Adolescent substance abuse system building and SAMHSA 5 Step Planning Process Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL Presentation at “UT CAN Local Academy 2006 Celebration, Integration and Painting the Vision”, June 5-7, 2006, Salt Lake City, Utah. The content of this presentations are based on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract and several individual 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) ,

2 1.To examine the prevalence, course, and consequences of adolescent substance use and co-occurring disorders and the unmet need for treatment 2.To summarize major trends in the adolescent substance use disorder (SUD) treatment system, client needs and outcomes 3.To highlight SAMHSA’s 5 step process for program planning and evaluation Goals of This Presentation

3 Substance Use Severity Is Related to Age Source: 2002 NSDUH and Dennis & Scott in press No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Age Severity Category Adolescent Onset Remission Increasing rate of non- users (2002 U.S. Household Population age 12+, n= 235,143,246)

4 Age of First Use Predicts Dependence an Average of 22 years Later Source: Dennis, Babor, Roebuck & Donaldson (2002) and 1998 NHSDA Tobacco, OR=1.3*, Pop.=151,442,082 Alcohol, OR=1.9*, Pop.=176,188,916 Marijuana, OR=1.5*, Pop.=71,704,012 Other, OR=1.5*, Pop.=38,997,916 % with 1+ Past Year Symptoms Under Age 15 Aged Aged 18 or older Tobacco: Pop.=151,442,082 OR=1.49* Alcohol: Pop.=176,188,916 OR=2.74* * p<.05 Marijuana: Pop.=71,704,012 OR=2.45* Other Drugs: Pop.=38,997,916 OR=2.65*

5 Substance Use Careers Last for Decades Cumulative Survival Years from first use to 1+ years abstinence Median of 27 years from first use to 1+ years abstinence Source: Dennis et al., 2005

6 Substance Use Careers are Longer the Younger the Age of First Use Cumulative Survival Years from first use to 1+ years abstinence under 15* * Age of 1 st Use Groups * p<.05 (different from 21+) Source: Dennis et al., 2005

7 Substance Use Careers are Shorter the Sooner People Get to Treatment Cumulative Survival * 10-19* Year to 1 st Tx Groups * p<.05 (different from 20+) Source: Dennis et al., 2005 Years from first use to 1+ years abstinence

8 Treatment Careers Last for Years Cumulative Survival Years from first Tx to 1+ years abstinence Median of 3 to 4 episodes of treatment over 9 years Source: Dennis et al., 2005

9 Source: OAS (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD: SAMHSA. The Growing Incidence of Adolescent Marijuana Use: Adult Initiation Relatively Stable Adolescent Initiation Rising

10 Importance of Perceived Risk Source: Office of Applied Studies. (2000) NHSDA Marijuana Use Risk & Availability

11 Actual Marijuana Risk From 1980 to 1997 the potency of marijuana in federal drug seizures increased three fold. The combination of alcohol and marijuana has become very common and appears to be synergistic and leads to much higher rates of problems than would be expected from either alone. Combined marijuana and alcohol users are 4 to 47 times more likely than non-users to have a wide range of dependence, behavioral, school, health and legal problems. Marijuana and alcohol are the leading substances mentioned in arrests, emergency room admissions, autopsies, and treatment admissions. Marijuana is specifically associated with progression of schizophrenia and other severe mental illnesses

12 Source: Dennis and McGeary (1999) and 1997 NHSDA Substance Use in the Community

13 Consequences of Substance Use Source: Dennis, Godley and Titus (1999) and 1997 NHSDA

14 Need for Treatment (% of 24,753,586 Adolescents in the U.S. Household Population) Source: NSDUH and TEDS (see state level estimates in appendix) 8.9% 0.7% 0.6% 5.7% 8.1% 11.5% 10.7% 14.9% 17.8% 0%5%10%15%20%25% Tobacco Alcohol Alcohol Binge Any Drug Use Marijuana Use Any Non-Marijuana Drug Use Past Year AOD Dependence or Abuse Any Treatment (From NHSDA) Public Treatment (From TEDS)  Past Month Use  Less than 1 in 10 getting treatment 88% of adolescents are treated in the public system

15 Adolescent AOD Dependence/Abuse Prevalence 6.0 to 8.4% 8.5 to 9.0% 9.1 to 9.9% 10.0 to 14.6% U.S.Avg.=8.9% UT=7.0% Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA , NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from ) and Kilpatrick et al, Up 27% from 7% in 1995

16 Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment) Prevalence 82.4 to 90.1% 90.2 to 92.3% 92.4 to 94.2% 94.3 to 98.0% U.S.Avg.=92.2% UT=89.8% Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA , NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from ) 9 in 10 Untreated

