Journal of Psychoactive Drugs Substance Abuse ...

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Substance Abuse Treatment Outcomes Among American Indians in the Telephone Aftercare Project a

Jenny Chong & Mindy Herman-Stahl a

b

Rural Health Office, College of Public Health, University of Arizona , Tucson, Arizona

b

Health, Social and Economics Research, Research Triangle Institute, Research Triangle Park , North Carolina Published online: 07 Sep 2011.

To cite this article: Jenny Chong & Mindy Herman-Stahl (2003) Substance Abuse Treatment Outcomes Among American Indians in the Telephone Aftercare Project, Journal of Psychoactive Drugs, 35:1, 71-77, DOI: 10.1080/02791072.2003.10399996 To link to this article: http://dx.doi.org/10.1080/02791072.2003.10399996

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Substance Abuse Treatment Outco01es A01ong American Indians in the Telephone Aftercare Projectt

Downloaded by [University of Arizona] at 12:43 30 April 2015

Jenny Chong, Ph . D . * & Mindy Herman-Stahl, Ph.D . * *

Abstract-Thirty American Indians who had successfully completed their residential substance abuse treatment program with Phoeni x-based Native American Connections, Inc. agreed to participate in the Telephone Aftercare Program when they returned to their homes on the reservation. They were provided with graduated monthly aftercare contacts through the telephone for a nominal period of six months, during which time they were interviewed monthly regarding their substance use, and on other life domains at three and six months following discharge from their residential program. Using their baseline data as the comparison, results suggest that six months following residential treatment, clients showed decreased drinking and other drug use, had fewer encounters with the criminal justice system, and had improved familial and social interactions and relationships. Keywords-Addiction Severity Index, aftercare, alcohol ism, substance abuse

alcohol use disorders among American Indians are high, ranging from 36% to 85% depending on measurement ap proaches (Bray et al. 1 999; Chong & Herman-Stahl 1 997; Manson et al. 1 992). Second, life on the reservation is as sociated with high levels of stress which is linked to alcohol use (e.g., Brindis et al 1 995; Manson et al. 1 992). Third, access to appropriate treatment is limited. Barriers to ob taining treatment i nc l ude l ack of transportation, low finances, few treatment choices, and inconvenient hours for treatment (Herman-Stahl , Chong & Dye 1 996). Many American Indians have to travel off-reservation to receive services provided by a limited number of American Indian specific facilities that contract directly with the Indian Health Service (IHS) or tribal health departments. Although many tribes have outpatient services or self-help recovery groups, they are often underutilized because potential cli ents lack trust in the confidentiality of such services. In addition, resource constraints, managed care, and conver sion to tribal compacting (i.e., giving tribes the opportunity

Abstinence following substance abuse treatment is dif ficult for all individuals, but may be particularly challenging for American Indians living on reservations. Several fac tors are l i kely contributors to this difficulty. First, -the widespread use of alcohol and drugs on the reservation can lead to pressure to reinitiate use. Prevalence rates of tFunding for this project was made possible by the National Institute on Alcohol Abuse and Alcoholism through contract # I R2 1 AA 120640 I . The Human Subjects Committee ( institutional review board) of the Uni versity of Arizona authorized the approval of this project through the e x p edited review procedure, w i t h the condition(s) that subjects' anony mity be maintained. The authors gratefu l l y acknowledge the assistance of B arbara Clarihew, Kristen Jennings, Judy Marut, Nolan Roberts, and the support of Diana Yazzie Devine, and also extend their si ncere thanks to the telephone aftercare participants. *Assistant Professor, Rural Health Office, College of Public Health, Uni versity of Arizona, Tucson, Arizona. * * Research Psychologist, Health, Social and Economics Research, Research Triangle Institute, Research Triangle Park, North Carolina. Please address all correspondence an d rep rint requests to Jenny Chong, Rural Health Office, College of Public Health, University of Arizona, 250 I East E l m Street, Tu cson, Arizona 857 1 6 . Emai l : jchong @ u .arizona.edu

