Implementing Evidence-Based Practice with King County Adult Offenders in Support of Drug Court & Other Court Mandated Treatment

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Implementing Evidence-Based Practice with

King County Adult Offenders in Support of

Drug Court & Other Court Mandated

Treatment

Kate Moritz

Chestnut Health Systems

Geoff Miller

King County MHCADSD

Presentation slides for the NADCP training conference in Nashville, TN, June 1, 2012. Please address

comments or questions to the author at kmoritz@chestnut.org. or 309-451-7831.

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Detailed Acknowledgements



Any opinions about this data are those of the authors and do not reflect official positions of

the government or individual grantees.



Please include the following acknowledgement and disclaimer if you use these data:



This presentation uses data supported by analytic runs provided by Substance Abuse and

Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse

Treatment (CSAT) under multiple contracts and uses data provided by the following 182

grantees:



TI11317 TI11321 TI11323 TI11324 TI11422 TI11423 TI11424 TI11432 TI11433 TI11871

TI19323 TI19942 20084 20085 20086 TI20017 TI20759 TI20781 TI20798 TI20806 TI20827

TI21774 TI21788 TI21815 TI21874 TI21883 TI21890 TI21892 TI21948 655372 655373 655374



The authors thank these grantees and their study clients for agreeing to

share their data

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3

Chronic Nature of Addiction and the

Correlates of Recovery

(4)

Alcohol and Other Drug Abuse, Dependence and

Problem Use Peaks at Age 20

4

Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

Other drug or

heavy alcohol use

in the past year

Alcohol or Drug Use

(AOD) Abuse or

Dependence in the

past year

Age

Severity Category

Over 90% of

use and

problems

start between

the ages of

12-20

It takes decades before

most recover or die

Percentage

People with drug

dependence die an

average of 22.5 years

sooner than those

without a diagnosis

(5)

Overlap with Crime and Civil Issues



Committing property crime, drug related crimes,

gang related crimes, prostitution, and gambling to

trade or get the money for alcohol or other drugs



Committing more impulsive and/or violent acts

while under the influence of alcohol and other drugs



Crime levels peak between ages of 15-20



Adolescent crime is still the main predictor of adult

crime



Parent substance use is intertwined with child

maltreatment and neglect – which in turn is

associated with more use, mental health problems

and perpetration of violence on others

(6)

After Initial Treatment…



Relapse is common, particularly for those who:

–

Are Younger

–

Have already been to treatment multiple times

–

Have more mental health issues or pain



It takes an average of 3 to 4 treatment

admissions over 9 years before half reach a

year of abstinence



Yet over 2/3

rds

do eventually abstain



Treatment predicts who starts abstinence



Self-help engagement predicts who stays

abstinent

6

Source: Dennis et al., 2005, Scott et al 2005

(7)

The Likelihood of Sustaining Abstinence

Another Year Grows Over Time

7

* p<.05

36%

66%

86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 to 12 months

1 to 3 years

4 to 7 years

Duration of Abstinence*

% Sustaining

Abstinence

Another Y

ear

.

After 1 to 3 years of

abstinence, 2/3rds will

make it another year

After 4 years of

abstinence, about

86% will make it

another year

Source: Dennis, Foss & Scott (2007)

Only a third of

people with

1 to 12 months of

abstinence will

sustain it

another year

But even after 7 years

of abstinence, about

14% relapse each year

(8)

What does recovery look like on average?

8

Source: Dennis, Foss & Scott (2007)

Duration of Abstinence

1-12 Months 1-3 Years 4-7 Years

• More social and spiritual support

• Better mental health

• Housing and living situations continue to improve

• Dramatic rise in employment and income

• Dramatic drop in people living below the poverty line

• Virtual elimination of illegal activity and illegal

income

• Better housing and living situations

• Increasing employment and income

• More clean and sober friends

• Less illegal activity and

incarceration

• Less homelessness, violence and

victimization

• Less use by others at home, work,

and by social peers

(9)

Sustained Abstinence Also Reduces

The Risk of Death*

9

Source: Scott, Dennis, Laudet, Funk & Simeone (in press)

Users/Early

Abstainers

more likely

to die in

the next 12

months

The Risk of Death

goes down with

years of sustained

abstinence

It takes 4 or

more years of

abstinence for

risk to get

down to

community

levels

(Matched on Gender, Race & Age)

