Volume 1, Issue 3

Spring 2000    

In 1996, consumers, family members, providers, and other stakeholders were asked to help prioritize the types of programs they felt should be funded using tobacco tax money that would soon become available from the state. An idea proposed by a consumer advocate was for a warm line phone service that would provide "a place" for consumers to call and chat in non-emergency situations. Through a competitive process the Peer Mentor Program was selected to be funded. While the Peer Mentor Program was conceived to provide persons with a serious mental illness an opportunity to become involved in community-based mutual help activities, it includes five components:

• A Warm Line that offers consumers in the community a phone line where they can receive support in non-emergency/non-crisis situations.

• Visits to individuals at both local psychiatric hospital units and the Arizona State Hospital.

• Community-wide social activities.
• Small group activities.

• An opportunity for e-mail discussions with other consumers.

Based on the principles of mutual help, the Peer Mentor Program trains individuals with serious mental illness to serve as mentors and offer peer support for other individuals with mental illnesses. The choice of the program name reflects its two primary goals:

• To relate to other consumers as peers who have firsthand knowledge of what it is like to deal with a mental illness.

• To act as mentors or role models for pathways to recovery.

The Peer Mentor Program recently made the transition from operating under the auspices of the Community Rehabilitation Division of the University of Arizona to a completely consumer-run program with oversight by HOPE, Inc. The University of Arizona continues to provide evaluation services to the program.

The core of the Peer Mentor program is a Warm Line staffed by approximately 15 volunteers who take calls from persons with mental illness who are looking for a friendly conversation. Mentors receive a small stipend for their volunteer time. The stipend is meant to cover the costs associated with volunteering, such as transportation and clothing. The Warm Line provides social contact for callers in less-than-crisis situations. All mentors undergo intensive training with Help-On-Call facilitators to improve listening skills, to deal with confidentiality issues, and to know when to refer a call to a "hotline." The Warm Line has been in operation since program funding began and typically handles between 300-470 calls per month. The phone lines are staffed by two or three mentors at a time and are open in the afternoon and early evening on weekdays and afternoons only on the weekend. Consumers of mental health services throughout the community call the Warm Line to talk with mentors, mostly just to chat, although a wide variety of topics are discussed, including physical health problems, psychiatric issues, feelings of loneliness and social isolation, hobbies, and relationship problems. An average call lasts about 20 minutes. Calls dealing with serious issues such as life-threatening drug/alcohol use or suicidal ideation, also known as "hot" calls, are referred to an appropriate community agency for follow up. While callers may choose to remain anonymous, the majority reveal their names or regularly use an alias. On average, the Warm Line attracts 30-40 new callers each quarter, with female callers outnumbering the male callers. A toll-free number was established so that consumers in rural areas of Southeastern Arizona would have access to the Warm Line. To date calls from rural locations number approximately 15-20 calls per month.

In addition to the Warm Line, the Peer Mentor program offers monthly social activities in the community, inpatient hospital visits by mentors, small group activities, and an Internet discussion group. The monthly social activities are structured to provide a safe social setting for members of the Tucson consumer community to meet and socialize. Typical social activities include picnics, parties, and holiday celebrations.

Mentors also make weekly visits to three psychiatric hospitals, including Kino Community Hospital, the local hospital in Pima County that serves the largest number of individuals with a serious mental illness. As part of the hospital visitation activities, the mentors also travel twice a month to Phoenix to meet with consumers in the Arizona State Hospital. These hospital visits provide inpatients with comfort and support from peers. The small group activities range from women’s and men’s groups to groups based on specific interests, such as movies and gardening. The groups typically reflect the interests of the mentors who facilitate them.

The Internet discussion opportunity is designed to allow consumers a forum for both communicating about upcoming events and concerns (of local and national interest) and to provide an opportunity to mobilize the consumer community for activism.

