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Substance Abuse Treatment: Addressing the Specific Needs of Women [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.)
In This Chapter.
Women often encounter numerous obstacles and barriers prior to and during the treatment process. While these hurdles may not be entirely unique to women, they are often more common for women due to the myriad pressures associated with assuming various caregiver roles, intrinsic socioeconomic and health conditions (particularly for women with substance use disorders), and societal bias and stigma associated with substance abuse. These challenges often interfere with treatment initiation and engagement.
This chapter is devoted to the exploration of treatment barriers as well as to the engagement strategies conducive to supporting treatment initiation for women. Considerations in treatment placement and the importance of client involvement are reviewed. The chapter ends with an overview of American Society of Addiction Medicine (ASAM) placement criteria for each treatment level with emphasis on issues specific to women, pregnant women, and women and children.
Making a decision to change is an essential step toward fulfilling any goal, but is only one ingredient of a successful outcome. Many times, the idea of making a change is shortsighted: How often has a decision been made without looking beyond the initial necessity or enthusiasm for the change? To support change across time, obstacles need to be anticipated and strategies need to be developed either to decrease the occurrence of the barriers or to find alternative routes around the potential obstacles.
Barriers to treatment are not exclusive to women (for review, see Appel et al. 2004), yet identifying potential challenges and obstacles can help enable successful treatment engagement and outcome. Historically, women have identified multiple factors as barriers to entering treatment, to engaging and continuing the utilization of treatment services across the continuum of care, and in maintaining connections with community services and self-help groups that support long-term recovery (see Figure 5-1 for an overview of barriers identified in the Substance Abuse and Mental Health Services Administration's (SAMHSA's) National Survey on Drug Use and Health [NSDUH]).
Percentages of Reasons for Not Receiving Substance Use Treatment in the Past Year Among Women Aged 18 to 49 Who Needed Treatment and Who Perceived a Need for It: 2004–2006.
While the identification of barriers is essential to effective case management and treatment planning, it is equally important to develop specific strategies to address each barrier as early as possible. As highlighted in the Center for Substance Abuse Treatment's (CSAT's) Comprehensive Substance Abuse Treatment Model for Women and Their Children (for review, see Appendix B; HHS 2004), strategies to overcome these barriers need to focus on three core areas: clinical treatment services, clinical support services, and community support systems. Without a proactive plan to address barriers, women will not be as able to engage in or benefit from substance abuse treatment.
At the outset, barriers may exist on several levels:
Intrapersonal: Individual factors including health problems, psychological issues, cognitive functioning, motivational status, treatment readiness, etc.
Interpersonal: Relational issues including significant relationships, family dynamics, support systems, etc.
Sociocultural: Social factors including cultural differences; the role of stigma, bias, and racism; societal attitudes; disparity in health services; attitudes of healthcare providers toward women; and others.
Structural: Program characteristics including treatment policies and procedures, program design, and treatment restrictions.
Systemic: Larger systems including Federal, State, and local agencies that generate public policies and laws; businesses including health insurance companies; and environmental factors such as the economy, drug trafficking patterns, etc.
Various individual factors impede interest in and commitment to entering treatment. The anticipation of not being able to use substances to cope with stress, to manage weight, or to deal with symptoms associated with other mental disorders creates considerable apprehension in making a commitment to treatment. While the level of motivation and the degree of treatment readiness may also obstruct a woman's commitment to treatment (Miller and Rollnick 2002), there are other individual characteristics that may serve as a barrier to treatment, including feelings related to previous treatment failures, feelings of guilt and shame regarding use and behavior associated with use, fear of losing custody of children if the drug or alcohol problem is admitted and treatment is sought, feelings of helplessness, and a belief that change is not possible (Allen 1995; Greenfield 1996).
Moreover, health issues can serve as a powerful roadblock for women. Depending on the medical diagnosis and severity of the disorder, women may encounter difficulties in accessing treatment, securing appropriate services, and coordinating medical and substance abuse treatment needs. Many women neglect their health while they are actively using substances, hence treatment entry may be delayed or difficult to coordinate due to the additional burden imposed by health issues (including HIV/AIDS, viral hepatitis and other infectious diseases, mental disorders, and gynecological and obstetric needs). Thus, poor physical health may hinder entry into treatment (Jessup et al. 2003).
Because women are usually the primary caregivers of children as well as of other family members, they are often unable or not encouraged to enter and remain in treatment. Also, sometimes their families and friends are involved with substance use and abuse. Further, women may share a social network in which drug or alcohol use is a central activity. This group of family and friends may see no benefit in and offer no encouragement for becoming alcohol and drug free (Amaro and Hardy-Fanta 1995; Finkelstein 1993; Salmon et al. 2000). While women report fear of losing their partner during treatment, they are particularly vulnerable to losing their partner upon entering treatment (Lex 1991). In addition, women generally fear family or partner reactions or resistance to asking for help outside the family.
