ADDICTIONS RECOVERY MENTOR PROGRAM
BRIDGING THE GAP: DETOX TO TREATMENT SERVICE ENGAGEMENT

January 2001

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Abstract

The Mentor Program was conceived as a potential intervention in response to mounting evidence of an epidemic of heroin related deaths and low successful treatment completion rates for heroin addicts in Multnomah County, Oregon.  A series of concurrent efforts by the Multnomah County Board of Commissioners, treatment providers, and activists from the Recovery Association Project facilitated the process to identify necessary county funding to design and implement the intervention program in June 1999.

This report documents the design, development, and start-up of the Mentor Program to enhance the effectiveness of established alcohol and drug treatment programs.  In addition to providing a description of the program, this report also provides an analysis of preliminary data in an attempt to determine the efficacy of the program during its first year of operation.

The primary purpose of the Mentor Program was to increase the number of heroin clients that engaged in outpatient treatment following detoxification.  The program was also expected to increase the number of admissions of heroin clients as well as the number of clients that successfully completed outpatient treatment.

The study found that the Mentor Program significantly increased the rate at which heroin clients referred from detoxification engaged in outpatient treatment from 51.6 percent to 85.2 percent.  The overall rate of enrollment of heroin clients referred from detoxification to outpatient treatment demonstrated a substantial increase of 96.4 percent for an annualized enrollment of 165 compared to 84 enrollments prior to program implementation.  Mentored clients also exhibited significantly higher outpatient treatment completion rates of 45.2 percent compared to a 16.1 percent baseline rate.  On an annualized basis, this would represent a 278 percent increase in the number of clients successfully completing outpatient treatment over the baseline rate.  (Completion rates were calculated using the state accepted formula that removes neutral discharges.)  The average length of treatment program enrollment increased significantly from 27.4 days to 68.2 days.  Increasing enrollments with increasing successful program completion rates should have a profound impact on the efficacy of both the mentoring and the outpatient treatment programs.

The completeness with which CCC has woven a community of recovery in downtown Portland can not be overlooked.  Attempts to replicate the Mentor Program must consider all aspects of the recovery process ranging from detoxification to aftercare and alcohol and drug free community (ADFC) housing, food, clothing, mental and physical health care, employment, and a close knit recovery community.

Clients interviewed formally as part of this study, and ex-clients interviewed formally in conjunction with other studies by the author, unquestionably reinforce strong support for the program in the recovering community.  Further study is most certainly warranted to ensure that the evaluation findings of startup program performance are maintained with a fully integrated program.  One of the beliefs of the program designers and mentors is that the skills and knowledge gained by clients from participation in the Mentor Program will have lasting effects on recovery.  Classically, treatment for alcohol and drug addictions does not include actual community based skill building.  Although definitive value and efficacy have been demonstrated, the true importance of this program most likely cannot be appropriately measured without several years’ experience and rigorous longitudinal follow-up with clients.

INTRODUCTION

This report documents the design and development of the Mentor Program to enhance the effectiveness of established alcohol and drug treatment programs. In addition to providing a description of the program, this report provides an analysis of quantitative and qualitative data to determine the efficacy of the program during its first year of operation.

The overarching goal of the Mentor Program was to increase the number of heroin clients who successfully engaged in treatment following detoxification. In concordance with this goal were two critical expectations. The first of these was that the mentoring process would also increase the number clients who successfully complete treatment.

Second, was the expectation that the number of heroin clients from Hooper Memorial Detoxification Center (Hooper) that enroll in treatment at the Portland Alternative Health Clinic (PAHC) would increase by closure of the “hole” in the referral process discussed in detail below.

Some caution should be exercised in the interpretation of the findings since the program was in its first year of operation that included start-up activities.

BACKGROUND

The concept, impetus, design, funding, and implementation of the addictions recovery Mentor Program was the culmination of concerns from the Multnomah County Board of Commissioners, the Recovery Association Project (RAP), and Central City Concern (CCC). Many long months before the Mentor Program (MP) began operation in June of 1999, there had been a growing anxiety within the recovering community that the number of deaths related to heroin overdose was reaching epidemic proportions in the county. Further, the recovering community was becoming agitated due to the perception that the County Public Health Department was purposefully ignoring the problem.

On the streets, there were several themes that had emerged to explain the high number of heroin related deaths. First, it was common to hear stories of individuals experiencing medical complications from heroin overdoses while those around them would not call for emergency medical services (“911”) for fear of being arrested by the police for possession. Another common theme was that others were dying from the synergistic effect between heroin and legally obtained medications prescribed by physicians. The third theme was that many of the heroin related deaths were due to misjudging doses by individuals who were placed back on the streets following periods of forced abstinence. This latter theme was primarily reported with individuals coming from incarceration (although there was evidence that some cases were associated with the return to the community from residential addictions treatment where sober living facilities, combined with appropriately intense outpatient services, were not available).