17 Adolescent Treatment Admissions have increased by 61% over the past decade Source: Office of Applied Studies Treatment Episode Data Set (TEDS) 61% increase from 95,271 in 1993 to 153,251 in 2003

18 Change in Public Sector Admissions (%=( )/1993) Change Not available -96 to -7% -8 to +33% +34 to +116% +117 to +337% U.S.Avg.=+61% UT=+25% Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA , NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from ) Both Cause & Consequence

19 Presenting Substances: UT vs. US Source: Primary, Secondary or Tertiary, from Treatment Episode Data Set (TEDS) Similar on Marijuana, Higher on Alcohol Methamphetamine higher; 20% or higher in AZ, CA,ID,MN,NV,WA Other Amp.similar; 20% or higher in OR Cocaine similar; 20% or higher in DE & TX Opiates similar; 20% or higher in MA & NM

20 Referral Sources: UT vs. US Source: Treatment Episode Data Set (TEDS) Lower Rate of Self/Parent Referrals Higher Rate of Juvenile Justice Referrals Lower Rate of School Referrals

21 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Outpatient Intensive Outpatient Detox Long-term Residential Short-term Residential UTU.S. Level of Care: UT vs. US Source: Treatment Episode Data Set (TEDS) Higher on Regular Outpatient and IOP Lower on Detox, Short and Long Term Residential

22 Severity Goes up with Level of Care Source: Treatment Episode Data Set (TEDS) % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Weekly use at intake First used under age 15 Dependence Prior Treatment Case Mix Index (Avg) OutpatientIntensive OutpatientDetoxification Long-term ResidentialShort-term Residential STR: Higher on Dependence Baseline Severity Goes up with Level of Care Detox: Higher on Use Detox: Higher on Use, but lower on prior tx

23 Median Length of Stay is only 50 days Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from Outpatient (37,048 discharges) IOP (10,292 discharges) Detox (3,185 discharges) STR (5,152 discharges) LTR (5,476 discharges) Total (61,153 discharges) Level of Care Median Length of Stay 50 days 49 days 46 days 59 days 21 days 3 days Less than 25% stay the 90 days or longer time recommended by NIDA Researchers

24 53% Have Unfavorable Discharges Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from Despite being widely recommended, only 10% step down after intensive treatment

25 The Current Renaissance of Adolescent Substance Use Disorder Treatment Research Feature Tx Studies*16Over 200 Random/Quasi944 Tx Manuals*030+ QA/AdherenceRareCommon Std Assessment*RareCommon Participation RatesUnder 50%Over 80% Follow-up Rates40-50%85-95% MethodsDescriptive/SimpleMore Advanced EconomicSome CostCost, CEA, BCA * Published and publicly available

26 CSAT Adolescent Treatment (AT) Outcome Data Set Recruitment: (updated annually) Sample: The 2005 CSAT adolescent treatment data set included data with 1 to 4 follow-ups on 9,276 unique adolescents from 72 local evaluations Levels of Care: Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care Instrument:Global Appraisal of Individual Needs (GAIN) (see Follow-up:Over 80% follow-up 3, 6, 9 & 12 months post intake Funding: CSAT contract and 72 individual grants

27 Geographic Location of Sites ART EAT SCY TCE YORP AK AL AR AZ CA CO DC FL GA IA ID IN KS LA ME MI MN MO MS MT NC ND NE NM NV NY OH OK OR PA SC SD TN TX UT VA WA WV WY WI IL KY Program DE HI MD NH NJ RI PR VT MA CT DC

28 Demographics

29 Clinical Severity

30 Primary, Secondary or Tertiary SUD Problems

31 Level of Care Includes 9% in continuing care outpatient (CCOP) after residential treatment or detention

32 Recovery Environment Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

33 Past 90 day HIV Risk Behaviors Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

34 Weekly or More Often Use in the Past 90 Days Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

35 Substance Use Problems Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

36 Co-Occurring Psychiatric Problems Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

37 Multiple Co-occurring Problems Were the Norm and Increased with Level of Care Source: CSAT’s Cannabis Youth Treatment (CYT) and Adolescent Treatment Model (ATM), Conduct Disorder ADHDMajor Depressive Disorder Generalized Anxiety Disorder Traumatic Stress Disorder Any Co- Occurring Disorder OutpatientLong Term ResidentialShort Term Residential

38 Past Year Violence & Crime *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

39 Intensity of Juvenile Justice System Involvement Source: CSAT 2004 AT Common GAIN Data set (n= 5,468 adolescents from 67 local evaluations) 17% In detention/jail 14+ days 25% On probation or parole 14+ days w/ 1+ drug screens 17% Other probation/parole/detention 16% Other JJ status 8% Past arrest/ JJ status 17% Past year illegal activity/SA use Highest severity for Long Term Residential (followed by STR, IOP, OP)

