1. 1 Advances in Identification and Treatment of Substance Abuse Randolph Muck, M.Ed Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration Presentation for the The National Policy Academy On Improving Services For Youth With Mental Health And Co-Occurring Substance Use Disorders Involved With The Juvenile Justice System. September 13-15, 2005, Hyatt Regency Hotel, Bethesda, Maryland. Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and coordinated by the National Center for Mental Health and Juvenile Justice (NCMHJJ) in partnership with the National Association of State Mental Health Program Directors (NASMHPD) and the Council of Juvenile Correctional Administrators (CJCA). 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 270-2003-00006 using data provided by the CYT and AMT grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888). The opinions are those of the author and do not reflect official positions of the consortium or government. Available by contacting the presenter at Randy.Muck@samhsa.hhs.gov.

2. 2 To summarize some of the key trends in the adolescent substance abuse treatment field To highlight the initial clinical characteristics of adolescent presenting for substance abuse treatment using the CSAT Adolescent Treatment Cooperative Data Set with 5,468 adolescents from 67 local evaluations To highlight the current approach to screening we will be recommending to the new CSAT state adolescent coordinators this fall Goals for Presentation Note that Mike Dennis will expand on this presentation tomorrow and focus more on the move towards evidenced based treatment and outcomes

3. 3 Substance Use Disorders primarily on-set during adolescences Source: Dennis (2002) and 1998 NHSDA 0 10 20 30 40 50 60 70 80 90 100 12131415161718192021 22-2324-2526-2930-3435-3950-64 65 + Age Alcohol Use Tobacco Use Binge Alcohol use Any Illicit Drug Use Marijuana Use

4. 4 Juvenile Justice Is the Dominate Source of Referrals to Treatment Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf JJ referrals have doubled and are driving growth

5. 5 The Current Renaissance of Adolescent Treatment Research 1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adol. (DATOS-A) 1995-1997 Drug Abuse Treatment Outcome Study (DOMS) 1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments 1998-2003 NIAAA/CSAT’s 15 individual research grants 1998-2003 CSAT’s 10 Adolescent Treatment Models (ATM) 2000-2003 CSAT’s Persistent Effects of Treatment Study (PETS-A) 2002-2007 CSAT’s 12 Strengthening Communities for Youth (SCY) 2002-2007 RWJF’s 10 Reclaiming Futures (RF) diversion projects 2002-2007 CSAT’s 12+ Targeted Capacity Expansion TCE/HIV 2003-2009 NIDA’s 14 individual research grants and CTN studies 2003-2006 CSAT’s 17 Adolescent Residential Treatment (ART) 2003-2008 NIDA’s Criminal Justice Drug Abuse Treatment Study (CJ-DATS) 2003-2007 CSAT’s 38 Effective Adolescent Treatment (EAT) 2004-2007 NIAAA/CSAT’s study of diffusion of innovation 2004-2009 CSAT 22 Young Offender Re-entry Programs (YORP) 2005-2008 CSAT 20 Juvenile Drug Court (JDC) 2005-2008 CSAT 16 State Adolescent Coordinator (SAC) grants Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)

6. 6 Adolescent and Adult Treatment Program GAIN Clinical Collaborators 30 to 60 10 to 29 2 to 9 1 Number of GAIN Sites One or more state or county wide systems uses the GAIN One or more state or county wide systems considering using the GAIN 07/05

7. 7 CSAT Adolescent Treatment Cooperative Data Set Recruitment: 1998-2004 Sample: The 2004 CSAT adolescent treatment data set included data on 5,468 adolescents from 67 local evaluations (and is growing exponentially in people, sites, and number of follow-ups) Levels of Care: Adolescent EI, OP, IOP, STR, LTR, CC Instrument:Global Appraisal of Individual Needs (GAIN) Follow-up:Over 85% follow-up 3, 6, & 9 months post discharge Funding: CSAT contract 270-2003-00006 and multiple individual grants

8. 8 Demographic Characteristics Source: CSAT AT Common GAIN Data set 26% 6% 1% 17% 45% 15% 16% 17% 76% 7% 0% 10%20%30%40%50%60%70%80%90%100% Female Am. Native Asian African Am. White Hispanic Mixed/Other Under 14 15-17 18 to 25

9. 9 Other Characteristics Source: CSAT AT Common GAIN Data set 50% 39% 34% 86% 45% 0%10%20%30%40%50%60%70%80%90%100% Single Parent Homeless or Runaway Employed In School Recently in a Controlled Environment 75% Juvenile Justice Involvement

10. 10 Intensity of Juvenile Justice System Involvement Source: CSAT AT Common GAIN Data set 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

11. 11 Weekly/Daily Substance Use Pattern Source: CSAT AT Common GAIN Data set 65% 20% 52% 5% 3% 8% 30% 0%10%20%30%40%50%60%70%80%90%100% Any AOD Use Alcohol Marijuana Cocaine/Crack Heroin/Opioids Other Drugs 14 or more days in Controlled Environment In our data and in TEDS, 1 in 5 did not use in the month before intake – hence the use of 90 day window and measures of pre-CE use

