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Adolescent substance abuse system building and SAMHSA 5 Step Planning Process

Adolescent substance abuse system building and SAMHSA 5 Step Planning Process. Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL

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Adolescent substance abuse system building and SAMHSA 5 Step Planning Process

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  1. 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 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: junsicker@Chestnut.Org

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

  3. Adolescent Onset Remission Substance Use Severity Is Related to Age Increasing rate of non-users 100 Severity Category 90 No Alcohol or Drug Use 80 70 Light Alcohol Use Only 60 Any Infrequent Drug Use 50 40 Regular AOD Use 30 Abuse 20 10 Dependence 0 (2002 U.S. Household Population age 12+, n= 235,143,246) 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Age Source: 2002 NSDUH and Dennis & Scott in press

  4. Substance Use Careers Last for Decades 1.0 Median of 27 years from first use to 1+ years abstinence .9 Cumulative Survival .8 .7 Years from first use to 1+ years abstinence .6 .5 .4 .3 .2 .1 0.0 0 5 10 15 20 25 30 Source: Dennis et al., 2005

  5. Substance Use Careers are Shorter the Sooner People Get to Treatment Year to 1st Tx Groups 1.0 .9 .8 Cumulative Survival .7 Years from first use to 1+ years abstinence 20+ .6 .5 .4 .3 10-19* .2 .1 0.0 0-9* * p<.05 (different from 20+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

  6. Treatment Careers Last for Years 1.0 .9 Cumulative Survival .8 Median of 3 to 4 episodes of treatment over 9 years .7 Years from first Tx to 1+ years abstinence .6 .5 .4 .3 .2 .1 0.0 0 5 10 15 20 25 Source: Dennis et al., 2005

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

  8. 61% increase from 95,271 in 1993 to 153,251 in 2003 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

  9. Similar on Marijuana, Higher on Alcohol Presenting Substances: UT vs. US Cocaine similar; 20% or higher in DE & TX Methamphetamine higher; 20% or higher in AZ, CA,ID,MN,NV,WA Opiates similar; 20% or higher in MA & NM Other Amp.similar; 20% or higher in OR Source: Primary, Secondary or Tertiary, from Treatment Episode Data Set (TEDS) 1993-2003.

  10. Referral Sources: UT vs. US Higher Rate of Juvenile Justice Referrals Lower Rate of School Referrals Lower Rate of Self/Parent Referrals Source: Treatment Episode Data Set (TEDS) 1993-2003.

  11. Higher on Regular Outpatient and IOP Lower on Detox, Short and Long Term Residential Level of Care: UT vs. US 100% 90% UT U.S. 80% 70% 60% 50% 40% 30% 20% 10% 0% Detox Outpatient Outpatient Intensive Short-term Residential Long-term Residential Source: Treatment Episode Data Set (TEDS) 1993-2003.

  12. CSAT Adolescent Treatment (AT) Data Set (9,276 unique adolescents from 72 local evaluations ) NH WA VT ME MT ND MN OR MA NY ID WI SD MI WY RI IA PA CT NE OH NJ NV DC IN UT IL CA CO WV VA DE DC KS MO KY MD NC TN AR AZ OK NM SC GA AL MS Program ART TX LA EAT AK SCY FL TCE YORP HI PR

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

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

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

  16. 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)

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

  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)

  19. 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)

  20. Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s Change in Emotional Problem Indexby Level of Care\a Note the lack of a hinge; Effect is generally indirect (via reduced use) not specific \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.

  21. Short- Term Resid. \t,s,ts Long- Term Resid \t,ts Outpatient \t,s Change in Illegal Activity Indexby Level of Care\a Residential Treatments have a specific effect Outpatient Treatments has an indirect effect \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.

  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. Needs Assessment 5. Evaluation 2. Capacity Building 4. Implementation 3. Program Selection Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm

  23. The SAMHSA 5 Step Program Planning and Evaluation Process 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 5. Evaluation 2. Capacity Building 4. Implementation 3. Program Selection Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm

  24. The SAMHSA 5 Step Program Planning and Evaluation Process 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 5. Evaluation 2. Capacity Building 4. Implementation 3. Program Selection Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm

  25. The SAMHSA 5 Step Program Planning and Evaluation Process 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 5. Evaluation 2. Capacity Building 4. Implementation 3. Program Selection Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm

  26. The SAMHSA 5 Step Program Planning and Evaluation Process 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 5. Evaluation 2. Capacity Building 4. Implementation 3. Program Selection Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm

  27. 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 The Quadrants of Care Model of a Systems of Care II. Severe Mental Disorder (MD) and No/Low Severity Substance Use Disorders (SUD) II. Severe MD / Low SUD: Treated in mental health treatment system Low SUD SUD III. Low MD / Severe SUD: Treated in substance abuse treatment system III. No/Low Severe Mental Disorder (MD) and Severe Substance Use Disorders (SUD) IV. Severe Mental Disorder (MD) and Severe Substance Use Disorders (SUD) 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 Source: NASMHPD and NASADAD (1999) and CSAT (2005) Tip 32 Low MD MD .

  28. Actual Services Needed The Problem is that if we go by actual diagnosis, the vast majority of the patients are actually in the fourth quadrant I. Low MD / Low SUD IV. Severe MD / Low SUD IV. Severe MD / Severe SUD III. Low MD / Severe SUD Low SUD SUD Moreover youth in all four groups show up in all systems of care 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 Low MD MD

  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

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