Advances in Identification and Treatment of Substance Abuse

1. Advances in Identification and Treatment of Substance Abuse Randolph Muck, M.Ed Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration Presentation for the The National Policy Academy On Improving Services For Youth With Mental Health And Co-Occurring Substance Use Disorders Involved With The Juvenile Justice System. September 13-15, 2005, Hyatt Regency Hotel, Bethesda, Maryland. Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and coordinated by the National Center for Mental Health and Juvenile Justice (NCMHJJ) in partnership with the National Association of State Mental Health Program Directors (NASMHPD) and the Council of Juvenile Correctional Administrators (CJCA). 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 using data provided by the CYT and AMT grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888). The opinions are those of the author and do not reflect official positions of the consortium or government. Available by contacting the presenter at Randy.Muck@samhsa.hhs.gov.

2. Goals for Presentation • To summarize some of the key trends in the adolescent substance abuse treatment field • To highlight the initial clinical characteristics of adolescent presenting for substance abuse treatment using the CSAT Adolescent Treatment Cooperative Data Set with 5,468 adolescents from 67 local evaluations • To highlight the current approach to screening we will be recommending to the new CSAT state adolescent coordinators this fall Note that Mike Dennis will expand on this presentation tomorrow and focus more on the move towards evidenced based treatment and outcomes

3. Substance Use Disorders primarily on-set during adolescences 100 Alcohol Use Tobacco Use 90 Binge Alcohol use 80 Any Illicit Drug Use 70 Marijuana Use 60 50 40 30 20 10 0 12 13 14 15 16 17 18 19 20 21 65 + 22-23 24-25 26-29 30-34 35-39 50-64 Age Source: Dennis (2002) and 1998 NHSDA

4. Juvenile Justice Is the Dominate Source of Referrals to Treatment JJ referrals have doubled and are driving growth Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf

5. Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN) The Current Renaissance of Adolescent Treatment Research • 1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adol. (DATOS-A) • 1995-1997 Drug Abuse Treatment Outcome Study (DOMS) • 1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments • 1998-2003 NIAAA/CSAT’s 15 individual research grants • 1998-2003 CSAT’s 10 Adolescent Treatment Models (ATM) • 2000-2003 CSAT’s Persistent Effects of Treatment Study (PETS-A) • 2002-2007 CSAT’s 12 Strengthening Communities for Youth (SCY) • 2002-2007 RWJF’s 10 Reclaiming Futures (RF) diversion projects • 2002-2007 CSAT’s 12+ Targeted Capacity Expansion TCE/HIV • 2003-2009 NIDA’s 14 individual research grants and CTN studies • 2003-2006 CSAT’s 17 Adolescent Residential Treatment (ART) • 2003-2008 NIDA’s Criminal Justice Drug Abuse Treatment Study (CJ-DATS) • 2003-2007 CSAT’s 38 Effective Adolescent Treatment (EAT) • 2004-2007 NIAAA/CSAT’s study of diffusion of innovation • 2004-2009 CSAT 22 Young Offender Re-entry Programs (YORP) • 2005-2008 CSAT 20 Juvenile Drug Court (JDC) • 2005-2008 CSAT 16 State Adolescent Coordinator (SAC) grants

6. Number of GAIN Sites Adolescent and Adult Treatment Program GAIN Clinical Collaborators 30 to 60 10 to 29 2 to 9 1 07/05 One or more state or county wide systems uses the GAIN One or more state or county wide systems considering using the GAIN

7. CSAT Adolescent Treatment Cooperative Data Set Recruitment: 1998-2004 Sample: The 2004 CSAT adolescent treatment data set included data on 5,468 adolescents from 67 local evaluations (and is growing exponentially in people, sites, and number of follow-ups) Levels of Care: Adolescent EI, OP, IOP, STR, LTR, CC Instrument: Global Appraisal of Individual Needs (GAIN) Follow-up: Over 85% follow-up 3, 6, & 9 months post discharge Funding: CSAT contract 270-2003-00006 and multiple individual grants

8. Demographic Characteristics 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 26% Female 6% Am. Native Asian 1% African Am. 17% White 45% 15% Hispanic 16% Mixed/Other Under 14 17% 15-17 76% 18 to 25 7% Source: CSAT AT Common GAIN Data set

9. Other Characteristics 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Single Parent 50% Homeless or 39% Runaway Employed 34% In School 86% Recently in a Controlled Environment 45% Juvenile Justice Involvement 75% Source: CSAT AT Common GAIN Data set

