I

Opportunities for Collaboration

Joseph Westermeyer

University of Minnesota and Minneapolis VA Medical Center

Many clinical areas will benefit from empirical scrutiny and investigations where clinicians collaborate with research teams to articulate research questions, design research protocols, collect and analyze data, and interpret results. The descriptions of opportunities for collaboration presented in this appendix are examples of a few such areas. They may also serve as a model for writing up a "one pager" to begin the discussion of a collaborative research project.

Table I-1 identifies some of the major gaps between what is known from treatment research and what is actually practiced in the outpatient drug abuse treatment system. It suggests questions that could be addressed with more services research and collaboration with treatment providers.

In the same volume, an assessment of drug abuse treatment research completed in field settings concluded that studies of phases of treatment have been uneven and will benefit from additional attention in at least six areas: (1) identification and recruitment of individuals in need of treatment, (2) motivation and readiness for treatment, (3) treatment induction processes, (4) matching services to client needs, (5) engaging and retaining individuals in care, and (6) understanding postdischarge improvements (Simpson, 1997).

A separate analysis of factors that affect access to care observed that changes in health care financing may alter access to care and the types of services available to clients (Horgan, 1997). Studies of the effects of managed care on the organization and financing of drug abuse treatment require substantial cooperation from the community-based programs that



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I Opportunities for Collaboration Joseph Westermeyer University of Minnesota and Minneapolis VA Medical Center Many clinical areas will benefit from empirical scrutiny and investigations where clinicians collaborate with research teams to articulate research questions, design research protocols, collect and analyze data, and interpret results. The descriptions of opportunities for collaboration presented in this appendix are examples of a few such areas. They may also serve as a model for writing up a "one pager" to begin the discussion of a collaborative research project. Table I-1 identifies some of the major gaps between what is known from treatment research and what is actually practiced in the outpatient drug abuse treatment system. It suggests questions that could be addressed with more services research and collaboration with treatment providers. In the same volume, an assessment of drug abuse treatment research completed in field settings concluded that studies of phases of treatment have been uneven and will benefit from additional attention in at least six areas: (1) identification and recruitment of individuals in need of treatment, (2) motivation and readiness for treatment, (3) treatment induction processes, (4) matching services to client needs, (5) engaging and retaining individuals in care, and (6) understanding postdischarge improvements (Simpson, 1997). A separate analysis of factors that affect access to care observed that changes in health care financing may alter access to care and the types of services available to clients (Horgan, 1997). Studies of the effects of managed care on the organization and financing of drug abuse treatment require substantial cooperation from the community-based programs that

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TABLE I-1 Drug Abuse Treatment—What We Know and Current Practice Treatment Processes and Inputs What We Know and Current Practice Treatment Process Review Findings Assessment Advances in assessment methods recently achieved Physical health not routinely assessed in drug-free outpatient treatment Mental health assessed, formal diagnosis less frequently Prevalence of addiction severity assessment unknown HIV assessment infrequent but growing Treatment planning Research on patient-treatment matching increasing Prevalence of individualized treatment planning unknown Current treatment goals are abstinence, physical health, relationship improvement, not "responsible use" Core treatment mechanisms Expert opinion identifies acceptance of responsibility, relapse prevention, denial reduction as core mechanisms of effective treatment Current practice involves individual and group therapy and addiction education High-dose methadone treatment is effective but many programs restrict dosage levels and client participation in treatment planning Supportive treatment services Supportive legal, family, job, and medical services are important for effective treatment Less than half of treatment settings provide supportive services AIDS prevention and counseling infrequent Aftercare New relapse prevention treatment and education available Follow-up and aftercare is critical to effective treatment Less than three-quarters of outpatient and half of methadone units have formal written follow-up plans