Women are more stigmatized by alcohol and illicit drug use than men, being characterized sometimes as morally lax, sexually promiscuous, and neglectful as mothers. In addition, women who have children often fear that admitting a substance use problem will cause them to lose custody of their children. They worry that they will be perceived as irresponsible or neglectful—as “bad mothers” if they admit to substance abuse or dependence. These fears and stereotypes compound a woman's shame and guilt about substance use (Finkelstein 1994) and subsequently interfere with help-seeking behavior.
To compound the issue, women in some cultural groups experience more negative attitudes toward their substance use in general and may express more difficulty in engaging in help-seeking behavior and treatment services based on gender roles and expectations. For example, Asian women, in conjunction with cultural practices and level of acculturation, may have considerable difficulty in engaging in mix-gender groups due to the value placed upon male offspring, gender role expectations, and patriarchal family hierarchy (Chang 2000). African-American and Native-American women are likely to mistrust treatment services. Specifically, Jumper Thurman and Plested (1998) reported that Native-American women list mistrust as one of the primary barriers to engaging in treatment services. A more recent study evaluating barriers among African-American women identified staff attitudes as a significant obstacle in maintaining treatment engagement and retention (Roberts and Nishimoto 2006).
The barriers that exist before treatment are often the same obstacles that interfere with successfully completing treatment or maintaining abstinence.
Similar to men, women may face language and cultural barriers that impede involvement or retention in substance abuse treatment. Women whose first language is not English may have language difficulties (Mora 2002). Women with specific needs or from specific groups can face social indifference, lack of culturally appropriate programming, and limited cultural competence among staff. For example, lesbians who are seeking treatment may not trust the service provider or treatment staff to appropriately handle their personal information in a group setting—fearing their sexual orientation will be prematurely disclosed.
According to SAMHSA's 2005 National Survey of Substance Abuse Treatment Services, 87 percent of these programs accepted women as clients, but only 41 percent provided special programs or groups for women. Overall, only 17 percent of treatment facilities offered groups or programs for pregnant or postpartum women (SAMHSA 2006). Being responsible for the care of dependent children is one of the biggest barriers to women entering treatment (Wilsnack 1991). Women who do not have access to a treatment program that provides child care or who cannot arrange alternative child care may have to choose between caring for their children or entering treatment.
Unfortunately, few residential programs have provisions that allow mothers to have their children with them, and outpatient programs often do not provide services for children or child care (Drabble 1996; Finkelstein 1994; Finkelstein et al. 1997). Only 8 percent of substance abuse treatment facilities provided child care in 2003, and only 4 percent provided residential beds for clients' children (SAMHSA 2004). Even when children are accepted into residential treatment, programs often impose age restrictions and limit the number of children a mother is permitted to bring to treatment.
Treatment resources for pregnant women who abuse substances are also scarce. Few programs can simultaneously combine the necessary prenatal care with substance abuse treatment and services for older children (Amaro and Hardy-Fanta 1995; Finkelstein 1993). Finkelstein (1993) stresses that the major barriers to providing resources for pregnant women are based on administrative concerns about medical issues for mothers, infants, and children; fear of program liability; inability to care for infants and lack of services for other children while mothers are in treatment; lack of financial resources; and limited staff training and knowledge about pregnancy and substance use.
Substance abuse treatment providers may not fully understand the needs and the types of interventions most conducive to assisting women in recovery. Vannicelli (1984) found that treatment staff attitudes and unsubstantiated myths about women actually may act as barriers to successful treatment completion among women. In addition, programs may lack cultural competence in addressing treatment issues for women from different cultural or language backgrounds; thus ethnic women may be reluctant to seek treatment if treatment staff or the programs feel foreign, judgmental, hostile, or indifferent.
Even women who are highly motivated for treatment face additional program barriers that may produce significant challenges. These barriers include waiting lists, delayed admission, limited service availability, and preadmission requirements (e.g., paperwork requirements, detoxification). Other barriers are related to program structure, policies, and procedures and include program location, lack of case management services, limited funding sources, and lack of transportation (Wechsberg et al. 2007). Because women are more likely to be poor, their ability to obtain transportation may make it difficult to receive treatment (Lewis et al. 1996). Also, women may have to travel with their children and use public transportation to reach treatment agencies; this can be a hindrance for women in rural areas and for those who have limited income.
Treatment services continue to struggle to effectively broaden the scope of clinical services, secure adequate resources, and adopt gender-responsive policies to address co-occurring disorders. While more programs have endorsed trauma-informed services in conjunction with programming for women, the coordination and integration of these specific services remains limited. In addition to the barriers mentioned above, others may exist regarding compliance with the Americans with Disabilities Act, such as no translators for women who are deaf, lack of materials for individuals who are visually impaired, and lack of treatment program policies and procedures and acceptance of women who are using methadone maintenance.
