Transcript Insert Workshop Title

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 2702003-00006 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]
This presentation will examine..
1. national trends in residential treatment for
adolescents
2. how the clinical severity of adolescents varies by
level of care
3. how the source of referral, length of stay, type of
discharge, outcomes, and type of evidenced
based practice varies by level of care
4. observational and experimental evidence on the
impact of continuing care
5. the interaction of level of care and victimization
2
Trends in Adolescent (Age 12-17) Treatment
Admissions in the U.S.
Number of Admissions Age 12-17 .
180,000
160,000
140,000
10% drop
off from
2004 to
2005
120,000
100,000
50% increase from
95,017 in 1992
to 142,646 in 2005
80,000
60,000
40,000
20,000
0
1992
1994
1996
1998
2000
2002
2004
Year of Admission
Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
3
Trends in Adolescent (Age 12-17)
Level of Care Placement in the U.S.
180,000
160,000
• Average 17% residential
• Size increasing over time
• % decreasing over time
140,000
120,000
100,000
80,000
60,000
Detoxcification
Short Term Residential
Long Term Residential
40,000
20,000
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
-
Intensive Outpatient
Outpatient
Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
4
Variation by State in the Percentage of Adolescent
Residential Treatment: 1995 to 2005
New Hampshire
Washington
Montana
North
Dakota
Oregon
Vermont
Minnesota
South
Dakota
Idaho
Massachusetts
Wisconsin
New York
Nebraska
Pennsylvania
Iowa
Illinois
Utah
Colorado
California
Indiana
Ohio
Delaware
Virginia
Missouri
Kentucky
Tennessee
Oklahoma
New Mexico
Arkansas
Alabama
Texas
District Of Columbia
% Residential
Georgia
1.6 to 5.9%
Louisiana
Florida
Hawaii
Maryland
South Carolina
Mississippi
Alaska
Connecticut
New Jersey
W. Virginia
Kansas
North Carolina
Arizona
Rhode Island
Michigan
Wyoming
Nevada
Maine
6.0 to 10.5%
10.6 to 18.7%
18.8 to 29.9%
30.0 to 52.3%
Puerto Rico
Virgin Islands
10/07
5
Severity Goes up with Level of CareBaseline
STR: Higher
on
Dependence
100%
90%
80%
70%
Detox:
Detox:
Higher
Higher on
Use,
but
on
Use
lower on
prior tx
Severity Goes
up with Level
of Care
60%
50%
40%
30%
20%
10%
0%
Weekly use
at intake
First used
under age 15
Outpatient
Long-term Residential
Dependence
Prior
Treatment
Case Mix
Index (Avg)
Intensive Outpatient
Detoxification
Short-term Residential
Source: Treatment Episode Data Set (TEDS) 1993-2003.
6
Median Length of Stay is only 50 days
Level of Care
Median Length of Stay
Total
(61,153 discharges)
50 days
LTR
(5,476 discharges)
49 days
STR
(5,152 discharges)
21 days
Detox
(3,185 discharges)
3 days
IOP
(10,292 discharges)
Less than
25% stay the
90 days or
longer time
recommended
by NIDA
Researchers
46 days
Outpatient
(37,048 discharges)
59 days
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 .
7
53% Have Unfavorable Discharges
Despite being widely
recommended, only
10% step down after
intensive treatment
T otal
(61,153 discharges)
LTR
(5,476 discharges)
STR
(5,152 discharges)
D etox
(3,185 discharges)
IO P
(10,292 discharges)
O utpatient
(37,048 discharges)
0%
C om pleted
20%
T ransferred
40%
60%
A S A / D rop out
80%
100%
A D /T erm inated
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
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
9
Key Issues that we try to address with the
Global Appraisal of Individual Needs (GAIN)




High turnover workforce with variable education
background related to diagnosis, placement and
treatment planning.