Evaluation is a vital component of the Peer Mentor Program. Information from the evaluation serves the dual purpose of quality improvement through feedback to the program and outcomes monitoring to evaluate effectiveness. Based on evaluation findings, the program can target trainings and modify practices. Evaluation of the Warm Line focuses on utilization patterns and satisfaction data. The data to date are overwhelmingly positive. The Warm Line mentors are rated as understanding and courteous. Many callers note the importance of the fact that the mentors are themselves persons with serious mental illnesses. The callers indicate that the mentors understand what it is like to deal with similar issues. The most frequent complaint from callers is that the Warm Line should be open for longer hours.

Consumers seen by the inpatient visitation teams and community members attending social events have similar positive responses. The program is working as intended to lessen the loneliness and social isolation experienced by adults with serious mental illness – both those living in the community and those in inpatient psychiatric treatment facilities.

In addition to evaluating the perceptions of those who use Peer Mentoring services, the impact of volunteering for the Peer Mentor Program on the mentors is of great interest. Initially, there were concerns that working as a mentor would be an additional stressor and perhaps lead to an exacerbation of psychiatric symptoms. In order to assess impact on the volunteer, the evaluation team from the University of Arizona designed an open-ended interview that was based on a review of the self-help and consumers-as-providers literature. Every quarter two or three mentors are interviewed by a member of the evaluation team. Contrary to the initial fears, mentors do not report feeling unduly stressed by their volunteer efforts. In fact, most report very positive outcomes such as increased feelings of self-esteem, satisfaction with their abilities, and improved mental health. Mentors, in turn, report that having something to do takes their mind off their own illness. Many of the mentors interviewed report that the feeling of helping someone like themselves is a rewarding experience, and very meaningful to them in terms of their own personal growth and recovery from mental illness.

For additional information about the Peer Mentor Program, contact Regina Koch-Mart at (520) 917-0841 or peermentor@cs.com. For information concerning the evaluation of the Peer Mentor Program, contact Michelle Stewart at (520) 917-0841 or vms@u.arizona.edu v

Persons with a co-existing serious mental illness and substance dependence disorder (referred to as dual diagnosis) can be some of the most challenging to treat. It is estimated that approximately one half of those individuals with a serious mental illness also abuse substances. Research has demonstrated that individuals with a dual diagnosis are at higher risk for hospitalization, incarceration, homelessness, violence, depression and suicide, HIV infection, and family problems. Persons with a dual diagnosis also tend to have lower functional status, higher treatment drop out rates, and higher treatment costs than individuals with a serious mental illness alone. They also tend to receive fragmented, inconsistent, and even conflicting treatment as a function of our bifurcated systems of care. Furthermore, there is little research on the efficacy of different treatment approaches with this population. La Frontera’s Admire Plus dual diagnosis program is based upon the findings and lessons learned from a five-year dual diagnosis treatment research project funded by the National Institute on Drug Abuse (NIDA) conducted at La Frontera Center, Inc. This article describes the evolution of our current Admire Plus program.

The primary goal of the NIDA project was to compare the effectiveness of two treatment models with very different philosophies and methods of providing services to dually diagnosed individuals receiving community- based services.

• One model was the frequently used but, at the time, little tested 12-Step approach, modified for use for the dually diagnosed.

• The other model was Self Management And Recovery Training (SMART), which uses the cognitive/behavioral therapy methods of Rational Emotive Behavior Therapy (REBT) modified for use with groups, treatment and community self-help.

A second goal of the project was to evaluate the efficacy of an intensive day treatment/partial hospitalization approach with our case-managed, dually diagnosed population. We chose this approach because funds for traditionally used intensive services, such as residential, have become very limited.

The intervention was six months of intensive day program/partial hospitalization IDP/PHP (up to 5 hours a day, 5 days a week). Participants were randomly assigned to either the 12-Step or SMART program, which met at different sites. Other than the program philosophy and method differences, the two programs were identical and included the following weekly activities and topics: relapse prevention, coping with having a serious mental illness, daily living skills, goal setting, mental health and substance education, lunch (included shopping and preparation), healthy recreation (included a weekly outing), in-house and community 12-Step or SMART groups, journaling, and individual sessions as needed. Abstinence was encouraged, but not required, as our aim was to keep individuals engaged. It quickly became evident that we also needed to allow members to complete the program in multiple phases, as opposed to continuously, if needed.

