Summary of SAMHSA behavioral health data findings related to Native Americans".

1. Summary of SAMHSA behavioral health data findings related to Native Americans". 1/14/13 Michael L. Dennis, Chestnut Health Systems. Normal, IL Created for: Rod Robinson, Director Substance Abuse and Mental Health Services Administration’s (SAMHSA) Office of Indian Alcohol and Substance Abuse (OIASA)

2. Goals for the Presentation • Summarize the major data available for supporting OIASA mission and what it shows about the quality chasm in behavioral health • Use existing data to identify some of the key needs • Discuss some of the things we can do now to address these needs Note: Back two thirds of this document are an appendix of other material to follow up with if desired

3. The Quality Chasm In Substance Use Disorder Tx • In general, less than 1 in 11 adults and 1 in 20 adolescents with substance use disorder access treatment • Half of those who enter leave before the 90 days recommended by research and less than 1 in 5 receive any kind of continuing care • While research suggest that approximately 2/3rds have them, less than 20% are identified with co-occurring mental health disorders • While few programs have formal assessment of HIV risk behaviors, trauma, and crime/violence, research suggests each are common • Over half relapse within 3 to 12 months post discharge

4. Native Americans are disproportionately effected by Substance Use Disorders (SUD) Native Americans (NA) have higher* than average rates of Substance Use Disorders (SUD) Source: SAMHSA, 2011 National Survey on Drug Use and Health (NSDUH; (p8 of SAMHSA 1/13 newsletter) * p<.001

5. Existing Data Sources on Substance Use Among Native Americans (NA)* by Age * Including Native Alaskans, Hawaiians and Pacific Islanders

6. The NA Rates of SUD & Unmet Need vary by Age Higher rates* of unmet need for adolescents and young adults Higher rates* of need for young adults Source:  SAMHSA 2011 National Survey on Drug Use and Health subset to Native Americans (n=1151, population estimate=2,281,422).  * p<.001

7. The NA Rates of SUD & Unmet Need vary by Gender Higher rates* of unmet need for adolescent girls than boys Higher rates* of need for Males overall and for adolescent girls Source:  SAMHSA 2011 National Survey on Drug Use and Health subset to Native Americans (n=1151, population estimate=2,281,422).  * p<.001

8. In Spite of Longer Stays, NA Teens less likely to Complete Tx Lengths of stay are longer * for young adults and adults Completion rates are lower * for adolescents and young adults Source: SAMHSA 2009 Treatment Episode Data Set – Discharges (TEDS-D) for Native Americans. P<.001

9. Native American/Alaskan/Hawaiian Clients by State(3,929 clients from 271 sites between 7/11-6/12) NH WA ME MT VT ND MN OR MA ID WI NY SD WY MI RI IA PA CT NE OH NJ NV DC IL IN UT CA CO WV VA DE KS MO KY NC MD TN OK AZ NM AR SC None GA AL MS 1 to 25 TX 26 to 100 LA AK 101 to 500 FL 500+ HI PR VI

10. NA Demographic Characteristics Mostly male, NA, multi-racial, and under 18 Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,929)

11. NA Pattern of Weekly Use (13+/90 days) *Not a weekly measure; any in past 90 days Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,894)

12. NA Substance Use Problems *Count of 8 items Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,862)

13. NA Substance Problem Recognition * n=2,876 Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,911)

14. NA Co-Occurring Psychiatric Problems * Count of Conduct Disorder, ADHD/ADD Major Depressive Disorder, Traumatic Stress Disorder, and Generalized Anxiety Disorder Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,749)

15. NA Past Year Crime & Justice Involvement *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,768)

16. NA Count of Major Clinical Problems at Intake *Based on count of self reporting criteria to suggest alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,811)

17. NA Severity of Victimization Scale *Mean of 15 items Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,803)

18. NA Count of Major Clinical Problems* at Intake by Severity of Victimization *Based on count of self reporting criteria to suggest alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,838)

19. NA Quarterly Cost of Health Care Utilization Using the GAIN, we are able estimate the quarterly cost to society of tangible services (e.g., hospital visits, emergency room visits, etc.) in 2011 dollars for the 90 days before intake. For the 3,929 clients served in 271 sites between 7/1/2011 and 6/30/2012, the average Quarterly Cost of Health Care Utilization (HCU) per client: in the quarter before they entered treatment, was $3,417 and totaled $12,535,510 across clients. in the year before they entered treatment, was $13,668 per client and totaled $50,142,040 across clients.

20. Cost to Society in 2011 Dollars *Quarterly Health Care Utilization 2011 dollars w/ SA TX based onFrench, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, 462-469.