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Telephone Aftercare Project


Chong & Herman-Stahl

telephone aftercare reported fewer alcohol-related prob lems and fewer visits to an outpatient center, spent fewer days in a mental health center and/or j ail, and were less likely to be arrested (Connors, Tarbox & Faillace 1992; Fitzgerald & Mulford 1 985). Furthermore, no differences in effectiveness were found between telephone aftercare and traditional group aftercare; similar positive outcomes (e.g., fewer outpatient visits) have been found within pri mary care settings (Wasson et al. 1 992). Recognizing the difficulty in preventing relapse among American Indians returning to the reservation following treatment at an urban center, the authors designed a spe cial "step-down" module to be provided via telephone. With funding provided by the National Institute on Alcohol Abuse and Alcoholism, Native American Connections, Inc. (NACI), in collaboration with the Rural Health Office of the University of Arizona, developed and implemented the Telephone Aftercare Project. NACI is a Phoenix-based substance abuse treatment agency providing culturally specific treatment for American Indians. The main aim of this project, which is essentially a pilot study, was to as sess the feasibility of providing aftercare contacts through the telephone to NACI clients following their return to the reservation. A secondary aim was to provide a preliminary assessment of treatment outcomes. This article reports on the preli minary outcomes of the Telephone Aftercare Project participants. Since this was a feasibility study, the number of clients participating in the project was limited to 30. As such, i ndividuals' change over time may not be reliably detected. Nevertheless, because there is so little information about treatment outcomes among American Indians, the results are offered here as a preliminary step to encourage future research.

to assure the responsibility of programs traditionally ad ministered by professional agencies) have all complicated the substance abuse service delivery system (Manson 2000; Noren, Kindig & Sprenger 1 998). Most of the studies on substance abuse treatment out comes for American Indians suggest high relapse rates. Westermeyer and Neider ( 1 984) reported that of the Ameri can Indians followed up ten years after discharge from a hospital inpatient program, 86% of male alcoholics were the same, worse, or dead, ten years later. Similarly, Kivlahan and colleagues ( 1 985) found that 94% of American Indian clients followed up two years after detox treatment were still symptomatic, and 70% had utilized detox 1 5 or more times. In our own work (Herman-Stahl & Chong In press), we found that 85% of those who had received treatment in the past year reported alcohol use in the past 30 days. To improve the chances of clients remaining abstinent, support must be available and accessible for them as they return home to the reservation. Such support can come in the form of aftercare services. Aftercare is a phase of treat ment involving continued contact and service provision to clients following the termination of a formal treatment pro gram (10M 1 990). Aftercare generally focuses on relapse prevention and is designed to "diminish, forestall, or at tenuate relapses following treatment" (Marlatt & Gordon 1 985). Clients are taught to anticipate and deal with high risk events using newly acquired cognitive and behavioral coping ski lls without reverting to pretreatment substance using behaviors (Annis & Davis 1 99 1 ). Relapse prevention aftercare extends the supportive context of treatment and offers a stabilizing force as the client becomes proficient in using the new skills while developing a supportive network. Participation in aftercare appears to have a positive impact on treatment outcomes (e.g., McKay 200 1 ; Marlatt & Gordon 1 985; Ornstein & Cherepon 1 985; Ahles et al. 1 983; Costello 1 980). In general, participation i n aftercare is associated with abstinence or lower levels of posttreat ment alcohol consumption (i.e., quantity), fewer drinking days (Ito & Donovan 1 990), fewer drinking-related prob lems (Timko et al 1 994 ), and fewer symptoms of alcohol dependence (Gilbert 1 988). Aftercare attendance also in creases the likelihood of using drinking reduction strategies, which are positively associated with abstinence and light drinking (Connors, Tarbox & Faillace 1 992). Because American I nd i a n s have l i m ited access to aftercare services, innovative approaches are needed to sus tain care. Following up clients through the telephone may offer a cost-effective and convenient approach. The poten tial of "long-distance" delivery of mental health services had been examined by the American Psychological Asso ciation (Sleek 1 997). There are only a few studies reporting on the use of substance abuse aftercare provided over the telephone. These interventions were found to be effective in decreasing alcohol-related problems. Individuals receiving

Journal of Psychoactive Drugs

METHOD Recruitment Clients from the NACI male and female residential facilities within two weeks of graduating from the 45-day treatment program were approached regarding participa tion in the study. There were three requirements for eligibility: ( 1 ) clients must have successfully completed the residential substance abuse treatment program; (2) cli ents must not be discharging to a controlled facility (e.g., prison, tran sitional hous i n g ) ; and ( 3 ) c l i ents must be returning to an Indian reservation upon discharge. Partici pation i n the Telephone Aftercare Project was voluntary and did not affect any other services offered at NACI. A daily census from the NACI administration was used to identify potential clients. Clients were required to give their active consent to participate and were assured that all in formation would be kept confidential . All participants received the aftercare intervention. (There is no control group.)

