Three-year chemical dependency and mental health treatment outcomes among adolescents: the role of continuing care

A holistic perspective on continuing care for substance use and dependence: Results and implications from an in-depth study of a Norwegian continuing care establishment

This article explores, systematically and in depth, users’ perceptions of participating in a Norwegian non-profit establishment that provides a continuing care programme for substance use and dependence. Identified results are linked to a holistic system perspective, where human, technology, and organisation (HTO), as well as external environment, are viewed as intertwined. At the establishment level, i.e., where the continuing care programme is delivered, we find that a clear holistic and user-oriented profile – comprising combined interventions including physical and social activities – can create a safe and stable environment that exerts a positive mental and physical influence on the user and thereby promotes abstinence from substances. However, our results suggest that the internal environment needs to connect more strongly with the external environment, such as a substance-free network, close family, and working life. At the establishment level, we conclude that there is a need to develop an explicit strategy and practice for collaborating with the external environment, built on systemisation and application of individual users’ insights into the design of the current interventions. Further research should explore the presence and absence of interplays between elements of human, technology, and organisation and the external environment, and the associated consequences for intervention processes and users’ health outcomes. Our holistic system model, empirically informed by data from a Norwegian context, can represent a starting point for such endeavours. The holistic system model also constitutes an original and novel contribution to research on continuing care interventions.

Post-residential treatment outpatient care preferences: Perspectives of youth with opioid use disorder

INTRODUCTION

We know little about what youth with opioid use disorders (OUD) think about outpatient substance use treatment and 12-step meetings following discharge from residential substance use treatment. This study explores youths' preferences between intensive outpatient treatment (IOP) and community-based 12-step groups.

METHOD

The study recruited youth (n = 35) from a larger randomized trial (N = 288) that examined the effectiveness of extended-release naltrexone versus treatment-as-usual. This study asked the youth to participate in semi-structured qualitative interviews at baseline, 3 months, and 6 months post-residential treatment discharge. Qualitative interviews probed youths' key decision points during the six-months following residential treatment for OUD, including medication and counseling, and 12-step continuation in the community.

RESULTS

Qualitative analyses revealed three overarching themes related to youths' preferences for either IOP or 12-step meetings: structure of recovery support, mechanisms of accountability, and relationships.

CONCLUSION

Despite varying preferences, this analysis highlights the complexity of benefits that youth report receiving from each approach. Research has yet to determine the degree to which these approaches are complementary or supplementary for this population.

Recovery and Youth: An Integrative Review

Although rates of alcohol and other substance use disorders in adolescents have been estimated for decades, little is known about the prevalence, pathways, and predictors of remission and long-term recovery among adolescents. This article provides an integrative review of the literature on youth recovery. A final selection of 39 relevant articles was grouped into five sections: treatment outcomes, special emphasis populations, recovery-oriented systems of care, families, and non-abstinence-based approaches. The review recommends more adolescent research in three basic areas: more research about medication-assisted treatment and recovery as well as harm reduction approaches for adolescents; expansion of research on recovery practices for youth who do not receive treatment due to personal choice or societal disparities; and more life course research, which may begin with adolescent participants and extend across the life span. Additionally, the authors suggest the recovery capital model for adolescents and the neuroscience of addiction may provide additional precision and direction for the study of youth recovery.

Adolescent recovery capital and recovery high school attendance: An exploratory data mining approach

Recovery high schools (RHSs) provide a recovery-supportive academic environment for adolescents in recovery from a substance use disorder and are located across the United States. However, only a small proportion of the 160,000 youth in recovery each year in the United States enroll in RHSs posttreatment, indicating that many youth do not access this relapse prevention resource despite its effectiveness. Thus, this study uses the adolescent-adapted recovery capital model (RCAM) to understand individual- and community-level predictors of attendance and identify disparities leading to barriers to accessing RHSs. Data were collected as part of a multisite observational study of adolescents in recovery (N = 294). Logistic regressions and classification trees explored which different recovery capital factors predicted the odds of attending an RHS for at least 28 days during a 12-month period (n = 171) versus a non-RHS (e.g., traditional school: n = 123). The RCAM model is a useful theoretical framework for examining predictors of RHS attendance, and both analysis methods identified multiple unique predictors of RHS attendance. The strongest predictors of RHS attendance were individual-level factors, including problem-solving skills, 12-Step frequency, and financial resources. The classification trees highlighted additional interactions that should be explored in future empirical research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Treating Mental Health and Substance Use Disorders in Adolescents: What Is on the Menu?