Outcome measures included selected items from the following instruments and measures: Addiction Severity Index (ASI), which assesses substance, psychiatric, legal, medical, employment, and social domains), Lehman Quality of Life Scale, urinalyses, treatment completion, attendance rates, participation levels, and hospitalization rates. In addition, an extensive process evaluation was conducted that included participation and attendance levels, client and counselor feedback, attrition, substance use during treatment, consumer satisfaction, method adherence measures, and supervision documentation.

From our outcome and process data, we were able to derive treatment recommendations for severely impaired dual diagnosis populations. The results indicate that the 12-Step and SMART approaches can both be effective. With the exception of individuals with polysubstance dependence, both approaches work relatively well across our population, which is diverse in diagnoses, ethnicity, genders, and severity levels. The 12-Step method seemed to work somewhat better for alcohol problems. SMART worked somewhat better with psychological problems. We found that SMART is a promising new treatment option for dual diagnosis treatment. It is easy to learn, has concrete methods, is inherently client-centered, is easily applicable to a wide variety of problems and habits, has motivational components, and can be used in a group setting. However, one of our main findings was that it is imperative that these or any methods be applied in a client-centered style (e.g., warm, welcoming, empathetic, building on strengths) or the clients will disengage. Even experienced counselors may need additional training in client-centered approaches in order to be effective with dually diagnosed clients.

We found that the IDP/PHP level of care works well in public sector treatment with this population. It is very cost effective, can easily be used to provide multifaceted integrated treatment, and can serve as the coordinating hub for overall integrated treatment. Further, the IDP/PHP level of care is more integrated into the clients’ lives than residential treatment, making generalization of gains easier. It has proved to be an important addition to case management services for the agency.

Our findings indicate that teaching individuals how to engage in healthy recreational activities is an important facet of treatment. Our data also suggest that harm reduction rather than abstinence is often the most advisable proximal goal for the severely dually diagnosed population. Long-term treatment, with options for engagement at varying intensity levels and the ability to move in and out of treatment as needed, is optimal, and the IOP/PHP format worked well for this. Although having treatment manuals was important to the research design and helpful clinically, it was not possible or desirable to mandate rigid schedules in the use of manuals. A certain amount of flexibility is required to deal with individual member needs.

Other important findings included:

• Providing food and including members in food planning, shopping, and preparation enhanced attendance and taught needed skills.

• The importance of transportation and teaching the use of public transportation.

• Finding ways to enhance utilization of medical treatment might have helped retain in treatment a large segment (33%) of clients with chronic medical problems.

• Including family/significant others was difficult due to their scarcity and may point to the need for more social skills training.

• Diagnoses were frequently incorrect, indicating a staff training need.

• Multi-method approaches seem optimal with this multiply challenged population.

Given these findings and experiences, when the grant ended, we took what we had learned and blended the SMART and 12-Step programs into the ADMIRE program (Alcohol, Drug, and Mental Health Issues of Recovery Examined – the name was created based on a client contest). This kept the same programmatic structure and elements outlined above and used both the 12-Step and SMART methods. Since a client-centered approach was found to be so critical, we borrowed additional methods from Motivational Interviewing. We were fortunate to be granted funds (through a SAMHSA grant to the state ADHS/DBHS via CPSA) to pilot and study a yearlong project for integrated dual diagnosis treatment. With these funds we were able to enhance ADMIRE (hence, ADMIRE Plus) with additional treatment components validated in similar settings, and make the treatment accessible to all persons with SMI in the CPSA network. The enhancements include intensive case management (PACT model), acupuncture detoxification to reduce cravings, and contingent reinforcement for achievement of client-identified goals.

