adolescent substance abuse system building and samhsa 5 step planning process michael dennis, ph.d....

Adolescent substance abuse system building and SAMHSA 5 Step Planning Process

Michael Dennis, Ph.D.Chestnut Health Systems, Bloomington, ILPresentation 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 270-2003-00006 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 www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: [email protected]

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

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

Age

Severity CategoryAdolescent

OnsetRemission

Increasing rate of non-

users

(2002 U.S. Household Population age 12+, n= 235,143,246)

4

Substance Use Careers Last for Decades C

um

ula

tive

Su

rviv

al

Years from first use to 1+ years abstinence302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

Median of 27 years from

first use to 1+ years

abstinence

Source: Dennis et al., 2005

5

Substance Use Careers are Shorter the Sooner People Get to Treatment

Cu

mu

lati

ve S

urv

ival

20+

0-9*

10-19*

Year to 1st TxGroups

302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

* p<.05 (different from 20+)Source: Dennis et al., 2005

Years from first use to 1+ years abstinence

6

Treatment Careers Last for Years C

um

ula

tive

Su

rviv

al

Years from first Tx to 1+ years abstinence2520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

Median of 3 to 4 episodes of treatment over 9 years

Source: Dennis et al., 2005

7

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)

--

----

--P

ast M

onth

Use

----

--

Less than 1 in 10 getting treatment

88% of adolescents are treated in the

public system

8

Adolescent Treatment Admissions have increased by 61% over the past decade

Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS)http://www.samhsa.gov/oas/dasis.htm

61% increase from95,271 in 1993

to 153,251 in 2003

9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Alc

ohol

Mar

ijuan

a/H

ash

Coc

aine

/Cra

ck

Her

oin/

Opi

ates

Hal

luci

noge

ns

Met

ham

phet

amin

es

Oth

erA

mph

etam

ines

Sti

mul

ants

Inha

llan

ts

Oth

er\e

UT U.S.

Presenting Substances: UT vs. US

Source: Primary, Secondary or Tertiary, from Treatment Episode Data Set (TEDS) 1993-2003.

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

10

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cri

min

al J

usti

ceS

yste

m Sch

ool

Sel

f/F

amil

y

Oth

erC

omm

unit

yR

efer

ral

Oth

er S

ubst

ance

Abu

seT

reat

men

tA

genc

y

Oth

er H

ealt

hC

are

Pro

vide

r

UT U.S.

Referral Sources: UT vs. US

Source: Treatment Episode Data Set (TEDS) 1993-2003.

Lower Rate of Self/Parent Referrals

Higher Rate of Juvenile Justice

Referrals

Lower Rate of School Referrals

11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Out

pati

ent

Inte

nsiv

eO

utpa

tien

t

Det

ox

Lon

g-te

rmR

esid

enti

al

Sho

rt-t

erm

Res

iden

tial

UT U.S.

Level of Care: UT vs. US

Source: Treatment Episode Data Set (TEDS) 1993-2003.

Higher on Regular Outpatient and IOP

Lower on Detox, Short and Long Term Residential

12

CSAT Adolescent Treatment (AT) Data Set (9,276 unique adolescents from 72 local evaluations )

ART

EATSCYTCEYORP

AK

AL

ARAZ

CA CODC

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

UTVA

WA

WV

WY

WI

IL

KY

Program

DE

HI

MD

NH

NJ

RI

PR

VT

MA

CT

DC

Admin

13

Recovery Environment

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

57%

49%

28%

74%

65%

14%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Social Peers Getting Drunk Weekly+

School/Work Peers Getting Drunk Weekly+

Others at Home Getting Drunk Weekly+

Social Peers Using Drugs

School/Work Peers Using Drugs

Others at Home Using Drugs

14

Substance Use Problems


84%

53%

31%

8%

37%

30%

24%

99%0% 10

%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Past Year Substance Diagnosis