21. NA Quarterly Health Care Utilization Cost Source: GAIN-I 2010 SuperData subset to Native American/ Hawaiian/A laskan (n=3,668)

22. NA Cost of Crime in the Past Year • Using the GAIN we are able estimate the cost to society associated with economic losses due to criminal activity (e.g., vandalism, forgery, theft, assault, arson, rape, murder) in 2011 dollars for the year prior to intake. • Of the 3,929 clients served in 271 sites between 7/1/2011 and 6/30/2012, the average Cost of crime per client, in the year before they entered treatment, was $308,148 and totaled $1,107,793,754 across clients.

23. Cost of Crime in 2011 Dollars* *Cost of Crime 2011 dollars w/ SA TX based on McCollister, K. E., French, M. T., & Fang, H. (2010). The cost of crime to society: New crime-specific estimates for policy and program evaluation. Drug and Alcohol Dependence, 108(2)(1-2), 98-109.

24. NA Cost of Crime in the Past Year Source: GAIN-I 2010 SuperData subset to Native American/ Hawaiian/ Alaskan (n=3,595)

25. NA GAIN Quick (GAIN-Q) Version 3 Problem Profile *Not used in the GQ Problem Count Across the 9 screeners on the Q3 85% of respondents have 3 or more that rate as moderate to high problems Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,188)

26. NA Four Summary Indices Beneficial Problematic *GSI groups are usually reversed (low satisfaction scores (0-2) are in the high problem group); here low satisfaction scores are in the low group, and high satisfaction scores are in the high group; n=1,823 Source: GAIN-I 2010 SuperData subset to Native American/Hawaiian/Alaskan (n=3,167)

27. NA Unmet Need for Medical Treatment by 3 Months Age* Gender* Unmet Need Higher for Males Unmet Need Higher for Adolescent and Young Adults * p<.05 SAMHSA 2011 GAIN SA Data Set subset to Native American/ Hawaiian/Alaskan w/ 3m Follow up (n=735)

28. NA Unmet Need for Mental Health Treatment by 3 Months Age* Gender* Unmet Need Higher for young adults and adolescents Unmet Need Higher for Males * p<.05 SAMHSA 2011 GAIN SA Data Set subset to Native American/ Hawaiian/Alaskan w/ 3m Follow up (n=1,202)

29. What can we do? • Implement low cost screening and assessment • Target locations youth because SUD is an adolescent on-set disorder and early intervention is the most effective and produces the greatest long term services (in lives and money) • Target assessment and treatment to assume that there will be “multi-morbidity” • To reduce health care and crime costs, target the smaller group of people producing most of the costs • Identify and reduce health disparities by targeting treatment to not only NA, but by age, gender, and other subgroups within NA

30. Regardless of Diagnosis or Where Patients Enter, High Quality Care Should be: • Safe – do no harm • Effective – based on scientific knowledge and average practice (based on actual data) • Patient-centered – respectful and responsible to individual preferences, needs, values and participation in clinical decision making (vs. staff centered) • Timely - reducing waits and delays and when care is most effective • Efficient -avoiding waste of time, energy and money • Equitable – providing effective care based on clinical criteria that does not vary by gender, race, age, geography or social economic status Source: IOM 2005

31. Structural Challenges to Delivery of Quality Care Heterogeneous needs and severity characterized by multiple problems, chronic relapse, and multiple episodes of care over several years High turnover workforce with variable education background related to diagnosis, placement, treatment planning and referral to other services Lack of access to or use of data at the program level to guide immediate clinical decisions, billing and program planning Missing, bad or misrepresented data that needs to be minimized and incorporated into interpretations Lack of Infrastructure that is needed to support adaptation to NA community and/or implementation with fidelity

32. Programs often LACK Evidenced Based Assessment to Identify and Practices to Treat: • Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment • Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidal thoughts) • Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime) • HIV risk behaviors (e.g. needle use, sexual risk, victimization) • Child maltreatment (e.g. physical, sexual, emotional) • Recovery environment and risk from social peers • Long Term Relapse /Recovery Management