Specific treatments targeting adolescents with substance use disorders (SUDs) have been developed over the last couple of decades. Despite these developmentally tailored treatments, long-term abstinence rates remain relatively low among adolescents receiving care. Research over the last decade has increasingly focused on adolescents with comorbid substance use and psychiatric disorders, in recognition of the barriers caused by inadequate treatment of co-occurring psychiatric disorders. Treatments targeting dually diagnosed youth are now regarded as essential to improving SUD treatment outcomes, but remain underutilized. A variety of treatment modalities such as behavioral therapy, family therapy, 12-step groups, motivational interviewing, contingency management, and combinations of these interventions have been modified for adolescents. In this article, we review the research on these treatments, as they apply to dually diagnosed youth. Furthermore, we explore the evidence for various treatments targeting comorbid SUD, specific to the presence of externalizing or internalizing disorders. The current evidence base supports the importance of integrated treatment targeting both SUD and psychiatric disorders simultaneously. High-quality treatment programs offering combinations of behavioral and family therapy, particularly with motivational interviewing and contingency management, are particularly well supported. In addition, we review various psychotropic medication treatments that have also been studied in conjunction with adolescent SUD treatment. Finally, we review research on post-treatment, supportive care that has been shown to improve long-term SUD outcomes. Recently conceptualized modular treatments, which offer personalized combinations of evidence-based treatments for specific disorders, have been proposed as a means of improving outcomes. Future research on modular programs must test the efficacy of individualized treatments when applied to combinations of psychiatric and SUDs in adolescents.

Point Prevalence of Co-Occurring Behavioral Health Conditions and Associated Chronic Disease Burden Among Adolescents

OBJECTIVE

To examine the point prevalence of behavioral health conditions (BHCs) and co-occurring chronic medical conditions among adolescents in an integrated health system.

METHOD

The sample consisted of adolescents in an integrated health care system diagnosed with at least 1 of the 5 most prevalent BHCs in 2014 (n = 30,643), and patients without a BHC matched on age, sex, and medical home facility (n = 30,643). Electronic health record data was used to identify all adolescents aged 11 to 18 years with at least 1 BHC diagnosis on their diagnosis list, which included current and pre-existing diagnoses from an outpatient (including psychiatry and chemical dependency specialty treatment), inpatient, or emergency department visit at a Kaiser Permanente Northern California (KPNC) facility between January 1, 2014, and December 31, 2014. The odds of having general medical conditions and specific chronic diseases were compared between adolescents with and without BHCs.

RESULTS

Among adolescents with at least 1 BHC in 2014, the 5 most common BHCs were: depressive disorders (42%), anxiety disorders (40%), attention-deficit/hyperactivity disorders (ADHDs; 37%), substance use disorders (SUDs; 10%), and bipolar spectrum disorders (8%). Overall, patients with a BHC did not have higher odds of any medical comorbidity compared with non-BHC patients. However, compared to individuals without BHCs, adolescents with depression (odds ratio [OR] = 1.16, 95% CI = 1.08-1.26), anxiety (OR = 1.30, 95% CI = 1.20-1.41), and substance use (OR = 1.25, 95% CI = 1.05-1.49) disorders had significantly higher odds of any medical comorbidities; individuals with ADHD and bipolar disorder did not differ from patients without BHCs.

CONCLUSION

BHCs were common and were associated with a disproportionately higher burden of chronic medical disease among adolescents in a large, private health care delivery system. As comorbidity can lead to elevated symptom burden, functional impairment, and treatment complexity, the study findings call for implementation of effective collaborative models of care for these patients.

Comparative health systems research among Kaiser Permanente and other integrated delivery systems: a systematic literature review

CONTEXT

Because of rising health care costs, wide variations in quality, and increased patient complexity, the US health care system is undergoing rapid changes that include payment reform and movement toward integrated delivery systems. Well-established integrated delivery systems, such as Kaiser Permanente (KP), should work to identify the specific system-level factors that result in superior patient outcomes in response to policymakers' concerns. Comparative health systems research can provide insights into which particular aspects of the integrated delivery system result in improved care delivery.

OBJECTIVE

To provide a baseline understanding of comparative health systems research related to integrated delivery systems and KP.

DESIGN

Systematic literature review.

METHODS

We conducted a literature search on PubMed and the KP Publications Library. Studies that compared KP as a system or organization with other health care systems or across KP facilities internally were included. The literature search identified 1605 articles, of which 65 met the study inclusion criteria and were examined by 3 reviewers.

RESULTS

Most comparative health systems studies focused on intra-KP comparisons (n = 42). Fewer studies compared KP with other US (n = 15) or international (n = 12) health care systems. Several themes emerged from the literature as possible factors that may contribute to improved care delivery in integrated delivery systems.

CONCLUSIONS

Of all studies published by or about KP, only a small proportion of articles (4%) was identified as being comparative health systems research. Additional empirical studies that compare the specific factors of the integrated delivery system model with other systems of care are needed to better understand the "system-level" factors that result in improved and/or diminished care delivery.

12-step participation and outcomes over 7 years among adolescent substance use patients with and without psychiatric comorbidity

This study examines the associations between 12-step participation and outcomes over 7 years among 419 adolescent substance use patients with and without psychiatric comorbidities. Although level of participation decreased over time for both groups, comorbid adolescents participated in 12-step groups at comparable or higher levels across time points. Results from mixed-effects logistic regression models indicated that for both groups, 12-step participation was associated with both alcohol and drug abstinence at follow-ups, increasing the likelihood of either by at least 3 times. Findings highlight the potential benefits of 12-step participation in maintaining long-term recovery for adolescents with and without psychiatric disorders.