During the fall of 1998 and through the spring of 1999 two potentially powerful agents emerged that began to cause change. The first of these was the increasing awareness within the Board of County Commissioners of the growing problem. This was championed by Commissioner Sharon Kelly, who had made public her son’s untimely death to related causes, and Chair Beverly Stein, who took the initiative to focus attention on problems facing the delivery of mental health services, in general, in the county. Although friends of the cause, these Commissioners had little visible public support for their initiatives to create change within the county’s health care delivery system.

The second agent for change was a project undertaken by CCC. In the fall of 1998, CCC was awarded a three-year grant, from the Center for Substance Abuse Treatment (CSAT), to pilot a project organizing the recovering community. The purpose of the Recovery Association Project (RAP) was to create a self-sustaining group to advocate for better care for those requiring alcohol and drug treatment services, primarily from the public sector. The concept for the Mentor Program originated from a discernment process, based on the personal experiences shared by Kim Matic and Randy Sorvisto, in a meeting of RAP members.

At this meeting, Matic and Sorvisto, discussed the extreme difficulty they experienced in early recovery attempting to find and meet their basic survival needs while becoming connected to the treatment and other service resources in Portland.

Within a few days of that meeting, Ed Blackburn, the project manager for the RAP grant, and Director of Chemical Dependency Services for CCC, was contacted by Bill Farver, of Chair Stein’s office, responding to the mounting evidence of the heroin overdose epidemic. Farver inquired what alternatives could be implemented quickly to help relieve the crisis. Armed with the information discerned from the RAP core team meeting Blackburn was able to propose the concept of the Mentor Program.
With the advocacy and public support of RAP at the county’s public hearings during the budgeting process, the commissioners were able to confirm funding to begin the project in the summer of 1999.

The Mentor Program quickly became an important element of the broad spectrum of services provided by CCC. To best understand the program, it is important to have a broad picture of how it fits in the service continuum. The following section provides an overview of Central City Concern.

CENTRAL CITY CONCERN OVERVIEW

Central City Concern (CCC), a 501 (c)(3) private non-profit organization, was founded in 1979 as a consolidated effort to deal with the growing homelessness in the city of Portland and Multnomah County. At that time, a National Institute of Alcohol Abuse and Alcoholism (NIAAA) Public Inebriate Project was transferred from management by the city of Portland and Multnomah County to the new CCC. With this mandate to provide solutions to homelessness, CCC grew in two essential directions: housing and chemical dependency (CD) services. In 1991, CCC realized that in order to achieve long-term, permanent solutions to homelessness, stable employment would be necessary. An aggressive campaign began to integrate federal and state employment assistance programs under their broad umbrella of services for the homeless.

CCC owns, or manages, well over 1600 units of low-income housing in fourteen buildings in Portland. Of these, over 600 are specifically Alcohol and Drug Free Communities (ADFC) and over half of all units are for populations requiring special needs such as the mentally ill, chemically dependent, HIV/AIDS, or multi-diagnosed.

The Hooper Memorial Detoxification Center (Hooper) has been operated by CCC since 1981 and has served over 110-thousand non-duplicated chemically dependent individuals since it’s founding in 1972. Hooper has three distinct programs that include an outreach and inebriate pick-up service for Portland (CHEIRS – CCC Hooper Emergency Inebriate Response Service); a sobering program; and a 52 bed sub-acute medical detoxification program that provides services to over 3,200 individuals each year.

CCC also manages a 50-bed residential chemical dependency treatment program for pregnant women and women with pre-school age children. This facility, ARA Letty Owings Center, was initially opened in 1989.

The CCC Jobs Program was implemented in 1992 to serve alcohol and drug free individuals who are motivated to find and keep stable employment. This program is designed to help individuals overcome the many barriers to employment that are created by homelessness by blending case management and employment readiness preparation with ADFC housing. The Jobs Program has utilized resources obtained through several grants and contracts including the Department of Labor (DOL), Veterans Administration (VA), and the Enterprise Community Project.

The Portland Alternative Health Center (PAHC), opened in 1988 as the Portland Addictions Acupuncture Center (PAAC), is operated by CCC. PAHC/PAAC provides traditional social model outpatient alcohol and drug (A&D) treatment that is augmented by alternative health improvement interventions including acupuncture, herbal therapy, exercise, and meditation. PAHC currently averages an enrollment of 300 client at any given time.

