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Morgenstern J., Hogue A., Dauber S. et al.
Journal of Studies on Alcohol and Drugs: 2009, 70, p. 955–963.
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In New York intensive case management coordinating multiple sources of support helped resolve the substance use problems of welfare applicants, but only among the women – who faced the greatest barriers to working – did this promote employment. Perhaps men would have done better being helped to rapidly enter the job market.
Summary Focusing on employment and training outcomes, the featured report complements an earlier report from the same US study which focused on substance use treatment participation and substance use outcomes.
The study tested whether relatively intensive case management support helps welfare applicants overcome substance use problems and gain employment. A particular issue was whether welfare recipients who despite recent reforms have yet to find work can be helped to do so, or whether this caseload faces barriers too great to overcome, even with intensive help. Implemented in New York's Bronx district in partnership with the city's welfare agency, it was designed to be a practical trial which maximised real-world applicability The case management functions at issue were delivered by an existing clinical programme supported by welfare funding, treatment fidelity was assessed with quality assurance methods, research assessments minimally intruded on routine care, and outcomes were used which were measurable in routine clinical care via self-report and biological confirmation. while maintaining research integrity.
Participants were 421 substance using single adults and adults with dependent children applying for welfare benefits. They were selected from 1519 such applicants on the basis of their reporting a substance use problem and being motivated to receive treatment. Initially they had been identified by welfare workers using a short questionnaire A modified version of the CAGE screening questionnaire. which screened applicants for substance use problems. Depending solely on where the next assessment slot was available, the workers transferred substance users for further assessment at one of the two offices in the study.
One of the offices offered usual assessment and care services: assessment by an addiction counsellor focused on substance use problems in relation to employability, followed by allocation to a generic welfare worker whose role was to assess eligibility for welfare payments and deal with non-compliance with the welfare system's requirements. They also referred the beneficiary to services, but only during infrequent meetings limited by a large caseload.
At the other office, more rounded and detailed assessments were conducted by a multidisciplinary team. Of psychiatrists, psychologists, social workers, nurses, vocational rehabilitation specialists, and addiction counsellors. After referring applicants to a range of services to meet identified needs, they transferred them to case managers. Their role was to maintain intensive contact Aided by relatively small caseloads, they contacted each client at least twice a week and visited them at their treatment programme every fortnight. They also familiarised themselves with local services, withdrawing clients from those not serving their needs, and cutting referrals to underperforming programmes. with the beneficiary and with the agencies providing them with services, and to ensure that these agencies matched the individual's needs and performed acceptably. In the usual care option, quarterly reassessments focused on welfare system requirements, but in the case management option the focus was on client progress and adjusting the service mix accordingly.
All 108 applicants who were in methadone maintenance treatment during the study were already in this treatment The study says that all clients in methadone maintenance were already enrolled in a programme when they entered the intervention, and transfer to another service was difficult and hence unlikely to occur. at the time they applied for benefits, and generally simply continued. Beyond these existing methadone patients, there were few if any heroin dependent applicants who might benefit from initiating treatment. Welfare case workers had more latitude to initiate or change other sorts of substance use treatments.
Diagnostic interviews found that about 6 in 10 of the sample met criteria for substance
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve Intoxication or desired effect;
markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
the characteristic withdrawal syndrome for the substance;
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. mainly in respect of cocaine, alcohol or heroin, and another fifth for substance abuse. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
• Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (eg, repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household).
• Recurrent substance use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine when impaired by substance use).
• Recurrent substance-related legal problems (eg, arrests for substance-related disorderly conduct).
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with spouse about consequences of intoxication, physical fights). Psychological problems and criminal justice involvement were common. About 1 in 6 had some degree of responsibility for dependent children.
Follow-up data was available for 394 of the sample (221 at the case management office, 173 at the office providing usual care) of whom two thirds were men. The earlier report had shown that, as intended, over the year of the follow-up period, case managed clients saw their case workers more often than their counterparts in usual care. Especially during the first three months, they also received a broader range of services. However, this was entirely due to greater service access among clients not already in methadone maintenance, and it was only among these clients that case management improved access to substance use treatment and rates of abstinence from alcohol and illegal drugs. Once other influences had been taken in to account, for every four people who were abstinent during any given month in the follow-up period, another three achieved this with the help of more intensive case management. This difference in abstinence rates emerged early in the follow-up year and was sustained throughout.
