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: (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. Age of First Use Predicts Dependence an Average of 22 years Later 100 Under Age 15 90 Aged 15-17 80 Aged 18 or older 71 70 63 62 60 51 48 % with 1+ Past Year Symptoms 50 45 41 39 37 40 34 30 30 23 20 10 0 Alcohol: Marijuana: Other Drugs: Tobacco: Pop.=151,442,082 Pop.=176,188,916 Pop.=71,704,012 Pop.=38,997,916 Tobacco, OR=1.3*, Alcohol, OR=1.9*, Marijuana, OR=1.5*, Other, OR=1.5*, Pop.=151,442,082 Pop.=176,188,916 Pop.=71,704,012 Pop.=38,997,916 OR=1.49* OR=2.74* OR=2.45* OR=2.65* Source: Dennis, Babor, Roebuck & Donaldson (2002) and 1998 NHSDA * p<.05

5. 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

6. Substance Use Careers are Longer the Younger the Age of First Use Age of 1st Use Groups 1.0 .9 .8 Cumulative Survival .7 Years from first use to 1+ years abstinence .6 .5 under 15* .4 15-20* .3 .2 21+ .1 0.0 * p<.05 (different from 21+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

7. 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

8. 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

9. Adolescent Initiation Rising Adult Initiation Relatively Stable The Growing Incidence of Adolescent Marijuana Use: 1965-2002 Source: OAS (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD: SAMHSA. http://oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.pdf

10. Importance of Perceived Risk Risk & Availability Marijuana Use Source: Office of Applied Studies. (2000). 1998 NHSDA

11. Actual Marijuana Risk • From 1980 to 1997 the potency of marijuana in federal drug seizures increased three fold. • The combination of alcohol and marijuana has become very common and appears to be synergistic and leads to much higher rates of problems than would be expected from either alone. • Combined marijuana and alcohol users are 4 to 47 times more likely than non-users to have a wide range of dependence, behavioral, school, health and legal problems. • Marijuana and alcohol are the leading substances mentioned in arrests, emergency room admissions, autopsies, and treatment admissions. • Marijuana is specifically associated with progression of schizophrenia and other severe mental illnesses

12. Substance Use in the Community Source: Dennis and McGeary (1999) and 1997 NHSDA

13. Consequences of Substance Use Source: Dennis, Godley and Titus (1999) and 1997 NHSDA

14. 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)

15. Adolescent AOD Dependence/Abuse Up 27% from 7% in 1995 Prevalence 6.0 to 8.4% 8.5 to 9.0% 9.1 to 9.9% 10.0 to 14.6% U.S.Avg.=8.9% UT=7.0% Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf ) and Kilpatrick et al, 2000.

16. Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment) 9 in 10 Untreated Prevalence 82.4 to 90.1% 90.2 to 92.3% 92.4 to 94.2% 94.3 to 98.0% U.S.Avg.=92.2% UT=89.8% Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf )

17. 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

18. Change in Public Sector Admissions (%=(2003-1993)/1993) Both Cause & Consequence Change Not available -96 to -7% -8 to +33% +34 to +116% +117 to +337% U.S.Avg.=+61% UT=+25% Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf )

19. 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.

20. 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.

21. 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.

22. Baseline Severity Goes up with Level of Care Detox: Higher on Use, but lower on prior tx Detox: Higher on Use Severity Goes up with Level of Care STR: Higher on Dependence 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Weekly use First used Prior Treatment Case Mix Index (Avg) Dependence at intake under age 15 Outpatient Intensive Outpatient Detoxification Long-term Residential Short-term Residential Source: Treatment Episode Data Set (TEDS) 1993-2003.

23. Median Length of Stay is only 50 days Median Length of Stay Total 50 days (61,153 discharges) Less than 25% stay the 90 days or longer time recommended by NIDA Researchers LTR 49 days (5,476 discharges) STR 21 days (5,152 discharges) Level of Care Detox 3 days (3,185 discharges) IOP 46 days (10,292 discharges) Outpatient 59 days (37,048 discharges) 0 30 60 90 Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

24. Despite being widely recommended, only 10% step down after intensive treatment 53% Have Unfavorable Discharges Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

25. The Current Renaissance of Adolescent Substance Use Disorder Treatment Research * Published and publicly available

26. CSAT Adolescent Treatment (AT)Outcome Data Set Recruitment: 1998-2005 (updated annually) Sample: The 2005 CSAT adolescent treatment data set included data with 1 to 4 follow-ups on 9,276 unique adolescents from 72 local evaluations Levels of Care: Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care Instrument: Global Appraisal of Individual Needs (GAIN)(see www.chestnut.org/li/gain) Follow-up: Over 80% follow-up 3, 6, 9 & 12 months post intake Funding: CSAT contract 270-2003-00006 and 72 individual grants

27. Geographic Location of Sites 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

28. Demographics

29. Clinical Severity

30. Primary, Secondary or Tertiary SUD Problems

31. Includes 9% in continuing care outpatient (CCOP) after residential treatment or detention Level of Care

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

33. Past 90 day HIV Risk Behaviors Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

34. Weekly or More Often Use in the Past 90 Days Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

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

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

37. Multiple Co-occurring Problems Were the Norm and Increased with Level of Care 100 88 80 78 80 70 68 65 56 60 52 52 47 44 44 43 35 36 40 25 21 21 20 0 Conduct ADHD Major Generalized Traumatic Any Co- Disorder Depressive Anxiety Stress Occurring Disorder Disorder Disorder Disorder Outpatient Long Term Residential Short Term Residential Source: CSAT’s Cannabis Youth Treatment (CYT) and Adolescent Treatment Model (ATM),

38. 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)

39. 17% Past year illegal activity/SA use 8% Past arrest/ JJ status Intensity of Juvenile Justice System Involvement 17% In detention/jail 14+ days Highest severity for Long Term Residential (followed by STR, IOP, OP) 25% On probation or parole 14+ days w/ 1+ drug screens 16% Other JJ status 17% Other probation/parole/detention Source: CSAT 2004 AT Common GAIN Data set (n= 5,468 adolescents from 67 local evaluations)

40. Multiple Problems* are the Norm 100% In fact, over half present acknowledging 5+ major problems 90% 80% Five to Twelve 70% 60% 50% 40% Four 30% Few present with just one problem (the focus of traditional research) Three Most acknowledge 1+ problems 20% Two 10% One None 0% * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: CSAT AT Common GAIN Data set

41. 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)

42. 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)

43. 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)

44. 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.

45. 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.

46. 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

47. 2. Identify Need for Treatment 3. Attend Recovery Management Checkup (RMC) Meeting 4. Agree to go for treatment intake assessment 5. Shows to treatment intake assessment 6. Shows to treatment 7. Engages in treatment (at least 14 days) 8. Less likely to be using 90 days latter (cycle repeats every quarter for 4 years) Example of a Simple Theory / Logic Model for Early Re-Intervention (ERI) Experiment Relapse is Common but hard to predict Monitoring and Early Re-Intervention Sustained Recovery In Long Term 1. Follow-up Quarterly Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming)

48. 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

49. Common starting places • Standardize assessment and identify most common problems • Senior staff do a walk through intake and treatment • Pool knowledge about what staff have done in the past, whether it worked, and what the barriers were • Identify system barriers (e.g., criteria to local access case management, mental health) that could be avoided if thought of in advance • Identify existing materials that could help and make sure they are readily available on site • Identify promising strategies for working with the adolescent, parents, or other providers • Develop a 1-2 page checklist of things to do when this problem comes up • Identify a more detailed protocol and trainer to address the problem, then go for a grant to support implementation

50. 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