Many women in need of treatment are involved in multiple social service systems that have different expectations and purpose. According to Young and Gardner (1997), the co-occurrence of a substance use disorder and involvement in the child welfare system ranges from 50 to 80 percent. Moreover, collaboration among substance abuse treatment, child welfare, and welfare reform systems is challenging and often not integrated because of differences in timetables, definition of clients, complexity of client needs, staff education and training, and funding streams (Goldberg 2000; Young et al. 1998).
Services may be fragmented, requiring a woman to negotiate a maze of service agencies to obtain assistance for housing, transportation, child care, substance abuse treatment, vocational training, education, and medical care. In addition, many agencies have requirements that conflict with each other or endorse repetitive intake processes, including different forms that gather the same information. Overall, these simultaneous demands can discourage a woman, particularly when seeking treatment or during early recovery.
Women who have substance use disorders often fear legal consequences. In entering treatment, they sometimes risk losing custody of their children as well as public assistance support (Blume 1997). Likewise, women who have substance use disorders often fear prosecution and incarceration if they seek treatment during pregnancy. The public debate over privacy and the fetus's right to be born free from harm fuels a legal focus on pregnant women who smoke, drink alcohol, or use illicit drugs. “These conflicts have impeded the diagnosis of women with substance abuse problems, the availability of services, and access to appropriate care” (Chavkin and Breitbart 1997, p. 1201).
Treatment engagement approaches are important regardless of gender, yet women are likely to benefit from services that support the initiation of treatment and address the diverse challenges that often hamper treatment involvement. Engagement services include an array of strategies that begin in the initial intake and can extend across the continuum of care. Ultimately, they are designed to promote appropriate access to treatment, to increase treatment utilization, to promote treatment retention, and to enhance treatment outcome. Promising engagement practices have evolved by integrating and centralizing services to meet the wide range of treatment needs and social services for women and children (Niccols and Sword 2005). Today, some programs and communities provide very formal strategies such as comprehensive case management and incentive programs to promote engagement (Jones et al. 2001). Other engagement strategies include more specific services such as transportation and escorts to appointments, phone calls to initiate services and to remind clients of appointments, and child care during scheduled appointments or sessions (for review, see Comfort et al. 2000).
Challenges in Maintaining a Therapeutic Alliance: Child Welfare and Issues of Confidentiality.
Women who are offered services during the intake period are more likely to engage in similar services throughout the treatment process than women from a comparison group (Comfort et al. 2000). Three core engagement strategies that are particularly beneficial for women are outreach services, pre-treatment intervention groups, and comprehensive case management.
Women are more likely to gain awareness of substance abuse treatment if outreach services are implemented. Outreach and engagement services can be clinically effective in increasing the likelihood of entering substance abuse treatment, particularly for those individuals who are less likely to access treatment services (Gottheil et al. 1997). Effective outreach programs, such as the one described in Figure 5-2 (p. 91), are designed to connect women to substance abuse treatment regardless of point of service entry. For example, programs that address domestic violence, HIV/AIDS, or crisis intervention can be a vital conduit for helping women take the first step in connecting to substance abuse services.
PROTOTYPES.
Gross and Brown (1993) outlined three major components of outreach: (1) identifying a woman's most urgent concerns and addressing those first, until she is ready to take on other issues; (2) empathizing with the woman's fears and resistances, while assisting her in following through on commitments; and (3) assisting the woman in negotiating the human service system, particularly when the decision to seek drug or alcohol treatment is stymied by the lack of adequate, appropriate, or accessible programs or when relapse alienates the woman from institutional connections. Although outreach appears to benefit women—in that they are more likely to initiate contact with treatment providers—women's response to outreach services appears related to level of readiness, history of trauma, and degree of support. For instance, Melchior et al. (1999) reported that women who have a history of trauma are more reluctant to follow through with referrals than men.
Clinical Tools and Activities Helping Women Overcome Barriers to Treatment.
Early identification and intervention may prevent more significant alcohol- and drug-related consequences. Pretreatment intervention groups are typically designed to initially provide personalized or structured feedback to clients about their alcohol and drug use, to provide information regarding available treatment services and treatment processes, and to utilize strategies to enhance motivation and to decrease alcohol and drug use. Specific to women, pretreatment groups are designed to address certain psychosocial barriers, including the stigma that is associated with women's substance use. Similar to frequent misconceptions held by clients that detoxification is treatment, pretreatment can be perceived as treatment rather than an initial step. This is particularly the case with women who are either reluctant or suspicious to use treatment services or who are unable to use treatment services at the time (Wechsberg et al. 2007). While research reports that brief interventions are not consistently helpful for women (Chang 2002), more specific research is needed to examine differences in factors that influence early intervention outcomes, including client-matching studies targeting gender.