Heterogeneous needs and severity characterized by
multiple problems, chronic relapse, and multiple
episodes of care
Lack of access to or use of data at the program
level to guide immediate clinical decisions, billing
and program planning
Missing or misrepresented data that needs to be
minimized and incorporated into interpretations
10
Issue
Instrument Feature
Protocol Feature
Outcome
High Turnover Workforce
with Variable Education
• 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
Improved Reliability and
Efficiency
Heterogeneous Needs
and Severity
• 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 evidencebased 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
GAIN Logic Model
11
Issue
Instrument Feature
Protocol Feature
Outcome
Lack of Access to or use of
Data at the Program Level
• 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
Improved Program Planning
and Outcomes
Missing or
Misrepresented Data
• 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
Improved Validity
GAIN Logic Model (continued)
12
GAIN Clinical Collaborators
Adolescent and Adult Treatment Program
New Hampshire
Washington
Montana
North
Dakota
Oregon
Vermont
Minnesota
South
Dakota
Idaho
Massachusetts
Wisconsin
New York
Michigan
Wyoming
Nebraska
Nevada
Pennsylvania
Iowa
Illinois Indiana
Ohio
Utah
Colorado
California
Maine
W. Virginia
Kansas
Delaware
Virginia
Missouri
Kentucky
North Carolina
Tennessee
Oklahoma
Arizona
New Mexico
Arkansas
Mississippi
Texas
Maryland
District Of Columbia
South Carolina
Number of GAIN Sites
Georgia
Alabama
0
1 to 10
11 to 25
Louisiana
Alaska
Florida
Hawaii
Rhode Island
Connecticut
New Jersey
26 to 130
GAIN State System
GAIN-SS State or
County System
Puerto Rico
Virgin Islands
10/07
13
TEDS vs. CSAT GAIN Data: Demographics
30
27
Female
TEDS (n=1,188,223)
18
16
African American
CSAT (n=15,254)
65
Caucasian
42
CSAT less
likely to be
Caucasian
11
Mixed/Other
32
16
Hispanic*
28
18
19
12 to 14 years old
82
79
15 to 17 years old
0
20
40
60
80
100
*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).
14
TEDS vs. CSAT GAIN Data: Level of Care
8%
Short Term
Residential
TEDS (n=1,804,151)*
3%
CSAT (n=12,824)**
CSAT more likely to be long
term residential
9%
Long Term
Residential
17%
CSAT breaks out Moderate
Term Residential (MTR; 30-90
days expected length of stay)
12%
Intensive
Outpatient
9%
68%
Outpatient
71%
0%
20%
40%
60%
80%
* 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).
15
100%
90%
80%
83%
Past Year Substance Diagnosis
50%
Any Past Year Dependence
29%
Any withdrawal symptoms in the past week
Severe withdrawal (11+ symptoms) in past week
70%
60%
50%
40%
30%
20%
10%
0%
Substance Use Problems
7%
94%
Can Give 1+ Reasons to Quit
Any prior substance abuse treatment
Acknowledges having an AOD problem
Client believes Need ANY Treatment
Source: CSAT 2007 AT Outcome Data Set (n=12,601)
34%
29%
26%
16
Past Year Substance Severity by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
72%
75%
LTR
MTR
86%
Use
Abuse
Dependence
57%
38%
10%
0%
Outpatient
IOP
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
STR
17
100%
90%
80%
70%
60%
64%
Sexually active
33%
Sex Under the Influence of AOD
29%
Multiple Sex partners
25%
Any Unprotected Sex
Victimized Physically, Sexually, or
Emotionally
Any Needle use
50%
40%
30%
20%
10%
0%
Past 90 day HIV Risk Behaviors
20%
2%
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
18
Sexual Partners by Level of Care
100%
90%
80%
70%
60%
No Sexual
Partners
50%
40%
30%
52%
20%
10%
27%
33%
39%
38%
LTR
MTR
Multiple
Sexual
Partners
0%
OP
IOP
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
One
Sexual
Partner
STR
19
100%
42%
Attention Deficit/Hyperactivity Disorder
35%
Major Depressive Disorder
24%
Traumatic Stress Disorder
14%
63%
Ever Physical, Sexual or Emotional Victimization
45%
High severity victimization (GVS>3)
31%
Ever Homeless or Runaway
22%
Any homicidal/suicidal thoughts past year
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
90%
50%
Conduct Disorder
Any Self Mutilation
80%
66%
Any Co-occurring Psychiatric
General Anxiety Disorder
70%
60%
50%
40%
30%
20%
10%
0%
Co-Occurring Psychiatric Problems
9%
20
Co-Occurring Psychiatric Diagnoses by Level of Care
100%
90%
80%
70%
60%
50%
40%
68%
30%
54%
10%
52%
42%
20%
None
One
29%
Multiple
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
21
Severity of Victimization by Level of Care
100%
90%
80%
70%
60%
50%
40%
64%
30%
20%
53%
59%
70%
Low
38%
Moderate
10%
High
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
22
68%
Physical Violence
63%
Any Illegal Activity
48%
Any Property Crimes
Any Interpersonal/ Violent Crime
45%
43%
85%
Lifetime Juvenile Justice Involvement
71%
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
100%
80%
Any violence or illegal activity
Other Drug Related Crimes*
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Past Year Violence & Crime
39%
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
23
Type of Crime by Level of Care
100%
90%
80%
70%
60%
50%
40%
20%
67%
64%
30%
54%
53%
Drug Use
only
Other
Crime
36%
10%
Violent
Crime
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
24
Multiple Problems* are the Norm
100%
90%
None
One
Most
acknowledge
1+ problems
80%
70%
60%
Two
Three
Four
50%
40%
30%
20%
Few present with just
one problem (the
focus of traditional
research)
In fact, 45%present
acknowledging 5+
major problems
Five to
Twelve
10%
0%
* (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)
25
Number of Problems by Level of Care
100%
90%
80%
70%
60%
50%
40%
67%
30%
50%
20%
78%
0 to 1
55%
2 to 4
39%
10%
5 or more
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
26
Adolescent Residential Treatment Sites
(N=1,997 adolescents from 30 sites)
NH
WA
MT
Eugene
Medford
VT
ND
OR
MN
ID
MA
SD
NV
MI
UT
IL
Ft. Collins
CO
KS
CA
San Diego
AZ
Phoenix
IA
Iowa City
NE
Washington Cnty.