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Data Collection The research protocol and the human subjects consent form were approved by the University of Arizona's Insti tutional Review Board. During the baseline (i ntake) interview, the research interviewer reviewed the purpose and requirements of the Telephone Aftercare Project and obtained a signed consent form and the relevant release of information forms. Follow-up interviews occurred monthly for six months. Full interviews occurred at baseline, and the third and sixth months fol lowing discharge. During the first, second, fourth, and fifth month post discharge, par ticipants were contacted for a brief 1 0-minute check-in to increase retention and to assess substance use behaviors in the past month. Participants were paid $4 for each brief check-in, and $ I 0 and $20 for the third month and sixth month full interviews respectively. The research interviewer was trained over several days on the use of Computer Assisted Personal Interviewing, clinical interviewing skills, project and interview protocols and client confidentiality. One of the principal investiga tors mon itored approx i m ate l y 20% of the base l i ne interviews and a random sample of follow-up interviews to ensure that the protocol was being followed.- Client per m i s s i o n was obtai ned before a n y i n terviews were monitored.

These questions concerned life events or milestones com monly experienced by American Indians returning to the reservation following substance abuse treatment. Questions included relationship changes (e.g., regaining custody of children, making new friends, or ending a relationship); negative feelings and emotions (e.g., feeling bored, crav ing alcohol ) ; and perceptions of physical and mental health. RESULTS Thirty individuals (2 1 females and nine males) were recruited into the Telephone Aftercare Project over a pe riod of l l months. Eight females refused to participate, and three females were dropped from the study because they did not meet with the aftercare counselor prior to discharge. The telephone aftercare participants ranged in age between 1 9 and 46 years, with a mean age of 3 1 . 1 years (SO 6.8). Clients were enrolled members of tribes located in Arizona, New Mexico, Utah, and Nevada. The majority of the cli ents who were followed up had some contact with the Telephone Aftercare Counselor. Clients at NACI had numerous problems in multiple realms of their lives. Many had a long history of abuse, trauma, family addiction, and poverty. Only half of the cli ents were employed, most earning very low wages despite the fact that most had a profession, trade, or skill. Most clients came from broken homes, and the majority reported having at least one parent with a substance abuse problem. Approximately half had experienced physical or sexual abuse during childhood. Violence and victimization con tinued into their adulthood, with more than three-fourths reporting emotional or physical abuse by their partner. Most clients reported legal problems and poor emotional health. The majority of clients had suffered from serious depres sion or anxiety and more than a third had attempted suicide. Many also had difficulties with anger control. Most clients reported living with family or partners and the majority had children. Two in three clients cited problematic family relationships. Clients had long histo ries of substance use. Alcohol use started when most were 1 3 years of age and drinking to intoxication followed shortly after at 14.6 years. Drinking to intoxication started as early as eight years of age for some. The onset of other drug use generally did not start until their twenties, except for mari juana use which began at around 1 5 years of age. Alcohol was considered the substance that caused the most prob lems, although seven clients named illegal drugs as highly problematic. Not all clients reported that their alcohol or drug-related problems were bothersome to them, although all clients reported criminal justice problems, hospitaliza tions, and a third reported chronic medical problems. More than 80% had received substance abuse treatment prior to entering NACI.

Outcome Measures The Native American Addiction Severity Index (NA ASI) was used to capture information regarding treatment outcomes. The NA-ASI is an adaptation of the Addiction Severity Index (ASI) and was developed to accommodate American Indian cultural practices (Carise et al. 1 998), based on pilot tests with North Dakota tribes (Carise & McLellan 1 997). The ASI is a structured, 45-minute clini cal research interview designed to assess problem severity in the fol lo w i n g seven doma i n s : ( l ) medical status, (2) employment status, (3) family and social relationship, (4) alcohol use, (5) drug use, (6) legal status, and (7) psy chiatric status. Items assess the number, extent, and duration of prob lem symptoms in the patient's lifetime and in the past 30 days. The client also supplies a subjective rating of the re cent (past 30 days) problems and the importance of each problem. These items are then used to create composite scores to measure change from intake to posttreatment follow-up (McLellan et al . l 985b ). The ASI has been used in a variety of settings and has been shown to have good rel i a b i l ity and validity among different populations (Grissom & Bragg 1 99 1 ; Kosten, Rounsaville & Kleber 1 98 3 ; McLellan et al. 1 985a). The NA-ASI includes an additional domain pertaining to American Indian cultural and spiritual experiences (e.g., use of tribal medicine provider, boarding school experience, years spent on the reservation). Another set of questions based on a questionnaire de veloped by B rindis and colleagues ( 1 995) was utilized. Journal of Psychoactive Drugs