Comprehensive case management helps bridge the gap between services and agencies. It is based on the premise that services need to match the client's needs rather than force the client to fit into the specific services offered by the agency. With the wide range of services often warranted for most women (especially for women who are pregnant or who have children), comprehensive case management that involves medical and social case management is an essential ingredient (Sorensen et al. 2005). According to Brindis and Theidon (1997), case management serves several functions and provides numerous services for the client, including outreach, needs assessment, planning and resource identification, service linkages, monitoring and ongoing reassessment, and client advocacy. In recent years, communities and agencies have shown considerable progress in developing formal linkages, protocols, and integrated care systems. To date, case management services are key to overseeing the appropriate referral and utilization of services. According to OAS (SAMHSA 2004), approximately 55 percent of facilities provide assistance with obtaining social services, 43 percent provide assistance in locating housing, and 69 percent provide case management services. For an in-depth review, see TIP 27 Comprehensive Case Management for Substance Abuse Treatment (CSAT 1998a).
Research sheds light on the potential value of case management, in that it may be particularly useful for individuals with complex problems (Havens et al. 2007; Morgenstern et al. 2003). Morgenstern and colleagues (2006) completed a study on intensive case management with women receiving Temporary Assistance for Needy Families (TANF). The results show that women assigned to intensive case management had significantly higher levels of substance abuse treatment initiation, engagement, and retention in comparison to women who received only screening and referral. In addition, alcohol and drug abstinence rates were higher and length of abstinence was longer among women involved in case management. An earlier study showed similar results, emphasizing that women assigned to intensive case management accessed a greater variety of services (Jansson et al. 2005). Improvement in abstinence rates and family and social functioning are also noted when case management services are employed (McLellan et al. 2003).
Based on the assessment process, appropriate treatment placement for a client depends on many factors, including the nature and severity of a woman's substance use disorder, the presence of co-occurring mental or physical illnesses or disabilities, and the identification of other needs related to her current situation. Placement decisions are also affected by other psychosocial factors. Once the comprehensive assessment is completed, the placement can be determined.
Women need to be able, whenever possible, to contribute to the planning and placement discussion for their treatment. For example, when residential care is recommended, barriers such as being unable to bring her children may cause a woman to reject the placement option. In this situation, it is critical to work with the woman to make appropriate arrangements to help her enter treatment. Treatment planning must also include assistance in helping her to express needs, make decisions and choices, and recognize that she is the expert on her life. Overall, active client involvement in all aspects of treatment planning significantly contributes to recovery, validates and builds on a woman's strengths, and models collaborative and mutual relationships, including, most importantly, the client–counselor relationship.
To date, limited literature has examined placement criteria specific to women. However, some States have developed criteria for placing women in appropriate treatment options (CSAT 2007). The available State substance abuse treatment standards listed in Figure 5-3, Services Needed in Women's Substance Abuse Treatment, should be considered in placing female clients in specific services.
Services Needed in Women's Substance Abuse Treatment.
The need for appropriate level of care and treatment is not gender specific; both men and women require a range of treatment services at various levels of care. In 1991, ASAM developed patient placement criteria based on matching severity of symptoms and treatment needs with five levels of care. ASAM's Patient Placement Criteria (ASAM's PPC; ASAM 2001) identifies six clinical dimensions: alcohol intoxication and/or withdrawal potential; biomedical conditions and complications; emotional, behavioral, or cognitive conditions and complications; readiness to change; relapse, continued use or continued problem potential; and recovery environment. The levels of care are determined by the presence and severity of issues within each dimension. The current version (PPC-2R) lists five broad levels of care:
Level 0.5: Early intervention
Level I: Outpatient treatment/partial hospitalization
Level II: Intensive outpatient treatment
Level III: Residential/inpatient treatment
Level IV: Medically managed intensive inpatient treatment (ASAM 2001)
ASAM's PPC-2R (2001) is used widely and standardizes treatment placement. It is focused on identifying individual treatment needs, but does not focus specifically on the placement of women or treatment needs that extend to children or family. Counselors needing detailed criteria for each level of care should consult ASAM's PPC-2R Manual. The following review of ASAM's levels of care contains information that is unique and important to women; it is not meant to be a comprehensive overview of ASAM's placement criteria. When there are relevant issues, the specific needs of pregnant women and children are discussed at the end of each level of care.
Early intervention, or ASAM Level 0.5, can be considered a pretreatment service that provides an opportunity for treatment providers to intervene across a wide variety of settings. It is designed for individuals with risk factors or problems associated with substance abuse but with whom an immediate substance-related disorder cannot be confirmed. Services that represent this level of care include assessment, psychoeducational services, and counseling. In essence, the goals for this level of care are prevention and intervention. For example, educational experiences allow clients to gain further awareness of their current substance use and the expected consequences of this use, along with the future consequences of use if they continue on their present course. This level of care also provides a forum to assist individuals in developing skills associated with behavioral change, in creating strategies to avoid future problems related to substance use, and in establishing a supportive pretreatment environment and therapeutic alliance.