Deaths

in the next 12 months

(10)

Other factors related to death rates



Death is more likely for those who

–

Are older

–

Are engaged in illegal activity

–

Have chronic health conditions

–

Spend a lot of time in and out of hospitals

–

Spend a lot of time in and out of substance abuse

treatment



Death is less common for those who

–

Have a greater percent of time abstinent

–

Have longer periods of continuous abstinence

–

Get back to treatment sooner after relapse

10

Source: Scott, Dennis, Laudet, Funk & Simeone (2011)

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The Need and Value of Standardized

Screening

(12)

12

Any Illegal Activity in the Next Twelve

Months by Intake Severity on Crime/Violence

and Substance Disorder Screeners

(13)

13

Predictive Power of Simple Screener

Crime/

Violence

Screener

Substance

Disorder

Screener

12 Month

Recidivism

Rate

Odds

Ratio

\a

Low (0)

17%

1.0

Low (0)

Mod (1-2)

29%

2.0*

Low (0)

High (3-5)

30%

2.1*

Mod (1-2)

Low (0)

30%

2.1*

Mod (1-2)

35%

2.6*

Mod (1-2)

High (3-5)

42%

3.5*

High (3-5)

Low (0)

41%

3.4*

High (3-5)

Mod (1-2)

55%

6.0*

High (3-5)

61%

7.6*

* p<.05

\a Odds of row (%/(1-%) over low/low odds across all groups

(14)

Number of Problems by Level of Care (Triage)

39%

50%

55%

67%

78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient

(OR=1)

Intensive

Outpatient

(OR=1.6)

Long Term

Residential

(OR=1.9)

Med. Term

Residential

(OR=3.2)

Short Term

Residential

(OR=5.5)

0 to 1

2 to 4

5 or more

14

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

Source: Dennis et al 2009; CSAT 2007 Adolescent

Treatment Outcome Data Set (n=12,824)

Clients entering

Short Term

Residential

(usually dual

diagnosis) have

5.5

times higher

odds of having 5+

major problems*

(15)

No. of Problems* by Severity of Victimization

15

15%

45%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low

(OR 1.0)

Mod.

(OR=4.6)

High

(OR=13.2)

None

One

Two

Three

Four

Five+

Severity of Victimization

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

Source: Dennis et al 2009; CSAT 2007 Adolescent

Treatment Outcome Data Set (n=12,824)

Those with high

lifetime levels of

victimization

have

13

times

higher odds of

having 5+ major

problems*

(16)

7.4%

20.1%

7.0%

0.4%

1.1%

0.6%

0%

5%

10%

15%

20%

25%

12 to 17

18 to 25

26 or older

Abuse or Dependence in past year Treatment in past year

While Substance Use Disorders are Common,

Treatment Participation Rates Are Low

16

Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2012). National Survey on Drug Use and Health, 2009. [Computer file] ICPSR29621-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-02-10. doi:10.3886/ICPSR29621.v2. Retrieved from http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/29621/detail .

Over 88% of adolescent and

young adult treatment and

over 50% of adult treatment is

publicly funded

Few Get Treatment:

1 in 20 adolescents,

1 in 18 young adults,

1 in 11 adults

Much of the private

funding is limited to 30

days or less and

authorized day by day or

(17)

Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars

$407

$1,132

$1,249

$1,384

$1,517

$2,486

$4,277

$10,228

$14,818

$0

$10,

000

$20,

000

$30,

000

$40,

000

$50,

000

$60,

000

$70,

000

Screening & Brief Inter.(1-2 days)

Outpatient (18 weeks)

In-prison Therap. Com. (28 weeks)

Intensive Outpatient (12 weeks)

Adolescent Outpatient (12 weeks)

Treatment Drug Court (46 weeks)

Methadone Maintenance (87 weeks)

Residential (13 weeks)

Therapeutic Community (33 weeks)

17

The Cost of Treatment Episode vs.

Consequences

$22,000 / year

to incarcerate

an adult

$30,000/

child-year in

foster care

$70,000/year to

keep a child in

detention

•

$750 per night in Medical Detox

•

$1,115 per night in hospital

•

$13,000 per week in intensive

care for premature baby

•

$27,000 per robbery

•

$67,000 per assault

SBIRT models popular due

to ease of implementation

(18)

Return on Investment (ROI)

18

Source: Bhati et al., (2008); Ettner et al., (2006), GAO (2012), Lee et al. (2012)

This also means that for every dollar treatment

is cut, it costs society more money than was

saved within the same year

•

Substance abuse treatment has been shown to have a

ROI within the year of between $1.28 to $7.26 per

dollar invested

•

GAO’s recent review of 11 drug court studies found

that the net benefit ranged from positive $47,852 to

negative $7,108 per participant.