For additional information about the ADMIRE Plus program, contact Jennifer Wilson at (520) 742-2351, ext. 221. For more information about the evaluation of ADMIRE Plus or the NIDA dual diagnosis grant results, contact Pat Penn at (520) 884-9920, ext. 224 or penn@u.arizona.edu

Dr. Penn will be making a presentation concerning the Admire Plus Program through the Arizona Substance Abuse Consortium Teleconference Series on May 16^th. For information concerning teleconference sites, contact Emily McWhorter at (520) 917-0841 or emcwhort@u.arizona.edu v

Because Americans are increasingly seeking out alternative therapies such as acupuncture for their health care needs, the National Institutes of Health (NIH) created an Office of Alternative Medicine in 1992 and a Center for Complementary and Alternative Medicine in 1998 to begin to address this interest. The purpose of these offices is to submit alternative therapies to the same scientific scrutiny as conventional therapies.

COPE Behavioral Services, Inc. first began offering acupuncture detoxification in 1997 in the Focus on Recovery through Education and Empowerment (FREE) program for HIV positive and substance abusing individuals.

While acupuncture is viewed as an alternative therapy in the United States and other Western countries, the Chinese have used it for several centuries for a variety of medical and behavioral conditions.

Acupuncture incorporates a system of diagnosis and treatment in which specific external body areas called acupuncture points are stimulated by needle insertion. The action of stimulating acupuncture points is thought to have effects on internal and external organ function. Examples of scientific verification for the existence of acupuncture points are numerous. One such piece of evidence is that acupuncture points have lower electrical impedance that can be demonstrated using a sensitive ohmmeter.

The treatment of withdrawal symptoms with acupuncture was first reported in 1973. Opiate addicted patients in China undergoing routine surgical procedures for medical conditions unrelated to their drug use were given acupuncture anesthesia during and after surgery. A serendipitous finding was that many of the patients reported a reduction in the severity of opiate withdrawal symptoms post-surgery. The procedure used electroacupuncture or the electrical stimulation of points via inserted needles, including one ear acupuncture point. After this initial report, pilot studies were conducted in which ear and body points and manual acupuncture were used to treat opiate withdrawal symptoms. Lincoln Hospital in the Bronx, New York was one of the first hospitals to implement an acupuncture detoxification program in 1974. The Lincoln Program personnel developed a standardized five-needle ear acupuncture protocol and noted that manual insertion was as effective, less expensive, and easier to administer than electroacupuncture. The National Acupuncture Detoxification Association (NADA) was established to teach and certify practitioners in the five-needle protocol. By 1985, an estimated 700 substance abuse programs in the U.S. and abroad used acupuncture in the treatment of addictions. The technique began to be applied to alcohol, nicotine, and cocaine dependence in addition to opiate dependence.

Is Acupuncture Detoxification Effective?

Because the initial reports on acupuncture detoxification were serendipitous and not based on well controlled, scientifically rigorous studies, the early research was justifiably criticized for numerous methodological faults. As studies with more rigorous control appeared, conflicting reports on efficacy resulted. Some researchers did not find evidence for the effectiveness of acupuncture detoxification, while others viewed the data as encouraging. The controversy concerning efficacy was due to differences in the protocols employed, the different outcome measures, and lack of attention to appropriate sample sizes for detecting effects. For example, few studies employed a standardized protocol of ear or body acupuncture, and outcome measures ranged from severity of withdrawal symptoms to craving and abstinence – outcomes associated with ongoing substance abuse treatment rather than detoxification. The research was also complicated by the expanded applications of the technique, which include acupuncture detoxification for non-opiate substances such as cocaine and alcohol. Generally, the research indicates that acupuncture detoxification can be a useful complement to traditional modalities, particularly as a point of entry to substance abuse treatment. There is no strong evidence, however, that acupuncture detoxification has any impact on relapse. Similar to methadone detoxification the acupuncture regimen is designed to alleviate withdrawal symptoms, only one factor that influences relapse. The reports listed at the end of this article can be helpful to those desiring more information regarding acupuncture detoxification research.

How Does Acupuncture Detoxification Work?

