1. Dennis
1/3/2019
Research to Inform Planning & Development of Recovery Services for Youth, Families, & Communities
Mark D. Godley, Ph.D.
Chestnut Health Systems
Bloomington, IL
Presentation at the SAMHSA Consultative Session on Recovery-Oriented Care for Youth November 13-14, 2008, Rockville, MD. This presentation reports on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under 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 government.
Chestnut Health Systems

2. Presentation Goals Describe adolescents entering SUD treatment
Dennis
1/3/2019
Presentation Goals
Describe adolescents entering SUD treatment
Provide an overview of treatment engagement and retention
Describe current issues with and potential of continuing care
Discuss research supporting recommendations for recovery supports and services
The overall goal for my presentation today is to provide you with good background information based on the national research that can be used to help guide the selection of recovery supports and services for adolescents and their families.
Start with providing some background on adolescent s.a. tx.
End with talking about recommendations for recovery supports
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3. The Severity and Course of Substance Use Disorders Varies by Age
Dennis
The Severity and Course of Substance Use Disorders Varies by Age
1/3/2019
Age
100
Severity Category 90
Adolescent Onset
Remission
No Alcohol or Drug Use 80 70
Light Alcohol Use Only 60
Any Infrequent Drug Use 50 40
Regular AOD Use 30
Reading from the bottom up, this figure shows how the prevalence of past year dependence, abuse, regular AOD use (weekly), less frequent drug use, less frequent alcohol use, and abstinence. Across the bottom it shows how severity varies by age.
1- Substance use disorders typically on set during adolescents and young adult hood. In fact, 90% of all adults with dependence started using under the age of 18, half under the age of 15.
2- After several decades, the rates of abuse and dependence do decrease as people go into remission, incarceration or die. Epidemiological studies of people with lifetime substance dependence suggest that 58% eventually enter sustained recovery (i.e., no symptoms for the past year) -- a rate that is considerably better than the 39% average rate of recovery across psychiatric disorders (Kessler, 1994; see also Dawson, 1996; Robins & Regier, 1991).
3 – Notice how the rates of no use go up with age.
Thus substance use disorders on set early and last for many years, but do get better over time.
Abuse 20 10
Dependence
(2002 U.S. Household Pop. age 12+= 235,143,246)
65+
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Source: 2002 NSDUH and Dennis et al 2007
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4. GAP between Adolescent SUD & Treatment
Dennis
1/3/2019
GAP between Adolescent SUD & Treatment
Less than 1 I
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
Chestnut Health Systems

5. CSAT Full GAIN Data (n=15,254)
Dennis
1/3/2019
CSAT Full GAIN Data (n=15,254)
CSAT data dominated by Male, Caucasians, age 15 to 17
CSAT data dominated by Outpatient
CSAT residential more likely to be over 30 days
*Any Hispanic ethnicity separate from race group.
Sources: CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).
Chestnut Health Systems

6. Substance Use Problems
Dennis
1/3/2019
Substance Use Problems
This is based on self-reported DSM IV symptoms over the past year
While all have lifetime diagnoses, most of the adolescents are presenting meeting criteria for their diagnoses in the past 12 months - about half for dependence. Some withdrawal symptoms are common, but the more severe withdrawal typical of alcohol or opioid users is more limited. While virtually all of the adolescents can identify reasons to quit and over a third have already been in treatment – only 30% acknowledge that they have an AOD problem and less than 1 in 4 think they need treatment. This illustrates the importance of motivational interviewing and other techniques to engage and retain them in treatment.
Source: CSAT 2007 AT Outcome Data Set (n=12,601)
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7. Co-Occurring Psychiatric Problems
Dennis
1/3/2019
Co-Occurring Psychiatric Problems
Externalizing Disorders
Internalizing Disorders
Co-occurring psychiatric problems are the norm among adolescents presenting for substance abuse treatment. The most common are externalizing conditions like conduct disorder and ADHD. There are also significant rates of depression, trauma and anxiety disorders. The lower half of this panel shows that a wide range of other key psychiatric issues are also present including any victimization, high severity victimization (i.e., that occurred multiple times, multiple people, someone they trusted, involved sexual penetration or near death, that people did not believe when they sought help), running away, homicidal or suicidal thoughts, and self multilation.
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Chestnut Health Systems

