Using administrative data to assess the process of treatment services for adolescents with substance use disorders

In 1998, the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) convened an expert panel comprised of a multidisciplinary group of providers, researchers, managed care representatives and public policymakers known as the Washington Circle (WC) to improve the quality and effectiveness of treatment for substance use disorders through the use of performance measures. The initial goals of the panel included developing, testing and implementing performance measures in health plans and encouraging collaboration with key stakeholders to ensure widespread adoption of the measures. The WC focused its initial efforts on the prevention, recognition and treatment of adults with alcohol and other drug (AOD) disorders who receive health care through private and/or public sector health plans (McCorry et al. 2000). In 2002, CSAT, aware of the need to improve access and quality of treatment for adolescents, supported the Washington Circle in the establishment of a special subcommittee focused specifically on adolescent treatment issues. This article introduces the work of the Washington Circle and describes the Adolescent Subcommittee's progress in developing performance measures for the treatment of adolescents with substance use disorders.     

Feasibility and outcomes of an innovative cognitive-behavioural skill training programme for co-occurring disorders in the youth alcohol and other drug (AOD) sector

There are limited treatment options available for young drug users with comorbid mental health problems who present to alcohol and other drug (AOD) services within Australia. While there is some evidence for the use of cognitive-behaviour therapy (CBT) in the treatment of co-occurring disorders, CBT is rarely used to address comorbidity in the AOD sector. This paper describes the development, implementation and evaluation of a brief cognitive-behavioural skills (BCBS) training programme for addressing comorbidity within two youth AOD services in Australia. Ten youth AOD workers completed a 2-day training programme in the BCBS. Training was evaluated using measures of trainees' cognitive-behavioural knowledge, attitudes towards mental health interventions and level of skills and confidence in each of the BCBS pre- and 6 months post-training. The BCBS training had a positive impact on the knowledge, skills and confidence of trainees and was perceived to be highly relevant and appropriate. These findings provide preliminary support for the feasibility and effectiveness of the BCBS training programme for workers within the youth AOD sector. [Hides L, Elkins K, Catania LS, Mathias S, Kay-Lambkin F, Lubman DI. Feasibility and outcomes of an innovative cognitive-behavioural skill training programme for co-occurring disorders in the youth alcohol and other drug (AOD) sector. Drug Alcohol Rev 2007;26:517 - 523]     

Feasibility and acceptability of a mental health screening tool and training programme in the youth alcohol and other drug (AOD) sector

The high prevalence of co-occurring mental health and substance use disorders in young people is well established. Despite this, there are low rates of detection of co-occurring disorders across alcohol and other drug (AOD) services within Australia. This paper describes the development, implementation and evaluation of a mental health screening tool and training programme within the youth AOD sector. Thirty youth AOD workers received training in mental health screening, and the screening tool was subsequently piloted on 84 young people accessing two youth AOD services. Training was evaluated using measures of the trainee's mental health knowledge, attitudes, skills and confidence in mental health screening at baseline and 12-month follow-up. Feedback from young people supported the feasibility, acceptability and relevance of the screening tool. Evaluation of the associated training programme indicated improvements in AOD workers' mental health knowledge, skills and confidence in mental health screening. These findings provide preliminary evidence of the feasibility and acceptability of the mental health screening tool to young people and the effectiveness of the training package within the youth AOD sector. [Hides L, Lubman DI, Elkins K, Catania LS, Rogers N. Feasibility and acceptability of a mental health screening tool and training programme in the youth alcohol and other drug (AOD) sector. Drug Alcohol Rev 2007;26:509 - 515]     

Predictors of contact with public service sectors among homeless adults with and without alcohol and other drug disorders

