The Main Profiles Of Treatment Planning Needs Among Adolescents Presenting For Substance Abuse Treatment Based On Cluster Analysis Rodney R. Funk, Michael L. Dennis, and Laverne Hanes-Stevens, Chestnut Health Systems, Bloomington, IL Panel at the Joint Meeting on Adolescent Treatment Effectiveness, March 25-27, 2008, Washington, DC. This presentation supported by Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) contracts and , as well as several individual CSAT, NIAAA, NIDA and private foundation grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax: (309) ,

Background  With 6 ASAM cells (8 levels) and 122 individual statements (2 levels), the number of possible combination of statements are 8 6 x = 1,393,796,574,908,160,000,000,000,000,000,000,000,000,000 (1.3 tredecillion [10 42 ]) possible combinations of treatment planning statements  While useful to help individualize treatment plans, this is more than the number of people in human history and too many possibilities to be useful for program planning.  The goal of this presentation is to use cluster analysis to identify the main presenting profiles that can be used to guide placement and program planning

Data on the Global Appraisal of Individual Needs (GAIN) from 203 level of care x site combinations Outpatient General Group Home Short-Term Residential Outpatient Continuing Care Intensive Outpatient Long-term Residential Moderate-Term Residential Early Intervention Other Corrections Levels of Care

Comparison of TEDS Public Treatment Data to CSAT GAIN Data: Demographics *Any Hispanic ethnicity separate from race group. Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age and CSAT AT 2006 dataset subset to adolescent studies (includes 2% 18 or older). CSAT more likely to be Mixed or Hispanic

Comparison of TEDS to CSAT GAIN Data: Level of Care * Excluding Detoxification ** Excluding Early Intervention, Corrections and Continuing Care Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age and CSAT AT 2006 dataset subset to adolescent studies (includes 2% 18 or older). CSAT more likely to be long term residential CSAT breaks out Outpatient from Outpatient Continuing Care

Method  Dropped 3691 people who were missing on Level of Care  Mean replacement for variables missing less than 15%  Dropped variables that were missing on 15% or more or which had less than 2% variation.  Collapse ASAM cells with less than 1%  Final cluster analysis based on 39 Dummy variables for ASAM cell placement, and 44 Other treatment planning statements (83 Total 0/1 variables)  Cluster analysis done using Ward’s minimum distance with binary variables in SPSS  Number of clusters selected based on percentage of variance explained in each measure greater than.7, Wilk’s lamda of variance in the joint distribution of less than 1%, and a minimum sample size of 5%

Method (cont)  Done on half sample, predicted with Fisher’s discriminant function analysis (DFA) and validated against the original (predicted to actual group kappa=.72) the remaining half sample in terms of variance explained in source items (within 1-2%).  Clusters based on DFA (which can be used to classify future cases)  Triaged (low/moderate/high) each cluster in terms of substance use disorder severity and ASAM placement dimensions – both in terms of the severity of the problem and the extent of current treatment utilization  Calculated average rating across dimension, profiled client characteristics, ASAM placement profile and most common needs of each group

Which specific problems they have or services they are using also vary Area SxTxSxTxSxTxSxTxSxTxSxTxSxTxSxTx A. Substance Use Disorder LLLMMMMLHMHHHMHM B1 Intoxication and Withdrawal LLLLMMMLHMMMHMHH B2 Bio-Medical (incl HIV Risk) LLLLMMHLMLHMMMMH B3a Psych-BehavioralLLLLMLHLMLHMMLHH B3b LegalMLLMMMHLMMHHMMLM B4 Readiness for Change LLMMMMHLHMLHHMHM B5 Relapse PotentialLLMMMMHLHMHHHHHM B6 Recovery Environment LLLLMLMLMMMHHLHM Summary Index* * Average rating on a scale of 0 to 100%, treating L at 0%, M as 50% and H as 100% 6%0%13%25%50%38%81%0%75%38%75%81% 44%81%69% A Low- Low B Low- Mod C Mod-Mod D Hi-Low F Hi-Hi (CC) G Hi-Mod (Env/PH) H Hi-Hi (Intoxic./ PH/ MH) E Hi-Mod

Ratings of Problem Severity (x-axis) by Treatment Utilization (y-axis) by Population Size (circle size) 12% 20% 14% 8% 14% 12% Average Current Problem Severity Average Current Treatment Utilization. A Low-Low B Low- Mod C Mod-Mod D Hi-Low E Hi- Mod F. Hi- Hi (CC) G. Hi-Mod (Env Sx/ PH Tx) 9% H. Hi-Hi (Intx Sx; PH/MH Tx) 12%

