the main profiles of treatment planning needs among adolescents presenting for substance abuse...

The Main Profiles Of Treatment Planning Needs AmongAdolescents Presenting For Substance Abuse Treatment Based On Cluster Analysis

Rodney R. Funk, Michael L. Dennis, and Laverne Hanes-Stevens, Chestnut Health Systems, Bloomington, IL

Panel at the Joint Meeting on Adolescent Treatment Effectiveness, March 25-27, 2008, Washington, DC. This presentation supported by Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) contracts 270-2003-00006 and 270-07-0191, as well as several individual CSAT, NIAAA, NIDA and private foundation 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]

Background

With 6 ASAM cells (8 levels) and 122 individual statements (2 levels), the number of possible combination of statements are 86 x 2122 = 1,393,796,574,908,160,000,000,000,000,000,000,000,000,000

(1.3 tredecillion [1042]) possible combinations of treatment planning statements

While useful to help individualize treatment plans, this is more than the number of people in human history and too many possibilities to be useful for program planning.

The goal of this presentation is to use cluster analysis to identify the main presenting profiles that can be used to guide placement and program planning

Data on the Global Appraisal of Individual Needs (GAIN) from 203 level of care x site combinations

Outpatient

General Group Home

Short-Term Residential

Outpatient Continuing CareIntensive Outpatient

Long-term ResidentialModerate-Term Residential

Early InterventionOtherCorrections

Levels of Care

Comparison of TEDS Public Treatment Data to CSAT GAIN Data: Demographics

*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 2006 dataset subset to adolescent studies (includes 2% 18 or older).

81

19

20

21

43

28

82

18

16

11

65

30

1618

0 20 40 60 80 100

15 to 17 years old

12 to 14 years old

Hispanic*

Mixed/Other

Caucasian

African American

Female TEDS (n=1,188,223)

CSAT (n=8,301)

CSAT more likely to be Mixed or

Hispanic

Comparison of TEDS to CSAT GAIN Data: Level of Care

* 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 2006 dataset subset to adolescent studies (includes 2% 18 or older).

75%

8%

2%

15%

68%

12%

8%

9%

0% 20% 40% 60% 80%

Outpatient

IntensiveOutpatient

Short TermResidential

Long TermResidential

TEDS (n=1,804,151)*

CSAT (n=8,301)**

CSAT more likely to be long term residential

CSAT breaks out Outpatient from

Outpatient Continuing Care

Method Dropped 3691 people who were missing on Level of Care Mean replacement for variables missing less than 15% Dropped variables that were missing on 15% or more or which had

less than 2% variation. Collapse ASAM cells with less than 1% Final cluster analysis based on 39 Dummy variables for ASAM cell

placement, and 44 Other treatment planning statements (83 Total 0/1 variables)

Cluster analysis done using Ward’s minimum distance with binary variables in SPSS

Number of clusters selected based on percentage of variance explained in each measure greater than .7, Wilk’s lamda of variance in the joint distribution of less than 1%, and a minimum sample size of 5%

Method (cont) Done on half sample, predicted with Fisher’s discriminant

function analysis (DFA) and validated against the original (predicted to actual group kappa=.72) the remaining half sample in terms of variance explained in source items (within 1-2%).

Clusters based on DFA (which can be used to classify future cases)

Triaged (low/moderate/high) each cluster in terms of substance use disorder severity and ASAM placement dimensions – both in terms of the severity of the problem and the extent of current treatment utilization

Calculated average rating across dimension, profiled client characteristics, ASAM placement profile and most common needs of each group

Which specific problems they have or services they are using also vary

Area

Sx Tx Sx Tx Sx Tx Sx Tx Sx Tx Sx Tx Sx Tx Sx TxA. Substance Use

DisorderL L L M M M M L H M H H H M H M

B1 Intoxication and Withdrawal

L L L L M M M L H M M M H M H H

B2 Bio-Medical(incl HIV Risk)

L L L L M M H L M L H M M M M H

B3a Psych-Behavioral L L L L M L H L M L H M M L H H

B3b Legal M L L M M M H L M M H H M M L M

B4 Readiness for Change

L L M M M M H L H M L H H M H M

B5 Relapse Potential L L M M M M H L H M H H H H H M

B6 Recovery Environment

L L L L M L M L M M M H H L H M

Summary Index*

* Average rating on a scale of 0 to 100%, treating L at 0%, M as 50% and H as 100%

6% 0% 13% 25% 50% 38% 81% 0% 75% 38% 75% 81% 81% 44% 81% 69%

ALow-Low

B

Low- Mod

C

Mod-ModD

Hi-Low

F Hi-Hi (CC)

G Hi-Mod

(Env/PH)

H Hi-Hi (Intoxic./PH/ MH)

EHi-Mod

Ratings of Problem Severity (x-axis) by Treatment Utilization (y-axis) by Population Size (circle size)

12%

20%

14%

8%

14%

12%

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

-0.20 0.00 0.20 0.40 0.60 0.80 1.00

Average Current Problem Severity

Ave

rage

Cur

rent

Tre

atm

ent U

tili

zati

on

.