PAHC provides specialized services for homeless, or low income, chemically dependent clients who may also have other cooccurring issues including mental illness, HIV/AIDS, or involvement with corrections. Highly specialized programs are provided for women and Spanish speaking clients.

In addition to this expansive network of integrated services, CCC has a long history of involvement in partnerships and coalitions. CCC founded the Homeless Alcohol and Drug Intervention Network (HADIN) in 1980. HADIN is a very active network of 15 member agencies that are formally integrated under a Qualified Service Provider Agreement. Line staff from each organization have been meeting weekly since inception of the network to actively case manage clients through the continuum of care. HADIN provides a well integrated, proactive safety net that extends from the streets of downtown Portland through the homeless shelters to outpatient and residential treatment programs.

Similar in design to HADIN, is the ADFC Network, organized by CCC, to coordinate alcohol and drug free housing and treatment services.

MENTOR PROGRAM OVERVIEW

Although no formal empirical evidence has been generated to document the difficulties individuals have in maintaining very early sobriety following sobering and brief detoxification services in Multnomah County, there is a plethora of anecdotal information readily available from interviews with clients in community based recovery programs and self-help groups that undeniably demonstrates the large number of individuals who relapse before engaging in follow-on care. Formal and informal interviews, by the author over the past six years with individuals in the recovery community in Portland, have identified countless cases where individuals had relapsed within a few hours of leaving detoxification. The primary causes cited included: no place to go; no knowledge or skills to successfully find food and shelter outside the street-environment they were accustomed to; and no knowledge to effectively engage in follow-on care after detox.

Purpose of the Mentor Program

As stated above, the overarching goal of the Mentor Program was to increase the number of heroin clients who successfully engaged in treatment following detoxification. In concordance with this goal were two critical expectations. The first of these was that the mentoring process would also increase the number clients who successfully complete treatment. Second, was the expectation that the number of heroin clients from Hooper that enroll in treatment at PAHC would increase by overcoming critical barriers found in the community as discussed in detail below.

A great deal of care should be taken to distinguish the difference between enrollment in follow-on treatment and engagement in follow-on treatment. Engagement in treatment is commonly identified as the point at which the client acknowledges the value of treatment and internalizes the responsibility for continuation of that treatment. Even with this point of actualization attained, there remains a profusion of barriers confronting the individual before any semblance of stabilization can be attained within a sobriety driven life style. The underlying goal of the Mentor Program, was then conceptualized to assist the client in eliminating as many of these barriers as possible to enhance the prospects of treatment engagement.

Mentees identified critical barriers blocking the connection between detox and engagement in treatment as encompassed within the framework of three crucial phases. The first phase was defined as the immediate attainment of basic needs including a source of food and shelter upon release from detox. Most of those selected as mentees indicated they would have relapsed within a few hours to a few days without direct linkage to a source of food and shelter in a safe environment. An environment that was free from the street culture of alcohol and drug users. They reported this was due to a complex interrelationship among several factors including the lack of ability to acquire food and shelter in a safe environment, the immediacy of need for food and shelter that put them quickly back into the familiar environment from which they had just emerged prior to detox, and finally, the quickly descending loss of hope associated with not seeing any alternatives to previous behaviors.

The second crucial phase was reported as the establishment of at least one trusted social relationship outside the network of substance using cohorts. Even with ADFC housing and a source of food, it was reported that integrating into a new culture of new people and new places was very difficult. Without a trusted social relationship, it would have been very easy to drift back into the familiar social network of substance users.

This factor of having at least one trusted relationship, from the beginning, cannot be over emphasized. This relationship is the pivotal factor of the project and subsequent emergence of the “mentor.”

The word “mentor,” taken from the Greek, represents the idea of a trusted counselor or guide. One who has gone before, has successfully overcome the barriers, and has emerged successful and then has become both the teacher and the coach. A person who has both the knowledge and skills to do what is desired by the mentee, as well as being able to guide, lead, motivate, comfort, and prod the mentee towards action.

Importantly, it was clear from interviews with the program managers, mentors, and mentees that, by design, the mentors were not intended to become, or replace, the mentee’s “sponsor” within the purview of the self-help groups such as Narcotics Anonymous (NA). Nonetheless, the mentoring relationship precedes the identification of a sponsor, which, under “normal” circumstances, may take several weeks before an individual new to self-help summons the courage to ask someone to become his or her sponsor. In application, then, this line becomes blurred as the mentor guides and counsels the mentee through the early stages of engaging in self-help as part of the overall mentoring process.

