Adolescent substance abuse system building and SAMHSA 5 Step Planning Process

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 [phone], e-Mail
  junsicker_at_Chestnut.Org

2
Goals of This Presentation

• To examine the prevalence, course, and
  consequences of adolescent substance use and
  co-occurring disorders and the unmet need for
  treatment
• To summarize major trends in the adolescent
  substance use disorder (SUD) treatment system,
  client needs and outcomes
• To highlight SAMHSAs 5 step process for program
  planning and evaluation

3
Substance Use Severity Is Related to Age
Increasing rate of non-users
100
Severity Category
90
No Alcohol or Drug Use
80
70
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
Dependence
0
(2002 U.S. Household Population age 12, n
235,143,246)
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Age
Source 2002 NSDUH and Dennis Scott in press
4
Age of First Use Predicts Dependence an Average
of 22 years Later
100
Under Age 15
90
Aged 15-17
80
Aged 18 or older
71
70
63
62
60
51
48
with 1 Past Year Symptoms
50
45
41
39
37
40
34
30
30
23
20
10
0
Alcohol
Marijuana
Other Drugs
Tobacco
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
Tobacco, OR1.3,
Alcohol, OR1.9,
Marijuana, OR1.5,
Other, OR1.5,
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
OR1.49
OR2.74
OR2.45
OR2.65
Source Dennis, Babor, Roebuck Donaldson
(2002) and 1998 NHSDA
plt.05
5
Substance Use Careers Last for Decades
1.0
Median of 27 years from first use to 1 years
abstinence
.9
Cumulative Survival
.8
.7
Years from first use to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
30
25
20
15
10
5
0
Source Dennis et al., 2005
6
Substance Use Careers are Longer the Younger the
Age of First Use
Age of 1st Use Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
.6
.5
under 15
.4
15-20
.3
.2
21
.1
0.0
plt.05 (different from 21)
30
25
20
15
10
5
0
Source Dennis et al., 2005
7
Substance Use Careers are Shorter the Sooner
People Get to Treatment
Year to 1st Tx Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
20
.6
.5
.4
.3
10-19
.2
.1
0.0
0-9
plt.05 (different from 20)
30
25
20
15
10
5
0
Source Dennis et al., 2005
8
Treatment Careers Last for Years
1.0
.9
Cumulative Survival
.8
Median of 3 to 4 episodes of treatment over 9
years
.7
Years from first Tx to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
25
20
15
10
5
0
Source Dennis et al., 2005
9
The Growing Incidence of Adolescent Marijuana
Use 1965-2002
Source OAS (2004). Results from the 2003
National Survey on Drug Use and Health National
Findings. Rockville, MD SAMHSA.
http//oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.p
df
10
Importance of Perceived Risk
Risk Availability
Marijuana Use
Source Office of Applied Studies. (2000). 1998
NHSDA
11
Actual Marijuana Risk

• From 1980 to 1997 the potency of marijuana in
  federal drug seizures increased three fold.
• The combination of alcohol and marijuana has
  become very common and appears to be synergistic
  and leads to much higher rates of problems than
  would be expected from either alone.
• Combined marijuana and alcohol users are 4 to 47
  times more likely than non-users to have a wide
  range of dependence, behavioral, school, health
  and legal problems.
• Marijuana and alcohol are the leading substances
  mentioned in arrests, emergency room admissions,
  autopsies, and treatment admissions.
• Marijuana is specifically associated with
  progression of schizophrenia and other severe
  mental illnesses