A Low-Low

B Low- Mod

C Mod-Mod

DHi-Low

EHi-Mod

F. Hi-Hi (CC)

G. Hi-Mod(Env Sx/ PH Tx)

9%

H. Hi-Hi(Intx Sx; PH/MH Tx) 12%

While there are difference, the clusters cross major demographics groups

56%

52%

56%

64%

64%

68%

64%

38%

27%

24%

34%

28%

23%

27%

25%

40%

30%

18%

25%

19%

16%

9%

15%

20%

0% 20% 40% 60% 80% 100%

A Low-Low

B Low-Mod

C Mod-Mod

D Hi-Low

E Hi-Mod

F Hi-Hi (CC)

G Hi-Mod (E/P)

H Hi-Hi (I/P/M)

Minority

Female

Under 15

…and major systems

0% 20% 40% 60% 80% 100%

A Low-Low

B Low-Mod

C Mod-Mod

D Hi-Low

E Hi-Mod

F Hi-Hi (CC)

G Hi-Mod (E/P)

H Hi-Hi (I/P/M)

Currently inschool

Any JusticeSystemInvolvement

Past AddictionTreatment

Past MentalHealthTreatment

CurrentlyEmployed

Severity of Victimization goes up with cluster…

0% 20% 40% 60% 80% 100%

A Low-Low

B Low-Mod

C Mod-Mod

D Hi-Low

E Hi-Mod

F Hi-Hi (CC)

G Hi-Mod (E/P)

H Hi-Hi (I/P/M)

Current Victimization High Levels of Victimization Past Victimization No Victimization

As does the number of major clinical problems*0% 20% 40% 60% 80% 100%

A Low-Low

B Low-Mod

C Mod-Mod

D Hi-Low

E Hi-Mod

F Hi-Hi (CC)

G Hi-Mod (E/P)

H Hi-Hi (I/P/M)

Five or more problem areas Four problem areas

Three problem areas Two problem areas

One problem area No major past year problems self reported

*Count of the whether they had a cannabis, alcohol or other substance disorder, internalizing or externalizing disorder, victimization, physical health problems, and illegal activity)

While over 50% go to outpatient in 7 of 8 clusters, there are a range of placements in each cluster

0% 20% 40% 60% 80% 100%

A Low-Low

B Low-Mod

C Mod-Mod

D Hi-Low

E Hi-Mod

F Hi-Hi (CC)

G Hi-Mod (E/P)

H Hi-Hi (I/P/M)

Outpatient (OP) Intensive Outpatient (IOP)

Outpatient Continuing Care (OPCC) Short Term Residential (STR)

Long Term Residential (LTR)

A Low-Low (n=1456): ASAM Placement Chart

0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral


B5 Relapse Potential


1. No problem 2. Past problems 3. Low-mod problems 4. High severity problems

0. inconsistent 5. In Tx, past prob. 6. In Tx, Low-mod prob. 7. In Tx, High severity prob.

Prominent Features• A lack of problems, past problems or low severity in B1, B2, B3, B4, & B6• Some current treatment in B2• Highest severity problem is “relapse potential” (B4) and for some recovery environment (B5)

A Low-Low (n=1456): Top 10 Tx Needs

79% - Not close to anyone in recovery, assign a recovery coach73% - Assign to relapse prevention52% - Discuss recent school problems and how they can be resolved50% - Coordinating care with juvenile justice system50% - HIV Intervention to reduce high risk pattern of sexual behavior41% - Increase structure to reduce recovery environment risk33% - Discussing the consequences of behavior control problems, the

plan to change, and possible referrals to help.31% - Referral for tobacco cessation30% - Review prior treatment experiences to determine what did and not

work29% - Develop plan for reduction of family fighting

B Low-Mod (n=2388): ASAM Placement ChartCluster B (n=2388) Low-Moderate ASAM Placement Cells

0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral






Prominent Features• More current problems in B2, B3, and B4• More continued problems in spite of some current intervention, particularly problematic in B5

(which is continued relapse potential in spite of some urine testing or intervention)