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Treatment Processes and Inputs What We Know and Current Practice Treatment Process Review Findings Less than two-thirds of outpatient services collect any follow-up information at all Treatment Inputs   Staffing Majority of staff are BA and MA level Only half have special training or certification in substance-abuse treatment Work experience and special training seen as important hiring qualifications Recovering addict status not seen as special qualification. Effectiveness unclear Understaffing and poor client-staff ratios produce poorer outcomes Client characteristics Women substance abuse clients have special service needs associated with pregnancy, sexual abuse, child care, and homelessness Less than half of outpatient services have special services for women, one-fifth have special services for pregnant women Minority clients need culturally sensitive supportive services to improve recruitment and reduce dropout New services for minority clients are not being developed rapidly Organization Staffing, client assessment, client characteristics vary in methadone vs. outpatient drug-free programs Hospital and mental health settings utilize more professionals in treatment Public programs provided better access than private-for-profit programs Private-for-profit programs may achieve lower cost by reducing individual treatment intensity   SOURCE: Price RH. 1997. What we know and what we actually do: Best practices and their prevalence. In: Egertson JA, Fox DM, Leshner Al, eds. Treating Drug Problems Effectively. Bodmin, Cornwall: Blackwell Publishers. Pp. 125-155. Reprinted by permission of Blackwell Publishers. Copyright 1997. All rights reserved.

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provide treatment services. Similarly, investigations of staffing patterns and the characteristics of the drug abuse treatment workforce can not be completed without the direct participation of treatment agencies (Brown, 1997; Price, 1997). There is also insufficient information on the characteristics of individuals seeking care and the interventions that best meet the unique needs of women, minorities, and adolescents (Price, 1997). Case management has been widely adopted and promoted for the care of men and women with serious mental illness but has not been well developed for the treatment of chronic alcohol and drug dependence (Willenbring, 1995; Willenbring et al., 1991). Managed care organizations, however, often promote case management as an essential tool. While investigations of case management for drug abuse treatment demonstrate that case managed clients receive more services, evidence that outcomes improve has emerged less clearly (Orwin et al., 1993) and more slowly (Shwartz et al., 1997). Thus, there is much opportunity for treatment providers with effective mature models of case management to collaborate with researchers and examine the factors that contribute to more beneficial outcomes. The committee heard many additional areas highlighted in testimony from both researchers and practitioners. The list of areas where collaboration between researchers and treatment programs will improve theory and enhance practice may be nearly infinite. REFERENCES Brown BS. 1997. Staffing patterns and services for the war on drugs. In: Fox DM, Egertson J, Leshner Al eds. Treating Drug Abusers Effectively. Malden, MA: Blackwell Publishers. Pp. 99-124. Horgan CM. 1997. Need and access to drug-abuse treatment. In: Egertson JA, Fox DM, Leshner Al eds. Treating Drug Abusers Effectively. Malden, MA: Blackwell Publishers. Orwin RG, Goldman HH, Sonnefeld LJ, Smith NG, Ridgely MS, Garrison-Morgren R, O'Neill E, Luchese J, Sherman A, O'Connell ME. 1993. Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals: Final Evaluation Report. NIH Pub. No. 92-3541. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Price RH. 1997. What we know and what we actually do: Best practices and their prevalence. In: Egertson JA, Fox DM, Leshner A eds. Treating Drug Abusers Effectively. Malden, MA: Blackwell Publishers. Pp. 125-155. Shwartz M, Baker G, Mulvey KP, Plough A. 1997. Improving publicly funded substance abuse treatment. American Journal of Public Health 87:1659-1664. Simpson DD. 1997. Effectiveness of drug-abuse treatment: A review of research from field settings. In: Egertson JA, Fox DM, Leshner Al eds. Treating Drug Abusers Effectively. Malden, MA: Blackwell Publishers. Willenbring ML. 1995. Case management application in substance use disorders. Journal of Case Management 3:150-157.