12
Substance Use in the Community
Source Dennis and McGeary (1999) and 1997 NHSDA
13
Consequences of Substance Use
Source Dennis, Godley and Titus (1999) and 1997
NHSDA
14
Need for Treatment ( of 24,753,586 Adolescents
in the U.S. Household Population)
10
15
20
25
0
5
14.9
Tobacco
17.8
Alcohol
10.7
Alcohol Binge
?--------Past Month Use------?
11.5
Any Drug Use
8.1
Marijuana Use
5.7
Any Non-Marijuana Drug Use
8.9
Past Year AOD Dependence or Abuse
Less than 1 in 10 getting treatment
0.7
Any Treatment (From NHSDA)
88 of adolescents are treated in the public
system
0.6
Public Treatment (From TEDS)
Source NSDUH and TEDS (see state level
estimates in appendix)
15
Adolescent AOD Dependence/Abuse
Up 27 from 7 in 1995
Prevalence 6.0 to 8.4 8.5 to 9.0 9.1 to
9.9 10.0 to 14.6 U.S.Avg.8.9 UT7.0
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf ) and Kilpatrick et al, 2000.
16
Unmet Treatment Need Adolescent ( of AOD
Dependence/Abuse without any private/public
treatment)
9 in 10 Untreated
Prevalence 82.4 to 90.1 90.2 to 92.3 92.4 to
94.2 94.3 to 98.0 U.S.Avg.92.2 UT89.8
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf )
17
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.samhs
a.gov/oas/dasis.htm
18
Change in Public Sector Admissions
((2003-1993)/1993)
Both Cause Consequence
Change Not available -96 to -7 -8 to 33 34 to
116 117 to 337 U.S.Avg.61 UT25
Source Wright, D., Sathe, N. (2005). State
Estimates of Substance Use from the 20022003
National Surveys on Drug Use and Health (DHHS
Publication No. SMA 05-3989, NSDUH Series H-26).
Rockville, MD Substance Abuse and Mental Health
Services Administration, Office of Applied
Studies (retrieved from http//oas.samhsa.gov/2k3
State/2k3SAE.pdf )
19
Presenting Substances UT vs. US
Cocaine similar 20 or higher in DE TX
Methamphetamine higher 20 or higher in AZ,
CA,ID,MN,NV,WA
Opiates similar 20 or higher in MA NM
Other Amp.similar 20 or higher in OR
Source Primary, Secondary or Tertiary, from
Treatment Episode Data Set (TEDS) 1993-2003.
20
Referral Sources UT vs. US
Higher Rate of Juvenile Justice Referrals
Lower Rate of Self/Parent Referrals
Lower Rate of School Referrals
Source Treatment Episode Data Set (TEDS)
1993-2003.
21
Level of Care UT vs. US
100
90
UT
U.S.
80
70
60
50
40
30
20
10
0
Detox
Outpatient
Intensive
Outpatient
Long-term
Residential
Short-term
Residential
Source Treatment Episode Data Set (TEDS)
1993-2003.
22
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.
23
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/teds02/2
002_teds_rpt_d.pdf .
24
53 Have Unfavorable Discharges
Despite being widely recommended, only 10 step
down after intensive treatment
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/teds02/2
002_teds_rpt_d.pdf .
25
The Current Renaissance of Adolescent Substance
Use Disorder Treatment Research
Published and publicly available
26
CSAT Adolescent Treatment (AT)Outcome Data Set

• Recruitment 1998-2005 (updated annually)
• Sample The 2005 CSAT adolescent treatment data
  set included data with 1 to 4 follow-ups on 9,276
  unique adolescents from 72 local evaluations
• Levels of Care Early Intervention, Outpatient,
  Intensive Outpatient, Short, Moderate Long term
  Residential, Corrections Based and Post
  Residential Outpatient Continuing Care
• Instrument Global Appraisal of Individual Needs
  (GAIN) (see www.chestnut.org/li/gain)
• Follow-up Over 80 follow-up 3, 6, 9 12 months
  post intake
• Funding CSAT contract 270-2003-00006 and 72
  individual grants