OBJECTIVE: Homeless persons with alcohol and other drug (AOD) disorders face multiple problems that go beyond their AOD use. As a consequence, they commonly access services in multiple sectors in addition to the AOD treatment system. This study examined the predictors of contact with agencies in the health, mental health, social welfare and criminal justice sectors by AOD status among a probability sample of homeless adults in Houston, Texas. METHOD: Cross-sectional data were collected from a multistage random sample of 797 homeless adults (579 men), age 18 or older, who were living in shelters and on the streets of Houston in 1996. Structured face-to-face interviews provided screening diagnoses for AOD disorders, self-report data on AOD treatment use and candidate predictors of treatment use. Service use was tracked retrospectively through administrative data obtained from 10 federal, state, county and municipal agencies that provide finding for physical and mental health services and AOD treatment, as well as emergency income; we also tracked criminal justice contacts. Logistic regression analyses were stratified by AOD status. RESULTS: Adjusting for eligibility factors, key aspects of need were significant predictors of any utilization among those without an AOD problem, but not for those with an AOD problem. For those with AOD disorders, contact with one sector was not predictive of contact with other sectors. CONCLUSIONS: Our findings indicate that AOD disorders hinder utilization of public sector services by homeless persons. These disorders may be masking need or otherwise acting as a barrier to accessing treatment and support.     

Replacing ineffective early alcohol/drug education in the United States with age-appropriate adolescent programmes and assistance to problematic users

Issues. Despite more than a decade of federal sponsorship of 'evidence-based' alcohol/drug education, there has been no consistent downward trend in overall prevalence among youth over the past 15 years. Reasons underlying this situation are examined. Approach. Published technical critiques of initial research supporting widely used evidence-based programs are reviewed along with replication studies conducted later by independent researchers not associated with initial program development. Social and institutional barriers in the US against changes in AOD policy and practice for young people are also suggested. Key Findings. Emerging use of diverted pharmaceuticals (now second to cannabis in prevalence) may underlie moderate recent decline in use of alcohol. Early federal certification standards for 'evidence based' prevention education have been seriously compromised. Technical critiques of initial evaluations and negative replication studies of these programs are consistent with lack of impact. Finally, fidelity of implementation in regular school settings is commonly flawed. Implications. Failure of these mainly pre-secondary educational programs may underlie recent federal support for forced random AOD testing of secondary school students. A new approach to drug education for adolescent students seems warranted as a positive alternative to personally intrusive surveillance. Conclusion. An interactive approach at the secondary school level that incorporates an age-appropriate educational process is proposed. While advising abstinence, this approach also facilitates identifying and assisting problematic AOD users. [Skager R. Replacing ineffective early alcohol/drug education in the United States with age-appropriate adolescent programmes and assistance to problematic users. Drug Alcohol Rev 2007;26:577 - 584]     

“Someone who is in this thing that I am suffering from”: The role of peers and other facilitators for task sharing substance use treatment in South African HIV care

South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a “siloed treatment experience”), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.     

Measuring alcohol and drug dependence with New York City ADAM data

The Arrestee Drug Abuse Monitoring (ADAM) Program collects self-report survey information and urine specimens from adult arrestees in 35 cities nationwide. In 2000, a new survey instrument was fielded that includes questions about alcohol and other drug (AOD) abuse and dependence. Despite high levels of drug use among national arrestee populations, no studies have examined need for AOD treatment among ADAM arrestees. To address this limitation, a secondary analysis was undertaken with New York City ADAM data collected in 2000. Thirty-seven percent of the arrestees were diagnosed in need of drug treatment, while 19% were diagnosed in need of alcohol treatment. Compared to those arrestees who were diagnosed as not needing AOD treatment, arrestees who met the criteria for ADAM abuse/dependence were more likely to be male, older, and to have tested positive by urinalysis for at least one illicit drug. Because “need for treatment” was operationalized as a diagnosis of abuse or dependence, the current results should be viewed as liberal estimates of treatment need. Implications for the delivery of drug treatment to criminal populations are discussed.     