Despite these gains in tackling substance use problems, the featured report found that case management clients did not work (on or off the books, full or part time) on more days over the 12 months. With or without this extra support, most clients did not find work. Nor across the entire sample was there any significant indication that as the year progressed, case management began to have the intended impact on employment.
However, overall equivalence was due to the cancelling out of opposing impacts among men and women. Among women case management did lead to more days worked and this advantage increased over the year as the case managed women increased their workdays to on average three per month, while women offered usual care remained stuck at very low levels of employment, averaging less than a day a month. Although not statistically significant, among men it was the usual care clients who worked on more days, especially during the middle of the follow-up year; by the end, the gap was negligible and both sets of men worked on average about five days a month. The same gender-based pattern was found for the proportions of clients who found any work at all in a given month, or worked for at least five days in a month but not full time (few did work full time): women benefited from case management, men did not chart.
Next the analysts tried to establish whether treatment (days in non-methadone treatment for substance use problems) and greater remission of substance use (the number of months clients sustained abstinence from alcohol and illegal drugs) might have been responsible for the employment findings. Only among case managed women were the expected relationships found: the more they participated in treatment and sustained abstinence, the more days they later worked. Among usual care women, the reverse was the case, and among men, there were no relationships between work and earlier abstinence or treatment participation. Across both genders, these trends summed overall to no significant relation between work and earlier treatment or abstinence. Being in methadone treatment in particular, while it was associated with fewer days worked, did not affect the impact of case management.
Conceivably case management might have led to more employment training or job search activities (which might in turn have led to more employment among the women), but no such relationship was found.
Broadly replicating findings among an exclusively female caseload of welfare applicants in New Jersey, the featured study found that among women, case management coordinating their care yielded significantly higher rates of employment during the 12-month follow-up when compared with usual referral and monitoring practices. Moreover, there were indications that this was due to case management increasing treatment participation and abstinence in the first half of the follow-up year, which in turn enabled the women to work more regularly in the following six months. How far case management could boost employment was however limited. Despite the extra help, women in both studies experienced multiple barriers to employment related to physical and mental health, housing and legal status, and child welfare issues, and about half the men did not work at all in any given quarter of the follow-up year. Whether still more intensive support would more effectively overcome these barriers is unclear.
In contrast, offered only usual and relatively minimal support, women who achieved more abstinence and participated more in treatment later actually worked on fewer days than women less successfully engaged in treatment. Without countervailing intensive employment support, it could be that these women were discouraged from working while in treatment and/or aided to mange better without working. Among men case management did promote abstinence, but men who found work seemed to do so regardless of prior case management, treatment or abstinence, and without much recourse to the employment supports offered by the case management programme. For men – generally both more ready and able to work than women – it may be that interventions focused on rapid engagement in the workforce, even if they are continuing to drink or use drugs, might be a better match than the case management option trialled in the study which emphasised substance use treatment.
commentary After reforms aimed at reducing welfare dependency, just how difficult it was for people left on welfare to find work is the overall finding of the study, though some minor headway was made among the women by mounting a comprehensive effort to address the multiple barriers they faced to working. This picture emerges despite the fact that the study selected the most promising candidates The 421 clients in the study were whittled down from 8986 applicants screened positive by welfare workers for substance use and sent for more comprehensive assessment. Over 1800 did not turn up for assessment. The remainder were sampled on a quasi-random basis by the research project's interviewers. Fewer than a third of this sample were selected for the study. Selected applicants were assessed as problem substance users motivated to attend treatment, who did not face major barriers such as serious mental illness or impending/actual homelessness. As intended, these selection processes would have resulted in a sample willing to accept both assessment and treatment, and potentially in a position benefit from that treatment. Indeed, just over half were already in treatment. for substance use treatment. Its results cannot be assumed to generalise to the bulk of welfare applicants identified by front-line welfare workers as potentially hindered by their substance use, but who do not have a serious problem, have one but are unwilling to acknowledge it, or are not motivated to tackle it.