While there are difference, the clusters cross major demographics groups 56% 52% 56% 64% 68% 64% 38% 27% 24% 34% 28% 23% 27% 25% 40% 30% 18% 25% 19% 16% 9% 15% 20% 0%20%40%60%80%100% A Low-Low B Low-Mod C Mod-Mod D Hi-Low E Hi-Mod F Hi-Hi (CC) G Hi-Mod (E/P) H Hi-Hi (I/P/M) Minority Female Under 15

…and major systems

Severity of Victimization goes up with cluster…

As does the number of major clinical problems* *Count of the whether they had a cannabis, alcohol or other substance disorder, internalizing or externalizing disorder, victimization, physical health problems, and illegal activity)

While over 50% go to outpatient in 7 of 8 clusters, there are a range of placements in each cluster

A Low-Low (n=1456): ASAM Placement Chart Prominent Features A lack of problems, past problems or low severity in B1, B2, B3, B4, & B6 Some current treatment in B2 Highest severity problem is “relapse potential” (B4) and for some recovery environment (B5)

A Low-Low (n=1456): Top 10 Tx Needs 79% - Not close to anyone in recovery, assign a recovery coach 73% - Assign to relapse prevention 52% - Discuss recent school problems and how they can be resolved 50% - Coordinating care with juvenile justice system 50% - HIV Intervention to reduce high risk pattern of sexual behavior 41% - Increase structure to reduce recovery environment risk 33% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 31% - Referral for tobacco cessation 30% - Review prior treatment experiences to determine what did and not work 29% - Develop plan for reduction of family fighting

B Low-Mod (n=2388): ASAM Placement Chart Prominent Features More current problems in B2, B3, and B4 More continued problems in spite of some current intervention, particularly problematic in B5 (which is continued relapse potential in spite of some urine testing or intervention)

B Low-Mod (n=2388): Top 10 Tx Needs 77% - Coordinating care with juvenile justice system 74% - Not close to anyone in recovery, assign a recovery coach 69% - Review participation (attendance, motivation, follow- through, etc.) of client, participation in family therapy, day treatment or other interventions to increase structure 69% - HIV Intervention to reduce high risk pattern of sexual behavior 55% - Referral for mental health treatment 52% - Increase structure and/or residential treatment to reduce recovery environment risk 48% - Referral for tobacco cessation 45% - Discuss recent school problems and how they can be resolved 40% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 36% - Review prior treatment experiences to determine what did and not work

C Mod-Mod (n=1734): ASAM Placement Chart Prominent Features More high severity current problems in Psychiatric (B3) and Recovery Environment (B6) More continued problems in spite of some current intervention in Biomedical (B2) and Relapse Potential (B5)

C Mod-Mod (n=1734): Top 10 Tx Needs 93% - Increase structure and/or residential treatment to reduce recovery environment risk 91% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 85% - Referral for mental health treatment 85% -Refer to anger management intervention 84% -Follow agency protocol related to child maltreatment reporting; Refer for trauma related intervention 82% - Review prior treatment experiences to determine what did and not work 76% - HIV Intervention to reduce high risk pattern of sexual behavior 72% - Discuss recent school problems and how they can be resolved 70% - Coordinating care with juvenile justice system 62% - Not close to anyone in recovery, assign a recovery coach

D Hi-Low (n=908): ASAM Placement Chart Prominent Features Over 3/4ths have high severity current problems in B4, B5, and B6. Majority have current or past problems in each dimension Minimal current services outside of B2 and even half of those are continuing to have problems

D Hi-Low (n=908): Top 10 Tx Needs 100%-Consider need for detoxification or withdrawal services 99% - Refer for motivational interview or other intervention to increase readiness for change 98% - Assign to relapse prevention 91% - Increase structure and/or residential treatment to reduce recovery environment risk 87% - Referral for mental health treatment 80% - HIV Intervention to reduce high risk pattern of sexual behavior 74% - Review prior treatment experiences to determine what did and not work 74% - Consider medication to reduce non-opioid withdrawal and relapse 74% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 73% - Referral for tobacco cessation

E Hi-Mod (n=1655): ASAM Placement Chart Prominent Features Current or past problems in every dimension Over 3/4ths have high severity current problems (red or purple) in B4, B5, and B6 Intervention underway in one more dimension but generally not working

E Hi-Mod (n=1655): Top 10 Tx Needs 99% - Consider need for detoxification or withdrawal services 90% - Referral for mental health treatment 88% - Increase structure and/or residential treatment to reduce recovery environment risk 86% - Review participation (attendance, motivation, participation, etc.) of client, participation in family therapy, day treatment or other interventions to increase structure. 84% - HIV Intervention to reduce high risk pattern of sexual behavior 78% - Coordinating care with juvenile justice system 73% - Refer for motivational interview or other intervention to increase readiness for change 72% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 68% - Referral for tobacco cessation 68% - Follow agency protocol related to child maltreatment reporting; Refer for trauma related intervention

