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Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL

Understanding the Role of Residential Addiction Treatment for Adolescent: An Overview of Characteristics, Services and Outcomes. Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL

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Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL

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  1. Understanding the Role of Residential Addiction Treatment for Adolescent: An Overview of Characteristics, Services and Outcomes Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL January 10th, 2008 presentation at the Symposium on Adolescent Residential Alcohol and Drug Treatment, Cromwell, CT. This presentation reports 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. This presentation will examine.. • national trends in residential treatment for adolescents • how the clinical severity of adolescents varies by level of care • how the source of referral, length of stay, type of discharge, outcomes, and type of evidenced based practice varies by level of care • observational and experimental evidence on the impact of continuing care • the interaction of level of care and victimization

  3. 10% drop off from 2004 to 2005 50% increase from 95,017 in 1992 to 142,646 in 2005 Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S. Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

  4. Average 17% residential • Size increasing over time • % decreasing over time Trends in Adolescent (Age 12-17) Level of Care Placement in the U.S. Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

  5. Variation by State in the Percentage of Adolescent Residential Treatment: 1995 to 2005 New Hampshire Washington Vermont North Maine Montana Dakota Minnesota Oregon Massachusetts South Wisconsin Idaho Dakota New York Rhode Island Michigan Wyoming Pennsylvania Iowa Connecticut Nebraska Ohio Nevada New Jersey Indiana Illinois Utah W. Virginia Delaware Colorado California Kansas Virginia Missouri Kentucky Maryland North Carolina Tennessee District Of Columbia Oklahoma New Mexico Arkansas Arizona South Carolina % Residential Mississippi Georgia 1.6 to 5.9% Alabama 6.0 to 10.5% Texas Louisiana 10.6 to 18.7% Alaska Florida 18.8 to 29.9% 30.0 to 52.3% Hawaii Virgin Islands Puerto Rico 10/07

  6. 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.

  7. 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 .

  8. 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 .

  9. So what does it mean to move the field towards Evidence Based Practice (EBP)? • Introducing reliable and valid assessment that can be used • At the individual level to immediately guide clinical judgments about diagnosis/severity, placement, treatment planning, and the response to treatment • At the program level to drive program evaluation, needs assessment, and long term program planning • Introducing explicit intervention protocols that are • Targeted at specific problems/subgroups and outcomes • Having explicit quality assurance procedures to cause adherence at the individual level and implementation at the program level • Having the ability to evaluate performance and outcomes • For the same program over time, • Relative to other interventions

  10. Key Issues that we try to address with the Global Appraisal of Individual Needs (GAIN) • High turnover workforce with variable educationbackground related to diagnosis, placement and treatment planning. • Heterogeneous needs and severitycharacterized by multiple problems, chronic relapse, and multiple episodes of care • Lack of access to or use of data at the program levelto guide immediate clinical decisions, billing and program planning • Missing or misrepresented datathat needs to be minimized and incorporated into interpretations

  11. GAIN Logic Model Issue Instrument Feature Protocol Feature Outcome • Standardized approach to asking questions across domains • Questions spelled out and simple question format • Lay wording mapped onto expert standards for given area • Built in transition statements, prompts, and checks for inconsistent and missing information. • Responses to frequently asked questions • Multiple training resources • Formal training and certification protocols on administration, clinical interpretation, data management, project coordination, local, regional, and national “trainers” • Above focuses on consistency across populations, level of care, staff and time • On-going quality assurance and data monitoring for the reoccurrence or problems at the staff (site or item) level • Availability of technical assistance High Turnover Workforce with Variable Education Improved Reliability and Efficiency • Multiple domains • Focus on most common problems • Participant self description of characteristics, problems, needs, personal strengths and resources • Behavior recency, breadth, frequency • Utilization lifetime, recency and frequency • Dimensional measures • Interpretative cut points • Items and cut points mapped onto DSM for diagnosis, ASAM for placement, and to multiple standards and evidence- based practices for treatment planning • Computer generated scoring and reports • Treatment planning recommendations and links to evidence-based practice • Basic and advanced clinical interpretation training and certification Comprehensive Assessment Heterogeneous Needs and Severity