33. In practice we need a Continuum of Measurement(Common Measures) More Extensive / Longer/ Expensive Screener Quick Comprehensive Special • Screening to Identify Who Needs to be “Assessed” (5-10 min) • Focus on brevity, simplicity for administration & scoring • Needs to be adequate for triage and referral • GAIN Short Screener for SUD, MH & Crime • ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD • SCL, HSCL, BSI, CANS for Mental Health • LSI, MAYSI, YLS for Crime • Quick Assessment for Targeted Referral (20-30 min) • Assessment of who needs a feedback, brief intervention or referral for more specialized assessment or treatment • Needs to be adequate for brief intervention • GAIN Quick • ADI, ASI, SASSI, T-ASI, MINI • Comprehensive Biopsychosocial (1-2 hours) • Used to identify common problems and how they are interrelated • Needs to be adequate for diagnosis, treatment planning and placement of common problems • GAIN Initial (Clinical Core and Full) • CASI, A-CASI, MATE • Specialized Assessment (additional time per area) • Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed) may be needed to rule out a diagnosis or develop a treatment plan • CIDI, DISC, KSADS, PDI, SCAN

34. Longer Measures Assess and Identify More Problems Source: CSAT 2010 AT Summary Analytic Data Set(n = 17,356)

35. Some Advantages of the GAIN System • Provides an integrated continuum of measurement using a series of evidenced based tools designed to support clinical decision making • Established training, certification and workforce development plan including in person & distance learning approaches • Extensive support for line administration, clinical interpretation, supervision, data management and interface with electronic health record systems • Existing Electronic infrastructure • Track record of building collaboration between clinical systems of care, clinical researchers & Health IT • Capitalize on SAMHSA’s 15 year investment

36. Appendix The following are more detailed slides supporting points above that might be useful to have readily available.

37. Substance Use Disorders are Common, US Treatment Participation Rates Are Low Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

38. Potential AOD Screening & Intervention SitesAdolescents (age 12-17) Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

39. Adolescent Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in WA state Under reporting of SA in mental health & children’s admin Problems could be easily identified & Comorbidity common Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

40. Adolescent Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in WA State Yet the two-page measure closely approximated all found in the clinical record after the next 2 years Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

41. Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring? School Assistance Programs (SAP) largest part of BH/MH system; 2nd largest of SA & Co-occurring systems SAP+ SA Treatment Over half of system Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

42. Total Disorder Screener Severity by Level of Care: Adolescents About 41% of Residential are below 10 (more likely typical OP) About 30% of OP are in the high severity range more typical of residential Outpatient Median=6.0 Residential Median= 10.5 Few missed (1/2-3%) Source: SAPISP 2009 Data and Dennis et al 2006 42

43. Any Illegal Activity in the Next Twelve Months by Intake Severity on Crime/Violence and Substance Disorder Screeners Source: CSAT 2010 Summary Analytic Dataset (n=20,982)

44. Predictive Power of Simple Screener: 12 Month Recidivism \a Odds of row (%/(1-%) over low/low odds across all groups with * p<.05 Source: CSAT 2010 Summary Analytic Dataset (n=20,932)

45. Major Predictors of Bigger Effects • A strong intervention protocol based on prior evidence • Quality assurance to ensure protocol adherence and project implementation • Proactive case supervision of individual • Triage to focus on the highest severity subgroup Source: Adapted from Lipsey, 1997, 2005

46. Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis The more features, the lower the recidivism Average Practice Source: Adapted from Lipsey, 1997, 2005

47. Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Juvenile Recidivism (29% vs. 40%) • Aggression Replacement Training • Reasoning & Rehabilitation • Moral Reconation Therapy • Thinking for a Change • Interpersonal Social Problem Solving • MET/CBT combinations and Other manualized CBT • Multisystemic Therapy (MST) • Functional Family Therapy (FFT) • Multidimensional Family Therapy (MDFT) • Adolescent Community Reinforcement Approach (ACRA) • Assertive Continuing Care NOTE: There is generally little or no differences in mean effect size between these brand names Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

48. Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate) The best is to have a strong program implemented well The effect of a well implemented weak program is as big as a strong program implemented poorly Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

49. Economic Analysis of SAMHSA/CSAT Funded Treatment • As part of SAMHSA/CSAT contract no. 270-07-0191, data were pooled from 22,045 clients from 148 local evaluations, recruited between 1997 to 2009, and followed quarterly for 6 to 12 months (over 80% completion). • In 2009 dollars, the 2,793 adults averaged $1,417 in costs to taxpayers in the 90 days before intake ($5,669 in the year before intake). • In 2009 dollars, the 16,915 adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake). • This would be $1.4 million per 1,000 adults served and $3.9 million per 1,000 adolescents served. • Within 12 months, the cost of treatment provided by CSAT grantees was offset by reductions in other costs producing a net benefit to taxpayers of $1,992 per adult and $4,592 per adolescent.

50. SAMHSA/CSAT’s Adult Clients by Level of Care \a Includes the cost of treatment \b Year after intake (including treatment) minus year before treatment \c Cost of residential treatment is not offset yet at one year after intake