Kathleen Meyers

Contemporary addiction treatment: A review of systems problems for adults and adolescents

There is national concern regarding the problems of alcohol and drug abuse and the adequacy and quality of the national addiction treatment system, particularly for adolescents. This article reviews the published literature evaluating the ability of health, education, and specialty treatment systems to identify and treat affected adolescents and adults. A separate section reviews the status of the national treatment system for adults through findings from a nationally representative survey of 175 specialty treatment programs. The findings are unambiguous and disturbing. Although substance abuse is prevalent in most schools, primary care practices, mental health clinics, and criminal justice agencies, there is insufficient training, organization, or reimbursement to screen, assess, and refer those with dependence or abuse disorders to appropriate services. There are too few programs available to treat those substance-dependent patients who are screened and significant barriers for patients attempting to enter those programs. Finally, the organizational, administrative, and personnel infrastructures of many treatment programs are fragile and unstable, making them unable to implement evidence-based care. These problems are serious in the adult system and even worse in the adolescent system. The article concludes with suggestions for improving systems integration to improve the quantity and quality of available care.

Does clinical case management improve outpatient addiction treatment

This project evaluated whether clinical case managers (CCMs) could increase access and utilization of social services in the community; and thereby improve outcomes of addiction treatment. No case management (NoCM)--patients received standard, group-based, abstinence-oriented, outpatient drug abuse counseling, approximately twice weekly. Clinical case management (CCM)--patients were treated in the same programs but also were assigned a CCM who provided access to pre-contracted, support services such as drug free housing, medical care, legal referral, and parenting classes from community agencies. CCM patients received more alcohol, medical, employment, and legal services than NoCM patients during treatment. At 6 month follow-up CCM patients showed significantly more improvement in alcohol use, medical status, employment, family relations, and legal status than NoCM patients. We conclude that CCM was an effective method of improving outcomes for substance abuse patients in community treatment programs. Essential elements for successful implementation included extensive training to foster collaboration; and pre-contracting of services to assure availability.

The development of the comprehensive addiction severity index for adolescents (CASI-A): An interview for assessing multiple problems of adolescents

The Comprehensive Addiction Severity Index for Adolescents (CASI-A) is a 45 to 90-minute comprehensive, semi-structured clinical interview for evaluating adolescents who present for treatment at various provider agencies. CASI-A modules and their individual items were selected and revised based on theory, clinical wisdom, and adolescent experiences obtained during pilot interviews and focus groups. The CASI-A assesses known risk factors, concomitant symptomatology, and consequences of adolescent alcohol/drug use within seven primary areas of functioning: education status, alcohol/drug use, family relationships, peer relationships, legal status, psychiatric distress, and use of free time. The CASI-A is not a diagnostic or screening instrument, but rather a clinical assessment tool that obtains clinically pertinent information designed to guide treatment planning and to evaluate treatment outcome. The CASI-As design makes it suitable for administration in a variety of settings, for repeat administration at posttreatment follow-up evaluations, and for assessment of virtually all adolescents in treatment regardless of their admission problem. Overall, the CASI-A has encouraging but preliminary evidence of validity and internal consistency. Information collected soon after admission during administration of the CASI-A by nonclinical interviewers corresponded quite well with that obtained over the course of the adolescents treatment stay by the entire treatment team. Revisions to the instrument are being made in those areas where correspondence between information on the CASI-A and that extracted from clinical records dropped below 75%, or in those early subscales, where alpha coefficients dropped below .6. As a result of the encouraging results reported in this paper, we are beginning additional psychometric testing, refining the proposed scoring system, and developing a computerized data entry, scoring, and report system.

What does it take to retain substance-abusing adolescents in research protocols? Delineation of effort required, strategies undertaken, costs incurred, and 6-month post-treatment differences by retention difficulty

Research retention rates vary widely due to practical difficulties that can be exacerbated when participants are minors. This article describes: (1) the range of effort required and type of follow-up strategies used to complete face-to-face follow-up interviews with substance-abusing adolescent research participants; (2) common locations of follow-up interviews; and (3) characteristics of difficult- versus easy-to-retain adolescent participants. Diverse contact strategies and numerous contact attempts were needed to obtain a 94% 1-month and 92% 6-month retention rate among substance-abusing adolescent research participants. About half of the youth did not respond to basic telephone tracking and required enhanced tracking efforts. Approximately 40% of the youth required 6 or more contacts prior to interview completion. The majority of follow-up interviews (60%) were conducted in community settings such as fast food restaurants, constituting the adolescents preferred interview location. Telephone interviews were infrequent since adolescents wanted privacy and were concerned that a household member would listen to their answers. Those youth proving difficult-to-retain were significantly more likely to report serious problem behavior and poorer outcomes 6-months post-treatment within the alcohol/drug, juvenile justice, family, and educational domains. It was estimated that an additional

Critical issues in adolescent substance use assessment

85 per participant per follow-up wave (over and above project budgets) was needed to adequately track, locate and interview an adolescent research participant. This expenditure appears reasonable to ensure a reliable/valid data set. Assessing the cost/benefit of different methods used in preventing attrition, identifying the minimum standards that avoid response bias and examining the impact of interviewer/participant alliances on data reliability/validity is discussed.