Effect of quality chronic disease management for alcohol and drug dependence on addiction outcomes

We examined the effect of the quality of primary care-based chronic disease management (CDM) for alcohol and/or other drug (AOD) dependence on addiction outcomes. We assessed quality using (1) a visit frequency based measure and (2) a self-reported assessment measuring alignment with the chronic care model. The visit frequency based measure had no significant association with addiction outcomes. The self-reported measure of care—when care was at a CDM clinic—was associated with lower drug addiction severity. The self-reported assessment of care from any healthcare source (CDM clinic or elsewhere) was associated with lower alcohol addiction severity and abstinence. These findings suggest that high quality CDM for AOD dependence may improve addiction outcomes. Quality measures based upon alignment with the chronic care model may better capture features of effective CDM care than a visit frequency measure.     

Implementation and evaluation of brief depression and anxiety screening in clients contacting a drug and alcohol service

Introduction and Aims. High prevalence mental health (HPMH) comorbidity is common in clients seeking alcohol and other drug (AOD) treatment yet can remain undetected. Although research has reported on the introduction of screening into AOD services, little research has reported on the processes surrounding the introduction or evaluated its effectiveness. This study reports on the implementation and evaluation of brief anxiety and depression screening within a specialised, publicly funded AOD service in South‐East Victoria. Design and Methods. Study one examined the implementation of standardised HPMH screening with 114 adult clients (Mean age = 35.49, SD = 9.53; 64% male) telephoning an AOD service over a 5 week period. Measures included severity of HPMH problems, AOD use, care plans and referrals. Study two used semistructured interviews with nine staff/managers to evaluate the effectiveness of screening and its impact on service delivery. Results. Ninety‐four per cent of clients were identified at risk of anxiety or depression. Most care plans incorporated counselling, and concurrent referrals commonly involved a general practitioner. Staff and management found systematic screening increased identification and understanding of comorbid issues and enhanced client interaction but impacted on resource requirements. Discussion and Conclusions. Most AOD treatment seekers were identified HPMH comorbid and care plans generally included counselling. Adjunctive referrals were more common for severely depressed clients. Screening was effective and enhanced client rapport. Evaluations revealed low confidence in treating HPMH issues in‐house. Training may increase worker confidence in managing mental health interventions with subclinical cases, enhancing services' ability to move towards dual diagnosis capability.[Thomas AC, Staiger PK, McCabe M. Implementation and evaluation of brief depression and anxiety screening in clients contacting a drug and alcohol service. Drug Alcohol Rev 2012;31:303–310]     

Mapping the Clinical Complexities of Adolescents with Substance Use Disorders: A Typological Study

SUMMARY

Because of the vast improvements in adolescent substance use assessment, it is widely recognized that adolescent substance use disorders (SUD) encompasses diverse drugs, patterns and etiologies and are characterized by extensive heterogeneity in other life domains. The next step in advancing adolescent SUD assessment is to classify adolescents with SUD into treatment-oriented typologies so that the question “What works with whom under what conditions?” can be empirically investigated. This paper: (1) identifies and describes seven subtypes of 205 adolescents with SUD in alcohol and other drug (AOD) treatment aged 12–18 years (via dimensions of delinquency, psychosocial problems, chemical dependency, and sexual risk behavior); and (2) examines whether certain patterns are distinctive among youth court-mandated to AOD treatment. Each profile type is described in terms of relative problem severity, prevalence for youth mandated to treatment through the courts, demographics, and performance on external measures of mental health and substance use disorders. Multiple logistic regression demonstrated that three profile types yielded 75.6% accuracy (sensitivity = 75.8%, specificity = 75.5%) for discrimination between court-mandated and non-court-mandated to treatment youth, even when controlled for the contributions of youth age, sex, and ethnicity. This paper discusses the need for triage to multiple treatments with varying levels of intensity for different subgroups of adolescents. If cost-effective services by setting by youth typology could be empirically identified and replicated, perhaps an empirically-guided cost-containment strategy would be developed and implemented by managed care and state government. In this way, the trend for a decline in the number and types of on-site services provided by AOD treatment programs might reverse, improving adolescent SUD outcomes.     

Contracting treatment services in Australia: Do measures adhere to best practice?