F Hi-Hi (CC) (n=1402): ASAM Placement Chart Prominent Features Majority have problems in remission (yellow or blue) Most are currently receiving some kind of intervention in B2, B3, B4, B5 or B6 Interventions appear to be working for over half – EXCEPT for Recovery Environment (B6)

F Hi-Hi (CC) (n=1402): Top 10 Tx Needs 98% - Refer to continuing care following discharge from controlled environment 97% - Referral for mental health treatment 94% - Develop plan for obtaining stable housing 87% - Increase structure and/or residential treatment to reduce recovery environment risk 85% - Coordinating care with juvenile justice system 81% - HIV Intervention to reduce high risk pattern of sexual behavior 78% - Develop community re-entry plan 78% - Follow agency protocol related to child maltreatment reporting; Refer for trauma related intervention 72% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 64% - Refer to anger management intervention

G Hi-Mod (Env/PH) (n=1038): ASAM Placement Prominent Features Majority have high severity problems (red or purple) in B2, B3, B4, B5, and B6 Intervention of B4, B5, and B6 does not appear to be working. High risk on B6 and high participation in treatment in B2

G Hi-Mod (Env/PH) (n=1038): Top 10 Tx Needs 100%-Consider need for detoxification or withdrawal services 100% Consider medication to reduce non-opioid withdrawal and relapse 99% - Review participation (attendance, motivation, participation, etc.) of client, participation in family therapy, day treatment or other interventions to increase structure. 93% - Increase structure and/or residential treatment to reduce recovery environment risk 91% - Referral for mental health treatment 79% - HIV Intervention to reduce high risk pattern of sexual behavior 79% - Referral for tobacco cessation 79% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 74% - Review prior treatment experiences to determine what did and not work 74% - Follow agency protocol related to child maltreatment reporting; Refer for trauma related intervention

H Hi-Hi (Intx/PH/MH) (n=1443): ASAM Placement Prominent Features Majority have high severity problems (red or purple) in B3, B4, B5, and B6 Receiving intervention across some combination of B2, B3, B4, B5, and B6, but it is not working for most

H Hi-Hi (Intx/PH/MH) (n=1443): Top 10 Tx Needs 100%-Discuss medication compliance and effectiveness 94% - Discussing the consequences of behavior control problems, the plan to change, and possible referrals to help. 91% - Referral for mental health treatment 91% - Increase structure and/or residential treatment to reduce recovery environment risk 80% - Follow agency protocol related to child maltreatment reporting; Refer for trauma related intervention 79% - HIV Intervention to reduce high risk pattern of sexual behavior 75% - Refer to anger management intervention 74% - Referral for tobacco cessation 69% - Review prior treatment experiences to determine what did and not work

Limitations  Data based only on self report, important to allow a clinician to over ride report if they have other information or validity concerns.  Not a representative sample.  Interpretation based largely on expert opinion, ideally the recommendations should be evaluated in terms of their ability to predict outcomes.

Conclusions  The large number of possible combinations can be accurately classified into 8 main groups.  The 8 groups vary along an axis of problem severity and a second axis based on the currently level of involvement in services.  Each group exists to a varying degree in each demographic and clinical groups, as well as each system and level of care.  Each group as a different profile of ASAM placement cells and individualized needs.  Even within group there are still considerable individual differences. Next question is do they predict outcomes?

The above presentation was supported by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT) under contracts , , , and using data provided by the following grantees: CSAT TI-13190, TI-13305, TI-13308, TI , TI-13313, TI-13322, TI-13323, TI-13340, TI-13344, TI-13345, TI-13354, TI , TI-13601, TI-14090, TI-14103, TI-14188, TI-14189, TI-14196, TI-14214, TI , TI-14254, TI-14261, TI-14267, TI-14271, TI-14272, TI-14283, TI-14311, TI , TI-14355, TI-14376, TI-15348, TI-15413, TI-15415, TI-15421, TI-15433, TI , TI-15447, TI-15458, TI-15461, TI-15466, TI-15467, TI-15469, TI-15475, TI , TI-15479, TI-15481, TI-15483, TI-15485, TI-15486, TI-15489, TI-15511, TI , TI-15524, TI-15527, TI-15545, TI-15562, TI-15577, TI-15584, TI-15586, TI , TI-15671, TI-15672, TI-15674, TI-15677, TI-15678, TI-15682, TI-15686, TI , TI-16400, TI-16414, TI-16904, TI-16915, TI-16928, TI-16939, TI-16961, TI , TI-16992, TI-17046, TI-17055, TI-17070, TI-17071, TI-17334, TI-17433, TI , TI-17475, TI-17484). Any opinions about these data are those of the authors and do not reflect official positions of the government or individual grantees. Suggestions, comments, and questions can be sent to Dr. Michael Dennis, Chestnut Health Systems, 720 West Chestnut, Bloomington, IL 61701, Acknowledgements