B Low-Mod (n=2388): Top 10 Tx Needs77% - Coordinating care with juvenile justice system74% - Not close to anyone in recovery, assign a recovery coach69% - Review participation (attendance, motivation, follow-through, etc.) of

client, participation in family therapy, day treatment or other interventions to increase structure

69% - HIV Intervention to reduce high risk pattern of sexual behavior55% - Referral for mental health treatment52% - Increase structure and/or residential treatment to reduce recovery

environment risk48% - Referral for tobacco cessation45% - Discuss recent school problems and how they can be resolved40% - Discussing the consequences of behavior control problems, the plan to

change, and possible referrals to help.36% - Review prior treatment experiences to determine what did and not work

C Mod-Mod (n=1734): ASAM Placement Chart0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral






Prominent Features• More high severity current problems in Psychiatric (B3) and Recovery Environment (B6)• More continued problems in spite of some current intervention in Biomedical (B2) and Relapse

Potential (B5)

C Mod-Mod (n=1734): Top 10 Tx Needs93% - Increase structure and/or residential treatment to reduce recovery

environment risk91% - Discussing the consequences of behavior control problems, the plan to

change, and possible referrals to help.85% - Referral for mental health treatment85% -Refer to anger management intervention84% -Follow agency protocol related to child maltreatment reporting;

Refer for trauma related intervention82% - Review prior treatment experiences to determine what did and not work

76% - HIV Intervention to reduce high risk pattern of sexual behavior72% - Discuss recent school problems and how they can be resolved70% - Coordinating care with juvenile justice system62% - Not close to anyone in recovery, assign a recovery coach

D Hi-Low (n=908): ASAM Placement ChartASAM Placement Cell:

Cluster D (n=908) Moderate Severity Needing Opioid Detox

0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral






Prominent Features• Over 3/4ths have high severity current problems in B4, B5, and B6. • Majority have current or past problems in each dimension• Minimal current services outside of B2 and even half of those are continuing to have problems

D Hi-Low (n=908): Top 10 Tx Needs100%-Consider need for detoxification or withdrawal services99% - Refer for motivational interview or other intervention to increase

readiness for change 98% - Assign to relapse prevention91% - Increase structure and/or residential treatment to reduce recovery

environment risk87% - Referral for mental health treatment80% - HIV Intervention to reduce high risk pattern of sexual behavior74% - Review prior treatment experiences to determine what did and not work74% - Consider medication to reduce non-opioid withdrawal and relapse74% - Discussing the consequences of behavior control problems, the plan to

change, and possible referrals to help.73% - Referral for tobacco cessation

E Hi-Mod (n=1655): ASAM Placement ChartASAM Placement Cell:

Cluster E (n=1655) Moderate Needing Non-Opioid Detox

0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral






Prominent Features• Current or past problems in every dimension• Over 3/4ths have high severity current problems (red or purple) in B4, B5, and B6• Intervention underway in one more dimension but generally not working

E Hi-Mod (n=1655): Top 10 Tx Needs99% - Consider need for detoxification or withdrawal services90% - Referral for mental health treatment88% - Increase structure and/or residential treatment to reduce recovery environment risk86% - Review participation (attendance, motivation, participation, etc.) of client,

participation in family therapy, day treatment or other interventions to increase structure.

84% - HIV Intervention to reduce high risk pattern of sexual behavior78% - Coordinating care with juvenile justice system73% - Refer for motivational interview or other intervention to increase readiness for

change 72% - Discussing the consequences of behavior control problems, the plan to change,

and possible referrals to help.68% - Referral for tobacco cessation68% - Follow agency protocol related to child maltreatment reporting; Refer for trauma

related intervention

F Hi-Hi (CC) (n=1402): ASAM Placement ChartASAM Placement Cell: Cluster F (n=1402) Moderate with Psychiatric,

Continuing Care and Housing Needs

0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral






Prominent Features• Majority have problems in remission (yellow or blue) • Most are currently receiving some kind of intervention in B2, B3, B4, B5 or B6 • Interventions appear to be working for over half – EXCEPT for Recovery Environment (B6)

F Hi-Hi (CC) (n=1402): Top 10 Tx Needs98% - Refer to continuing care following discharge from controlled

environment97% - Referral for mental health treatment94% - Develop plan for obtaining stable housing87% - Increase structure and/or residential treatment to reduce recovery

environment risk85% - Coordinating care with juvenile justice system81% - HIV Intervention to reduce high risk pattern of sexual behavior78% - Develop community re-entry plan78% - Follow agency protocol related to child maltreatment reporting; Refer for

trauma related intervention72% - Discussing the consequences of behavior control problems, the plan to

change, and possible referrals to help.64% - Refer to anger management intervention