Twelve-Step attendance trajectories over 7 years among adolescents entering substance use treatment in an integrated health plan

AIMS

This study examines 12-Step attendance trajectories over 7 years, factors associated with the trajectories, and relationships between the trajectories and long-term substance use outcomes among adolescents entering out-patient substance use treatment in a private, non-profit integrated managed-care health plan.

DESIGN

Longitudinal observational study.

SETTING

Four Kaiser Permanente Northern California substance use treatment programs.

PARTICIPANTS

A total of 391 adolescents entering treatment between 2000 and 2002 who completed at least one follow-up interview in year 1, and at least one during years 3-7, after treatment entry.

MEASUREMENTS

Alcohol and drug use, 12-Step meeting attendance and activity involvement and post-treatment medical service utilization.

FINDINGS

Semiparametric group-based modeling identified three distinct 12-Step attendance trajectory groups over 7 years: low/no attendance (60%), early but not continued (26%) and continued (14%). There were lower proportions of males and of adolescents with prior substance use treatment experience in the low/no attendance group (P = 0.019 and P = 0.003, respectively). In addition, those in the low/no attendance group had lower perception on circumstances, motivation and readiness for treatment at baseline (P = 0.023). Multivariate logistic generalized estimating equation analyses found that those in the continued group were more likely to be abstinent from both alcohol and drugs during follow-ups than those in the low/no attendance group [odds ratio (OR) = 2.40, P = 0.003 and OR = 1.96, P = 0.026, respectively]. However, no differences in long-term outcomes were found between those in the other two groups.

CONCLUSION

Robust connection with 12-Step groups appears to be associated with better long-term outcomes among adolescents with substance use disorders.

What Adolescents Need to Prevent Relapse after Treatment for Substance Abuse: A Comparison of Youth, Parent, and Staff Perspectives

OBJECTIVE

Little is known about what factors and supports youths identify as important for their sustained recovery after substance abuse treatment, and if their caregivers and treatment staff identify similar needs. The purpose of this study was to explore what youths, caregivers, and staff perceive as important to remain substance free after completing a residential treatment program.

METHODS

Semi-structured interviews were conducted with 28 adolescents, 30 parents, and 29 staff at 3 treatment agencies. Data were coded thematically and themes were organized by respondent type.

RESULTS

There was high frequency and concordance across respondents regarding the need for aftercare services, supportive relationships, and activities. Only one item, outpatient treatment, demonstrated significant differences across groups.

CONCLUSIONS

External supports and activities are important to recovery of adolescents from substances following treatment completion. Implications and potential areas of inquiry are discussed.

Peer influences on adolescent alcohol and other drug use outcomes

PURPOSE

To examine the role of family environment and peer networks in abstinence outcomes for adolescents 1 year after intake to alcohol and other drug (AOD) treatment.

DESIGN

Survey of 419 adolescents 13 to 18 years of age at consecutive intakes to AOD treatment programs at four sites of a large health system, with telephone follow-up survey 1 year after intake.

METHODS

Examined association of 1-year abstinence with baseline characteristics. Using logistic regression, we examined characteristics predicting 1-year abstinence and predicting having fewer than four substance-using friends at 1 year.

RESULTS

We found that family environment scores related to family conflict, limit setting, and positive family experiences, were not related to abstinence outcomes, but peer networks were related. Adolescents with fewer (less than four) AOD-using friends were more likely to be abstinent than those with four or more AOD-using friends (65% vs. 41%, p= .0002). Having fewer than four AOD-using friends at intake predicted abstinence at 1 year (odds ratio [OR]= 2.904, p= .0002) and also predicted having fewer than four AOD-using friends at 1 year (OR= 2.557, p= 0.0007).

CONCLUSIONS

Although family environment is an important factor in the development of AOD problems in adolescents, it did not play a significant role in treatment success. The quality of adolescent peer networks did independently predict positive outcomes.

CLINICAL RELEVANCE

For physicians, advanced practice registered nurses, and other primary and behavioral care providers who screen and care for adolescents with AOD and other behavioral problems, our finding suggest the importance of focusing on improving the quality of their peer networks.

Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model

OBJECTIVES

How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry.

METHODS

In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure.

RESULTS

A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without.

CONCLUSIONS

Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model

OBJECTIVES

How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry.

METHODS

In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure.

RESULTS

A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without.

CONCLUSIONS

Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

A review of Alcoholics Anonymous/ Narcotics Anonymous programs for teens

The investigation of the applicability of Alcoholics Anonymous/Narcotics Anonymous (AA/NA) for teens has only been a subject of empirical research investigation since the early 1990s. In the present review, the author describes teen involvement in AA/NA programming, provides an exhaustive review of the outcomes of 19 studies that used an AA/NA model as part of their formal teen substance abuse treatment programs, and provides data on the effects of AA/NA attendance on abstinence at follow-up, on which youth tend to become involved in AA/NA, and on mediation of the benefits of AA/NA participation. In addition, the author suggests the reasons for somewhat limited participation by teens in more informal, community-based 12-step meetings, and makes suggestions for maximizing participation at meetings in the community. The author concludes that AA/ NA participation is a valuable modality of substance abuse treatment for teens and that much can be done to increase teen participation, though more research is needed.