NY
New York
WI
WY
Oakland
San Jose
Los Angeles
ME
Shiprock
OK
NM
MO
St Louis
TX
Fairbanks
Laredo
Dallas
Houston
DE
Baltimore
MD
ART
SCY
TCE-HIV
ATM
DC
YORP
TCE
AAFT
SC
MS
AK
NJ
WV VA
Louisville Richmond
KY
NC
TN
AR
Tucson
CT
OH
IN
AL
RI
PA
Philadelphia
GA
LA
FL
Orlando
Paia
HI
PR
VI
10/07
27
Sources of Referral by Level of Care
100%
90%
80%
70%
60%
Community
50%
Other
Sources
40%
30%
20%
34%
10%
Other
Treatment
25%
14%
Juvenile
Justice
0%
LTR
MTR
Source: CSAT 2007 AT Outcome Data Set (n=1689)
STR
28
Length of Stay by Level of Care
STR (Median= 30 days)
MTR (Median=60 days)
LTR (Median=145 days)
100%
90%
Percent Still in Treatment
80%
Length of Stay Varies
Both by level of care
and within level of care
70%
60%
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)
29
Type of Discharge by Level of Care
100%
90%
11%
23%
23%
80%
70%
22%
60%
Completed
50%
54%
75%
Transfer to
Treatment
40%
30%
20%
All levels
significantly
better than the
10% national
average
Juvenile
Justice
47%
10%
19%
AMA/ASA
11%
0%
LTR
MTR
Source: CSAT 2007 AT Outcome Data Set (n=1689)
STR
30
Abstinent
100%
80%
60%
40%
20%
0%
Selected Outcomes by Level of Care
Longer
lengths of
stay doing
better
Remission from SUD
Good Health
Crime Free
MTR doing better
No Family Problems
Mental Health
LTR
No Juv. Just. Invovlement
MTR
In Community
STR
Vocational Engaged
Source: CSAT 2007 AT Outcome Data Set (n=1,997)
Shorter lengths of
stay doing better
31
Types of Treatment by Level of Care
100%
90%
Other CBT
Other
Other 12-Step
80%
70%
60%
50%
Other CBT
Other TC
Other Ther.
Community
ACRA
Dynamic Youth
7 Challenges
Walking in Beauty
on the Red Road
La Cañada
Mountain Manor
40%
30%
Phoenix Academy
AR-Hazeldon
20%
10%
Thunder Road
Thunder Road
LTR (n=660)
MTR (n=1,094)
Thunder Road
0%
Source: CSAT 2007 AT Outcome Data Set (n=2677)
STR (n=243)
32
Percent in Past Month Recovery*
Recovery* by Level of Care:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
CC
better
OP &
Resid
Similar
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)
33
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
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)
35
Assertive Continuing Care (ACC)
Hypotheses
Assertive
Continuin
g Care
General
Continuin
g Care
Adherence
Early
Abstinence
Sustained
Abstinence
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.
36
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ACC Improved Adherence
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
UCC
ACC
* p<.05
37
GCCA Improved Early (0-3 mon.) Abstinence
100%
90%
80%
70%
60%
55%
50%
43%
36%
40%
30%
55%
38%
24%
20%
10%
0%
Any AOD (OR=2.16*)
Low (0-6/12) GCCA
Source: Godley et al 2002, forthcoming
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
38
Early (0-3 mon.) Abstinence Improved
Sustained (4-9 mon.) Abstinence
100%
90%
80%
73%
69%
70%
59%
60%
50%
40%
30%
20%
19%
22%
22%
10%
0%
Any AOD (OR=11.16*)
Alcohol (OR=5.47*)
Early(0-3 mon.) Relapse
Early (0-3 mon.) Abstainer
Source: Godley et al 2002, forthcoming
Marijuana (OR=11.15*)
* p<.05
39
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.
40
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 Programs
Substance 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


41