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TABLE 1 Paired t-Tests Comparing Baseline and Follow-up Regarding the Past 30 Days

Number No alcohol use Days used alcohol in past 30 days Observed (t-values) Days used alcohol in past 30 daysIntention-to-treat model (t-values)

Baseline

Baseline

(all)

(Month 3) II

30 4

Month 3

Baseline

Month 6

(Month 6) II

13

9

13 II

4.6**

4. 1 * *

1 .4 1

2.04*

Note: Month 3 baseline includes only those participants who were interviewed at the month 3 follow-up. Month 6 baseline includes only those participants who were interviewed at the month 6 follow-up


* P 0.01

Changes in Substance Use Behaviors To assess client outcomes, the client's baseline infor mation was compared with that obtai ned d uri n g the follow-up interviews using paired t-tests (two-tailed). To assess changes in substance use behaviors, analyses focused on use of alcohol (yes/no) in the past 30 days as well as the number of days drinking alcohol in the past 30. At baseline, 87% of clients reported alcohol use in the past 30 days. At the follow-up, among those who were reached for inter views, 1 5 % to 1 9% reported alcohol use in the past 30 days depending on the month of interview (see Table I ). To guard against bias due to attrition, an intention-to-treat model was also analyzed. In this model, results were recoded so that any client not located at follow-up was considered to have relapsed. When those who were not reached were coded as relapsed, the estimated proportion of participants using al cohol in the past 30 days at follow-up ranged from 43% to 73% (again, depending on the month the interview was con ducted). A paired-sample t-test also was used to compare the number of days in the past 30 that alcohol was used prior to entering treatment at NACI and at the follow-up. Results showed significant reductions (p < .00 1 ) at all fol low-up points, with an average difference of 1 3 to 1 5 days of drinking. Moreover, the percentage of those drinking to intoxication decreased from 67% at baseline to 33% in the first month and 5 1 % at the six month follow-up (not shown). Using paired t-tests, results comparing the same subjects at baseline and fol low-up intervals showed clients to have had significantly fewer days using alcohol in the past 30 days at months one, two, and six. In the intention-to-treat model, the decline from baseline to follow-up was not significant at months three, four, and five.

sixth month follow-up interviews were used to assess change over time (see Table 2). The alcohol and drug composite indices were created by merging items concerning number of substance using days, amount of money spent on substances, alcohol- or drug-related problems and their perceived i mportance, polydrug use, and the importance of treatment. At three months post discharge, clients demonstrated significant re ductions in alcohol but not other drug-related problems. At six months post discharge there was a significant re duction in other drug-related symptoms, and the reduction in alcohol-related symptoms remained significant. The severity of legal problems showed a significant decline from baseline to three months and six months post discharge. The legal composite score includes information on illegal activities, criminal j ustice involvement, and cli ents' rating of their legal problems. The employment status of clients did not change from intake to post-test. How ever, it must be noted that unemployment is very high on I nd i an reservation s ; therefore, there may be l i m i ted opportunity for employment. No differences between baseline and follow-up were found on the medical status index during either the three-month or six-month follow-up. How ever, only 20% of clients reported medical problems at baseline. The composite score for family and social interactions includes family conflict, marital satisfaction, importance of perceived problems, and importance of problem resolu tion. S i g n i ficant reductions were found at both the three-month and six-month fol low-up. The psychiatric symptoms index was based on reports of the number of days experiencing psychiatric problems and the importance of these symptoms. At three months, there was no signifi cant decline i n psychiatric symptoms; however, at six months post discharge clients evidenced notable declines in the frequency and severity of emotional problems.

Changes in the Severity of Problems The severity of the problems experienced in the different domains of the participant's life was assessed using com posite scores calculated from responses to items in the AS I . The composite scores have a maximum o f I (indicating severe problems) and a minimum of 0 (indicating no prob lem in the past 30 days). Data obtained from the third and

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DISCUSSION It was clear from the participants' background and experiences that many factors existed that would present 74

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TABLE 2 Changes in ASI Composite Scores from Baseline to Follow-up

ASI Categories

Alcohol Drugs


Legal Employment Medical Family/social Ps:r:chiatric *P