40 Multiple Problems* are the Norm Source: CSAT AT Common GAIN Data set None One Two Three Four Five to Twelve 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Most acknowledge 1+ problems Few present with just one problem (the focus of traditional research) In fact, over half present acknowledging 5+ major problems * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

41 No. of Problems* by Severity of Victimization Source: CSAT AT Common GAIN Data set (odds for High over odds for Low) * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Low (31%)Moderate (17%)High (51%) Five or More Four Three Two One None Those with high lifetime levels of victimization have 117 times higher odds of having 5+ major problems* GAIN General Victimization Scale Score (Row %)

42 Treatment Outcomes by Level of Care: Days of AOD Abstinence* * Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT AT Outcome Data Set (n-9,276)

43 Treatment Outcomes by Level of Care: Recovery* * Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT AT Outcome Data Set (n-9,276)

44 Change in Emotional Problem Index by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect. Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s Note the lack of a hinge; Effect is generally indirect (via reduced use) not specific

45 Change in Illegal Activity Index by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect. Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s Residential Treatments have a specific effect Outpatient Treatments has an indirect effect

46 The SAMHSA 5 Step Program Planning and Evaluation Process 1. Needs Assessment: Define the problem Quantify with available information (collect pilot data if necessary) Identify targets for prevention, treatment, continuing care, and/or systems integration Identify individual, staff, organizational and community assets and challenges Develop tentative theory of change or logic model 1. Needs Assessment 2. Capacity Building 3. Program Selection 4. Implementation 5. Evaluation Source: SAMHSA/CSAP Pathways Course Evaluation 101

47 Example of a Simple Theory / Logic Model for Early Re-Intervention (ERI) Experiment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming) Relapse is Common but hard to predict Monitoring and Early Re-Intervention Sustained Recovery In Long Term 1. Follow-up Quarterly 2. Identify Need for Treatment 3. Attend Recovery Management Checkup (RMC) Meeting 4. Agree to go for treatment intake assessment 5. Shows to treatment intake assessment 6. Shows to treatment 7. Engages in treatment (at least 14 days) 8. Less likely to be using 90 days latter (cycle repeats every quarter for 4 years)

48 2. Capacity Building: Examine agency resources, skills, & strengths Examine community resources and readiness Think about what will be needed to sustain the effort Build collaboration Consider the need to start small and grow the change/collaboration Use a walk through, simple pilot study, or rapid assessment to get initial momentum 1. Needs Assessment 2. Capacity Building 3. Program Selection 4. Implementation 5. Evaluation The SAMHSA 5 Step Program Planning and Evaluation Process Source: SAMHSA/CSAP Pathways Course Evaluation 101

49 Common starting places Standardize assessment and identify most common problems Senior staff do a walk through intake and treatment Pool knowledge about what staff have done in the past, whether it worked, and what the barriers were Identify system barriers (e.g., criteria to local access case management, mental health) that could be avoided if thought of in advance Identify existing materials that could help and make sure they are readily available on site Identify promising strategies for working with the adolescent, parents, or other providers Develop a 1-2 page checklist of things to do when this problem comes up Identify a more detailed protocol and trainer to address the problem, then go for a grant to support implementation

50 3. Program Selection: Prioritize a specific problem or cluster of problems Attempt to quantify the problem, how it is related to other common problems, and challenges for implementation Identify protocols that have been demonstrated to impact the problem with as similar a population/ context as possible Select best fit based on effectiveness, likelihood of successful implementation, and cost/benefit 1. Needs Assessment 2. Capacity Building 3. Program Selection 4. Implementation 5. Evaluation The SAMHSA 5 Step Program Planning and Evaluation Process Source: SAMHSA/CSAP Pathways Course Evaluation 101

51 Resources for Finding Promising Programs: Screeners and Other Measures related to adolescents: CSAT TIP NIAAA Handbook- pubs.niaaa.nih.gov/publications/Assesing%20Alcoholpubs.niaaa.nih.gov/publications/Assesing%20Alcohol Drug Strategies Handbook- GAIN Coordinating Center- Co-Occurring Center for Excellence- Prevention Programs related to adolescents: Substance use- modelprograms.samhsa.gov/modelprograms.samhsa.gov/ Suicide- Violence- Co-Occurring Cen. for Excel.- Other materials- Treatment Programs related to adolescents: Substance use disorder (SUD)- Mental disorder (MD) & systems of care- Traumatic disorders and child maltreatment- Co-Occurring Cen. for Excel.-

52 Implementation is Essential ( Reduction in Recidivism from.50 Control Group Rate) The effect of a well implemented weak program is as big as a strong program implemented poorly The best is to have a strong program implemented well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005 meta analysis of 509 juvenile justice programs