8. Relapse Trajectories: Days Of AOD Use
Dennis
Relapse Trajectories: Days Of AOD Use
1/3/2019
54% are Low AOD Use ; 16% Low AOD/HI CE; 27% Increasing AOD use; >3% Consistently High AOD Use
Adolescents admitted to treatment were clustered on days of use, days of heavy use, days of problems from use across all 4 waves. Cluster analysis is a statiscal procedure for forming groups of people that are simlar on variables of interest. In this case the variables of interest were days of AOD use, heavy use, and problems from AOD use across all 4 follow-up waves
141/953 or nearly 15% were totally abstinent or 8% of total sample
The course of outcomes is not the same for all clients entering tx—we see that they fall into four groups with different use patterns
Most are not abstinent but they are low users---question is: who do we target recovery services to?
Source: CSAT 2007 AT Outcome Data Set (n=1,754)
Chestnut Health Systems

9. Relapse Trajectories: Days Of Emotional Problems
Dennis
Relapse Trajectories: Days Of Emotional Problems
1/3/2019
We also looked at behavioral problems (Conduct Disorder; ADHD) and found a similar pattern of decreasing days of problems.
Source: CSAT 2007 AT Outcome Data Set (n=1,754)
Chestnut Health Systems

10. Treatment is helpful but not sufficient for many youth
Dennis
1/3/2019
Treatment is helpful but not sufficient for many youth
Less than 25% stay the 90 days or longer time recommended by NIDA Researchers ● Overall, only 47% have planned discharges TEDS, 2006
These lower lengths of stay and poor completion rates could be compensated for by continuing care services
Chestnut Health Systems

11. Dennis
1/3/2019
Linkage to Continuing Care Following Residential Treatment: Adolescents
2000
But as you can see from this graph, nearly 2/3rds of adolescents do not receive any CC within 90 days of discharge
Source: DARTs, 2000
Chestnut Health Systems

12. Aftercare Definition The purpose of Aftercare is to maintain the
Dennis
1/3/2019
Aftercare Definition
The purpose of Aftercare is to maintain the
clinical gains made after treatment
Assess Res. Tx IOP OP Step
Aftercare:
Assumptions:
Clients complete each tx phase successfully
Clients successfully link to next tx phase.
Works for a small % of patients
Most do not complete
There are varying degrees of improvement
Tx effectiveness is enhanced by aftercare but relatively few receive it
It assumes that adolescents will complete each phase of the treatment and aftercare “successfully
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13. Continuing Care Definition
Dennis
1/3/2019
Continuing Care Definition
“The provision of a treatment plan and organizational structure that will ensure that a patient receives whatever kind of care he or she needs at the time. The treatment program thus is flexible and tailored to the shifting needs of the patient and his or her level of readiness to change.” (p. 361, ASAM Placement Criteria-2nd edition; Mee-Lee et al., 2001)
American Society on Addiction Medicine
Chestnut Health Systems

14. Who Links to Continuing Care?
Dennis
1/3/2019
Who Links to Continuing Care?
100%
90%
80%
Planned / transfer
within agency
70%
60%
Percent of Clients Linked
50%
40%
Planned / Referred to
other agency
30%
The green and red curves represent planned discharges, while the red curve represents unplanned discharges. Again you see that if clients are going to link—it is most likely to happen in the first 1-2 weeks out of residential
These data illustrate the problems in linkage when multiple agencies must coordinate services
Those with unplanned discharges (ASA/ASR’s) had almost no possibility of receiving continuing care
the pairwise comparisons between the lines are each significantly different from the other, p < .001.
20%
10%
Unplanned Discharge 0% 10 20 30 40 50 60 70 80 90
Days from Residential Discharge
Source: CSAT ART Grantees Wilcoxon (Gehen) statistic (df=2)=79.83, p < .001.
Chestnut Health Systems

15. Residential Completers Residential Non-Completers
Dennis
1/3/2019
Compliance with Washington Circle Continuity of Care Standard by Completion Status & Condition
Residential Completers
Residential Non-Completers
Nearly
Doubled
Largest improvement in CoC was in the ACC condition for those who did not complete Res Tx
2 = 6.51, p < .01, d=.31
2 = 17.71, p < .001, d=.59
Chestnut Health Systems