  12. GAIN Logic Model (continued) Issue Instrument Feature Protocol Feature Outcome • Data immediately available to support clinical decision making for a case • Data can be transferred to other clinical information system to support billing, progress reports, treatment planning and on-going monitoring • Data can be exported and cleaned to support further analyses • Data can be pooled with other sites to facilitate comparison and evaluation • PC and (soon) web based software applications and support • Formal training and certification on using data at the individual level and data management at the program level • Data routine pooled to support comparisons across programs and secondary analysis • Over two dozen scientists working with data to link to evidence-based practice Lack of Access to or use of Data at the Program Level Improved Program Planning and Outcomes • Assurances, time anchoring, definitions, transition, and question order to reduce confusion and increase valid responses • Cognitive impairment check • Validity checks on missing, bad, inconsistency and unlikely responses • Validity checks for atypical and overly random symptom presentations • Validity ratings by staff • Training on optimizing clinical rapport • Training on time anchoring • Training answering questions, resolving vague or inconsistent responses, following assessment protocol and accurate documentation. • Utilization and documentation of other sources of information • Post hoc checks for on-going site, staff or item problems Missing or Misrepresented Data Improved Validity

  13. GAIN Clinical Collaborators Adolescent and Adult Treatment Program New Hampshire Washington Vermont North Maine Montana Dakota Minnesota Oregon Massachusetts South Wisconsin Idaho Dakota New York Michigan Wyoming Rhode Island Pennsylvania Iowa Connecticut Nebraska Ohio Nevada New Jersey Illinois Indiana Utah W. Virginia Delaware Colorado California Kansas Virginia Missouri Kentucky Maryland North Carolina Tennessee District Of Columbia Oklahoma New Mexico Arkansas Arizona South Carolina Number of GAIN Sites Mississippi Georgia 0 Alabama 1 to 10 Texas 11 to 25 Louisiana 26 to 130 Alaska GAIN State System Florida GAIN-SS State or County System Hawaii Virgin Islands Puerto Rico 10/07

  14. TEDS vs. CSAT GAIN Data: Demographics CSAT less likely to be Caucasian *Any Hispanic ethnicity separate from race group. Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age 12-17. and CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).

  15. TEDS vs. CSAT GAIN Data: Level of Care CSAT more likely to be long term residential CSAT breaks out Moderate Term Residential (MTR; 30-90 days expected length of stay) * Excluding Detoxification ** Excluding Early Intervention, Corrections and Continuing Care Sources: TEDS 1992 to 2005 Concatenated file subsetted to 1998 to 2005, age 12-17. and CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).

  16. Substance Use Problems Source: CSAT 2007 AT Outcome Data Set (n=12,601)

  17. Past Year Substance Severity by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

  18. Past 90 day HIV Risk Behaviors Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

  19. Sexual Partners by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

  20. Co-Occurring Psychiatric Problems Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

  21. Co-Occurring Psychiatric Diagnoses by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

  22. Severity of Victimization by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

  23. Past Year Violence & Crime *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

  24. Type of Crime by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

  25. Multiple Problems* are the Norm Few present with just one problem (the focus of traditional research) Most acknowledge 1+ problems In fact, 45%present acknowledging 5+ major problems * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

  26. Number of Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

  27. Adolescent Residential Treatment Sites (N=1,997 adolescents from 30 sites) NH WA VT ME MT ND Eugene OR MN MA Medford ID NY SD WI New York RI WY MI PA IA CT Philadelphia NV NE Iowa City Oakland UT OH NJ IN IL San Jose Ft. Collins VA Los Angeles WV Washington Cnty. MO DE CO KS Louisville Richmond CA St Louis KY Baltimore MD NC Shiprock AZ San Diego TN OK ART AR Phoenix SCY SC NM TCE-HIV AL GA Tucson ATM MS DC Dallas TX LA YORP Houston AK FL TCE AAFT Fairbanks Laredo Orlando Paia PR HI VI 10/07

