Integrating substance abuse Integrating substance abuse treatment in the social treatment in the social

servicesservicesPaper presented for the International Conference on Paper presented for the International Conference on

Building Delivery Systems for Substance Abuse Building Delivery Systems for Substance Abuse Treatment,Treatment,

Istanbul, September 5-7, 2005Istanbul, September 5-7, 2005by Kerstin Stenius, Ph.D.,by Kerstin Stenius, Ph.D.,

SoRAD, Stockholm University, Sweden andSoRAD, Stockholm University, Sweden andStakes, Helsinki, FinlandStakes, Helsinki, Finland

DispositionDisposition

- On the role of social work and social - On the role of social work and social support in substance abuse support in substance abuse treatmenttreatment

- Sweden as a case: formative - Sweden as a case: formative moments, implications of this moments, implications of this integration, present challenges integration, present challenges

- Integrating health care addiction - Integrating health care addiction treatment and social services: treatment and social services: Results from a Stockholm study Results from a Stockholm study

"Optimal [substance abuse] "Optimal [substance abuse] care is likely to happen within care is likely to happen within

the context of an ongoing the context of an ongoing relationship, in which support relationship, in which support and services are provided as and services are provided as needed through the normal needed through the normal ups and downs of life" (W. ups and downs of life" (W. Miller, 2002, 22, in Miller & Miller, 2002, 22, in Miller &

Weisner, 2002)Weisner, 2002)

Social services can be such a Social services can be such a context context

high density of substance use high density of substance use disorders in social services disorders in social services

early detection possibleearly detection possible

(Miller & Weisner 2002)(Miller & Weisner 2002)

Social services can provide Social services can provide social support to substance social support to substance

abusersabusers Defending human and social rights Defending human and social rights

of substance users of substance users Giving support to families and other Giving support to families and other

important networks around important networks around substance userssubstance users

Providing respectful, available and Providing respectful, available and continous relationscontinous relations

Social services can be the primary Social services can be the primary frame for substance abuse frame for substance abuse treatment, as in Sweden:treatment, as in Sweden:

Detoxification and acute medical Detoxification and acute medical care of substance use takes place care of substance use takes place within mental health care, but the within mental health care, but the main responsibility for providing care main responsibility for providing care lies with the social serviceslies with the social services

On any given day 60% of clients in On any given day 60% of clients in social services, 40 % in health care social services, 40 % in health care

Implications of this framing:Implications of this framing:The dual mandate of social The dual mandate of social

workwork "Social work's place and function in society "Social work's place and function in society

centres on the creation of internal centres on the creation of internal social social peacepeace, to be established not primarily by , to be established not primarily by coercive meanscoercive means but through the considered, but through the considered, informed and professional informed and professional negotiationnegotiation of of differences and inequalities. Social work has a differences and inequalities. Social work has a 'dual mandate''dual mandate' for these negotiations, from for these negotiations, from individuals and from society at large, either individuals and from society at large, either through state agencies or through non-through state agencies or through non-governmental organisations" (Lorenz 1994, 4)governmental organisations" (Lorenz 1994, 4)

Emphasis on social peace or orderEmphasis on social peace or order Two perspectives: the client's and the social Two perspectives: the client's and the social

environment'senvironment's Mediate between individual and state/society Mediate between individual and state/society "Unlikely to be convergence towards one "Unlikely to be convergence towards one

internationally recognised form of social work internationally recognised form of social work and a unified profession" (Lorenz, ibid)and a unified profession" (Lorenz, ibid)

Can we then learn anything from the Can we then learn anything from the experiences from other countries? experiences from other countries?

Analysing the Swedish caseAnalysing the Swedish case

a) The impact of the formative a) The impact of the formative moment? moment?

b) How did this social services b) How did this social services institutionalisation shape the institutionalisation shape the treatment system treatment system

c) What are the present c) What are the present (internationally recognisable) (internationally recognisable) challenges - A new formative moment?challenges - A new formative moment?

Conceptual excursion: What is Conceptual excursion: What is a "formative moment"?a "formative moment"?

Concept within historical institutionalism, a Concept within historical institutionalism, a school of political science emphasising the school of political science emphasising the importance of (national) social institutions importance of (national) social institutions for policy developments (Thelen & Steinmo for policy developments (Thelen & Steinmo 1992)1992)

Formative moments: When existing Formative moments: When existing structures are unable to solve a societal structures are unable to solve a societal problem and political actors intentionally problem and political actors intentionally can create new institutions (Rothstein 1996)can create new institutions (Rothstein 1996)

1916 a formative moment for 1916 a formative moment for substance abuse treatment in substance abuse treatment in