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Willenbring ML, Ridgely MS, Stinchfield R, Rose M. 1991. Application of Case Management in Alcohol and Drug Dependence: Matching Techniques and Populations . DHHS Pub. No. ADM 91-1766. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. OPPORTUNITIES FOR COLLABORATION: ADOLESCENT OUTREACH AND EARLY INTERVENTION Studies of substance use among youth go back a half-century in the United States (Glad, 1947). Four decades ago an official at the World Health Organization first identified a worldwide pandemic of substance abuse among youth (Cameron, 1968). Since that time, investigators have identified the association of substance abuse with numerous social and behavior problems among youth, including: delinquency (Farrow and French, 1986); risk of physical and sexual abuse (Dembo et al., 1987); suicide, at least in some subgroups of adolescents (Berlin, 1987; Bechtold, 1988; Dizmang et al., 1974; Grossman et al., 1991); driving while intoxicated (Harwood and Leonard, 1989); illegitimate pregnancy (Gilchrist et al., 1990); and running away, especially among females (Fors and Rojek, 1991). Considerable information exists regarding the epidemiology and clinical characteristics of adolescent substance abuse (Johnson and Marcos, 1988). Young substance abusers are more apt to abuse alcohol, cannabis, inhalants (Beauvais et al., 1985; Padilla et al., 1979; Schwartz, 1988; Westermeyer et al., 1994) and less apt to abuse cocaine and heroin. Antisocial behavior is especially apt to accompany substance abuse in adolescents (Osuna and Luna, 1988) although many cases do not involve such behavior. High rates of several comorbid psychiatric disorders accompany early onset substance abuse in adolescents (Burke et al., 1994; Deykin et al., 1992; King et al., 1993; Myers et al., 1990; Westermeyer et al., 1994). Institutionalized youth are at particular risk to substance abuse (Cockerham, 1975), as are particular ethnic and socioeconomic groups (Cockerham et al., 1976). Prevention services for adolescents have been developed and well studied (Perry, 1986). However, much of these data indicate a delay in substance use rather than prevention of eventual substance abuse. Most data on adolescent treatment focuses on description of services, anecdotal reports, or uncontrolled studies (Tarter, 1990). Data on outreach, early intervention, treatment outcome, and cost efficacy for adolescent substance

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abusers is remarkably sparse. Special treatment alternatives for adolescents (e.g., school-based adult-led self-help groups, switching schools, relocation of families with affected adolescents to a new neighborhood) remain essentially unstudied, although they often undertaken and sometimes even recommended by clinicians. Some interesting models for working with adolescents in groups have been developed, but not well researched (Red Horse, 1982). Local mass media may be a useful means for reaching adolescents in particular (Skirrow, 1987). In order to conduct quantitative research among adolescents, adolescent-specific instruments are needed (Mayer and Filstead, 1979). Issues regarding validity of data obtained from adolescents differ in certain respects from adults (Winters et al., 1991). REFERENCES Beauvais F, Oetting ER, Edward RW. 1985. Trends in the use of inhalants among American Indian adolescents. White Cloud Journal 3:3. Bechtold DW. 1988. Cluster suicide in American Indian adolescents. American Indian and Alaska Native Mental Health Research 1(3):26-35. Berlin IN. 1987. Suicide among American Indian adolescents: An overview. Suicide and Life Threatening Behavior 17(3):218-232. Burke JD, Burke KC, Rae DS. 1994. Increased rates of drug abuse and dependence after onset of mood or anxiety disorders in adolescence. Hospital Community Psychiatry 45(5):451-455. Cameron DC. 1968. Youth and drugs: A world view. Journal of the American Medical Association 206:1267-1271. Cockerham WC. 1975. Patterns of drinking behavior among institutionalized and non-institutionalized Wyoming youth. Journal of Studies on Alcohol 36:993-995. Cockerham WC, Forslund MA, Roboin RM. 1976. Drug use among White and American Indian high school youth. International Journal of Addiction 11(2):209-220. Dembo R, Derthke M, LaVoie L, Borders S, Washburn M. 1987. Physical abuse, sexual victimization and illicit drug use: A structural analysis among high risk. Journal of Adolescence 10(1):10-34. Deykin EY, Buka SL, Zeena TH. 1992. Depressive illness among chemically dependent adolescents . American Journal of Psychiatry 149(10): 1341-1347. Dizmang LH, Watson J, May PA, Bopp J. 1974. Adolescent suicide at an Indian reservation. American Journal of Orthopsychiatry 44(1):43-49. Farrow JA, French J. 1986. The drug abuse-delinquency connection revisited. Adolescence 21:951-960. Fors SW, Rojek DG. 1991. A comparison of drug involvement between runaways and school youths. Journal of Drug Education 21(1):13-25. Gilchrist LD, Gillmore MR, Lohr MJ. 1990. Drug use among pregnant adolescents. Journal of Consulting and Clinical Psychology 58(4):402-407. Glad DD. 1947. Attitudes and experiences of American-Jewish and American-Irish male youth as related to differences in adult rates of inebriety. Quarterly Journal of Studies of Alcohol 8:406-472. Grossman DC, Milligan BC, Deyo RA. 1991. Risk factors for suicide attempts among Navajo adolescents. American Journal of Public Health 81(7):870-874.

