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. 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. 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 12-1314-1516-1718-2021-2930-3435-4950-64 65+ No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Age Severity Category Adolescent Onset Remission Increasing rate of non- users (2002 U.S. Household Population age 12+, n= 235,143,246)

4. 4 Substance Use Careers Last for Decades Cumulative Survival Years from first use to 1+ years abstinence 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Median of 27 years from first use to 1+ years abstinence Source: Dennis et al., 2005

5. 5 Substance Use Careers are Shorter the Sooner People Get to Treatment Cumulative Survival 20+ 0-9* 10-19* Year to 1 st Tx Groups 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 * p<.05 (different from 20+) Source: Dennis et al., 2005 Years from first use to 1+ years abstinence

6. 6 Treatment Careers Last for Years Cumulative Survival Years from first Tx to 1+ years abstinence 2520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Median of 3 to 4 episodes of treatment over 9 years Source: Dennis et al., 2005

7. 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)  --------Past Month Use------  Less than 1 in 10 getting treatment 88% of adolescents are treated in the public system

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

9. 9 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. 10 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. 11 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Outpatient Intensive Outpatient Detox Long-term Residential Short-term Residential UTU.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. 12 CSAT Adolescent Treatment (AT) Data Set (9,276 unique adolescents from 72 local evaluations ) ART EAT SCY TCE YORP AK AL AR AZ CA CO DC 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 UT VA WA WV WY WI IL KY Program DE HI MD NH NJ RI PR VT MA CT DC

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

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

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

16. 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. 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. 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. 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. 20 Change in Emotional Problem Index by 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. 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. 21 Change in Illegal Activity Index by 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. 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. 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 2. Capacity Building 3. Program Selection 4. Implementation 5. Evaluation Source: SAMHSA/CSAP Pathways Course Evaluation 101 http://pathwayscourses.samhsa.gov/eval102/eval102_1_pg2.htm

23. 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. Needs Assessment 2. Capacity Building 3. Program Selection 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. 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. Needs Assessment 2. Capacity Building 3. Program Selection 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. 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. Needs Assessment 2. Capacity Building 3. Program Selection 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. 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. Needs Assessment 2. Capacity Building 3. Program Selection 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. 27 The Quadrants of Care Model of a Systems of Care Low MD MD. Low SUD SUD 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 Severity Substance 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. 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. 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. 30 Resources for Finding Promising Programs: Screeners and Other Measures related to adolescents: CSAT TIP 42- http://store.health.org/catalog/productDetails.aspx?ProductID=16979http://store.health.org/catalog/productDetails.aspx?ProductID=16979 NIAAA Handbook- pubs.niaaa.nih.gov/publications/Assesing%20Alcoholpubs.niaaa.nih.gov/publications/Assesing%20Alcohol Drug Strategies Handbook- www.drugstrategies.com/teenswww.drugstrategies.com/teens GAIN Coordinating Center- www.chestnut.org/li/gainwww.chestnut.org/li/gain Co-Occurring Center for Excellence- www.coce.samhsa.gov/cod_resources/cb_assessment.htmwww.coce.samhsa.gov/cod_resources/cb_assessment.htm Prevention Programs related to adolescents: Substance use- modelprograms.samhsa.gov/modelprograms.samhsa.gov/ Suicide- www.sprc.org/www.sprc.org/ Violence- www.sshs.samhsa.gov/www.sshs.samhsa.gov/ Co-Occurring Cen. for Excel.- http://www.coce.samhsa.gov/cod_resources/cb_prevention.htmhttp://www.coce.samhsa.gov/cod_resources/cb_prevention.htm Other materials- http://www.health.org/http://www.health.org/ Treatment Programs related to adolescents: Substance use disorder (SUD)- www.chestnut.org/li/apss/CSAT/protocolswww.chestnut.org/li/apss/CSAT/protocols Mental disorder (MD) & systems of care- http://www.mentalhealth.samhsa.gov/cmhs/ChildrensCampaign/practices.asp http://www.mentalhealth.samhsa.gov/cmhs/ChildrensCampaign/practices.asp Traumatic disorders and child maltreatment- www.nctsnet.orgwww.nctsnet.org Co-Occurring Cen. for Excel.- www.coce.samhsa.gov/cod_resources/cb_treatmentservice.htmwww.coce.samhsa.gov/cod_resources/cb_treatmentservice.htm