Tennessee s Adolescents in Publicly-Funded Treatment for Substance Abuse Problems: Baseline Interview Findings for TennCare Beneficiaries

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1 Center for Mental Health Policy Vanderbilt Institute for Public Policy Studies Vanderbilt University Tennessee s Adolescents in Publicly-Funded Treatment for Substance Abuse Problems: Baseline Interview Findings for TennCare Beneficiaries The IMPACT Study July 2000 Craig Anne Heflinger, Ph.D., Principal Investigator Celeste G. Simpkins, Research Associate

2 Center for Mental Health Policy Vanderbilt Institute for Public Policy Studies Vanderbilt University Tennessee s Adolescents in Publicly-Funded Treatment for Substance Abuse Problems: Baseline Interview Findings for TennCare Beneficiaries The IMPACT Study July 2000 Craig Anne Heflinger, Ph.D., Principal Investigator Celeste G. Simpkins, Research Associate For questions or comments, please contact Dr. Heflinger at (615) or For additional copies of this report: FREE at or send $15 to Vanderbilt University attn: Resource Specialist, Center for Mental Health Policy, th Avenue, South, Nashville, TN TENNESSEE S ADOLESCENTS IN PUBLICLY-FUNDED TREATMENT FOR SUBSTANCE

3 Table of Contents Executive Summary...i Purpose and Overall Design of the IMPACT Study...1 Sample...3 Data Collection Methods...5 Youth Behavioral Health Status: Substance Use, Symptoms, Psychosocial Functioning, and SED Status...6 Alcohol or Drug Use...6 Type, Amount and Method of Substance Use...7 Consequences of Alcohol or Drug Use...11 Diagnostic Indicators of Substance Abuse or Dependence...13 Emotional and Behavioral Symptoms...14 Psychosocial Functioning...16 Classification of Youth as Having a Serious Emotional Disorder...16 Youth Taking Medication for Emotional and Behavioral Problems...18 Co-Occurring Substance and Mental Disorders...20 Issues Surrounding Admission to Current Treatment...20 Type of Current Treatment and Referral Source...20 Waiting for and Coming to Treatment Admission...22 Residence Immediately Prior to Treatment Admission...23 Satisfaction with the Intake Process...25 Current Motivation for Substance Abuse Treatment...26 Length of Stay at Current Treatment...27 Youth Health Issues...28 Global Ratings of Health Status...28 Weight Status...28 Chronic Health Conditions and Injuries...29 Risk Behavior...29 History of Behavioral Health Services Use...32 Educational Status...34 History of Juvenile Court Involvement...35 References...37 Appendix A...40 Appendix B...41 Appendix C...44

4 Table of Tables Table 1: Demographic Characteristics of the Interview Sample...4 Table 2. Alcohol or Drug Use...7 Table 3. Substances Used...8 Table 4. Level and Method of Use (for those with any use of the drug during the past 6 months)...9 Table 5. Consequences of Alcohol or Drug Use During Past 6 Months...11 Table 6. Consequences of Substance Use: Summary Scores...12 Table 7: Diagnostic Indicators...13 Table 8: Youth Scores on the Youth Self Report (YSR)...14 Table 9. Youth with Scores in the Borderline or Clinical Range on the YSR Subscales...15 Table 10. Columbia Impairment Scale (CIS)...16 Table 11. Emotional/Behavioral Symptoms by Level of Psychosocial Functioning...17 Table 12. Psychotropic Medication...18 Table 13. Psychotropic Medication: Type Prescribed as a Proportion of all Youth...19 Table 14. Co-Occurring Emotional/Behavioral and Substance Abuse or Dependence...20 Table 15. Issues Surrounding Treatment...21 Table 16. Admission Issues...23 Table 17. Residence Immediately Prior to Treatment Admission...24 Table 18. Satisfaction with Intake Process at Current Provider...25 Table 19. Motivation for Treatment...26 Table 20. Length of Stay...27 Table 21. Youth Global Health Status...28 Table 22. Weight Status Rating...28 Table 23. Chronic Health Conditions and Injuries Past 6 Months...29 Table 24. Risk Behaviors...30 Table 25. Ever Used Services for Substance Abuse, Emotional or Behavioral Problems..32 Table 26. Residential Treatment and Other Residences in Past 6 Months...33 Table 27. Highest Grade Completed...34 Table 28. Criminal Justice History...35 TENNESSEE S ADOLESCENTS IN PUBLICLY-FUNDED TREATMENT FOR SUBSTANCE