Any Past Year Dependence

Any withdrawal symptoms in the past week

Severe withdrawal (11+ symptoms) in past week

Can Give 1+ Reasons to Quit

Any prior substance abuse treatment

Acknowledges having an AOD problem

Client believes Need ANY Treatment

15

Co-Occurring Psychiatric Problems


79%

54%

45%

37%

26%

17%

59%

47%

31%

25%

16%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Co-occurring Psychiatric

Conduct Disorder

Attention Deficit/Hyperactivity Disorder

Major Depressive Disorder

Traumatic Stress Disorder

General Anxiety Disorder

Ever Physical, Sexual or Emotional Victimization

High severity victimization (GVS>3)

Ever Homeless or Runaway

Any homicidal/suicidal thoughts past year

Any Self Mutilation

16

Past Year Violence & Crime

*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)


82%

69%

66%

51%

49%

45%

84%

68%

39%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence or illegal activity

Physical Violence

Any Illegal Activity

Any Property Crimes

Other Drug Related Crimes*

Any Interpersonal/ Violent Crime

Lifetime Juvenile Justice Involvement

Current Juvenile Justice involvement

1+/90 days In Controlled Environment

17

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 %)

18

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)

0

30

60

90

Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Day

s of

Ab

stin

ence

(of

90)

Outpatient (+20%, -2%)

Residential(+69%, -15%)

Post Corr/Res (+2%, -6%)

19

Treatment Outcomes by Level of Care: Recovery*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Per

cen

t in

Pas

t M

onth

Rec

over

y* Outpatient (+79%, -1%)

Residential(+143%, +17%)

Post Corr/Res (+220%, +18%)

* 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)

20

Change in Emotional Problem Indexby 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.

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,s,ts

OP\t,s

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

21

Change in Illegal Activity Indexby 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.

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\s

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

22

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. NeedsAssessment

2. CapacityBuilding

3. ProgramSelection

4. Implementation

5. Evaluation

Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm

23

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. NeedsAssessment

2. CapacityBuilding

3. ProgramSelection

4. Implementation

5. Evaluation



24

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. NeedsAssessment

2. CapacityBuilding

3. ProgramSelection

4. Implementation

5. Evaluation



25

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. NeedsAssessment

2. CapacityBuilding

3. ProgramSelection

4. Implementation

5. Evaluation



26

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. NeedsAssessment

2. CapacityBuilding

3. ProgramSelection

4. Implementation

5. Evaluation



27

The Quadrants of Care Model of a Systems of Care

Low MD MD .

Low

SUD

SU

D

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 SeveritySubstance 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

28

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 12-18 entering SAP, SUD, MH, & JJ

Moreover youth in all four groups show up in all systems of care

29

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.

30

Resources for Finding Promising Programs:

Screeners and Other Measures related to adolescents: CSAT TIP 42- http://store.health.org/catalog/productDetails.aspx?ProductID=16979 NIAAA Handbook- pubs.niaaa.nih.gov/publications/Assesing%20Alcohol Drug Strategies Handbook- www.drugstrategies.com/teens GAIN Coordinating Center- www.chestnut.org/li/gain Co-Occurring Center for Excellence- www.coce.samhsa.gov/cod_resources/cb_assessment.htm

Prevention Programs related to adolescents: Substance use- modelprograms.samhsa.gov/ Suicide- www.sprc.org/ Violence- www.sshs.samhsa.gov/ Co-Occurring Cen. for Excel.- http://www.coce.samhsa.gov/cod_resources/cb_prevention.htm Other materials- http://www.health.org/

Treatment Programs related to adolescents: Substance use disorder (SUD)- www.chestnut.org/li/apss/CSAT/protocols Mental disorder (MD) & systems of care-

http://www.mentalhealth.samhsa.gov/cmhs/ChildrensCampaign/practices.asp Traumatic disorders and child maltreatment- www.nctsnet.org Co-Occurring Cen. for Excel.- www.coce.samhsa.gov/cod_resources/cb_treatmentservice.htm

adolescent substance abuse system building and samhsa 5 step planning process michael dennis, ph.d....

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