SwedenSweden Drinking put on the agenda as a social Drinking put on the agenda as a social problemproblem

by strong temperanceby strong temperance The movement provided The movement provided actorsactors with belief in with belief in

treatment and education treatment and education Social orderSocial order (public drunkenness) important in (public drunkenness) important in

time rapid urbanisation and industrialisationtime rapid urbanisation and industrialisation Alcoholism viewed as cause of Alcoholism viewed as cause of povertypoverty Alcohol treatment integrated in existing Alcohol treatment integrated in existing

municipal institutional structuresmunicipal institutional structures for poor for poor relief. Municipalities would benefit from relief. Municipalities would benefit from decreased poor relief costs and could provide decreased poor relief costs and could provide close social control of drinkersclose social control of drinkers

Treatment of drug users added from the 1960sTreatment of drug users added from the 1960s

How did this organisational How did this organisational frame shape the treatment frame shape the treatment

system?system? one one big and corporatistic big and corporatistic system with system with free free

accessaccess to treatment to treatment focus on the focus on the poor and marginalised drinkers poor and marginalised drinkers

and drug usersand drug users great local variations in treatmentgreat local variations in treatment non-professionalised and ideological non-professionalised and ideological

systemsystem - very broad treatment concept, little - very broad treatment concept, little interest for systematic evaluationsinterest for systematic evaluations

administrative paternalism and coercion - administrative paternalism and coercion - the collectivist gazethe collectivist gaze

abstinence - not harm reductionabstinence - not harm reduction

What are the present What are the present challenges for this system?challenges for this system?

corporatism challengedcorporatism challenged by new public by new public management in the welfare state - social movements management in the welfare state - social movements politically marginalised, new privatisation of politically marginalised, new privatisation of treatment provisiontreatment provision

weakened solidaristic thinkingweakened solidaristic thinking - social - social acceptance of marginalised groups acceptance of marginalised groups

money talksmoney talks - cost-effeiciency and cost- - cost-effeiciency and cost- containment in the welfare statecontainment in the welfare state

medicalisation and recentralisationmedicalisation and recentralisation of treatment: of treatment: evidence-based treatment, new pharmacological evidence-based treatment, new pharmacological treatmentstreatments

economic and scientific-professional rationality economic and scientific-professional rationality instead of value-based discussion instead of value-based discussion

One respons to these One respons to these challenges: integration of challenges: integration of

social services and health care social services and health care addiction treatment addiction treatment

Study in Stockholm county of Study in Stockholm county of addiction treatment (Room et addiction treatment (Room et

al. 2003)al. 2003) app. 2 million inhabitantsapp. 2 million inhabitants mental health care (county council) mental health care (county council)

addiction treatment divided into Addiction addiction treatment divided into Addiction Centre North (ACN) and Addiction Centre Centre North (ACN) and Addiction Centre South (ACS) 1996-2002 South (ACS) 1996-2002

social service addiction treatment handled social service addiction treatment handled by 26 municipalities within the countyby 26 municipalities within the county

alltogether ca 350 hospital beds, alltogether ca 350 hospital beds, numerous rehabilitations centres, ca 45 numerous rehabilitations centres, ca 45 outpatient unitsoutpatient units

Reform decided by county Reform decided by county council and municipalities in council and municipalities in

19961996 out-patient emphasis, moving health out-patient emphasis, moving health

care based resources from hospitals care based resources from hospitals to local out-patient units to local out-patient units

ideally co-localisation of health care ideally co-localisation of health care and social service's addiction out-and social service's addiction out-patient treatmentpatient treatment

Goals of reformGoals of reform

towards one system with common towards one system with common guidelines and body of knowledgeguidelines and body of knowledge

continuity and planning in treatmentcontinuity and planning in treatment local availaibility of treatmentlocal availaibility of treatment responsiveness to less developed responsiveness to less developed

problems, vulnerable groupsproblems, vulnerable groups less inpatient treatment - savingsless inpatient treatment - savings

Different policies in north and Different policies in north and southsouth

North adopted the policy quickly: de- North adopted the policy quickly: de- crease of hospital beds, new local unitscrease of hospital beds, new local units

South was reluctant, wanted to South was reluctant, wanted to strengthen hospital treatment for strengthen hospital treatment for research and for recruitment of research and for recruitment of qualified staff: increase of hospital bedsqualified staff: increase of hospital beds

social services: politicians decidesocial services: politicians decide

Gave us possibilities to Gave us possibilities to comparecompare

To investigate if a decentralisation of health To investigate if a decentralisation of health based addiction treatment and its based addiction treatment and its integration with social service addiction integration with social service addiction treatment in Stockholm county had an treatment in Stockholm county had an impact on:impact on:

catchment of addiction treatmentcatchment of addiction treatment treatment consumptiontreatment consumption patients/clients perception of treatment patients/clients perception of treatment some outcome measuressome outcome measures

DataData

- structured interviews 2000-2002 - structured interviews 2000-2002 with with

1 865 patients/clients from the north 1 865 patients/clients from the north and the south with follow-up (71 %) and the south with follow-up (71 %) after one year after one year