Relationships among parental monitoring and sensation seeking on the development of substance use disorder among college students

Despite advances in methodology and instrumentation, the assessment of adolescent drug and alcohol involvement remains a complex clinical and practical process. It requires the careful and skillful implementation of procedures across a wide range of service systems and providers. While the literature identifies and provides information on singular aspects of the assessment of adolescents, few sources furnish an integrated overview of the key issues necessary for appropriate and accountable assessment. Consequently, this paper synthesizes theoretical, research, and clinical issues into a practical framework that can be used by clinical and research staff making assessment decisions. Issues discussed have been informed by the literature and by our collective experience during the 8-year development and testing of the Comprehensive Adolescent Severity Inventory (CASI).

Inpatient vs outpatient treatment for substance dependence revisited

Substance use disorder is a serious health problem that tends to manifest in late adolescence. Attempting to influence targetable risk and protective factors holds promise for prevention and treatment. Survey data from 1253 college students (48.5% male, 26.9% non-White) were used to investigate the independent and combined effects of two prominent factors, sensation seeking and parental monitoring, on the probability of alcohol and/or cannabis dependence during the first year of college. In multivariate analyses that controlled for high school use, gender, race, mothers education, and importance of religion, retrospective reports by the student of parental behavior during the last year of high school indicated that higher levels of parental monitoring had a direct effect on reducing risk for alcohol dependence during the first year of college, but not on cannabis dependence. High levels of sensation seeking were associated with increased risk for both alcohol and cannabis dependence. No interaction effects were found. The results extend prior findings by highlighting influences of pre-college parental monitoring and sensation seeking on the probability of alcohol and/or cannabis dependence during the first year of college. The findings also suggest that these two factors are useful in identifying college students at high risk for alcohol and/or cannabis dependence.

Current advances in the treatment of adolescent drug use

Miller and Hesters 1986 review of inpatient versus outpatient alcohol treatment studies concluded with no “justification” for inpatient treatment. Further examination of these studies revealed shortcomings such as the use of random assignment designs which excluded psychiatrically-complicated patients. Carrier Foundations inpatient/outpatient study of private psychiatric patients with alcohol and/or cocaine dependence includes a patient-treatment matching design to address weaknesses in the existing literature. Patients with high psychiatric severity and/or a poor social support system are predicted to have a better outcome in inpatient treatment, while patients with low psychiatric severity and/or a good social support system may do well as outpatients without incurring the higher costs of inpatient treatment. Preliminary results from 183 inpatients and 120 outpatients indicated outpatients, regardless of level of psychiatric severity, were 4 times more likely to be early treatment failures (chi-square=41.2,df=1,p<.01). While the determination of long-term follow-up status of early treatment failures is currently underway, this finding underscores the potential risk of early treatment failure in outpatient compared to inpatient substance abuse treatment programs and the importance of addressing the issue of early attrition in conducting outcome analyses.

Factor structure of the Comprehensive Adolescent Severity Inventory (CASI): results of reliability, validity, and generalizability analyses.

Research on the development and efficacy of drug abuse treatment for adolescents has made great strides recently. Several distinct models have been studied, and these approaches range from brief interventions to intensive treatments. This paper has three primary aims: to provide an overview of conceptual issues relevant to treating adolescents suspected of drug-related problems, including an overview of factors believed to contribute to a substance use disorder, to review the empirical treatment outcome literature, and to identify areas of need and promising directions for future research.

HIV risks among homeless men differentiated by cocaine use and psychiatric distress.

This article describes the results of psychometric work conducted on the Comprehensive Adolescent Severity Inventory (CASI) among 205 in-treatment substance-abusing adolescents. Four dimensions, each composed of component subscales, resulted from standard psychometric analyses: Chemical Dependency, Psychosocial Functioning, Delinquency, and Risk Behavior. Each dimension had high internal consistency (alpha coefficients for the component subscales comprising each clinical dimension range from. 78 to. 96) and test-retest reliability (intraclass correlation coefficients range from. 88 to. 96 and all are significant at p < .0001.). Concurrent validity and specificity of the CASI dimensions also were found: significant and substantial variance in NIMH Diagnostic Interview Schedule for Children-Revised (DISC-IV) and Brief Symptom Inventory (BSI) scores was associated with relevant CASI dimensions; CASI dimensions that theoretically should show no significant relationship with divergent pathology were not associated. The dimensions forecasted substantial variance in adolescent functioning posttreatment discharge, supporting predictive validity. Finally, the dimensional clinical structure was found to be generalizable over male and female adolescents, younger and older adolescents, and adolescents from different ethnic groups. These results provide further evidence for the CASIs promise in research and practice as an adolescent-specific assessment instrument that comprehensively assesses multidimensional areas of functioning within a developmental context of measurement. Limitations of the study along with future work currently being conducted on the CASI are discussed.