27
Geographic Location of Sites
NH
WA
VT
ME
MT
ND
MN
OR
MA
NY
ID
WI
SD
MI
WY
RI
IA
PA
CT
NE
OH
NJ
NV
DC
IN
UT
IL
CA
CO
WV
VA
DE
DC
KS
MO
KY
MD
NC
TN
AR
AZ
OK
NM
SC
GA
AL
MS
Program
ART
TX
LA
EAT
AK
SCY
FL
TCE
YORP
HI
PR
28
Demographics
29
Clinical Severity
30
Primary, Secondary or Tertiary SUD Problems
31
Level of Care
32
Recovery Environment
Source CSAT AT Outcome Data Set (n9,276
adolescents)
33
Past 90 day HIV Risk Behaviors
Source CSAT AT Outcome Data Set (n9,276
adolescents)
34
Weekly or More Often Use in the Past 90 Days
Source CSAT AT Outcome Data Set (n9,276
adolescents)
35
Substance Use Problems
Source CSAT AT Outcome Data Set (n9,276
adolescents)
36
Co-Occurring Psychiatric Problems
Source CSAT AT Outcome Data Set (n9,276
adolescents)
37
Multiple Co-occurring Problems Were the Norm and
Increased with Level of Care
100
88
80
78
80
70
68
65
56
60
52
52
47
44
44
43
35
36
40
25
21
21
20
0
Conduct
ADHD
Major
Generalized
Traumatic
Any Co-
Disorder
Depressive
Anxiety
Stress
Occurring
Disorder
Disorder
Disorder
Disorder
Outpatient
Long Term Residential
Short Term Residential
Source CSATs Cannabis Youth Treatment (CYT) and
Adolescent Treatment Model (ATM),
38
Past Year Violence Crime
Dealing, manufacturing, prostitution, gambling
(does not include simple possession or
use) Source CSAT AT Outcome Data Set (n9,276
adolescents)
39
Intensity of Juvenile Justice System Involvement
17 In detention/jail 14 days
Highest severity for Long Term Residential
(followed by STR, IOP, OP)
25 On probation or parole 14 days
w/ 1 drug screens
16 Other JJ status
17 Other probation/parole/detention
Source CSAT 2004 AT Common GAIN Data set (n
5,468 adolescents from 67 local evaluations)
40
Multiple Problems are the Norm
100
In fact, over half present acknowledging 5
major problems
90
80
Five to Twelve
70
60
50
40
Four
30
Few present with just one problem (the focus of
traditional research)
Three
Most acknowledge 1 problems
20
Two
10
One
None
0
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT Common GAIN Data set
41
No. of Problems by Severity of Victimization
100
Those with high lifetime levels of victimization
have 117 times higher odds of having 5 major
problems
90
80
70
60
50
Five or More
Four
40
Three
30
Two
20
One
None
10
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD,
CD, victimization, violence/ illegal activity)
0
Low (31)
Moderate (17)
High (51)
GAIN General Victimization Scale Score (Row )
Source CSAT AT Common GAIN Data set (odds for
High over odds for Low)
42
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)
43
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)
44
Change in Emotional Problem Indexby Level of
Care\a
Note the lack of a hinge Effect is generally
indirect (via reduced use) not specific
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
45
Change in Illegal Activity Indexby Level of
Care\a
Residential Treatments have a specific effect
Outpatient Treatments has an indirect effect
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
46
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
5. Evaluation
2. Capacity Building
4. Implementation
3. Program Selection
Source SAMHSA/CSAP Pathways Course Evaluation
101 http//pathwayscourses.samhsa.gov/eval102/eval
102_1_pg2.htm
47
Example of a Simple Theory / Logic Model for
Early Re-Intervention (ERI) Experiment
Relapse is Common but hard to predict
Monitoring and Early Re-Intervention
Sustained Recovery In Long Term
1. Follow-up Quarterly
Source ERI experiments (Dennis, Scott, Funk
2003 Scott, Dennis, Funk, 2005 Scott
Dennis, forthcoming)
48
The SAMHSA 5 Step Program Planning and Evaluation
Process

• 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
5. Evaluation
2. Capacity Building
4. Implementation
3. Program Selection
Source SAMHSA/CSAP Pathways Course Evaluation
101 http//pathwayscourses.samhsa.gov/eval102/eval
102_1_pg2.htm
49
Common starting places

• Standardize assessment and identify most common
  problems
• Senior staff do a walk through intake and
  treatment
• Pool knowledge about what staff have done in the
  past, whether it worked, and what the barriers
  were
• Identify system barriers (e.g., criteria to local
  access case management, mental health) that could
  be avoided if thought of in advance
• Identify existing materials that could help and
  make sure they are readily available on site
• Identify promising strategies for working with
  the adolescent, parents, or other providers
• Develop a 1-2 page checklist of things to do when
  this problem comes up
• Identify a more detailed protocol and trainer to
  address the problem, then go for a grant to
  support implementation

50
The SAMHSA 5 Step Program Planning and Evaluation
Process

• 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
5. Evaluation
2. Capacity Building
4. Implementation
3. Program Selection
Source SAMHSA/CSAP Pathways Course Evaluation
101 http//pathwayscourses.samhsa.gov/eval102/eval
102_1_pg2.htm
51
Resources for Finding Promising Programs