- interveiws with head of units- interveiws with head of units

PopulationPopulation

28 % women28 % women Mean age 43 yearsMean age 43 years 80 % born in Sweden80 % born in Sweden 24 % live with partner24 % live with partner ¼ no stable housing situation¼ no stable housing situation ¼ working¼ working 60% alcohol dependent, 1/3 drug 60% alcohol dependent, 1/3 drug

dependent (ICD-10, 3+ criteria)dependent (ICD-10, 3+ criteria)

Results: Catchment 1 ("high Results: Catchment 1 ("high threshold groups")threshold groups")

Intregrated system recruits more Intregrated system recruits more immigrants,immigrants,

more persons with lower education,more persons with lower education,

more people who live alone more people who live alone

and more without stable housing and more without stable housing situationsituation

Results: Catchment 2 ("less Results: Catchment 2 ("less developed substance abuse developed substance abuse

problems" )problems" ) 29 % in both parts had received addiction 29 % in both parts had received addiction

treatment the year before first interviewtreatment the year before first interview ¾ in both parts had experienced informal ¾ in both parts had experienced informal

pressure to go to treatment, 45 formal pressure to go to treatment, 45 formal pressuer pressuer

integrated system recruited more patients with integrated system recruited more patients with less frequent use of 12+ units of alcoholless frequent use of 12+ units of alcohol

no differences in days of drug use (of last 30) no differences in days of drug use (of last 30) or number of alcohol and drug dependency or number of alcohol and drug dependency criteriacriteria

Results: Consumption of Results: Consumption of treatment between baseline treatment between baseline

and follow-upand follow-up no difference in consumption of no difference in consumption of

outpatient bewteen T1 and T2 (mean outpatient bewteen T1 and T2 (mean 63 days)63 days)

no difference in consumption of no difference in consumption of inpatient treatment measured as inpatient treatment measured as number of daysnumber of days

Results: Clients' perception of Results: Clients' perception of treatment treatment

Patients/clients from integrated system finds Patients/clients from integrated system finds it easier to get into treatment and it easier to get into treatment and experiences treatment as more coherent and experiences treatment as more coherent and continouscontinous

This holds true controlling for drug This holds true controlling for drug dependence and drug related life area dependence and drug related life area problems problems

As a whole about 85 % says that they have As a whole about 85 % says that they have someone in the treatment system they can someone in the treatment system they can turn to with their problemsturn to with their problems

Results: OutcomesResults: Outcomes

ASI medical status: no differences in reported ASI medical status: no differences in reported changes bewteen baseline and follow upchanges bewteen baseline and follow up

ASI psychiatric status: integrated system less ASI psychiatric status: integrated system less negative changes in no of days with problems negative changes in no of days with problems of last 30, in how bothered they are and in of last 30, in how bothered they are and in how important it is to get helphow important it is to get help

dependence: no differences, ¼ showed dependence: no differences, ¼ showed positive change in no of alcohol dependency positive change in no of alcohol dependency criteria, ca 15 % in drug dependency criteriacriteria, ca 15 % in drug dependency criteria

Study findings summarisedStudy findings summarised

decentralised/integrated treatment may attract some decentralised/integrated treatment may attract some groups with higher thresholdgroups with higher threshold

not clear that it attracts more persons with "less not clear that it attracts more persons with "less developed" problems developed" problems

no signs of less inpatient treatment in the no signs of less inpatient treatment in the decentralised/integrated system - no cost differencies?decentralised/integrated system - no cost differencies?

clients/patients perceive integrated and decentralised clients/patients perceive integrated and decentralised treatment as more available and coherent treatment as more available and coherent

no clear signs of better outcome with either system no clear signs of better outcome with either system (exception ASi psychiatric status)(exception ASi psychiatric status)

the greater consumer satisfaction, and particularly if the the greater consumer satisfaction, and particularly if the catchment seems to be broader, may, if supported by catchment seems to be broader, may, if supported by further analyses, be an argument for a decentralised and further analyses, be an argument for a decentralised and integrated system - at least in Sweden integrated system - at least in Sweden

Integrating substance abuse Integrating substance abuse treatment in social services: treatment in social services:

ConclusionsConclusions It does matter if you integrate treatment in social It does matter if you integrate treatment in social

services or in primary health care - the systems services or in primary health care - the systems have different rationaleshave different rationales

We know too little about the effects of different We know too little about the effects of different organisational solutions for substance abuse organisational solutions for substance abuse treatment, and particularly within the social treatment, and particularly within the social servicesservices

Generalising from experiences from other countries Generalising from experiences from other countries is difficult: social services have more nationally is difficult: social services have more nationally shaped logics than health care shaped logics than health care

Integrating/co-locating outpatient social services' Integrating/co-locating outpatient social services' and health care addiction treatment may increase and health care addiction treatment may increase the availability and attractiveness, the quality, of the availability and attractiveness, the quality, of addiction treatmentaddiction treatment

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