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Harwood MK, Leonard KE. 1989. Family history of alcoholism, youthful antisocial behavior and problem drinking among DWI offenders. Journal of Studies on Alcohol 50(3):210-216. Johnson RE, Marcos AC. 1988. Correlates of adolescent drug use by gender and geographic location. American Journal of Drug and Alcohol Abuse 14(1):51-63. King CA, Naylor MW, Hill EM, Shain BN, Greden JF. 1993. Dysthymia characteristics of heavy alcohol use in depressed adolescents. Biological Psychiatry 33(3):210-212. Mayer J, Filstead WJ. 1979. The Adolescent Alcohol Involvement Scale: An instrument for measuring adolescents' use and misuse of alcohol. Journal of Studies on Alcohol 40(3):291-300. Myers WC, Burket RC, Lyles WB, Stone L, Kemph JP. 1990. DSM-III diagnoses and offenses in committed female juvenile delinquents. Bulletin of the American Academy of Psychiatry and the Law 18(1):47-54. Osuna E, Luna A. 1988. Adolescent drug use and antisocial behavior. Medicine and Law 7(4):365-330. Padilla ER, Padilla AM, Morales A. 1979. Inhalant, marijuana and alcohol abuse among barrio children and adolescents. International Journal of the Addictions 14:945-964. Perry CI. 1986. Results of prevention programs with adolescents. Drug and Alcohol Dependence 20:13-19. Red Horse Y. 1982. A cultural network model: Perspectives for adolescent services and paraprofessional training. In: Manson S ed. New Directions in Prevention Among American Indian and Alaska Native Communities. Portland, OR: University of Oregon. Schwartz RH. 1988. Deliberate inhalation of isobutyl nitrate during adolescence: A descriptive study. NIDA Research Monograph 83:81-85. Skirrow J. 1987. II. Influencing the adolescent life style: The role of mass media. Drug and Alcohol Dependence 20:21-26. Tarter RE. 1990. Evaluation and treatment of adolescent substance abuse: A decision tree method. American Journal of Drug and Alcohol Abuse 16(1-2):1-46. Westermeyer J, Specker S, Neider J, Lingenfelter MA. 1994. Substance abuse and associated psychiatric disorder among 100 adolescents. Journal of Addictive Diseases 13(1):67-83. Winters KC, Stinchfield RD, Henly GA, Schwartz R. 1991. Validity of adolescent self-report of substance involvement. International Journal of the Addictions 25:1379-1395. OPPORTUNITIES FOR COLLABORATION: COMMUNITY REINFORCEMENT Formal research on Community Reinforcement began 25 years ago, with the work of Hunt, Azrin and coworkers (Azrin, 1976; Hunt and Azrin, 1973). Despite the utility of their early work and the time that has elapsed since then, relatively few studies have been undertaken regarding community reinforcement. Those few that have been undertaken have demonstrated the cost efficacy of this approach. They include the following: the role of the community in motivating drug abusers to seek treatment, organizing groups of addicts to seek treatment concurrently, and in providing family/household support for the addict in treatment (Westermeyer and Bourne, 1978);