10. 17% Past year illegal activity/SA use 8% Past arrest/JJ status Intensity of Juvenile Justice System Involvement 17% In detention/jail 14+ days 25% On probation or parole 14+ days w/ 1+ drug screens 16% Other JJ status 17% Other probation/parole/detention Source: CSAT AT Common GAIN Data set

11. Weekly/Daily Substance Use Pattern 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 65% Any AOD Use 52% Marijuana 20% Alcohol In our data and in TEDS, 1 in 5 did not use in the month before intake – hence the use of 90 day window and measures of pre-CE use 5% Cocaine/Crack 3% Heroin/Opioids 8% Other Drugs 14 or more days in Controlled Environment 30% Source: CSAT AT Common GAIN Data set

12. Severity of Substance Use Disorders 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Self reported abuse/ dependence 88% First use under 15 86% Weekly or more AOD use 65% Past Year Dependence 58% Prior Substance Abuse Tx 43% Past week withdrawal 34% Past week severe withdrawal 12% First use under 10 11% Source: CSAT AT Common GAIN Data set

13. Mixed Problem Recognition 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Acknowledges AOD problem 35% Believes treatment needed 81% Self reports 1+ abuse/dependence 92% Problem criteria Gives one or more 99% reasons to quit Source: CSAT AT Common GAIN Data set

14. High Risk Recovery Environments 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% In home 29% among work/ school peers 52% Regular alcohol use among social peers 61% 17% In home among work/ school peers 67% Regular drug use among social peers 79% Source: CSAT AT Common GAIN Data set

15. High Rates of Other Psychiatric Problems 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Any Internal Disorder 49% Depressive Disorder 38% Anxiety Disorder 21% 28% Trauma Related Disorder 32% Any Self Mutilation Any homicidal/ suicidal thoughts 28% 67% Any External Disorder Conduct Disorder 59% With External Disorders more prominent in Adolescents Attention Deficit-Hyperactivity Disorder (ADHD) 48% Source: CSAT AT Common GAIN Data set

16. High Rates of HIV/STI risk behaviors 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 81% Sexual Activity Victimization 57% Lifetime 16% Needle Use Sexual Activity 61% Sex Under AOD Influence 51% Multiple Sex Partners 35% Past 90 Days Unprotected Sex 29% Victimization 23% Needle Use 4% Source: CSAT AT Common GAIN Data set

17. High rate of crime and violence 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Past Year Any violence or 86% illegal activity Physical Violence 72% Property Crimes 58% 57% Drug Related Crime Interpersonal/violent 51% Crimes Source: CSAT AT Common GAIN Data set

18. Development of the GAIN Short Screener (GSS) Recruitment: 1996-2005 Sample: The adult clinical norms are based on 1805 adults from 40 sites.   The adolescent clinical norms are based on 6204 adolescents from 70 sites. Levels of Care: Adult OP, IOP, OMT, HH, STR, LTR, TASC, Detox; Adolescent EI, OP, IOP, STR, LTR, CC Instrument: Global Appraisal of Individual Needs (GAIN) Follow-up: Over 85% follow-up 3, 6, & 9 months post discharge Funding: CSAT contract 270-2003-00006 and multiple individual grants

19. Statistical Structure of the GAIN’s Psychopathology Scales

20. Characteristics of the Clinical Samples

21. Screeners are evaluated in terms of • Sensitivity - percent of people with actual diagnoses correctly identified at this score or higher. • Specificity - percent of people with no diagnosis correctly excluded at this score or higher. • Efficiency – The combined ability of the tool to rapidly (2-3 minutes) identify who will end up with a diagnosis after a full 1-2 hour interview and rule out those who do not.

22. Clinical Validation Of the Gain-Short Screener By Age

23. Specificity should be over 90% at 3+ Sensitivity should be over 90% at 1+ Substance Disorder Scale: Adults

24. Substance Disorder Scale: Adolescent

25. Internal Disorder Scale: Adults

26. Internal Disorder Scale: Adolescent

27. External Disorder Scale: Adults

28. External Disorder Scale: Adolescent

29. Violence/Crime Scale: Adult

30. Violence/Crime Scale: Adolescent

31. Conclusions/Next steps… • Multiple co occurring substance, mental health and crime/violence problem are the norm in adolescents presenting for substance abuse treatment. • The GAIN-Short Screener should provide an efficient tool to help systems identify who needs a full assessment and track them into the necessary services systems. • By being short and comprehensive, it can be used across multiple systems of care and provide a denominator for evaluating coverage/referral patterns • Tomorrow Mike Dennis will present part 2 of this presentation, looking more at outcomes and evidenced based practice.