5 Tennessee s Adolescents in Publicly-Funded Treatment For Substance Use Problems The IMPACT Study Baseline Report on Interview Data For TennCare Beneficiaries Executive Summary The IMPACT Study was funded by the United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration as part of a national study of the impact of managed care on vulnerable populations. 1 The Center for Mental Health Policy at Vanderbilt University s Institute for Public Policy Studies, under the direction of Dr. Craig Anne Heflinger, is conducting an evaluation of the Medicaid programs in Mississippi and Tennessee (TennCare). The Impact Study is a collaboration between academic, government, providers, and consumer and advocacy groups in both states. The TennCare program participates as a managed care site since the state received a HCFA 1115 Medicaid waiver in 1994; in 1996 the mental health and substance abuse services became a managed care carve out program called TennCare Partners. The focus of the project is on TennCare behavioral health services; however, all services under the TennCare program will be included in several components of the study. In addition, all publicly-funded treatment programs for adolescents with substance abuse problems are included. This report focuses on information from a baseline interview with 262 TennCare youth who were entering publicly-funded treatment for substance use problems. Publicly-funded treatment included inpatient, residential, and outpatient services provided through the TennCare Partners Program, the Substance Abuse Prevention and Treatment Block Grant administered by the Tennessee Department of Health Bureau of Alcohol and Drug Abuse Services, and contracts with the Tennessee Department of Children s Services. All youth were TennCare beneficiaries, although their treatment was most often paid by another source (see pages 4-5). Findings are reported in detail in the accompanying report. Highlighted findings include: Youth in publicly funded treatment were primarily male and white. The male to female ratio was approximately 3:1. The white to African-American ratio was approximately 2:1 (see pages 3-4). While youth in outpatient treatment were generally able to access treatment close to home, some youth had to travel up to 200 miles from home for inpatient or residential treatment for substance use problems (see pages 4-5). 1 UR7 TI11304 from the Center for Substance Abuse Prevention and UR7 TI11332 from the Center for Substance Abuse Treatment (Principal Investigator: Craig Anne Heflinger). See for more information. i

6 Although all youth in treatment had a history of substance use, only 40% reported active use during the month immediately prior to admission (see page 7). Half (48%) of the youth were in some type of restrictive or controlled placement immediately prior to being admitted to treatment for substance abuse problems (see page 24), which influenced their reports of recent substance use. Primary substance use reported by Tennessee youth in publicly-funded treatment was alcohol and cannabis. Most youth reported poly-substance use, with one third using 4 different types of substances over the past 6 months (see pages 6-10). The most frequently reported consequences of substance use among all youth were interpersonal problems related to use, dangerous behavior, interference with role obligations (family, work, school), and excessive use (see pages 11-12). Based on reported substance use and related consequences, 92% appeared to meet diagnostic criteria for substance abuse or dependence (see page 13). Approximately 21% of the inpatient/residential youth, and 25% of those admitted to outpatient programs met criteria for substance abuse. Seven of ten (70%) of the youth admitted to inpatient/residential, and 67% of the youth admitted to outpatient programs could be classified as having substance dependence. One quarter of the youth in publicly-funded substance use treatment had co-occurring substance and mental disorders (see page 20). Note that this is considered lower than actual prevalence of co-occurrence since many youth with co-occurring disorders are not admitted to substance abuse treatment (see page 20). Over one-third (35%) of the youth were exhibiting emotional and behavioral problems of a high enough level to be classified as in the clinical range, in need of treatment. Problems with delinquent behavior were the most prevalent type of emotional/behavioral problems reported in this population, followed by attention and aggression problems (see pages 14-15). Overall, more than one-quarter (27%) of the total youth who had been admitted to publicly-funded services for substance use problems also met criteria as having a serious emotional disorder at the time of the interview (see pages 16-17). Over one quarter of youth in treatment for substance use problems had been prescribed medication for emotional or behavioral problems. The most frequently prescribed type of medication for emotional and behavioral problems was antidepressants. Almost one quarter (21%) of all youth in treatment for substance use problems were taking prescribed antidepressants (see pages 18-19). Youth in substance abuse treatment frequently had co-occurring physical health problems, as well. One in six (16%) of the youth in treatment were overweight or obese. Many reported chronic diseases or injuries in need of medical treatment. This group of youth also reported health risks regarding unsafe sexual practices (see pages 28-31). Youth in state custody, and youth who were admitted to inpatient/residential treatment were significantly more likely to have been in controlled settings, such as juvenile detention or diagnostic shelters, while they waited to be admitted to treatment (see pages 22-24). ii

