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Transcript of 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
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
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
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
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
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)
Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
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
The SAMHSA 5 Step Program Planning and Evaluation Process
Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm
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
The SAMHSA 5 Step Program Planning and Evaluation Process
Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm
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
The SAMHSA 5 Step Program Planning and Evaluation Process
Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm
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
The SAMHSA 5 Step Program Planning and Evaluation Process
Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm
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