Adolescent substance abuse system building and SAMHSA 5 Step Planning Process

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 [phone], e-Mail
  junsicker_at_Chestnut.Org

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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 SAMHSAs 5 step process for program
  planning and evaluation

3
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
30
25
20
15
10
5
0
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
plt.05 (different from 20)
30
25
20
15
10
5
0
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
25
20
15
10
5
0
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
5.7
Any Non-Marijuana Drug Use
8.9
Past Year AOD Dependence or Abuse
Less than 1 in 10 getting treatment
0.7
Any Treatment (From NHSDA)
88 of adolescents are treated in the public
system
0.6
Public Treatment (From TEDS)
Source NSDUH and TEDS (see state level
estimates in appendix)
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.samhs
a.gov/oas/dasis.htm
9
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 Self/Parent Referrals
Lower Rate of School Referrals
Source Treatment Episode Data Set (TEDS)
1993-2003.
11
Level of Care UT vs. US
100
90
UT
U.S.
80
70
60
50
40
30
20
10
0
Detox
Outpatient
Intensive
Outpatient
Long-term
Residential
Short-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 (n9,276
adolescents)
14
Substance Use Problems
Source CSAT AT Outcome Data Set (n9,276
adolescents)
15
Co-Occurring Psychiatric Problems
Source CSAT AT Outcome Data Set (n9,276
adolescents)
16
Past Year Violence Crime
Dealing, manufacturing, prostitution, gambling
(does not include simple possession or
use) Source CSAT AT Outcome Data Set (n9,276
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
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, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
21
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, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
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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/eval
102_1_pg2.htm
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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/eval
102_1_pg2.htm
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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/eval
102_1_pg2.htm
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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/eval
102_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/eval
102_1_pg2.htm
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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
IV. Severe Mental Disorder (MD) and Severe
Substance Use Disorders (SUD)
III. No/Low 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 .
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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
IV. Severe MD / Low SUD
I. Low 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
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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.

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Resources for Finding Promising Programs

• Screeners and Other Measures related to
  adolescents
• CSAT TIP 42- http//store.health.org/catalog/produ
  ctDetails.aspx?ProductID16979
• NIAAA Handbook- pubs.niaaa.nih.gov/publications/As
  sesing20Alcohol
• Drug Strategies Handbook- www.drugstrategies.com/t
  eens
• GAIN Coordinating Center- www.chestnut.org/li/gai
  n
• Co-Occurring Center for Excellence-
  www.coce.samhsa.gov/cod_resources/cb_assessment.ht
  m
• 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.samh
  sa.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/ChildrensC
  ampaign/practices.asp
• Traumatic disorders and child maltreatment-
  www.nctsnet.org
• Co-Occurring Cen. for Excel.- www.coce.samhsa.gov/
  cod_resources/cb_treatmentservice.htm