7 Almost half of the youth (45%) reported a history of residential services at some point prior to the current admission for substance use treatment (see pages 32-34). Educational problems were also evident for this population of youth. Two-thirds (69%) of the youth in treatment were placed one to two years behind their age-determined grade level (see page 34). The juvenile court system played a key role for youth admitted to treatment: Overall, almost two thirds (64%) of the youth reported that they had been court-ordered into treatment (see page 21). Approximately one in five (17% of the youth overall, 22% of those in custody) of the youth waited in juvenile detention centers an average of 29 days before being admitted to treatment (see page 24). Almost all the youth had recent contact with the juvenile courts. The most frequent contact with the juvenile justice system over the past 6 months was some type of status or criminal charges (73%) including drug-related offenses, property crimes, and crimes against persons -- or time in a jail/detention or correctional facility (72%) (see pages 35-36). iii

8 Tennessee s Adolescents in Publicly-Funded Treatment for Substance Use Problems: Baseline Interview Findings Purpose and Overall Design of the IMPACT Study The IMPACT Study was funded by the United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) as part of a national study of the impact of managed care on vulnerable populations. 2 In response to GFAs TI and from the Substance Abuse and Mental Health Services Administration (SAMHSA) (U.S. Department of Health and Humans Services) and as part of their Cooperative Agreements for Managed Care, the Center for Mental Health Policy at Vanderbilt University s Institute for Public Policy Studies (VIPPS) is conducting an evaluation of the Medicaid programs in Mississippi and Tennessee. The TennCare program participates as a managed care site since the state received a HCFA 1115 Medicaid waiver in 1994; in 1996 the mental health and substance abuse services became a managed care carve out program called TennCare Partners. The focus of the project is on TennCare behavioral health services; however, all services under the TennCare program will be included in several components of the study. 3 In addition, all publicly-funded treatment programs for adolescents with substance abuse problems are included. This project is part of a national study that includes 13 states and examines four population groups: children with serious emotional disorders, adolescents with substance abuse problems, adults with serious mental illness, and adults with chemical dependence. Information on the national study is available at To meet the overarching goals, this project is organized into four related components: 1) The Standardized Interview component is a prospective study based on the national common protocol. This component follows a sample of publicly funded adolescents entering treatment for substance abuse problems. 4 Interviews were held with all adolescents and, when available and the youth gave consent, their parents (or the designated most knowledgeable caregiver) at three points in time, six months apart over the course of a year. 5 This report focuses on information from a baseline interview with 262 TennCare youth who were entering publicly-funded treatment for substance use problems. Publicly-funded treatment included inpatient, residential, and outpatient services provided through the TennCare Partners Program, the Substance Abuse Prevention and Treatment Block Grant administered by the Tennessee Department of Health 2 UR7 TI11304 from the Center for Substance Abuse Prevention and UR7 TI11332 from the Center for Substance Abuse Treatment (Principal Investigator: Craig Anne Heflinger). 3 See for a link to the IMPACT Study reports that are available on various aspects of the study. 4 See Appendix A for a list of participating provider agencies. 5 See Appendix B for a description of the interview components. 1

9 Bureau of Alcohol and Drug Abuse Services, and contracts with the Tennessee Department of Children s Services. 2) The In-Depth component is an addendum to the standardized interview data and was collected at 6 months after the baseline interview for a subsample of adolescents. For these youth, the standardized interview was enhanced by a series of professional treatment-related interviews and record reviews to provide a comprehensive description of their experiences during the six months between admission to treatment (at Wave 1 interview) and the Wave 2 interview. This component will be the focus of a future report. 3) The Administrative Data component relies on TennCare enrollment and claims data and management information system data from the Tennessee Department of Health Bureau of Alcohol and Drug Abuse Services about services funded through the Substance Abuse Prevention and Treatment Block Grant (from SAMHSA), both statewide and for a subsample of children and adolescents that participated in the standardized interview component. There will be series of future reports on administrative data. 4) The Implementation Study component builds on stakeholder interviews and document analyses to describe the system of publicly-funded treatment for adolescents with substance abuse problems in Tennessee. This will also be the focus of a future report. The Impact Study is a collaboration between academic, government, providers, and consumer and advocacy groups in the states of Tennessee and Mississippi. The VIPPS Center for Mental Health Policy has collaborated with: State agencies that provided data and other support for the project: the Tennessee Department of Mental Health and Mental Retardation, Tennessee Department of Health Bureau of Alcohol and Drug Abuse Services, Tennessee Department of Children s Services, the TennCare Bureau; and the Tennessee Commission on Children and Youth, which collected interview and in-depth case review data for the project; Advocacy agencies and provider groups: Tennessee Voices for Children, which also collected interview data using the standardized interview protocol; the Alcohol and Drug Council of Middle Tennessee, which helped with participant recruitment and in-depth case reviews; and a network of mental health and substance abuse providers across the state. It should be noted that the IMPACT Study also follows a representative sample of TennCare children and youth that are the focus of another series of reports. 6 This report is the first in a series of reports about Tennessee s publicly-funded adolescents with substance use problems and includes information from a baseline youth interview on their behavioral health issues, health status, history of past service use, and satisfaction with intake to the target provider. 6 See for a link to the IMPACT Study reports that are available on various aspects of the study. 2