• Screeners and Other Measures related to
  adolescents
• CSAT TIP 42- http//store.health.org/catalog/produ
  ctDetails.aspx?ProductID16979
• NIAAA Handbook- pubs.niaaa.nih.gov/publications/As
  sesing20Alcohol
• Drug Strategies Handbook- www.drugstrategies.com/t
  eens
• GAIN Coordinating Center- www.chestnut.org/li/gai
  n
• Co-Occurring Center for Excellence-
  www.coce.samhsa.gov/cod_resources/cb_assessment.ht
  m
• 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.samh
  sa.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/ChildrensC
  ampaign/practices.asp
• Traumatic disorders and child maltreatment-
  www.nctsnet.org
• Co-Occurring Cen. for Excel.- www.coce.samhsa.gov/
  cod_resources/cb_treatmentservice.htm

52
Implementation is Essential (Reduction in
Recidivism from .50 Control Group Rate)
Thus one should optimally pick the strongest
intervention that one can implement well
Source Adapted from Lipsey, 1997, 2005 meta
analysis of 509 juvenile justice programs
53
The SAMHSA 5 Step Program Planning and Evaluation
Process

• 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
5. Evaluation
2. Capacity Building
4. Implementation
3. Program Selection
Source SAMHSA/CSAP Pathways Course Evaluation
101 http//pathwayscourses.samhsa.gov/eval102/eval
102_1_pg2.htm
54
Improving Adherence to Recovery Management
Checkup (RMC)
100
80
60
40
20
0
(96 avg)
Follow-up
Needed Tx
(45 avg)
Agreed to Tx
(48 avg)
(99 avg)
Assessment
(60 avg)
Stayed in Tx
14 days
Showed to Tx
Assessment
(42 avg)
(35 avg)
Showed to Tx
Attended RMC
ERI 1
Max
Avg
Min
Source ERI experiments (Dennis, Scott, Funk
2003 Scott, Dennis, Funk, 2005 Scott
Dennis, forthcoming)
55
The SAMHSA 5 Step Program Planning and Evaluation
Process

• 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
5. Evaluation
2. Capacity Building
4. Implementation
3. Program Selection
Source SAMHSA/CSAP Pathways Course Evaluation
101 http//pathwayscourses.samhsa.gov/eval102/eval
102_1_pg2.htm
56
Common Local Evaluation Questions

• Who is being served?
• who are we missing?
• How are we welcoming, accomodating and/or
  building on their strengths?
• What services are being provided?
• to what extent are services being targeted toward
  the most needy or appropriate?
• to what extent are the services being implemented
  / delivered?
• Which of several different approaches to
  providing services are working the best?
• for which subgroups, for which outcomes?
• Are there a range of approaches that work
  similarly?
• What do the approaches costs?
• Is a given service more cost-effective in terms
  of the core outcome?
• Is a given service more cost-beneficial across
  multiple outcomes?

57
What is needed to shift from program level to
systems of care level evaluations?

• Building a coalition of families community
  leaders, staff, systems and funders who
• Have common clients, interest and can find common
  cause
• Can align their vision, missions resources to
  do more than they can if working apart
• Introducing reliable and valid assessment/records
  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

58
The Quadrants of Care Model of a Systems of Care
II. Severe Mental Disorder (MD) and No/Low
Severity Substance Use Disorders (SUD)
II. Severe MD / Low SUD Treated in mental
health treatment system
Low SUD SUD
III. Low MD / Severe SUD Treated in substance
abuse treatment system
IV. Severe Mental Disorder (MD) and Severe
Substance Use Disorders (SUD)
III. No/Low Severe Mental Disorder (MD) and
Severe Substance Use Disorders (SUD)
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
Source NASMHPD and NASADAD (1999) and CSAT
(2005) Tip 32
Low MD MD .
59
Actual Services Needed
The Problem is that if we go by actual diagnosis,
the vast majority of the patients are actually in
the fourth quadrant
IV. Severe MD / Low SUD
I. Low MD / Low SUD
IV. Severe MD / Severe SUD
III. Low MD / Severe SUD
Low SUD SUD
Moreover youth in all four groups show up in all
systems of care
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
Low MD MD
60
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.