attitudes on staff capacity and evidence-based clinical training: Results from a national 51 study. The American Journal on Addictions, 20(3),

52 References Continued Lundgren, L., Krull, I., Zerden, L. & McCarty, D. (2011). Community-based addiction treatment staff attitudes about the usefulness of sciencebased addiction treatment and CBO organizational linkages to research institutions. Evaluation and Program Planning, 34(4), Lundgren, L., Amodeo, M. & Sullivan, S. (2006). How do drug treatment repeaters use the drug treatment system? An analysis of injection drug users in Massachusetts who enter multiple treatments. Journal of Substance Abuse Treatment, 30(2), Lundgren, L., Amodeo, M., Ferguson, F. & Davis, K. (2001). Racial and ethnic differences in drug treatment entry by injection drug users in Massachusetts, Journal of Substance Abuse Treatment, 21(3), Mark, T., Levit, K., Coffey, R., McKusick, D., Harwood, H., King, E. et al. (2007). National expenditures for mental health services and substance abuse treatment: Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. DHHS Publication No. SMA Martino, S. (2010). Strategies for training counselors in evidence-based treatments. Addiction Science & Clinical Practice, 5(2), 30. PMCID: PMC McCarty, D., McConnell & Schmidt. (2010). Priorities for Policy Research on Treatments for Alcohol and Drug Use Disorders. Journal of Substance Abuse Treatment, McCarty, D., Fuller, B., Arfken, C., Miller, M., Nunes, E., Edmundson, E.,... Laws, R. (2007). Direct care workers in the national drug abuse treatment clinical trials network: Characteristics, opinions, and beliefs. Psychiatric Services, 58(2), 181. PMCID: PMC

53 References Continued McCarty, D., Edmundson, E. & Hartnett, T. (2006). Charting a path between research and practice in alcoholism treatment. Alcohol, Health & Research, 29 (1), Mckay, J., Foltz, C., Leahy, P. et al. (2004). Step down continuing care in the treatment of substance abuse: Correlates of participation and outcome effects. Evaluation and Program Planning, 27: McLellan, T., Chalk, M., and Bartlett, J. (2007). Outcomes, performance and quality What s the difference? Journal of Substance Abuse Treatment, 32: McLellan, T., Meyers, K. (2004). Contemporary addiction treatment: A review of systems problems for adults and adolescents. Biological Psychiatry, 56(10), McLellan, T., Carise, D., and Kleber, H. (2003). Can the national addiction treatment infrastructure support the public s demand for quality care? Journal of Substance Abuse Treatment, 25: Miller, N., Sheppard, L., Colenda, C. & Magen, D. (2001). Why physicians are unprepared to treat patients who have alcohol- and drugrelated disorders. Academic Medicine, 76: National Institute of Drug Abuse (NIDA). (2012). Research Reports: Comorbidity: Addiction and Other Mental Illnesses. Retrieved from National Institute of Drug Abuse (NIDA). (2009). Principles of effective treatment: A research based guide. Retrieved from National Institutes of Drug Abuse (NIDA). (2007) Research Update on Co-Morbid Drug Abuse and Mental Illness. Retrieved from National Institute of Drug Abuse (NIDA). Drugs, brains, and behavior: the science of drug use and addiction. Retrieved from National Institutes of Mental Health (NIMH). (2012). The Economics of Health Care Reform: Director s Blog. Retrieved from of-health-care-reform.shtml. Reif, S., Larson, M.,Cheng, D., Allensworth-Davies, D., Samet, J., & Saitz, R. (2011). Chronic disease and recent addiction treatment utilization among alcohol and drug dependent adults. Substance Abuse Treatment, Prevention, and Policy, 6(1), 28. Retrieved from: 53

54 References Continued Substance Abuse and Mental Health Services Administration (SAMHSA) (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration (SAMHSA) (2005). Results from the 2004 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H- 41, HHS Publication No. (SMA). Rockville, MD: Substance Abuse and Mental Health Services Administration. Shin, S., Lundgren, L., & Chassler, D. (2007). Examining drug treatment entry patterns among young injection drug users. The American Journal on Drug and Alcohol Abuse, 33(2), The Addiction Recovery Guide (2012). Your Online Guide to Drug and Alcohol Recovery. Retrieved from ttp://www.addictionrecoveryguide.org/resources/recovery/. Warren, K. R., & Hewitt, B. G. (2010). NIAAA: Advancing alcohol research for 40 years. Alcohol Research & Health, 33(1/2), Wilkey, C., Lundgren, L., & Amodeo, M. (2013). Addiction Training in Social Work Schools: A Nationwide Analysis. Journal of Social Work Practice in the Addictions, 13(2), Wong, J., Marshall, B., Kerr, T., Lai, C., Wood, E. (2009). Addiction treatment experience among a cohort of street-involved youths and young adults. Journal of Child & Adolescent Substance Abuse, 18(4),

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