The third crucial phase was identified as that which united the mentee across a myriad of barriers with essential needs of healthy living that would, if not met, pose threats to continued sobriety. These included access to physical and mental health care; social services; appropriate recreational opportunities; and eventual employment or welfare opportunities.
The coordination of these types of services is commonly associated with case management and “wrap-around” services.
Notwithstanding, the vision of the Mentor Program was to go well beyond the simple coordination of services to the point of physically ensuring the mentee made and kept appointments by accompanying them to the service agency as necessary.
Mentor Project Organization

The Mentor Program office is located in the Portland Alternative Health Care (PAHC) facility and falls within the functional responsibilities of the Director of PAHC, who in turn reports to the Director of Addictions Programs for CCC. The Mentor Project staff consists of a manager/mentor and two additional mentors.

The Mentor Program staff share a small office space in the basement of the PAHC building. This space has come to double as administrative space and an informal drop-in center. For the most part, mentors are in the community transporting clients to and from services, facilities, sober recreational activities, and self-help groups. Much of this time in the field is spent with more than one client at a time. This serves to develop additional awareness, knowledge, and skills among the clients as to the availability and location of community services and how to effectively access these services. These “mobile group settings” have been consistently described as “mini-meetings” in reference to the similarity of the types of discussions that occur at self-help meetings. Mentors make a clear distinction, nonetheless, for the clients between these “mini-meetings” and the “real” self-help meetings.
Mentor Qualifications

The formal position title within the CCC organizational structure for the mentors is Intervention Specialist. In addition to the basic requirements for physical mobility to be able to accompany clients throughout their environment and a safe driving record, mentors, if recovering, must have three years sobriety. Additionally, mentors must have the ability to effectively interact with others who have diverse ethnic or cultural backgrounds, religious views, political affiliations, lifestyles, and sexual orientation. Two key requirements for this position include “substantial experience with issues involving opiate addiction” and the ability to employ a “flexible approach to client treatment support.”

Importantly, the emphasis of qualifications for the mentor position is the mentor’s knowledge of all aspects of opiate addiction, including the language, values, norms, and other attributes of the subculture; the subtleties and linguistic nuances of the differences between the honest dialogue of a client and that of a client making statements for an intended effect; and, knowing how and when to appropriately intervene on the client’s behalf. Of equal importance is the first hand knowledge of how to efficiently navigate the social service network from the bottom up. None of these skills can be learned in an academic environment. They can only be learned by the experience of spending a great deal of time within the environment learning, most often by trial and error, how to be successful. Congruently, the minimum requirements for the intervention specialist do not include a formal education.

Consistent with this vision of the role and qualifications of the mentors, each of those that have been hired are actively involved in self-help recovery from heroin addiction with substantial experience in personally overcoming the barriers to recovery. Their personal stories include homelessness, involvement in the criminal justice system, all the customary attributes of living within the sub-culture of on-the-street heroin users, as well as infection with hepatitis C virus (HCV).

Each is highly dedicated to his and her role as mentor and carry a mobile phone on and off the job. Clients are given their mentor’s phone number and are encouraged to call them anytime. Although the clients report this as a very positive aspect of the relationship with their mentor, one of the issues facing the mentors has been how to effectively separate their personal life from their work life. This issue appears to be in resolution but will certainly reappear from time to time. One of the concerns, noted by this evaluation, is the vulnerability this position could have to burnout. This is due to the high level of constant interpersonal contact with clients and the inherent difficulty in separating personal and professional activities. Care should be taken to ensure routine time off from the mobile phone on evenings and weekends by rotating coverage and the development of self-help “home groups” where clients are not likely to be in attendance.

Role of the Mentor

The role of the mentor is difficult to clearly define since it can entail an innumerable variation of activities. Notwithstanding, the general areas of responsibilities can be divided into three functions: 1.) screening and selecting clients to participate; 2.) mentoring clients until they are engagement in treatment; and, 3.) deciding when to terminate a client from the program because services are not longer necessary or that client is not responding to the mentor model.
Selection Criteria for the Mentor Client

The Mentor Program was designed to serve the very difficult to treat population comprised of homeless heroin addicts who have demonstrated a desire for recovery and are in detoxification at the Hooper Memorial Detoxification Center. It must be stressed that this is the most difficult to treat population of individuals with usually long “careers” in substance abuse including multiple treatment failures, homelessness, chronic cooccurring mental health and comorbid physical health illnesses, and ensuing disenfranchisement with society in general and the public social service system in particular.
Due to simple capacity issues with only three mentors and limited ADFC housing, not all heroin addicts can receive mentoring assistance. In order to assure that very limited mentoring services are put to the most efficacious use, the mentors screen each applicant while the applicant is still in Hooper.