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the adjunctive role of disulfiram in the Community Reinforcement treatment of alcoholism (Azrin et al., 1982); the effectiveness of a work program for young drug abusers in the community (Stead et al., 1990); the application of these principles to the chronic public inebriate (Willenbring et al., 1990); and the utility of the Community Reinforcement treatment in the care of substance abusers and addicts, as well as in rural settings and among ethnic minority groups (Miller et al., 1992). Although these investigators have demonstrated the effectiveness, and even the cost efficacy of these methods, they have not been widely applied. This is probably due to the complexity of the approach, the need for community and treatment resources to cooperate, the requirement for an overarching plan with ''reinforcement" of the respective positive as well as negative consequences. In order to work effectively, the reinforcements must be consistently and fairly applied over lengthy periods of time. Political support and diverse funding streams add to the further difficulty of establishing and maintaining Community Reinforcement programs. REFERENCES Azrin NH. 1976. Improvements in the community-reinforcement approach to alcoholism. Behavior Research Therapy 14:339-348. Azrin NH, Sisson RW, Meyers R, Godley M. 1982. Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry 13:105-112. Hunt GM, Azrin NH. 1973. A community-reinforcement approach to alcoholism. Behavior Research Therapy 11:91-104. Miller WR, Meyers RF, Tonigan JS, Hester RK. 1992. Effectiveness of the Community Reinforcement Approach. Albuquerque, NM: Center on Alcoholism, Substance Abuse, and Addictions. Stead P, Rozynko V, Berman S. 1990. The SHARP carwash: A community-oriented work program for substance abuse patients. Social Work 35(1):79-80. Westermeyer J, Bourne P. 1978. Treatment outcome and the role of the community in narcotic addiction. Journal of Nervous Mental Disorders 166:51-58. Willenbring ML, Whelan JA, Dahlquist JS, O'Neal MW. 1990. Community treatment of the chronic public inebriate: I. Implementation. Alcoholism Treatment Quarterly 7(1):79-98. OPPORTUNITIES FOR COLLABORATION: OUTREACH STRATEGIES FOR EARLY INTERVENTION AND TREATMENT FOLLOW-UP Outreach activities can be used for two purposes: to intervene early in the course of addiction and bring substance abusers to treatment before

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their resources diminish and their problems exacerbate. However, there are several difficulties associated with outreach, as follows: expense for personnel, material, and other resources; deciding how to target endeavors in the most cost-effective manner; the need to collaborate closely with social institutions with which addiction treatment facilities have limited experience (e.g., churches, schools, police, private associations); risk to violence, especially in certain lower socioeconomic neighborhoods or in groups that might be threatened by early intervention activities (e.g., gangs, certain clubs or bars); and many clinicians and researchers have little experience in outreach activities, or virtually any intervention activities outside of the clinic or laboratory. Despite the obstacles, outreach efforts have been successful in several settings. These include: outpatient clinics (Lowe and Alston, 1973); seeking community cohorts of addicts to enter treatment concurrently or at least within months of one another (Westermeyer and Bourne, 1978); schools (Red Horse, 1982); community programs for mentally retarded persons (Westermeyer et al., 1988); and building a community consensus about modal or acceptable use versus unacceptable use (Beauvais, 1992). Outreach has not been studied in a variety settings in which results might be fruitful. One of these involves individuals who have been injured and/or involved in vehicular crashes (Morbidity and Mortality Weekly Report, 1989). Cost efficacy of various outreach strategies are not available. REFERENCES Beauvais F. 1992. The need for community consensus as a condition of policy implementation in the reduction of alcohol abuse on Indian reservations. American Indian and Alaska Native Mental Health Research 4(3):77-81. Lowe GD, Alston JP. 1973. An analysis of racial differences in services to alcoholics in a southern clinic. Hospital Community Psychiatry 24:547-551. Morbidity and Mortality Weekly Report. 1989. Motor vehicle crashes and injuries in an Indian community-Arizona. Morbidity and Mortality Weekly Report 38:589-591.