•

Best estimates are that Treatment Drug Courts have

an average ROI of $2.14 to $3.69 per dollar invested

(19)

Implementation is Key

(20)

Major Predictors of Bigger Effects

1.

A strong intervention protocol based on

prior evidence

2.

Quality assurance to ensure protocol

adherence and project implementation

3.

Proactive case supervision of individual

4.

Triage to focus on the highest severity

subgroup

(21)

Impact of the numbers of these Favorable

features on Recidivism in 509 Juvenile

Justice Studies in Lipsey Meta Analysis

21

Source: Adapted from Lipsey, 1997, 2005

Average

Practice

The more

features, the

lower the

recidivism

(22)

22

Implementation is Essential

(

Reduction in Recidivism from .50 Control Group Rate)

The effect of a well

implemented weak program is

as big as a strong program

implemented poorly

The best is to

have a strong

program

implemented

well

Thus one should optimally pick the

strongest intervention that one can

implement well

(23)

Evidence-Based Assessment

Global Appraisal of Individual Needs



Progressive assessment approach

–

Screening (GAIN-Short Screener)

–

Brief assessment (GAIN-Q3)

–

Comprehensive assessment (GAIN-Initial)

–

*Specialized assessment

–

*Program level assessment



All instruments:

–

Norms established for both adults and adolescents

overall and by level of care

–

Available online using the GAIN ABS web application

(24)

GAIN Short Screener (GAIN-SS)



3- to 5-minute screener



Designed for self or staff administration



Used in general populations to identify or rule-out

clients with behavioral health disorders



Easy for use by staff with minimal training or

direct supervision



Available in English or Spanish

(25)

GAIN-Q3



30 minute brief assessment



Length dependent on version of GAIN-Q3 and

individual severity



Used for:

–

Screening and supporting brief interventions/referrals

in targeted populations (e.g., justice or school settings)

–

Monitoring of client change over time, including costs

to society

–

Communications and referrals to other systems

–

Subgroup- and program-level needs assessment and

evaluation

(26)

26

King County & the GAIN

(27)

10.6%

20.4%

69.1%

14.0%

16.5%

69.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Low Severity

Problem

Moderate

Severity Problem

High Severity

Problem

2010 Percentage

2011 Percentage

GAIN-SS Total Severity

Community Center for Alternative Programs

(28)

Moderate

Severity

Problem

20%

Low Severity

Problem

11%

High Severity

Problem

69%

GAIN-SS Total Severity

Community Center for Alternative Programs

(29)

45.8%

53.8%

26.8%

58.3%

29.0%

48.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

High severity SDS High severity IDS High severity EDS

2010 Percentage

2011 Percentage

GAIN-SS Severity by Scale

(30)

High Mental

Health/Low

Substance Use

Disorder

21%

High Mental

Health/High

Substance Use

Disorder

45%

Low Problems

10%

High Substance

Use

Disorder/Low

Mental Health

11%

No Problems

13%

GAIN-SS Score Analysis

(31)

References

 Bhati et al. (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute.

 Capriccioso, R. (2004). Foster care: No cure for mental illness. Connect for Kids. Accessed on 6/3/09 from http://www.connectforkids.org/node/571

 Chandler, R.K., Fletcher, B.W., Volkow, N.D. (2009). Treating drug abuse and addiction in the criminal justice system: Improving public health and safety. Journal American Medical Association, 301(2), 183-190

 Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An eight year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612.

 Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice , 4(1), 45-55.

 Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28(2 Suppl), S51-S62.

 Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN): Administration guide for the GAIN and related measures. (Version 5 ed.). Bloomington, IL: Chestnut Health Systems. Retrieved from www.gaincc.org.

 Dennis, M.L., White, M., Ives, M.I (2009). Individual characteristics and needs associated with substance misuse of adolescents and young adults in addiction treatment. In Carl Leukefeld, Tom Gullotta and Michele Staton Tindall (Ed.), Handbook on Adolescent Substance Abuse Prevention and Treatment: Evidence-Based Practice. New London, CT: Child and Family Agency Press.