No formalized screening criteria exist, yet there is consistency among mentors in relations to what they are looking for that might be predictive of successfully completing a follow-on treatment program. It must be emphatically made clear that the Mentor Program is not selecting the “easier to treat, high bottom addict.” It is quite the contrary, they appear to be looking for the candidate that has nothing left to lose and is clearly aware of that fact – the “low bottom addict.”

This finding was confirmed by individual interviews with the mentors, their supervisor, counseling staff from Hooper, individual informal interviews with mentees, and a formal focus group with mentees.

With that in mind, the primary criteria for selection into the program could be described as motivation. Care should be taken to understand that the use of the term “motivation” is not necessarily meant to construe “eagerness” to jump right into follow-on treatment. In many cases, the prospective client can demonstrate a keen awareness of the consequences of their using including mental, emotional, physical, social, moral, and spiritual losses. Mentors are careful to distinguish motivation and define it in terms of the prospective mentee’s willingness to follow direction with the absence of excuses or balking at any element of the Mentor Program. Finally, the mentors also report they evaluate the client’s readiness by the absence of any ritual linguistic interaction that would suggest, to an experienced, street-wise individual, that the prospective client was attempting to say things to elicit an intended response – lack of sincerity and honesty.

With the informality of the selection criteria, mentors rely greatly on their intuition, based on their own experience, as well as on the client’s treatment, self-help, and family support history gained during the screening. It should be kept in mind, that each of the mentors has had significant experiences within the local using and recovery communities so that many of the prospective clients were already “known” by the mentors before screening.

Clients with a history of sexual predation, arson, and some violent crimes are automatically excluded from consideration because they are beyond the skill level of the mentors.

Typical Day for the Mentor

If there is anything like a “normal” day for the mentor it usually begins at the Hooper Center with a daily meeting at 8:30 AM with Hooper clinical staff. It is at this meeting that Hooper staff identify potential clients for the Mentor Program usually within 1 to 3 days of admission for detoxification. Following this meeting, the mentor will interview prospective clients (this usually gives the mentor 2 to 3 days to begin setting resources up for the new client while the client is still in detoxification) or meet a client being discharged to provide transportation to housing and other services.

For the new clients, the mentor will guide them through the process to meet basic survival needs (food, clothing, shelter, and safety) and will be with the client for the entire first and most of the next few days. This includes signing up for housing, or moving into housing that has become available while the client was in detoxification; accessing food programs through local agencies that provide meals for the homeless, obtaining clean clothing, and enrolling in follow-on treatment.
Normally, the new client will attend a self-help meeting (one or more on the first day) with the mentor and generally begin the process of organizing for early recovery. This includes the socialization process with other clients in the Mentor Program.

Within a short period of time, the mentor will take the client to sign up for food stamps, enroll in the Oregon Health Plan, access other services (social, mental health, physical health, and legal) as appropriate and ensure the client is participating in the follow-up treatment. Most, but not all, clients enroll in the treatment program offered by PAHC.

Because the mentors are co-located with PAHC, access to treatment staff is excellent and includes participation by mentors in patient staffing conducted by PAHC. Dialogue with other treatment programs has been reported as improving but as of this report, mentors are not invited to attend formal client staffings at these agencies.

The mentors usually have lunch with their clients and frequent take evening meals also with them on their way to self-help meetings or sober recreational and social activities designed to encourage the diversification of sober activities. Weekend time is frequently spent with the clients. Each Friday from 4:00 PM to 5:00 PM mentors and mentees meet for a community meeting to discuss progress and schedules. The mentoring process has encouraged the development of a peer-level therapeutic community at the assigned SRO ADFC housing facility where new mentees are supported and assisted by those who have been in the Mentor Program longer.

Mentors reported that with the current design, their most effective caseload is around 10 clients. They also reported the number of clients can be extended to 15 if the mix includes several clients that have been in the program a few weeks. The mentors attempt to balance the caseload among themselves to ensure no one is over committed with a large portion of new clients and that there is a good fit between the mentor and the assigned clients. Mentors have noted that their caseload is including more individuals with cooccurring mental illnesses that makes their job more difficult.

Termination Criteria for the Mentor Client

When clients enroll in the Mentor Program they are required to sign a program participation agreement that includes the following agreements:

1. I cannot use drugs or alcohol while I’m in the program. I agree to give a U.A. when asked.

2. Violence, physical threats, verbal abuse and racial remarks will not be tolerated.

3. I will respect other persons and property at all times. Demeaning, discriminatory or coercive behavior will not be tolerated.

