A brief introduction and background description of treatment services we are currently evaluating as part of our project “Expansion of a Multi-Diagnosis Treatment Program: Integrated Recovery Management Model for Ex-offenders with Co-Occurring Mental Illness, Addictive Disorders, and HIV Seropositive or High Risk Status”:
Despite abundant data supporting the tangling of co-occurring substance abuse and psychiatric disorders with STDs/HIV and the criminal justice system, individuals with this complicated symptom profile are too often excluded from treatment programs, leading to escalating health care and criminal justice costs — with no better chance of receiving comprehensive care. In Memphis, Tennessee, system fragmentation and reimbursement structures are significant barriers: Tennessee?s managed Medicaid program has virtually decimated local efforts through denying reimbursement for addictions treatment; ex-offenders face multiple barriers in reinstituting benefits to obtain services; and services that once included model case management programs are overloaded to the extent crisis management is the norm. The purpose of the expansion component is to devise a model response that untangles these complexities through applying a logical series of coordinated and integrated services and defines a practice approach specific to both seropositive and high risk seronegative consumers that can be replicated in other settings. The project integrates ASAM PPC-IIR Intensive Outpatient Level II.1 with research-based principles of integrated care outlined by Robert Drake (2001), along with the clinical prevention concepts of the CDC (1997; 1999), NIDA, and SAMHSA.
Shelby County, home to the city of Memphis, is in the southwestern corner of Tennessee bordered by the Mississippi River to the west and the State of Mississippi to the south. Shelby County has a population slightly below 900,000 residents, 49% of whom are African American, 47% are Caucasian, and approximately 3% are Hispanic. In the City of Memphis, approximately 55% of the population is African American, and over 40% of African-American households in Memphis have median incomes below poverty level. Throughout Memphis, lower-, middle-, and upper-income neighborhoods are interspersed, and public housing projects are distributed throughout the city. While parts of the city have improved in the past 10 to 15 years due to re-development efforts, many areas continue to experience problems with gangs, violence, and prostitution. Shelby County has 175,000 residents enrolled in TennCare, Tennessee?s Medicaid program, and an additional 65,100 Memphians are uninsured (Clay and Tomlinson, 2000).
People with co-occurring disorders are at higher risk for sexually transmitted diseases, are more likely to experience complex medical problems, and are disproportionately represented among those individuals continually recycled through the criminal justice system. A significant problem in Memphis, Tennessee, an MSA with annual AIDS Case Rates in 2001 at 57.8, resources for this growing, highly underserved population are scarce and fragmented.
As of 2000, there were nearly 6,500 reported cases of HIV and AIDS in Memphis and Shelby County. Each year since 1992, HIV antibodies have turned up in the blood of more than 500 Memphians. An average of 277 documented cases of full-blown AIDS are reported each year (Tennessee Department of Health, 2000), and Memphis has twice as many cases of STDs as St. Louis and more HIV-positive cases per capita than cities such as Atlanta (Fantz, 2000). In fact, Memphis holds the grim distinction as the 6th leading city in the country in reported rates of STDs (CDC, 1997).
In addition to the increased incidence of STDs among Shelby County residents, a corresponding growth has also occurred within the county?s criminal justice system — The number of inmates housed by the Shelby County Division of Corrections has grown from an average of 571 inmates per day in 1985 to a daily average of 2,900 today (Shelby County Division of Corrections, 2002). Within Memphis jails, an inmate is processed every 7 minutes and, on average, more than 3,000 inmates are housed there (Fantz, 2000). National research supports that rates of many diseases are higher for incarcerated individuals than for the total US population (e.g., among the incarcerated, HIV rates are 5-8 times higher, Hepatitis C rates are 9-10 times higher and TB rates are 4-17 times higher than the general public (Hammett and Maruschak, 1999).