Healthcare providers have a window of opportunity in working with women who abuse substances. Brief interventions can provide an opening to engage women in a process that may lead toward treatment and wellness.
Early intervention approaches can be provided through many channels—a drop-in model, in-home or mobile treatment services, or a pretreatment group in a treatment setting. It can also be provided through involuntary venues such as drug courts, or voluntary settings such as outpatient or primary medical care clinics. Faith-based initiatives can also provide opportunities for early interventions.
For women, early intervention services appear quite valuable in enhancing motivation, decreasing anxiety and reluctance in initiating current and future treatment services, gaining support, and establishing strategies to address obstacles associated with treatment access and engagement (Wechsberg et al. 2007). Programs that provide flexibility in attendance, easy access to care, and at-home or mobile services are particularly conducive for women, especially those who have the primary role of parenting. TIP 34 Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a), discusses how to implement brief interventions in substance abuse treatment and other settings.
Pregnancy creates an increased sense of urgency for both clients and counselors because of the temporary upswing in motivation to change and the need for problem resolution. For some women who abuse substances, pregnancy creates a window of opportunity to enter treatment, become abstinent, quit smoking, eliminate risk-taking behaviors, and lead generally healthier lives (Hankin et al. 2000; Nardi 1998). Brief interventions are sometimes effective in helping pregnant women stop using substances (Hankin et al. 2000). Abstinence for pregnant women should be construed to include alcohol, tobacco, caffeine, and many over-the-counter medications, in addition to illicit substances.
Some studies have found that brief interventions using motivational interviewing (MI) in prenatal care can reduce problem drinking by pregnant women (Handmaker and Wilbourne 2001; Miller 2000). Therapists using MI employ a gentle, empathic style to avoid client defensiveness and constructively and compassionately explore ambivalence about change and motivation for recovery (refer to TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999b]). MI may be more effective for those women who are primarily dependent on alcohol; studies targeting pregnant women identified as primarily abusing drugs have shown no differences between MI and other standard practices in reducing substance use (Winhusen et al. 2007).
Detoxification is a set of procedures employed to manage acute intoxication and withdrawal symptoms from drug and alcohol dependence. During this process, the body's physiology adjusts to the absence of alcohol or drugs. Detoxification alone is not substance abuse treatment; it is only the beginning of the treatment process. Issues such as retaining clients in detoxification, stabilization, and fostering treatment entry are discussed in TIP 45 Detoxification and Substance Abuse Treatment (CSAT 2006a).
Not all communities have detoxification services. Furthermore, women's programs do not often have adequate medical supervision to perform detoxification, hence women must be detoxified at another facility. Typically detoxification from alcohol or addictive drugs has been a 3- to 5-day inpatient procedure, but as more and more health insurers have declined to reimburse inpatient detoxification, it increasingly is done on an outpatient basis. Yet, if severe withdrawal is expected (as from severe alcohol or sedative-hypnotic dependence), detoxification should be done in a medical facility. Withdrawal from severe alcohol use, sedatives, and benzodiazepines can have severe medical complications.
Some women who are dependent on sedative-hypnotics (tranquilizers) may need a 30-day withdrawal regimen with pharmacological medical intervention to prevent seizures. Concerning alcohol, more recent studies have begun to focus on the effects of sex-specific hormones in response to alcohol dependence and withdrawal. Although research on sex-specific hormonal differences in alcohol withdrawal is in its infancy, currently there appears to be a robust sex difference in seizure susceptibility, in that women appear to have less risk for alcohol withdrawal-induced seizures (Devaud et al. 2006). Women also tend to display fewer and less severe alcohol withdrawal symptoms than men. However, even though research reflects less risk associated with withdrawal from alcohol among women, clinicians and health professionals need to maintain vigilance in evaluating withdrawal symptoms and other health concerns. Detoxification can be a vulnerable period for women who have a history of trauma and violence. They may have significant distress associated with not feeling physically or psychologically safe, and anxiety associated with the anticipation of trying to manage their emotions and trauma-related symptoms without being able to self-medicate. From the outset of treatment, women need interventions and education surrounding traumatic stress reactions. Along with supportive and frequent contact with staff, trauma-informed services can help create or increase a sense of safety and a feeling of control.
For all intents and purposes, if a woman's contact with a substance abuse treatment agency stops at detoxification, the treatment system has failed. Women without treatment subsequent to detoxification are likely to relapse and be lost to followup. Thus, detoxification programs should have adequate funding to include case management, brief interventions, and discharge planning. Immediately after detoxification, a woman may be more likely to be ready for treatment, and this opportunity for engaging the woman in treatment should be maximized. Aggressive case management, referral networks, and treatment linkages are needed to prevent women from disengaging from treatment. From initial contact with the client, the ability to follow up, to coordinate care, and to provide comprehensive services (such as transportation and child care), is essential to effective treatment.