BackgroundContracting non-government services to provide alcohol and other drug (AOD) treatment requires the specification of performance measures to ensure accountability for public funds. There is currently no standardised approach by funders to the measurement of performance of AOD treatment in Australia. Funding to non-government organisations (NGOs) is complex, with NGOs managing funding agreements from a range of sources that contain a large number of differing performance measures. This study aimed to assess performance measures used in contracts for NGO AOD treatment providers and how they align with best practice.MethodsPerformance measures contained in funding agreements for treatment providers were collected from a diverse sample of both funders (n=8) and treatment providers (n=20) resulting in more than 1,100 measures. The list of measures was synthesized to a finite, non-duplicative list (n=537). Measures were assessed by three raters against 11 criteria (for example, measurable and timely) documented as best practice elements of performance measures (Council of Australian Governments, 2011a). Measures were also coded into different measurement types (such as outcome and process).ResultsNone of the 537 unique performance measures used in funding agreements for treatment providers fully met the criteria for best practice in performance measurement. Whilst the literature and government policy is being directed towards outcomes-based funding and reporting, only 7.6% of measures were classified as outcome measures. The majority of measures were classified at output (41.3%) and process (23.6%) measures.ConclusionCurrent measures in contracts applied by funders to treatment services do not adhere to best practice. The development and implementation of new performance measures is required to inform AOD policy and accountability of public funds. Further, identifying more robust performance measures has the potential to lead to reduced reporting burden on service providers and better monitoring of service quality and outcomes.     

Co-occurring mental health and drug dependency disorders: work-force development challenges for the AOD field

In this paper it is argued that the sheer extent of the co-occurrence of mental health and drug dependency disorders means inevitably that alcohol and other drug (AOD) staff encounter such problems. However, it is contended that the AOD work-force has a number of characteristics that often act as impediments to people with co-occurring disorders receiving, in that sector, appropriate, integrated, 'one-stop-shop' care. Nevertheless, because of the configuration of mental health services in Australia, as essentially acute services for people with severe mental illnesses, there has been, and will continue to be, an overspill of people with mental health disorders and drug problems disorders into the AOD sector. It is there absolutely necessary that initiatives are put into place that support and enable the AOD sector to respond more effectively to people with co-occurring disorders.     

Improving services for prevention and treatment of substance misuse for Aboriginal communities in a Sydney Area Health Service

Introduction and Aims. Substance misuse among Aboriginal Australians is both a symptom of disadvantage and suffering but also a cause of health and social problems. Few data are available on how mainstream drug and alcohol services meet the needs of Aboriginal Australians. We assessed acceptability and accessibility of mainstream services for Aboriginal Australians with alcohol or drug use disorders in an urban Area Health Service (AHS). We identified priorities for improvement and an implementation plan. Methods. We collected feedback via consultation with client groups, with the Aboriginal community and community organisations, with staff of the AHS and of the local Aboriginal Medical Service (AMS) and through direct observation. We examined attendance data. Results. Aboriginal people were well represented in this mainstream service, partly because of existing collaboration with the AMS. Good points in the service were reported to be priority appointments for new Aboriginal clients, professional and caring service and collaboration with the AMS. Suggested improvements included increased cultural sensitivity of communication, more appropriate physical surrounds and printed materials, having Aboriginal staff available, peer support groups and integration of health care for individual, family and community. The action plan included increased recruitment and career opportunities for Aboriginal staff, strengthened partnerships with the Aboriginal community, including ongoing collaboration with the AMS in improving and monitoring mainstream service quality. Discussion and Conclusions. Given the adverse impact of substance use disorders, there is a pressing need for services to work with Aboriginal communities to optimise the quality of mainstream treatment services. [Teasdale KE, Conigrave KM, Kiel KA, Freeburn B, Long G, Becker K. Improving services for prevention and treatment of substance misuse for Aboriginal communities in a Sydney Area Health Service. Drug Alcohol Rev 2008; 27:152-159]     

Do attitudes about unhealthy alcohol and other drug (AOD) use impact primary care professionals' readiness to implement AOD‐related preventive care?