Chronic users of heroin, cocaine, alcohol, and tobacco experience substance-specific symptoms during abstinence. Withdrawal syndromes associated with opiate and alcohol abuse are initially physical and easier to identify than those associated with tobacco and cocaine withdrawal in which symptoms are primarily psychological (e.g., irritability, craving, depression, and anxiety). All types of substance dependence, however, have an abstinence syndrome that includes craving and psychological discomfort. The analgesic effects of acupuncture on both physical and psychological symptoms have been noted. Substantial research with animals and human subjects supports that acupuncture has a variety of neurochemical and physiological effects. The primary theory of the therapeutic mechanism of acupuncture on withdrawal symptoms is that it causes the production of naturally occurring opiates in the brain called endogenous opiate peptides (EOP). According to this model, stimulating EOP production affects neurochemical imbalances related to opiate withdrawal and provides relief from pain and mood elevation. Mood elevation is actually hypothesized as the primary mechanism responsible for the usefulness of acupuncture in treating different substance abuse problems. Although limited, there is research evidence that acupuncture is as effective as amitriptyline for depression and mood disorders associated with withdrawal. It is proposed that acupuncture affects the severity of depressive symptoms associated with abstinence, and that this might be subjectively experienced as an increase in positive affect following treatment or reduced craving for a particular substance.

Acupuncture Detoxification at COPE

COPE Behavioral Services, Inc. first began offering acupuncture detoxification to clients in the FREE program in 1997. Clients in the FREE program were HIV positive and substance abusing individuals, and the focus of the program was on harm reduction using case management, education, and acupuncture detoxification. In January 1998 acupuncture detoxification was made available to all COPE members, including seriously and persistently mentally ill individuals with active substance abuse problems. The clinic program serves clients who are seeking to become abstinent, decrease their use, or prevent relapse of substance use. All acupuncture detoxification is coordinated with more traditional substance abuse treatment to address relevant psychosocial issues. Clinic staff trained in the NADA five-needle protocol provide the acupuncture in a group environment that is conducive to relaxation, and treatment lasts from 35 to 45 minutes. The program is entirely voluntary. Clients with serious and persistent mental illness are additionally required to attend a weekly harm reduction support group during the first 90 days of clinic attendance. The clinic is open five days a week with morning, afternoon, and evening hours available. Generally, clients follow a treatment protocol of daily treatments for the first two weeks, three treatments per week for the next six weeks, and two treatments per week for the remaining four and a half weeks of the program. At the end of 90 days clients can choose to continue or discontinue treatment at the clinic.

Currently, clients attending the clinic are from the FREE and Insiders programs for HIV positive individuals, the Treatment is Available program for substance abusing people with disabilities, and the case management program for seriously and persistently mentally ill. Although the clinic receives referrals from outside agencies, there are difficulties funding treatment for these referrals. COPE hopes to be able to meet this need more effectively in the future. From January 1998 to August 1999, a total of 4,682 treatments were given. Of individuals surveyed concerning their subjective feelings after acupuncture treatment, 73% felt their cravings were reduced, 56% felt less angry, 66% felt less depressed and 76% felt less anxious. Client interest and attendance at the clinic have increased, and COPE hopes to continue the program as a complement to substance abuse treatment.

References

Wen H, Cheung S. How acupuncture can help addicts. Drugs and Society. 1973; 2:18-20.

Wen H, Cheung S. Treatment of drug addiction by acupuncture and electrical stimulation. American Journal of Medicine. 1973; 9:138-141.

Smith M, Kan I. An acupuncture program for the treatment of drug-addicted persons. Bulletin on Narcotics. 1988; 40:35-41.

Brewington V, Smith M, Lipton D. Acupuncture as a detoxification treatment: An analysis of controlled research. Journal of Substance Abuse Treatment. 1994; 11;289-307.

Shwartz M, Saitz R, Mulvey K. The value of acupuncture detoxification programs in a substance abuse treatment system. Journal of Substance Abuse Treatment. 1999; 17;305-312.

Moner S. Acupuncture and addiction treatment. Journal of Addictive Diseases. 1996; 15:79-100.

Brumbaugh A. Acupuncture: New perspectives in chemical dependency treatment. Journal of Substance Abuse Treatment. 1993; 10:35-43.