The safety of children often is a chief concern and one of the principal barriers to treatment engagement and retention for parents—especially women—entering detoxification programs. Even if women do not have custody of their children, they often are the ones who continue to care for them. Thus, ensuring that children have a safe place to stay while their mothers are in detoxification is of vital importance. Working with parents to identify supportive family or friends may help identify available temporary child care resources. A consult or referral to the treatment facility's social services while the patient is being detoxified is indicated when the care of children is uncertain (CSAT 2006).
Some detoxification programs will not treat a pregnant woman because they lack the necessary obstetrical support and are concerned about liability. Detoxification presents critical risks to a fetus, and withdrawal of a pregnant woman from addictive drugs or alcohol should always be accompanied by close medical supervision and monitoring. Risks of detoxification depend on the drug being abused, but the primary drugs of concern are typically opioids and, potentially, sedative-hypnotics. Sudden withdrawal of these drugs results in withdrawal by a fetus and sometimes leads to fetal distress or death. Withdrawal should be done under supervised conditions and with proper substitutes, such as methadone for opioids. TIP 45 Detoxification and Substance Abuse Treatment (CSAT 2006a), TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs (CSAT 2005b), and TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (CSAT 2004a), have more comprehensive information on this subject.
In general, it is neither recommended nor necessary for pregnant women to cease methadone treatment. In situations where withdrawal is being contemplated, a thorough assessment should be conducted to determine whether the woman is an appropriate candidate for medical withdrawal. It is important to note that relapse rates among women who use heroin are high, thus placing their fetuses at risk for adverse consequences (Jones et al. 2001). Situations in which medically supervised methadone withdrawal during pregnancy may be considered include the following:
The client moves to an area where methadone maintenance is not available.
The client has been stable during treatment and requests withdrawal before delivery.
The client refuses to be maintained on methadone.
The client plans to detoxify through a structured treatment program (Archie 1998; Kaltenbach et al. 1998).
If withdrawal is elected, it should be conducted under the supervision of physicians experienced in perinatal addiction and under the guidance of a protocol using fetal monitoring. Medical withdrawal usually is conducted in the second trimester because of the danger of miscarriage in the first trimester and because withdrawal-induced stress may cause premature delivery or fetal death in the third trimester (Donaldson 2000; Kaltenbach et al. 1998). While pharmaceutical agents other than methadone have been introduced to treat symptoms of opioid withdrawal, the research is still preliminary (Anderson et al. 1997; Dashe et al. 1998; Jones and Johnson 2001; McElhatton 2001).
Outpatient, or ASAM Level I, treatment usually consists of one or two weekly sessions of group or individual therapy. Outpatient treatment settings are the most common, are widely available, and are the setting in which most women receive treatment. In general, outpatient treatment is most appropriate for women with less severe substance use problems and with greater social support and resources. While outpatient services are used for less severe symptoms of substance use disorders, this level of treatment can be employed at various points across the continuum of care. Specifically, continuing care services use outpatient treatment to provide support for ongoing recovery and treatment in a less restrictive environment as recovery evolves. (Refer to chapter 8 for review of continuing care services.)
Women who benefit most from outpatient therapy frequently have some stability in their lives, such as housing and employment. Effective outpatient treatment programs for women should be more comprehensive than traditional programs and should provide a constellation of services (refer to Figure 5-3). For example, outpatient services should evaluate the need for and provide child care and children's treatment services.
Although few women-only outpatient programs exist, mix-gender programs can be made more responsive to women's needs by providing comprehensive case management, services, and programs that support more client-provider contact, more opportunities for individual therapy, and referral to other community services. The development of interagency relationships is essential, yet referral alone will not guarantee utilization of these services. Beyond staff support, it is often necessary to initiate the first contact with the agency referral, to assist the client in developing or making the necessary arrangements to access the community service or referral, and to provide followup to obtain the outcome of the referral. Throughout the last two decades, substance abuse programs have acknowledged the necessity of establishing formalized relationships among community agencies to streamline services and to effectively address and manage the diverse needs of women seeking treatment for substance use disorders. TIP 46 Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT 2006b), provides more information on this level of care.
Intensive outpatient treatment (IOP), or ASAM Level II, provides a higher treatment level than traditional outpatient programs but does not require structured residential living. Generally, IOP provides many of the same services as residential treatment; however, the intensity of treatment, the time of engaging services, and level of counselor involvement are less. IOP appears to have higher completion rates than traditional outpatient services among postpartum women (Strantz and Welch 1995). The flexibility of IOP may help women overcome barriers to treatment, provided the program attends to the unique needs identified during intake (refer to Figure 5-3). Although IOP historically provides more accommodating schedules and offers treatment during the evening, weekends, and other times of the day, it will not be as useful for some women unless child care and transportation are available. TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (CSAT 2006c), provides more information on this level of care.