53 4. Implementation: Use logic model to create an action plan Track each step of the action plan with a process measure Monitor process measures in real time Document changes and their impact on these process measures Document and analyze intermediate outcomes. If less than expect, consult, adapt if indicated, and re- measure. 1. Needs Assessment 2. Capacity Building 3. Program Selection 4. Implementation 5. Evaluation The SAMHSA 5 Step Program Planning and Evaluation Process Source: SAMHSA/CSAP Pathways Course Evaluation 101

54 ERI 1 0% 20% 40% 60% 80% 100% Follow-up (96% avg) Needed Tx (45% avg) Attended RMC (99% avg) Agreed to Tx Assessment (48% avg) Showed to Tx Assessment (42% avg) Showed to Tx (35% avg) Stayed in Tx 14+ days (60% avg) Max Avg Min Improving Adherence to Recovery Management Checkup (RMC) Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming) Second ERI study averaged as well or better as the first study Quality assurance and transportation assistance reduced the variance Improved Screening increased detection ERI 2 Engagement Specialist Improved Retention

55 5. Evaluation: Check assumptions about problem, population severity, degree of implementation and reliability of outcomes Evaluate outcomes overall, for different subgroups, different outcomes, and over time Use to support Needs Assessment (i.e., what worked, what had problems, where do we still need to improve) and to identify new areas in need of program planning 1. Needs Assessment 2. Capacity Building 3. Program Selection 4. Implementation 5. Evaluation The SAMHSA 5 Step Program Planning and Evaluation Process Source: SAMHSA/CSAP Pathways Course Evaluation 101

56 Common Local Evaluation Questions Who is being served? – who are we missing? – How are we welcoming, accomodating and/or building on their strengths? What services are being provided? – to what extent are services being targeted toward the most needy or appropriate? – to what extent are the services being implemented / delivered? Which of several different approaches to providing services are working the best? – for which subgroups, for which outcomes? – Are there a range of approaches that work similarly? What do the approaches costs? – Is a given service more cost-effective in terms of the core outcome? – Is a given service more cost-beneficial across multiple outcomes?

57 What is needed to shift from program level to systems of care level evaluations? Building a coalition of families community leaders, staff, systems and funders who – Have common clients, interest and can find common cause – Can align their vision, missions & resources to do more than they can if working apart Introducing reliable and valid assessment/records that can be used – At the individual level to immediately guide clinical judgments about diagnosis/severity, placement, treatment planning, and the response to treatment – At the program level to drive program evaluation, needs assessment, and long term program planning Introducing explicit intervention protocols that are – Targeted at specific problems/subgroups and outcomes – Having explicit quality assurance procedures to cause adherence at the individual level and implementation at the program level Having the ability to evaluate performance and outcomes – For the same program over time, – Relative to other interventions

58 The Quadrants of Care Model of a Systems of Care Low MD MD. Low SUD SUD IV. Severe Mental Disorder (MD) and Severe Substance Use Disorders (SUD) III. No/Low Severe Mental Disorder (MD) and Severe Substance Use Disorders (SUD) Source: NASMHPD and NASADAD (1999) and CSAT (2005) Tip 32 II. Severe Mental Disorder (MD) and No/Low Severity Substance Use Disorders (SUD) I. No/Low Severity Mental Disorder (MD) and No/Low Severity Substance Use Disorders I. Low MD / Low SUD: Treated in primary care, student assistance programs II. Severe MD / Low SUD: Treated in mental health treatment system III. Low MD / Severe SUD: Treated in substance abuse treatment system IV. Severe MD / Severe SUD: Often un or under served by above and end up emergency rooms, state hospitals and/or detention/jail – new programs needed

59 Actual Services Needed Low MD MD Low SUD SUD IV. Severe MD / Severe SUD IV. Severe MD / Low SUD III. Low MD / Severe SUD I. Low MD / Low SUD The Problem is that if we go by actual diagnosis, the vast majority of the patients are actually in the fourth quadrant This is why we need to make an integrated system of care Source: Chan et al in press. GAIN Data on 4939 adolescents age entering SAP, SUD, MH, & JJ Moreover youth in all four groups show up in all systems of care

60 Some Concluding Thoughts We are entering a renaissance of new knowledge in this area, but are only reaching 1 of 10 adolescent in need of substance abuse treatment Multiple co-occurring problems are the norm Most people will take multiple episodes of care over several years and systems before they are better Rather than acting as panacea, evidenced based practices usually work to pull up the bottom and address many small problems Similarly, systems of care are less about solving all of the problems with a new grand design, then aligning the existing systems and resources so that they stop working against each other and collaborate to work more efficiently.