McLellan A, Grossman D, Blaine J. Acupuncture treatment for drug abuse: A technical review. Journal of Substance Abuse Treatment. 1993; 10:569-576

Brewington V, Smith M, Lipton D. Acupuncture as a detoxification treatment: An analysis of controlled research. Journal of Substance Abuse Treatment. 1994; 11: 289-307.

For more information contact Dr. Cruz at cruz@dakotacom.net v

CPSA has recently analyzed outcome data for Alcohol and Drug programs provided under its auspices. Using the ALFA scales (Family/Living Situation, Feeling/Affect/ Mood, Interpersonal Relations, Medical/Physical, Role Performance, Self-care/Basic Living Skills, Social-Legal Status, Substance Abuse, and Thinking) the analysis focused on members’ change in functioning from the time of enrollment to disenrollment. As a part of the analysis, a comparison was made of changes in functioning for members who completed treatment with those members who dropped out of treatment.

While the results support the notion that treatment works, they also demonstrate the dramatic impact of completing treatment. The change scores presented in the graph above were significantly greater on every scale for those individuals who completed treatment, compared to those who did not complete treatment. Substance Abuse showed the largest difference, with those completing treatment improving more than eight points (on a 50-point scale).

Published studies in the substance abuse treatment literature report similar results. Individuals who complete treatment generally have more positive outcomes than do individuals who do not complete treatment (e.g. Nemes, Wish and Messina, 1999). A large CSAT funded study also found differences in outcome between treatment completers and non-completers. (Arizona Treatment Outcomes Pilot Study [TOPPS I], 1999). In that study, the issue of "dosage" was emphasized. That is, "What is the minimal amount of treatment necessary for individuals to show improvement"?

While the findings concerning treatment completion are important, they do not necessarily indicate a cause and effect relationship. That is, while it is quite possible that better outcomes are the result of completing treatment, there might be other intervening variables. For example, one alternative explanation is that the better outcomes might be a function of the fact that individuals who were doing better tended to remain in treatment until it was complete, while individuals who were not doing as well tended to drop out. Although the results do not necessarily provide an answer, they certainly suggest a need to look further at the relationship between treatment completion and outcome.

Given the above, some possible steps to be taken in attempting to improve outcomes might include:

• Identification of factors associated with treatment completion.

• Based on those factors, implement interventions aimed at increasing treatment completion (or at least dosage).
• Monitor to see if increased treatment retention increases average improvement scores.

References

Nemes S, Wish ED: Comparing the impact of standard and abbreviated treatment in a therapeutic community: Findings from the District of Columbia Treatment Initiative experiment. Journal of Substance Abuse Treatment 1998; 17, 339-347.

Arizona Treatment Outcomes Pilot Study [TOPPS I], Bureau of Substance Abuse and General Mental Health, ADHS/DBHS, 1999.

For additional information contact Dr. Berren at (520) 318-6950 ext. 2867 or miber@cpsa-rbha.org

For additional information about the TOPPS I contact Christina Dye at (602) 553-9142 or cdye@hs.state.az.us v

If you received a "hand me down" copy of Outcomes, Innovations & Best Practices, and would like future copies mailed directly to you, please call Yolanda Hernandez at (520) 325-4268, or (800) 959-1063.

Also, if you did not receive a 3-ring binder for storing copies of Outcomes, Innovations & Best Practices, and would like one, please let us know and we will send you one.

In order to ensure that Outcomes, Innovations & Best Practices is a community based effort, we have put together an impressive Editorial Advisory Board. The advisory board will play an important role in reviewing submissions, and providing input concerning the focus of future issues.

Michael Berren, Ph.D. of CPSA

Editorial Advisory Board

Linda Arzoumanian, Ed.D. Pima County School Superintendent

Robyn F. Cruz, Ph.D. of COPE

Rick Duran, M.A. of CPSA

Cristóbal Eblen, Ph.D. of CPSA

Patricia E. Penn, Ph.D. of La Frontera Center, Inc.

Karl Sachs, Psy.D. of Arizona’s Children Association

Michelle Stewart, M.A. of the University of Arizona

Editorial Assistant

Yolanda Claxton of CPSA