 Ettner, S.L., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., & Hser, Y.I. (2006). Benefit Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?. Health Services Research, 41(1), 192-213.

 French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates of cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, 462-469

 General Account Office (GAO, 2011). Adult Drug Courts: Studies Show Courts Reduce Recidivism, but DOJ Could Enhance Future Performance Measure Revision Efforts. Washington, DC: Author. Retrieved from

http://www.gao.gov/Products/GAO-12-53 on April 18, 2012.

 Lee, S., Aos, S., Drake, E., Pennucci, A., Miller, M., & Anderson, L. (2012). Return on investment: Evidence-based options to improve statewide outcomes, April 2012 (Document No. 12-04-1201). Olympia: Washington State Institute for Public Policy. Retrieved from http://www.wsipp.wa.gov/pub.asp?docid=12-04-1201 on 5/4/12. Marlowe, D. (2008). Recent studies of drug courts and DWI courts: Crime reduction and cost savings.

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References

 Lipsey, M. W. (1997). What can you build with thousands of bricks? Musings on the cumulation of knowledge in program evaluation. New Directions for Evaluation, 76, 7-23.

 Lipsey, M. W. (2005). What works with juvenile offenders: Translating research into practice. Paper presented at the presented at the Adolescent Treatment Issues Conference, Tampa.

 Office of Juvenile Justice and Delinquency Prevention (OJJDP). (May 2001). Juvenile Drug Court Program. Department of Justice, OJJDP, Washington, DC. NCJ 184744

 Neumark, Y.D., Van Etten, M.L., & Anthony, J.C. (2000). Drug dependence and death: Survival analysis of the Baltimore ECA sample from 1981 to 1995. Substance Use and Misuse, 35, 313-327.

 Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2012). National Survey on Drug Use and Health, 2009. [Computer file] ICPSR29621-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-02-10. doi:10.3886/ICPSR29621.v2. Retrieved from

http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/29621/detail .

 Scott, C.K. & Dennis, M.L. (2009). Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction, 104, 959-971.

 Scott, C. K., Foss, M. A., & Dennis, M. L. (2005). Pathways in the relapse, treatment, and recovery cycle over three years. Journal of Substance Abuse Treatment, 28, S61-S70.

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E

VIDENCE

-

BASED

P

RACTICES

AND

I

MPLEMENTATION

O

RIGAMI

King County, WA

June 1, 2012

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(35)

E

VIDENCE

-

BASED

P

RACTICES BEING

IMPLEMENTED IN

K

ING

C

OUNTY

, WA





GAIN SS, GAIN I, GAIN Q, GAIN Q3, GAIN TxSI

&(TxSS), GAIN M90



Motivational Interviewing



Moral Reconation Therapy



Seven Challenges (youth)



Community Reinforcement Approach



Adolescent Community Reinforcement Approach



Trauma-focused Cognitive Behavioral Therapy



Clinical Supervision (Learning Collaborative)



Treatment Planning (linking with assessment)

(36)

(37)

C

HANGE REQUIRES



Vision



Skills



Incentives



Resources



And Planning (

the end result of will

(38)

(39)

(40)

(41)

(42)

(43)

T

ABLE OF

C

HANGE OR

I

MPLEMENTATION

O

RIGAMI

Change

Vision Skills Incentives Resources Action Plan

Confusion

Skills Incentives Resources Action Plan

Anxiety

Vision Incentives Resources Action Plan

Resistance

Vision Skills Resources Action Plan

Frustration

Vision Skills Incentives Action Plan

Treadmill

Vision Skills Incentives Resources

(44)

(45)

(46)

T

RAINING AND

T

RAINING

I

NFRASTRUCTURE

How often? Linkage with other training/skill sets Costs? Retraining? What skill sets? How many?