16. The Cyclical Course of Relapse, Incarceration,
Dennis
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
1/3/2019
P not the same in both directions
Incarcerated 7%
27% 3%
(46% stable) 5%
12% 7%
20%
24%
10%
Treatment is the most likely path to recovery
26%
7 %
19%
In the
Community
In Recovery
Using
(62% stable)
(75% stable)
Similar to patients with SED we see cycling between periods of recovery and relapse.
To shift to a chronic condition management paradigm it is necessary to start by recognizing that most people are typically cycling through multiple periods of being in the community using, incarceration, treatment and being in the community in recovery for a month or more. The circles in this figure show the average percent staying in each condition between two annual interviews for this same large sample.
1 From the beginning to end of the quarter an average of 39% change status
2,3,4, these arrows show the percent moving along each pathway from one state to another.
5- Notice that the percentages are not the same in both directions.
6- Also notice that the probability of moving from the three states on the left to recovery on the right are not the same --- with treatment being the most likely pathway to recovery over a 3 month period.
Avg of 39% change status each quarter
In Treatment
(48% stable)
Source: 2006 CSAT AT data set
Chestnut Health Systems

17. Probability of Going to Using vs. Early “Recovery” (+ good)
Dennis
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
1/3/2019
Probability of Going to Using vs. Early “Recovery” (+ good)
- Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46)
- Past Month Substance Problems (0.48) + Times Urine Screened (1.56)
- Substance Frequency (0.48) + Recovery Environment (r)* (1.47)
+ Positive Social Peers (r)** (1.69)
In the
Community
In Recovery
Using
(62% stable)
(75% stable)
When they come out of treatment adolescents are more likely to relapse the higher their base rate of substance use severity, the number of past month problems and frequency of substance use at the beginning of the quarter.
They are more likely to transition to recovery the higher the total symptoms count (other problems), the more urine testing they received during the transition period and the better their recovery environment and positive social peers.
26%
19%
* Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home
** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.
In Treatment
(48 v 35% stable)
Source: 2006 CSAT AT data set
Chestnut Health Systems

18. The Cyclical Course of Relapse, Incarceration,
Dennis
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
1/3/2019
Probability of Going from Use to Early “Recovery” (+ good)
Age (0.8) Female (1.7),
Frequency Of Use (0.23) Non-White (1.6)
+ Self efficacy to resist relapse (1.4)
+ Substance Abuse Treatment Index (1.96)
In the
12%
Community
In Recovery
Using
(62% stable)
27%
(75% stable)
Probability of going from Recovery to “Using” (+ bad)
+ Freq. Of Use ( ) - Initial Weeks in Treatment (0.97)
+ Illegal Activity (1.42) - Treatment Received During Quarter (0.50)
+ Age (1.24) Recovery Environment (r)* (0.69)
- Positive Social Peers (r) (0.70)
If we focus on movement between the two most common states
Below are less likely to transition from using to early recovery if they are older or use more.
1. They are more likely to enter early recovery if they are female, non-white, have self efficacy to resist relapse,
and the more treatment they receive during the transition period.
2. Once in recovery, adolescents are more likely to relapse the more they used recently, were involved in illegal activity and are older.
They were less likely to relapse the longer their initial length of treatment, the range of treatment they received during the quarter, and the more positive their recovery environment and positive social peers during the transition period . Where
recovery environment is defined as the average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home
positive social peers during transition period is based on the percent in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.
* Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home
** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.
Chestnut Health Systems

19. Dennis
1/3/2019
Conclusions
Treatment is helpful for many youth but there are many more we fail to adequately engage and retain.
Co-occurring MH disorders are common. MH Symptoms improve for many during treatment; but others need MH interventions
Continuing care can help prevent or minimize relapse; but it is not accessed or available for most.
Need more diversity of services, especially services outside the clinic.
Tie diversity of services back to improving the recovery environment and decreasing social risk.
Point 3: With ACC we showed that even those who don’t complete tx if we are assertive we can link them to services. This issue will come up with recovery support services too. We should not believe that “if we build it they will come”
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20. Recommendations for Recovery Supports
Recovery supports and services should be available as soon as reasonably possible
AOD-free, structured activities, including self-help meetings (especially for more severe SUD)
Increase training and support to parents and other caregivers to support recovery and minimize relapse
Decrease drug use and fighting in home
Increase non-using peers, peers in school and treatment

21. Dennis
1/3/2019
Questions?
For more information or for a copy of this presentation please me at:
Chestnut Health Systems