Residential treatment, or ASAM Level III, is for women who have multiple and complex needs and require a safe environment for stabilization, intensive treatment, and an intensive recovery support structure. Professional staff are available 24 hours a day, and the facility is clinically managed. The type of residential or inpatient placement depends in part on the severity and complexity of the woman's conditions, including but not limited to co-occurring medical and psychiatric disorders, history of trauma (including sexual and domestic violence), and pregnancy. Clinical experience has shown that women in residential care frequently require some or all of the services listed in Figure 5-3 in addition to specific substance abuse treatment services.
Residential treatment can take place in various settings, including halfway houses and other extended care facilities, primary residential or inpatient programs, and recovery homes. As an example, SHIELDS for Families (a Los Angeles agency) uses a combination of day treatment and housing to provide comprehensive residential treatment for families. Overall, the effectiveness of residential treatment appears to rely on at least one key element—length of treatment. Greenfield and colleagues (2004) reviewed data about the effectiveness of residential substance abuse treatment for women from CSAT's Residential Women and Children/Pregnant and Postpartum Women (RWC/PPW) Cross-Site Study and two other national studies. Despite differences in treatment programs, client profiles, followup intervals, data collection methods, and other factors, all three studies found high treatment success rates—ranging from 68 to 71 percent abstinence—among women who spent 6 months or more in treatment. Success rates were lower for clients with shorter stays in treatment.
While length of stay seems paramount, residential treatment has several other components that must be in place to meet the various roles, needs, and other presenting issues of women with substance use disorders. Whether short or long term, residential treatment must maintain a healing, nurturing, and safe environment. This may require special accommodations for women, particularly in mix-gender treatment centers. These accommodations include adequate facilities for visits with children, safety precautions, and treatment programming and policies that decrease the likelihood of potential assaults and sexual involvement in mix-gender residential settings and women-only space. Women who are trauma survivors benefit from secure sleeping accommodations where they can maintain their sense of security and control over bedroom access (except staff rounds; Harris 1994).
For many women, having their children with them in treatment is essential to their recovery and removes a barrier to treatment entry. Research suggests that allowing children to accompany their mothers to a residential program has a positive effect on engagement, retention, and recovery (Lungren et al. 2003; Szuster et al. 1996). For example, studies have found that length of stay in residential treatment is associated with women being able to bring their children with them (Hughes et al. 1995; Wobie et al. 1997). One study suggested that the earlier a mother's infant resides with her in the treatment setting, the longer the mother's stay in treatment will be (Wobie et al. 1997). Overall, women in residential treatment accompanied by their children showed better outcomes (abstinence, employment, child custody, and involvement with continuing care or support groups) than women not accompanied by their children at 6 months after discharge (Stevens and Patton 1998). Review Appendix B to obtain an overview of CSAT's Comprehensive Substance Abuse Treatment Model for Women and Their Children.
Since 2004, CSAT has funded over 50 grants to treatment facilities under its Residential Women and Children/ Pregnant and Postpartum Women (RWC/PPW) programs. This cross-site evaluation found that the 6- to 12-month treatment programs had several positive outcomes. First, alcohol and drug use was much lower 6 months after discharge compared with pretreatment. The percentage of women reporting alcohol use decreased from 65 percent at pretreatment to 27 percent 6 months after discharge, and the percentage of women reporting crack/cocaine use decreased from 51 to 20 percent. Second, 60 percent of the women reported being completely abstinent throughout the 6 months following discharge. Third, criminal involvement dropped markedly, and economic well-being improved. Next, pregnancy outcomes improved (fewer premature deliveries, fewer low-birth-weight babies, and lower infant mortality) compared with expected rates for this population. In addition, 75 percent of the women had custody of one or more children 6 months after discharge, up from 54 percent before initiating treatment, and fewer clients had children in foster care (CSAT 2001a).
Women who completed treatment that allowed children in residence had less psychological distress and improved skills for independent living, parenting, employment, and relationships (Saunders 1993). In fact, one study found that outcomes from a treatment environment that welcomed children were more positive for women both with and without children. Researchers suggest that “living with and helping with other women's children may provide a sense of shared responsibility and community” in a therapeutic community (Wexler et al. 1998, p. 232). Chapter 7 addresses parenting and the need for children services; it also emphasizes the importance of providing assessment and treatment for both mothers and their children.
The amount of responsibility the mother has for her children during her stay needs to be determined on an individual basis; some mothers can keep their children with them almost continually, whereas others may need to attend treatment apart from their children. Specifically, some women may not want the responsibility of parenting at such a stressful time in their lives but may feel social pressure to keep their children with them during treatment. These mothers should be supported in their decision to place their children in the care of others (such as reliable family members) during their treatment. The following questions can be used by agencies to determine some key decisions regarding children:
How will child care be handled if the mother is hospitalized?