  28. Sources of Referral by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=1689)

  29. Length of Stay by Level of Care STR (Median= 30 days) 100% MTR (Median=60 days) 90% LTR (Median=145 days) 80% Length of Stay Varies Both by level of care and within level of care 70% 60% Percent Still in Treatment 50% All better than the National average 40% 30% 20% 10% 0% 0 30 60 90 120 150 180 210 240 270 300 330 360 Length of Stay (Days) Source: CSAT AT 2007 dataset subset to adolescent studies (N=1,997)

  30. Type of Discharge by Level of Care All levels significantly better than the 10% national average Source: CSAT 2007 AT Outcome Data Set (n=1689)

  31. Longer lengths of stay doing better MTR doing better Shorter lengths of stay doing better Selected Outcomes by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=1,997)

  32. Types of Treatment by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=2677)

  33. Recovery* by Level of Care: 100% Outpatient (+79%, -1%) 90% Residential(+143%, +17%) 80% Post Corr/Res (+220%, +18%) 70% CC better 60% Percent in Past Month Recovery* 50% OP & Resid Similar 40% 30% 20% 10% 0% Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12 * 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 2006 Adolescent Treatment Outcome Data Set (n-9,276)

  34. Findings from the Assertive Continuing Care (ACC) Experiment 183 adolescents admitted to residential substance abuse treatment Treated for 30-90 days inpatient, then discharged to outpatient treatment Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC) Over 90% follow-up 3, 6, & 9 months post discharge Source: Godley et al 2002, forth coming

  35. ACC Enhancements • Continue to participate in UCC • Home Visits • Sessions for adolescent, parents, and together • Sessions based on ACRA manual (Godley, Meyers et al., 2001) • Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., job finding, medication evaluation)

  36. Sustained Abstinence Early Abstinence General Continuing Care Adherence Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA) GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence Early abstinence will be associated with higher rates of long term abstinence. Assertive Continuing Care (ACC)Hypotheses Assertive Continuing Care

  37. UCC ACC * p<.05 ACC Improved Adherence 100% 20% 30% 10% 40% 50% 60% 70% 80% 90% 0% Weekly Tx Weekly 12 step meetings Relapse prevention* Communication skills training* Problem solving component* Regular urine tests Meet with parents 1-2x month* Weekly telephone contact* Contact w/probation/school Referrals to other services* Follow up on referrals* Discuss probation/school compliance* Adherence: Meets 7/12 criteria* Source: Godley et al 2002, forthcoming

  38. 55% 55% 43% High (7-12/12) GCCA * p<.05 GCCA Improved Early (0-3 mon.) Abstinence 100% 90% 80% 70% 60% 50% 38% 36% 40% 30% 24% 20% 10% 0% Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA Source: Godley et al 2002, forthcoming

  39. 73% 69% 59% Early (0-3 mon.) Abstainer * p<.05 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence 100% 90% 80% 70% 60% 50% 40% 30% 22% 22% 19% 20% 10% 0% Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse Source: Godley et al 2002, forthcoming

  40. Some Concluding Thoughts… • Residential Treatment continues to play a critical role by targeting higher severity clients • Evidenced based practices are not panacea, but they pull up the bottom and improve average outcomes • Implementing continuing care improves average outcomes • More work is need on the use of schools and recovery schools as a location for continuing care after residential treatment.

  41. Other Assessment and Treatment Resources • Assessment Instruments • GAIN Coordinating Center at www.chestnut.org/li/gain • CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html • NIAAA Assessment Handbook at http://www.niaaa.nih.gov/publications/instable.htm • Treatment Programs • CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols and on CDs provided • SAMHSA Knowledge Application Program (KAP) at http://kap.samhsa.gov/products/manuals • NCADI at www.health.org • National Registry of Effective Prevention ProgramsSubstance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov • Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate • Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/jmate/ • next meeting March 30-April 2, 2008, Washington, DC

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