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Red Horse Y. 1982. A cultural network model: Perspectives for adolescent services and paraprofessional training. In: Manson S ed. New Directions in Prevention Among American Indian and Alaska Native Communities. Portland, OR: University of Oregon. Westermeyer J, Bourne P. 1978. Treatment outcome and the role of the community in narcotic addiction. Journal of Nervous Mental Disorders 166:51-58. Westermeyer J, Phaobtong T, Neider J. 1988. Substance use and abuse among mentally retarded persons: A comparison of patients and a survey population. American Journal of Drug and Alcohol Abuse 14(1):109-123. OPPORTUNITIES FOR COLLABORATION: RESEARCHING SPIRITUAL, "FOLK," AND OTHER NONTRADITIONAL INTERVENTIONS Large numbers of substance abusers seek relief in a variety of spiritual, religious, ethnic, and nontraditional treatments and programs. Acupuncture, one example of this category, has been addressed elsewhere in this report. Students of addiction, such as Galanter, have described the potent influence of religious influence on the lives of those affiliating with religious groups (Galanter and Westermeyer, 1980). Of interest, active substance abuse and religious practice tend to be inversely related (Westermeyer and Walzer, 1975). Certain modern treatments for addiction, such as the "anonymous" self-help groups, have their bases in religious movements (Johnson and Westermeyer, 1997). So far, most studies in this area have focused on descriptions (Jilek, 1976; Westermeyer, 1988). Several qualitative and anecdotal reports have documented religious affiliation as a successful means of recovering from substance abuse (Kearny, 1970). A few studies have shown the feasibility of studying addiction treatment in religious settings (Westermeyer, 1980). In one quasi-experimental comparison of a religion-based program versus a medically based program for opiate addicts in Asia, the religion-based program had a higher mortality during opiate withdrawal; but follow-up failed to show differences between abstinence rates between the two therapies (Westermeyer and Bourne, 1978). In the latter study, community factors (e.g., community cohort treatment, a clinician or mentor committed to the addict's sobriety) were potent correlates of abstinence in both groups. More such studies are needed in a variety of settings in order to establish those dimensions of such interventions that may be efficacious in abating drug misuse, abuse, and dependence. REFERENCES Galanter M, Westermeyer J. 1980. Charismatic religious experience and large-group psychology. American Journal of Psychiatry 137(12):1550-1552.

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Jilek WG. 1976. "Brainwashing" as a therapeutic technique in contemporary Canadian Indian spirit dancing: A case in theory building. Anthropology and Mental Health 201-213. Johnson DR, Westermeyer J. 1997. Psychiatric therapies influenced by religious movements. In: Boehnlein J ed. Textbook on Religion and Psychiatry. Washington, DC: American Psychiatric Press. Kearny M. 1970. Drunkenness and religious conversion in a Mexican village. Quarterly Journal of Studies on Alcohol 31:248-249. Westermeyer J. 1980. Treatment for narcotic addiction in a Buddhist monastary. Journal of Drug Issues 10:221-228. Westermeyer J. 1988. Folk medicine in Laos: A comparison between two ethnic groups. Social Science and Medicine 27(8):769-778. Westermeyer J, Bourne P. 1978. Treatment outcome and the role of the community in narcotic addiction. Journal of Nervous Mental Disorders 166:51-58. Westermeyer J, Walzer V. 1975. Drug usage: An alternative to religion? Diseases of the Nervous System 36(9):492-495.