The same research team had recently conducted a similar study among substance-dependent mothers applying for benefits for families in need. Those offered case management were over twice as likely to be abstinent during any particular month in the two-year follow-up period, and across this period were 68% more likely to be in full time employment. As the authors comment, this coincidence of findings strengthens the case for women welfare recipients suffering from substance use problems to be offered these services.
The findings in respect of substance use were line with a sparse evidence base suggesting that increased provision/receipt of welfare and medical services improves outcomes from addiction treatment. Lack of impact among methadone-maintained patients was expected because at the start of the study they were already in a treatment which entailed regular clinical and counselling contacts, leaving in this respect little for case managers to improve on. Had case managers been able to initiate methadone treatment, the picture might have been reversed, with greater impacts among those introduced to methadone programmes. However, the US requirement for long-term supervised consumption of methadone would constrict vocational and employment opportunities.
These two studies are at odds with the general picture reported in a review of studies of case management for drug users. Across 11 studies which randomly allocated clients to case management versus 'usual care', case management did improve access to services, but there was no statistically significant impact on illegal drug use. Just one study was found which reported employment outcomes, and these were not improved by case management. Substance use outcomes varied substantially from study to study, suggesting that effectiveness depends on circumstances. The authors of the two studies have argued that their findings may have contradicted the generally negative trend because the interventions they tested were robust, well resourced by the providing authority, and there was a clear divide between these services and those provided to comparison groups. Other factors include whether services are so easily accessible that case management is unnecessary, or so hard to access that case management cannot help (or not until new systems/resources have been developed), and the type and intensity of the case management model.
The suggestion in the featured report that men – even if they are continuing to drink or use drugs – might have benefited more from interventions focused on rapid engagement in the workforce relates to the Individual Placement Support (IPS) model favoured in a report for drug and alcohol services in London and for psychiatric patients by the Sainsbury Centre for Mental Health. Rather than awaiting treatment success or a long process of step-by-step vocational support and training, the model involves rapid job search and aims to get any who wants this into competitive employment. Several US studies have randomised dual diagnosis patients to this model versus comparison vocational services offering stepwise entry into competitive employment. Though employment overall including sheltered placements may not have been promoted by the model, competitive employment certainly was and to a substantial degree.
In Britain's national drug policies, employment is seen as both a bulwark against relapse to dependent drug use and an obligation on patients who can work and contribute to society rather than living on benefits. The English policy stresses the clinical and fiscal need to move the estimated 400,000 substance-dependent benefit claimants through treatment and rehabilitation to sustained employment. Scotland's core treatment objective is that patients "move on from their addiction towards a drug-free life as a contributing member of society". For Wales, employment is among the life changes "essential to assist and sustain recovery". In contrast, in alcohol strategies employment is more likely to feature as a benefit of alcohol and allied leisure industries.
Despite this interest in employment in the UK, studies have been few and none have tested intensive case management as an employment aid. There is however some evidence that treatment services which package employment services within their programmes have the intended effect. Such services are a step towards the more comprehensively coordinated programme tested in the featured study. In 2001 the Drug Outcome Research study in Scotland sampled 1033 patients starting treatment for drug problems in different modalities and observed what happened as they went through the normal treatment process. Though using many other drugs, most saw their main problem as heroin. Some of the findings suggested that receipt of employment help from treatment services was an important influence on later employment, that the treatment modality was less influential, and that whether treatment eliminates heroin use was less important than whether it reduced dependence and the crime that often comes with it. The fact that similar help from outside agencies did not enter the frame possibly indicates that on-site help from familiar and trusted faces is most likely to be acted on, or that external help was sought only after prompting from the treatment service.
Last revised 16 December 2011
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MATRIX CELL 2014 Drug Matrix cell A2: Interventions; Generic and cross-cutting issues