G Hi-Mod (Env/PH) (n=1038): ASAM Placement 0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral






Prominent Features• Majority have high severity problems (red or purple) in B2, B3, B4, B5, and B6• Intervention of B4, B5, and B6 does not appear to be working. • High risk on B6 and high participation in treatment in B2

G Hi-Mod (Env/PH) (n=1038): Top 10 Tx Needs100%-Consider need for detoxification or withdrawal services100% Consider medication to reduce non-opioid withdrawal and relapse99% - Review participation (attendance, motivation, participation, etc.) of client,

participation in family therapy, day treatment or other interventions to increase structure.

93% - Increase structure and/or residential treatment to reduce recovery environment risk

91% - Referral for mental health treatment79% - HIV Intervention to reduce high risk pattern of sexual behavior79% - Referral for tobacco cessation79% - Discussing the consequences of behavior control problems, the plan to change,

and possible referrals to help.74% - Review prior treatment experiences to determine what did and not work74% - Follow agency protocol related to child maltreatment reporting; Refer for

trauma related intervention

H Hi-Hi (Intx/PH/MH) (n=1443): ASAM Placement0% 20% 40% 60% 80% 100%


B2 Bio-Medical

B3 Psych-Behavioral






Prominent Features• Majority have high severity problems (red or purple) in B3, B4, B5, and B6 • Receiving intervention across some combination of B2, B3, B4, B5, and B6, but it is not

working for most

H Hi-Hi (Intx/PH/MH) (n=1443): Top 10 Tx Needs100%-Discuss medication compliance and effectiveness94% - Discussing the consequences of behavior control problems, the plan to

change, and possible referrals to help.91% - Referral for mental health treatment91% - Increase structure and/or residential treatment to reduce recovery

environment risk80% - Follow agency protocol related to child maltreatment reporting; Refer for

trauma related intervention79% - HIV Intervention to reduce high risk pattern of sexual behavior75% - Refer to anger management intervention74% - Referral for tobacco cessation69% - Review prior treatment experiences to determine what did and not work

Limitations

Data based only on self report, important to allow a clinician to over ride report if they have other information or validity concerns.

Not a representative sample.

Interpretation based largely on expert opinion, ideally the recommendations should be evaluated in terms of their ability to predict outcomes.

Conclusions The large number of possible combinations can be accurately

classified into 8 main groups.

The 8 groups vary along an axis of problem severity and a second axis based on the currently level of involvement in services.

Each group exists to a varying degree in each demographic and clinical groups, as well as each system and level of care.

Each group as a different profile of ASAM placement cells and individualized needs.

Even within group there are still considerable individual differences.

Next question is do they predict outcomes?

The above presentation was supported by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT) under contracts 207-98-7047, 277-00-6500, 270-2003-00006, and 270-07-0191 using data provided by the following grantees: CSAT TI-13190, TI-13305, TI-13308, TI-13309, TI-13313, TI-13322, TI-13323, TI-13340, TI-13344, TI-13345, TI-13354, TI-13356, TI-13601, TI-14090, TI-14103, TI-14188, TI-14189, TI-14196, TI-14214, TI-14252, TI-14254, TI-14261, TI-14267, TI-14271, TI-14272, TI-14283, TI-14311, TI-14315, TI-14355, TI-14376, TI-15348, TI-15413, TI-15415, TI-15421, TI-15433, TI-15446, TI-15447, TI-15458, TI-15461, TI-15466, TI-15467, TI-15469, TI-15475, TI-15478, TI-15479, TI-15481, TI-15483, TI-15485, TI-15486, TI-15489, TI-15511, TI-15514, TI-15524, TI-15527, TI-15545, TI-15562, TI-15577, TI-15584, TI-15586, TI-15670, TI-15671, TI-15672, TI-15674, TI-15677, TI-15678, TI-15682, TI-15686, TI-16386, TI-16400, TI-16414, TI-16904, TI-16915, TI-16928, TI-16939, TI-16961, TI-16984, TI-16992, TI-17046, TI-17055, TI-17070, TI-17071, TI-17334, TI-17433, TI-17434, TI-17475, TI-17484). Any opinions about these data are those of the authors and do not reflect official positions of the government or individual grantees. Suggestions, comments, and questions can be sent to Dr. Michael Dennis, Chestnut Health Systems, 720 West Chestnut, Bloomington, IL 61701, [email protected] .

Acknowledgements

the main profiles of treatment planning needs among adolescents presenting for substance abuse...

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