12. 12 Severity of Substance Use Disorders Source: CSAT AT Common GAIN Data set 88% 86% 65% 58% 43% 34% 12% 11% 0% 10%20%30%40%50%60%70%80%90%100% Self reported abuse/ dependence First use under 15 Weekly or more AOD use Past Year Dependence Prior Substance Abuse Tx Past week withdrawal Past week severe withdrawal First use under 10

13. 13 Mixed Problem Recognition Source: CSAT AT Common GAIN Data set 35% 81% 92% 99% 0%10%20%30%40%50%60%70%80%90%100% Acknowledges AOD problem Believes treatment needed Self reports 1+ abuse/dependence Problem criteria Gives one or more reasons to quit

14. 14 High Risk Recovery Environments Source: CSAT AT Common GAIN Data set 29% 52% 61% 17% 67% 79% 0%10%20%30%40%50%60%70%80%90%100% Regular alcohol use In home among work/ school peers among social peers Regular drug use In home among work/ school peers among social peers

15. 15 High Rates of Other Psychiatric Problems Source: CSAT AT Common GAIN Data set 49% 38% 21% 28% 32% 28% 67% 59% 48% 0%10%20%30%40%50%60%70%80%90%100% Any Internal Disorder Depressive Disorder Anxiety Disorder Trauma Related Disorder Any Self Mutilation Any homicidal/ suicidal thoughts Any External Disorder Conduct Disorder Attention Deficit- Hyperactivity Disorder (ADHD) With External Disorders more prominent in Adolescents

16. 16 High Rates of HIV/STI risk behaviors Source: CSAT AT Common GAIN Data set 81% 57% 16% 61% 51% 35% 29% 23% 4% 0%10%20%30%40%50%60%70%80%90%100% Sexual Activity Victimization Needle Use Sexual Activity Sex Under AOD Influence Multiple Sex Partners Unprotected Sex Victimization Needle Use Lifetime Past 90 Days

17. 17 High rate of crime and violence Source: CSAT AT Common GAIN Data set 86% 72% 58% 57% 51% 0%10%20%30%40%50%60%70%80%90%100% Any violence or illegal activity Physical Violence Property Crimes Drug Related Crime Interpersonal/violent Crimes Past Year

18. 18 Development of the GAIN Short Screener (GSS) Recruitment: 1996-2005 Sample: The adult clinical norms are based on 1805 adults from 40 sites. The adolescent clinical norms are based on 6204 adolescents from 70 sites. Levels of Care: Adult OP, IOP, OMT, HH, STR, LTR, TASC, Detox; Adolescent EI, OP, IOP, STR, LTR, CC Instrument:Global Appraisal of Individual Needs (GAIN) Follow-up:Over 85% follow-up 3, 6, & 9 months post discharge Funding: CSAT contract 270-2003-00006 and multiple individual grants

19. 19 Statistical Structure of the GAIN’s Psychopathology Scales

20. 20 Characteristics of the Clinical Samples Adults (n=1809) Adolescents (n=6204) Male49%73% Caucasian36%47% African American56%17% Hispanic4%15% Average Age36.115.8 Substance Disorder90%86% Internal Disorder68%56% External Disorder40%66% Crime/Violence41%66% Residential Tx73%34% Current CJ/JJ invol.51%70%

21. 21 Screeners are evaluated in terms of Sensitivity - percent of people with actual diagnoses correctly identified at this score or higher. Specificity - percent of people with no diagnosis correctly excluded at this score or higher. Efficiency – The combined ability of the tool to rapidly (2-3 minutes) identify who will end up with a diagnosis after a full 1-2 hour interview and rule out those who do not.

22. 22 Clinical Validation Of the Gain-Short Screener By Age

23. 23 Notes

24. 24 Substance Disorder Scale: Adults Sensitivity should be over 90% at 1+ Specificity should be over 90% at 3+

25. 25 Substance Disorder Scale: Adolescent

26. 26 Internal Disorder Scale: Adults

27. 27 Internal Disorder Scale: Adolescent

28. 28 External Disorder Scale: Adults

29. 29 External Disorder Scale: Adolescent

30. 30 Violence/Crime Scale: Adult

31. 31 Violence/Crime Scale: Adolescent

32. 32 Conclusions/Next steps… Multiple co occurring substance, mental health and crime/violence problem are the norm in adolescents presenting for substance abuse treatment. The GAIN-Short Screener should provide an efficient tool to help systems identify who needs a full assessment and track them into the necessary services systems. By being short and comprehensive, it can be used across multiple systems of care and provide a denominator for evaluating coverage/referral patterns Tomorrow Mike Dennis will present part 2 of this presentation, looking more at outcomes and evidenced based practice.