Are there limits on the severity of illness of mothers or children beyond which they will not be accepted by the program?
What rule infractions will result in expulsion from the program?
How will suspected child abuse or neglect be identified and reported?
Does the program allow overnight home visits? What guidelines and rules need to be in place to permit mothers and their children to leave residential treatment overnight (Metsch et al. 1995)?
How will children be disciplined?
How will visitation by the mother's partner be handled when court-ordered visitation privileges have been issued but the partner continues to abuse alcohol and/or drugs?
Maintenance of relationships with noncustodial children is important. Reunification with children in the care of child protective service agencies is a sensitive issue. Staff of residential programs should be knowledgeable about child welfare issues and develop collaborations with child protective services to facilitate an effective and supportive reunification process for mothers and children.
Acknowledging the urgency of treating women who are pregnant, Federal law requires that pregnant women receive priority admission into substance abuse treatment programs, allowing them to bypass waiting lists and gain immediate admission when a bed in a residential program is available (42 U.S.C. § 300x-27[a]). The primary treatment provider must secure prenatal care if a pregnant woman is not already receiving such care.
Notably, collaboration among providers of substance abuse treatment, obstetric care, and pediatric care is a necessity. A comprehensive care program for pregnant women that includes prenatal care and substance abuse treatment has been shown to improve birth outcomes and increase the chances of being drug free at delivery for women who used cocaine (Burkett et al. 1998). Corse and colleagues (1995) looked at innovative possibilities such as bringing primary obstetric care providers (usually a nurse practitioner or certified nurse midwife) onsite. They found that educating nurse midwives about substance use disorders and pregnancy enhanced their effectiveness and level of comfort in working with this population. Foremost, residential staff should learn the danger signs of pregnancy complications and when to triage a woman to an emergency department or to the doctor of the woman's choice. An internal or external medical or nursing resource is helpful to evaluate need for emergency care.
Telling Their Stories: Reflections of the 11 Original Grantees That Piloted Residential Treatment for Women and Children for CSAT (CSAT 2001c), provides profiles of residential programs for women and children, along with issues that arose in treatment and management, evaluation information, and lessons learned.
Upon delivery, some infants have withdrawal symptoms that require supportive care. In individual cases, depending on symptom severity, babies may need to be managed pharmacologically, and most experts agree that newborns should remain hospitalized while on medication related to drug withdrawal. In a residential center, public health nursing visits are critical to the evaluation of infant and maternal status. If a program does not have a nursing staff, public health nurses can provide some service.
The consensus panel recommends that residential programs provide a number of specialized services for pregnant women, including:
Nutrition services
Prenatal care
Transportation to obstetric appointments
Childbirth education and preparation and a coach, if possible
Mental health evaluation at least twice during the pregnancy and postpartum periods, and treatment as needed to rule out (or treat) postpartum depression or other disorders
Education about alcohol and drug use specifically related to pregnancy, including education about neonatal abstinence syndrome and, if possible, a tour of the delivery site's nursery for the woman in anticipation of the need for infant monitoring in the hospital
Education about HIV/AIDS risk and management during pregnancy, especially because HIV/AIDS transmission to the fetus and infants can be prevented
Education about breastfeeding and strong support for mothers who nurse their babies unless they are HIV positive
Comprehensive programs for women who are parents or pregnant typically include outreach, family support services, medical care, case management, and continuing care for women and their children (Finkelstein 1993, 1994). Some researchers recommend individual and group counseling services, independent living skills training, and parenting classes (Haskett et al. 1992). Childbirth education and family planning also are recommended for women in treatment at childbirth and postpartum, along with activities that address bonding and attachment. Home visits help in assessing a woman's needs and in identifying family members who can support her in recovery (Grella 1996). Children who accompany their mothers to treatment can benefit from separate, developmental- and age-appropriate programming, health care, and education programs including substance abuse prevention. For an overview of CSAT's Comprehensive Substance Abuse Treatment Model for Women and Their Children, refer to Appendix B.
Treatment in a medically managed intensive inpatient setting, or ASAM Level IV, commonly is used for a person who is medically compromised and meets ASAM Level IV criteria. This patient is at high risk for complications associated with withdrawal and requires the full resources provided by a hospital. Typically, this type of acute inpatient treatment lasts between 3 and 5 days; stays of 10 to 14 days are more likely in an acute care psychiatric unit. It most often includes medical detoxification, client education, group therapy, individual therapy, family therapy, and medical treatment.
As discussed in the detoxification section, appropriate referral from inpatient care to subsequent long-term treatment is needed. Repeat assessments are performed to indicate when a client is ready for a less intrusive or less intense setting for treatment. This referral should include case management and linkage to other treatment services, community services, and support groups.
Advice to Clinicians and Medical Staff: The Impact of Trauma and Prenatal Care.
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