Introduction and Aims. To explore the association between primary care professionals' (PCPs) attitudes towards unhealthy alcohol and other drug (AOD) use (from risky use through dependence) and readiness to implement AOD‐related preventive care. Design and Methods. Primary care professionals from five health centres in Sao Paulo were invited to complete a questionnaire about preventive care and attitudes about people with unhealthy AOD use. Logistic regression models tested the association between professional satisfaction and readiness. Multiple Correspondence Analysis assessed associations between stigmatising attitudes and readiness. Results. Of 160 PCPs surveyed, 96 (60%) completed the questionnaire. Only 25% reported implementing unhealthy AOD use clinical prevention practices; and 53% did not feel ready to implement such practices. Greater satisfaction when working with people with AOD problems was significantly associated with readiness to implement AOD‐related preventive care. In Multiple Correspondence Analysis two groups emerged: (i) PCPs ready to work with people with unhealthy AOD use, who attributed to such patients lower levels of dangerousness, blame for their condition and need for segregation from the community (suggesting less stigmatising attitudes); and (ii) PCPs not ready to work with people with unhealthy AOD use, who attributed to them higher levels of dangerousness, blame, perceived level of patient control over their condition and segregation (suggesting more stigmatising attitudes). Discussion and Conclusions. More stigmatising attitudes towards people with unhealthy AOD use are associated with less readiness to implement unhealthy AOD‐related preventive care. Understanding these issues is likely essential to facilitating implementation of preventive care, such as screening and brief intervention, for unhealthy AOD use. [Amaral‐Sabadini MB, Saitz R, Souza‐Formigoni MLO. Do attitudes about unhealthy alcohol and other drug (AOD) use impact primary care professionals' readiness to implement AOD‐related preventive care? Drug Alcohol Rev 2010;29;655–661]     

An Outcome Study of the CASA-CHESS Smartphone Relapse Prevention Tool for Latinx Spanish-Speakers with Substance Use Disorders

Background: Hispanic/Latinx persons with alcohol and other drug disorders (AOD) have limited access to culturally competent continuity of care. To address this, the evidence-based smartphone recovery application Addiction-Comprehensive Health Enhancement Support System (A-CHESS) was translated and adapted for Latinx Spanish-speakers with AOD, developing CASA-CHESS. Objectives: This study examined the AOD and mental health outcomes for Latinx Spanish-speaking clients using the CASA-CHESS smartphone tool over a 6-month period, post-residential treatment. This single group, pre-post study design included seventy-nine male and female Spanish-speaking Latinx clients, equipped with CASA-CHESS as they completed residential AOD treatment. Primary outcome measures at baseline and 6-month follow-up included substance use and other mental health symptoms. Results: While over 70% of the sample reported past heroin use and alcohol use, clients had low baseline rates of substance use, depression and anxiety and elevated social support scores as they graduated from residential treatment. Overall participants maintained their relatively low baseline rates during the 6-month post-residential period while using the CASA-CHESS relapse prevention tool. Those who discontinued using CASA-CHESS within the first 4?months after leaving residential treatment reported higher rates of substance use as well as anxiety and depression symptoms than those using it for 4 or more months, suggesting that continued use of CASA-CHESS may contribute to maintenance of successes gained in treatment. Conclusions/Importance: CASA-CHESS may reduce the risk of relapse for Latinx Spanish-speakers following residential services and extend needed access to culturally and linguistically competent aftercare services for those with AOD.     