(47)

(48)

F

INANCING

I

MPLEMENTATION

data

outcomes

(49)

(50)

(51)

(52)

R

ESOURCES





GAIN SS, GAIN I, GAIN Q, GAIN TxSI, GAIN M90

--http://gaincc.org/



Motivational Interviewing

--http://www.motivationalinterview.org/



Moral Reconation Therapy --

http://www.moral-reconation-therapy.com/



Seven Challenges

--http://www.sevenchallenges.com/About.aspx



Community Reinforcement Approach

--http://www.robertjmeyersphd.com/cra.html



Adolescent Community Reinforcement Approach

--http://www.chestnut.org/LI/acra-acc/index.html



Clinical Supervision (Learning Collaborative)

--http://www.attcnetwork.org/regcenters/generalContent.asp

?rcid=10&content=STCUSTOM5

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 The GAIN-SS is a 3 to 5 minute screener used in general populations to identify clients with behavioral health disorders. It is designed for self or staff

administration with paper and pen or on the Web.

 The GAIN-SS cannot be used to assist with diagnosis, but it does provide a detailed report of the participant’s responses in narrative and table formats. These reports generate recommendations for subsequent referrals.

 There is no certification process to use the GAIN-SS. Training is available, but it is not required. It is often sufficient enough to read the GAIN-SS manual, which can be found online at gaincc.org/GAINSS.

 The GAIN-SS is available in English or Spanish. Please contact the GAIN Coordinating Center at gaininfo@chestnut.org for more information.

 Web applications that allow agencies to complete the screener online and instantly generate reports are available for the GAIN-SS. For more information about each application and assistance determining which one would be most appropriate for your agency, please contact us at gaininfo@chestnut.org.

GAIN Short Screener Overview

For more information, please contact our GAIN Project Coordination Team at gaininfo@chestnut.org

Chestnut Health Systems | GAIN Coordinating Center 448 Wylie Drive Normal, IL 61761

309.451.7900 | gaincc.org

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Chestnut Health Systems | GAIN Coordinating Center 448 Wylie Drive Normal, IL 61761

309.451.7900 | gaincc.org

An Overview of the GAIN-Q3

 The Global Appraisal of Individual Needs Q3 (GAIN-Q3) is a brief, 20-45 minute assessment used to identify and address a wide range of problems among adolescents and adults in clinical and general populations.

 As a clinical tool, the GAIN-Q3 is designed for use by personnel in diverse settings that include employee assistance programs, student assistance programs, health clinics, juvenile justice, criminal justice, child welfare, mental health, and substance abuse treatment programs.

 Once the GAIN-Q3 interview is completed, there are a number of reports that can be generated through the use of GAIN ABS to support your clinical decision making and referral process.

 The GAIN-Q3 training model takes a distance-learning approach to help individualize the training

process and make training and certification more affordable.

The GAIN-Q3-Lite is the most basic form of the assessment. It consists of nine screeners that estimate the

severity of problems and the recency of treatment participation in each life area represented. The Lite also computes a measure of participants' quality of life. The average time to administer the GAIN-Q3-Lite is about 25 minutes.

The GAIN-Q3-Standard contains the same nine screeners as the GAIN-Q3-Lite, plus additional items that

record information on the frequency of participants' service utilization and behaviors during the preceding 90 days. The GAIN-Q3-Standard provides more detailed outcome measures than the GAIN-Q3-Lite. This additional information can be used to monitor participants' progress when the Q3 is used as a follow-up assessment. In addition to the quality of life measure, the GAIN-Q3-Standard computes indices on the participant's prevalence of problems and quarterly costs to society. A six-item measure on current life satisfaction is also included in the Standard. The average time to administer the GAIN-Q3-Standard is about 25 to 35 minutes.

The GAIN-Q3-MI (Motivational Interviewing) contains the same nine screeners, recency items, and measure

of life satisfaction as the GAIN-Q3-Standard with the addition of items that address reasons for and readiness to change. These additional items help facilitate a motivational interviewing session, making the GAIN-Q3-MI best suited for participants who may be in need of a brief intervention. For any life area that screens as problematic, or for any problematic area that a site chooses in advance to address, GAIN-Q3-MI interviewers have the option of collecting information on the participant's reasons for and readiness to change their

behaviors. This information is then used during the GAIN-Q3-MI brief intervention, which can be conducted either during the assessment session or at a separate meeting. The time to conduct the screening and brief intervention varies, depending on the number of life areas the participant reports as problematic. On average, the GAIN-Q3-MI takes about 35 to 45 minutes to administer. Following up with a motivational-interviewing intervention can take another 15 to 30 minutes, depending on how many life areas are covered.

GAIN-SS manual,

gaincc.org/GAINSS.

gaincc.org

GAIN-Q3) is a

of GAIN ABS

GAIN-Q3 training model