4. Children under 18 are allowed to spend the night only with prior approval. There are no other overnight guests including other residents.

5. New clients will be required to observe a 10:00 PM curfew for the first seven days.

6. No visitors for the first 30 days. Visiting hours are: Monday through Friday from 6:00 PM to 9:00 PM and Saturday and Sunday from 9:00 AM to 9:00 PM

7. I agree to maintain myself and my room in a clean and appropriate manner.

8. If I am given a legal prescription by a licensed provider I will submit documentation of that prescription to my mentor within 24 hours.

9. I will attend the weekly mentor meeting on Friday from 4:00 PM to 5:00 PM.

10. I will attend 90 Twelve Step meetings in 90 days.

11. I will notify my mentor or the mentor office if I’m going to be away from the building for more than 24 hours. Units vacated for more than three days will be considered abandoned.

12. If I have a visitor in my room, I will leave my door open.

I have read and understand this agreement and will abide by all conditions, rules and requirements of the program. I understand that a violation of any condition, rule, or requirement will be reviewed by staff and may be grounds for immediate dismissal.

Clients are terminated from the Mentor Program for use of alcohol or drugs. Due to concerns regarding clients relapsing, an additional policy decision was made that individuals are only eligible for the Mentor Program once. If they relapse, they cannot be re-enrolled in the program. This criteria is explained in detail to prospective clients and is reinforced frequently. Mentors report that this policy does appear to be an added motivational factor for mentees to engage in their recovery.

The criteria for graduation from the Mentor Program is achieved when the client has engaged in a treatment program. This normally occurs between 6 to 8 weeks after enrollment in the mentor program. Mentors report they like to see clients with a permanent sponsor and a home group in NA. This however, is not a hard and fast rule for graduation. Regular attendance at self-help meetings; doing service work for the self-help group; progressing well in treatment; attaining stabilization in housing, food, and physical/mental health; and the development of a health, sobriety oriented social network are all considered for graduation.

Mentor Clients’ Perceptions

On July 24, 2000, a special focus group was convened by the evaluator in a group room at the PAHC facility. The group consisted of four females and three males who were either current clients of the Mentor Program or had recently graduated from the Mentor Program. Participants were selected by Mentor Program staff, notified of the nature and purpose of the focus group and were invited to attend. Selection criteria was wholly based on the participants availability and interest.
Once assembled, the evaluator introduced himself, again explained the purpose of the focus group, stressed that participation was voluntary, and that all information provided was confidential.

Three topic areas were presented for discussion. The topics included how the mentees would describe the Mentor Program to someone who was unfamiliar with addictions treatment; what they felt were the most important elements of the program for their recovery; and, how they thought the Mentor Program could be improved.

Participants were extremely eager to discuss the program. To the point at which, even in a relatively small group, side conversations sprang up spontaneously and frequently. Once engaged, all participants were animated and forthright.
One comment, that seemed to capture several others in describing the program, was “…an open door for those of us that have burned all our bridges,” but “you have to be willing and ready.”

A comment that truly captured the essence of the program from the designers’ perspective was “…I didn’t have a clue how to do life – I knew how to do treatment but that just didn’t work.” This program “…showed me how to go back into the community and be sober.” Being able to “…wake up in the morning and not worry about food or a place to live” gave me the opportunity to begin to learn life skills – how to deal with early sobriety and basic living needs without “stressing out and relapsing because that was the routine.”

The most effective elements of the program for this group were its availability and timing. There was consensus that having the mentors meet with the client while still at Hooper greatly facilitated the critical passage from Hooper to a transitional living situation. With this were the provisions for basic needs of food, clothing, shelter, and safety. Most reported that previous experience would suggest that without these needs being met they would be back out on the street in a matter of hours.

Participants were highly complementary of the services provided by the mentors that included just being with them and available; finding transportation; taking them to self-help meetings; and helping them to schedule and access other social services. Underlying these comments was a clear theme of the dedication and caring exhibited by the mentors. Their “…support was critical … the fact that someone cared enough about me to help me,” “I felt important.” “It doesn’t matter who we are,” my “mentor took me under his wing, understood me, trusted me,” and “…knew when I was lying” all the mentors “have been there also.” “(It) gave me hope” from a hopeless life.

The only consistent recommendation from this group for the future was to have more mentors to allow more individuals the opportunity for a chance at recovery.

A very rudimentary written survey was administered to the focus group participants. The average number of previous admissions for addictions treatment was 3.1. The average number of arrests where they spent at least one night in jail was 19.2 (one individual responded “more times than I can remember”). The group indicated that they had been homeless about 30 percent of the time over the past 5 years. They reported being employed nearly 40 percent of the time also over the past 5 years. The average number of days of sobriety for the group was 89.4 days. Three of the individuals had children under the age of 18 years.