Arrests in Shelby County are most commonly due to felony drug charges (Shelby County Division of Corrections, 2002). This is consistent with Federal trends (e.g., drug offenses increased from 58% of the total prison population in 1991 to 63% in 1997. Drug use also increased from 60% of Federal inmates in 1991 reporting illicit drug use at some time, to 73% in 1997 – U.S. Department of Justice, 1999). In addition, drug offenders are now more likely to be incarcerated and for longer amounts of time: the average sentence increased from 47 to 80 months between 1980 and 1994 (Office of National Drug Control Policy, 1996). There are more IDUs in correctional facilities in the U.S. than in drug treatment centers, hospitals, or social service agencies. In 1997, only 13% of all State prisoners and 15% of all Federal prisoners who used drugs regularly received drug treatment (Hammett and Maruschak, 1999).
The purpose of the expansion component is to devise a model that untangles these complexities through applying a logical series of coordinated and integrated services and defines a practice approach specific to both seropositive and high risk seronegative consumers that can be replicated in other settings. The project integrates ASAM PPC-IIR Intensive Outpatient Level II.1 with research-based principles of integrated care outlined by Robert Drake (2001), along with the key clinical prevention concepts of the CDC (1997; 1999), NIDA, and SAMHSA which include the following key components:
- Comprehensive Evaluation: Designed to assess risk and to develop a plan of care that integrates necessary resources for medical preventive or reactive treatments, linkages with Ryan White HIV Consortia agencies, housing, social services, and additional resources as needed. The primary counselor assigned to each participant provides assistance to facilitate access to needed and available resources.
- Group Therapy: ASAM PPC-IIR Intensive Outpatient (IOP) Level II.1 provides a field-tested, five days per week, three hours per day intensive, integrated dual treatment program with three daily groups, each one hour in length, designed to provide psycho-education, addictions treatment, relapse prevention, therapy, and coping strategies with a superimposed risk reduction component. Transportation is provided to all attending participants. SAMHSA?s TIP 8 supports use of IOP as a model approach for this population.
- Risk Management and Individual Therapy: Individual therapy is an essential part of that system to offer privacy, flexibility, and to allow a more precise tailoring of interventions (Rounsaville & Carroll). In addition, a Risk Reduction specialist, a nurse with expertise in IDU/STDs and dual diagnosis treatment, shall continue to meet on an ongoing basis with each client to discuss risk management and health status issues.
- Pharmacologic Treatment: Includes an initial assessment to examine need for psychotropic treatment, medication education, medication monitoring, and ongoing evaluation provided by a psychiatrist with expertise in both psychopharmacologic and addictions treatment.
Project methodologies integrate best practice approaches for co-occurring substance abuse/psychiatric treatment applying the research-based principles of integrated care outlined by Robert Drake (2001), considered by many as the foremost national expert on co-occurrence treatment, along with the key clinical prevention concepts of the CDC (1997; 1999), NIDA, and SAMHSA Treatment Improvement Protocol Series #37, Substance Abuse Treatment for Persons with HIV/AIDS.
Foundations? dual treatment approach integrates medical and behavioral health monitoring/education which offer demonstrated efficacy in trial prison release programs for HIV seropositive inmates in reducing both recidivism and high-risk behaviors (JAMA, 1998). Cost-effectiveness studies have reported that, by preventing HIV infections, community-based outreach interventions help avert future medical costs associated with the care and treatment of HIV/AIDS (NIDA, 1999). Drug users who enter and continue in treatment are more likely than those who remain out of treatment to reduce risky activities, such as sharing needles and injection equipment or engaging in unprotected sex (NIDA, 2002). Several principles of the NIDA Outreach Model are adopted in this project, including risk reduction strategies, use of indigenous staff, outreach, engaging at-risk individuals in personalized assessments of their own risk behaviors, assisting in identifying barriers and resources to risk behaviors, developing protection strategies, enhancing motivation to change behavior patterns, and teaching concrete strategies and behavioral skills for reducing risk.