The relationship between non-acute adolescent cannabis use and cognition

Research indicates that cannabis continues to be a popular illegal drug internationally. Furthermore, adolescent rates of use appear to be significant. Whilst the non-acute effect of cannabis use on adult cognition has been extensively researched, there has been less examination of adolescents. This study aimed to investigate the non-acute relationship between cannabis and cognitive function in a sample of adolescents with a continuum of cannabis use, taking into account additional predictor variables (psychiatric functioning, general functioning, demographics and other drug use). Seventy adolescents were recruited from clinical and community sources as well as through newspaper advertisements. After 12 hours abstinence from cannabis, adolescents completed a two-hour interview covering: demographics; alcohol and drug use history; drug use in the past 28 days; depression; further psychiatric functioning (including ADHD and Conduct Disorder); and cognitive functioning as measured by computerised tasks (CANTAB) and traditional pen and paper tests. Adolescents who were regular cannabis users (more than once a week) had a significantly poorer performance on four measures of cognitive function reflecting attention, spatial working memory and learning. Cannabis use remained an independent predictor of performance on the working memory and strategy measures after additional predictor variables were included in a multivariate regression analysis. The results suggest that aspects of adolescent cognitive function are independently related to the frequency of cannabis use beyond acute intoxication. [Harvey MA, Sellman JD, Porter RJ, Frampton CM. The relationship between non-acute adolescent cannabis use and cognition. Drug Alcohol Rev 2007;26:]     

The general practitioner's role in AOD issues: overcoming individual,professional and systemic barriers

General practitioners (GPs) and increasingly other medical practitioners are well placed to address alcohol and other drug (AOD) problems. Their involvement in this area of care, however, is assessed to be less than optimal. There is, however, a growing body of evidence for the potential efficacy of medical practitioner intervention at the primary care, emergency department and in-patient level. There is also considerably expanded scope to operate from an evidence-based perspective. However, key questions arise regarding what constitutes best practice in the translation of the growing AOD knowledge base into clinical practice behaviours. This paper explores possible contributory factors to the low level of engagement with AOD issues by GPs and examines a wide range of individual, structural and systemic issues that may be amenable to change. Strategies for the dissemination of research findings, changing professional practice behaviour and introducing sustainable structural reforms are also addressed.     

One-year treatment patterns and change trajectories for adolescents participating in outpatient treatment for the first time

The American Society on Addiction Medicine's Patient Placement criteria are commonly used in adolescent treatment. However, the use of these criteria and how they affect the course of treatment and interact with adolescent change has not been examined. Twelve-month treatment patterns were examined for 176 adolescents who entered their first ever episode in a treatment system using these criteria. Forty-one percent of the adolescents received additional treatment after their initial outpatient episode with over 30 unique treatment sequences (i.e., various combinations of outpatient, intensive outpatient, and residential treatment). Significant differences in treatment patterns were found between the change trajectory groups. For example, adolescents who participated in only one outpatient treatment episode were more likely to be in the low alcohol and drug use (AOD) group and less likely to have high rates of time in a controlled environment or to report moderate AOD use. Over one-third of the adolescents participated in additional treatment and almost one-quarter of those who only participated in outpatient treatment had problematic use. These findings suggest the need for clinical monitoring protocols that can be used to identify adolescents needing additional treatment or recovery services.     

Innovative Recruitment Using Online Networks: Lessons Learned From an Online Study of Alcohol and Other Drug Use Utilizing a Web-Based, Respondent-Driven Sampling (webRDS) Strategy

ABSTRACT. Objective: We used a web version of Respondent-Driven Sampling (webRDS) to recruit a sample of young adults (ages 18-24) and examined whether this strategy would result in alcohol and other drug (AOD) prevalence estimates comparable to national estimates (National Survey on Drug Use and Health [NSDUH]). Method: We recruited 22 initial participants (seeds) via Facebook to complete a web survey examining AOD risk correlates. Sequential, incentivized recruitment continued until our desired sample size was achieved. After correcting for webRDS clustering effects, we contrasted our AOD prevalence estimates (past 30 days) to NSDUH estimates by comparing the 95% confidence intervals of prevalence estimates. Results: We found comparable AOD prevalence estimates between our sample and NSDUH for the past 30 days for alcohol, marijuana, cocaine, Ecstasy (3,4-methylenedioxymethamphetamine, or MDMA), and hallucinogens. Cigarette use was lower than NSDUH estimates. Conclusions: WebRDS may be a suitable strategy to recruit young adults online. We discuss the unique strengths and challenges that may be encountered by public health researchers using webRDS methods. (J. Stud. Alcohol Drugs, 73, 834-838, 2012).