MENTOR PROGRAM FINDINGS

The goal and expectations for the Mentor Program was to: 1.) increase the number of heroin clients who engaged in treatment; 2.) increase the number of clients who successfully completed treatment; and, 3.) increase the number of clients that enrolled in treatment In an effort to retrospectively control as many intervening variables as possible, a decision was made to focus the analysis only on PAHC heroin clients that had received detoxification and pre-treatment services at Hooper. The primary reason for this decision was the availability of data from a continuum of care that included Hooper, PAHC, and the Mentor Program databases.

Study Design

The initial evaluation effort was mounted after the Mentor Program had started and consequently there was no opportunity to employ an experimental design with random selection. With this limitation, a retrospective ex post facto design was utilized. In addition to the treatment group (clients that had been mentored), a quasi-control group was identified. The rational for the quasi-control group was to establish baseline treatment enrollment, engagement, and completion rates before the Mentor Program was introduced into the spectrum of services provided by PAHC. Following is a more specific definition of each of the groups.

Study Groups

The treatment group, “Mentored,” was comprised of 69 heroin clients that had completed detox services at Hooper and were Mentor Program clients that had been discharged from PAHC during the period of August 1, 1999 through June 30, 2000 (study window).

The quasi-control group, “Baseline,” had 49 heroin clients that had been referred from Hooper to PAHC for a seven-month period (January 1, 1999 through July 31, 1999) just prior to the initiation of the Mentor Program. This relatively short baseline was selected because of the availability of existing data that had been audited for accuracy as part of a pervious program evaluation of the effectiveness of PAHC.

Demographic Characteristics of Participants

Overall, 70.5 percent of the participants were male, 84.7 percent were White, and the average overall age was 37.3 years (standard deviation [sd] = 9.2 years). A statistical analysis of the demographic characteristics of these groups demonstrated no significant differences in age, gender, or ethnicity. Further, there were no differences in the number of prior treatments, age at which they first used drugs, age at which they first used heroin, or identification of cooccurring mental health conditions. Mentored clients were however more likely to have been diagnosed with hepatitis C virus (HCV) than subjects in the control groups.

Outcomes

Following is a discussion of the findings relating to the independent variables of length of enrollment, engagement rates, and successful treatment program rates.

Due to the relatively small size of the mentored group, all clients were included in the analysis. Within the first cadre of mentees were several individuals that, due to startup and early ADFC housing availability limits, were initially given non-ADFC housing. Several of this initial cadre failed to engage in treatment. Nonetheless, because some did engage and successfully completed treatment, a decision was made to include all mentored clients in the sample due to the difficulty in controlling for other potentially intervening variables.

Comparison of Referrals from Hooper and Total Admission to PAHC

The average number of referrals per month from Hooper to PAHC during the baseline period was 16 clients. During the study period, this increased slightly to 19.6 clients per month. The increase was not statistically significant. Interviews with Hooper staff confirmed that no major changes had occurred in the number of clients being seen nor the number of clients being referred to PAHC.

More specifically, during the baseline period, 112 referrals were made from Hooper to PAHC. Of these, 49 (43.8 percent) were enrolled in treatment at PAHC. During the study window, 216 referrals were made from Hooper to PAHC. Of theses, a total of 124 clients (57.4 percent) were enrolled. This increase was statistically significant. Importantly, all the mentored clients that were referred from Hooper enrolled in PAHC. Of the remaining 147 referrals from Hooper that were not mentored, 55 (37.4 percent) enrolled at PAHC. This information is presented in Table1. Comparison of Referrals to Enrollments.

Although this study focused on two windows of unequal length for the baseline and study groups, it is possible to estimate the changes in enrollment of heroin clients from Hooper at PAHC. To accomplish this rudimentary comparison the number of enrollments from the baseline period was annualized producing an estimated 84 heroin client enrollments per year. For the study period, the estimated annualized enrollments jumped to 165. This estimate represents a 96.4 percent increase in enrollments.

Treatment Engagement Rates

An important measure that is not reflected in the successful completion rates is the rate at which clients engage in treatment. This measure is important in that failure to engage encompasses a separate subset of quality improvement and treatment effectiveness efforts than when a client simply stops coming in the middle of treatment. The engagement rate for the Baseline group was 51.2 percent while the Mentored group demonstrated a significantly higher engagement rate of 85.2 percent. Table 2. Treatment Engagement Rates is a presentation of these findings.
Successful Program Completion Rates

The successful program completion rate for the Baseline group was 16.1 percent. The Mentored group demonstrated a significantly higher program completion rate (45.2 percent) when compared to the Baseline group. These findings are presented in Table 3. Successful Program Completion Rates. On an annualized basis, this would represent a 278 percent increase in the number of successful completions when compared to baseline.
Average Length of Enrollment

The average length of enrollment for the Baseline group was 27.4 days (sd = 41.95 days). The Mentored group was enrolled a significantly longer time for an average of 68.2 days (sd = 62.82 days) than the Baseline group. Table 4. Length of Enrollment is a presentation of these findings.

Non-mentored Clients

Fifty-five clients referred from Hooper enrolled in PAHC during the study window and were not mentored. Although an analysis of this groups’ performance on the key measures suggested somewhat higher engagement and successful completion rates than those found for the baseline group, these findings were most likely an anomaly caused by the result of the selection process that removed the more likely to fail mentees from the pool of clients – an artifact of increasing the denominator in the calculation of those rates.

Nonetheless, subsequent interviews of mentees and mentors suggested that the mentoring process may have a synergistic effect on non-mentored clients. Although reasonable, it is extremely difficult to measure empirically, but should be considered when future evaluation efforts are being designed for the Mentor Program.

SUMMARY

The design of this study utilizing opportunity samples, as opposed to a controlled experimental design, allow for a plethora of potential intervening variables to contaminate findings. These weaknesses must be considered when interpreting the findings. Nonetheless, this preliminary study strongly supports the finding that the Mentor Program has had an important impact on the enrollment, engagement, and completion rates of participants. This study found that a combination of effective screening, mentoring, and the availability of ADFC housing greatly increased the overall successful program completion rates of heroin clients in outpatient treatment.

The completeness with which CCC has woven a community of recovery in downtown Portland can not be overlooked. Attempts to replicate the Mentor Program must consider all aspects of the recovery process ranging from detoxification to aftercare and include alcohol and drug free community housing, food, clothing, mental and physical health care, employment, and a close knit recovery community.

Clients interviewed formally as part of this study, and ex-clients interviewed formally in conjunction with other studies by the author, unquestionably reinforces the very strong support for the program in the recovering community. Further study is most certainly warranted to ensure that the evaluation findings of short-term outcomes are maintained with a fully integrated program. One of the beliefs of the program designers and mentors is that the skills and knowledge gained by clients from participation in the Mentor Program will have lasting effects on recovery. Classically, treatment for alcohol and drug addictions does not include actual community based skill building. The true value of this program most likely cannot be appropriately measured without several years’ experience and rigorous longitudinal follow-up with clients.

This study was not intended to evaluate the cost efficiency of the Mentor Program in conjunction with outpatient treatment and ADFC housing. Nonetheless, discussion regarding the findings raised an interesting question that could be of potential value for county and state planning. With the high level of successful program completion rates for this very difficult to treat population of homeless heroin addicts, the Mentor model may prove to be an effective and cost efficient alternative to residential care. The current OADAP reimbursement rate for alcohol and drug residential care is $113 per day. On a monthly basis, this equates to approximately $3390 per client month. The cost of treating the mentored clients is approximately 33.6 percent of the monthly residential treatment cost, or $1140 per month. The cost per client month was achieved by summing the monthly ADFC housing cost of $330, the average monthly treatment cost per client at PAHC of $333, the average cost per client month for mentoring of $347 (based on a case load of 12 mentees per mentor), and the average monthly cost of food stamps at $130 for a single person.

It is highly recommended that future research consider a controlled comparison study of the mentor model with the residential treatment model as well as an aggressive longitudinal follow up with mentored clients.

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Questions regarding Central City Concern, Portland Alternative Health Center, Portland Addictions Acupuncture Center, or the treatment programs discussed in this report should be addressed to Mr. Ed Blackburn, Director of Addiction Programs, Central City Concern, 232 NW Sixth Avenue, Portland, Oregon 97209.  (503) 294-1681 or Dr. David Eisen, Director, Portland Alternative Health Center, 1201 SW Morrison, Portland, Oregon 97205. (503) 228-4533

Technical questions regarding this report, or the study, may be addressed directly to the author Thomas L. Moore, PhD at Herbert & Louis, PO Box 304, Wilsonville, OR 97070-0304.  (503) 625-6100 or tlmoore@herblou.com

Suggested citation of this report:

Moore, T. (2001, January).  Addictions Recovery Mentor Program bridging the gap: detox to treatment service engagement.  Portland, OR: Central City Concern