10 Sample All youth were recruited from Tennessee behavioral health providers who were serving youth with substance abuse problems through public funds (see Appendix A for a listing). Providers were asked to refer youth who met the following criteria: Had just entered treatment for substance use issues and/or had a primary or secondary diagnosis of some type of substance abuse or dependence; Were TennCare beneficiaries at the time of admission (whether or not TennCare was paying for the treatment); 7 and Were between the ages of 12 and 17 years at the date of their first interview. A total of 421 referrals were received and 262 youth were interviewed. 8 Information below is presented in the following manner: First, information is provided by the type of service to which the youth were admitted (inpatient/residential service, n=214; some type of outpatient treatment, n=48). The next set of columns presents information on youth by custody status (in state custody, n=174; not in custody, n=88). The last column indicates the information for all youth who participated in the study (n=262). A series of tables is also included in Appendix C that displays the findings by custody status within service type, so that youth in custody and not in custody can be compared with those in inpatient/residential services and in outpatient treatment. Table 1 describes demographic characteristics of the youth. Youth in publicly funded treatment were primarily male and white. The male to female ratio was approximately 3:1. The white to African-American ratio was approximately 2:1. The youth interviewed from inpatient/residential services were three-quarters male (78%), corresponding to those in all treatment settings (76%) and slightly more than those in outpatient programs (65%). Females outnumbered males only for those in outpatient programs who were in state custody (58% female) (see Appendix C-1). A proportion of 3:1 male:female is similar to other reports of treated children and youth. Youth were almost two-thirds white (63%) and one quarter (28%) African-American. This proportion differs somewhat from census reports for this age group for all Tennesseans of 79% white and 20% African-American. All youth ranged in age from 12 to 17 years of age, with a mean age of 15 years and 11 months. Youth in outpatient services tended to be younger than those in inpatient/residential programs. While youth in outpatient treatment were generally able to access treatment close to home, some youth had to travel up to 200 miles from home for inpatient or residential treatment for substance use problems. Youth came from a variety of home counties, with three quarters (77%) in urban or mixed (those counties surrounding an urban area) settings. Those attending outpatient programs generally traveled less distance to the service, on average miles, with a range of 0 to 39 miles. 7 See Table 1 for information on expected payment sources. 8 Note that this is a convenience sample of youth who were referred by their treatment providers, rather than a random or representative sample. The representativeness of this sample will be the subject of future analyses. 3

11 Table 1: Demographic Characteristics of the Interview Sample Service Status Inpatient/ Outpatient Residential 9 All Youth Gender* Male 78%* 65% 77% 75% 76% Female 22% 35%* 23% 25% 24% Race/ Ethnicity American Indian 3% - 1% 3% 2% Asian/Pacific Islander 2% 2% 1% 2% 2% African-American 29% 23% 27% 29% 28% White 61% 73% 66% 62% 63% Other 5% 2% 5% 5% 5% Hispanic 1 3% 2% - 5% 3% Age* 14 Years and Younger 10% 23% 15% 12% 13% 15 Years 19% 19% 18% 20% 19% 16 Years 34% 29% 31% 34% 33% 17 Years and Older 37% 29% 36% 35% 35% Mean Age (Years) 16.0* Urbanization Rural 22% 28% 26% 22% 23% Rural Youth Who Traveled Less Than 60 Miles to Treatment 70% 100% 75% 78% 77% Mixed 42% 38% 38% 43% 41% Urban 36% 34% 36% 35% 36% Urban Youth Who Traveled Less Than 30 Miles to Treatment 89% 100% 100% 86% 91% Distance from Home Mean # Miles (range) 37.7* (0-201) 12.7 (0-39) 33.9 (0-201) 32.7 (0-178) 33.1 (0-201) Status 72%* 40% - 100% 66% Expected Primary Payment Source 10 TennCare 21% 83% 84% 6% 32% DCS Contract 72% - 0% 89% 59% Block Grant 7% 17% 16% 5% 9% Number of Youth Note, youth were designated as Hispanic in addition to their primary racial group, so race sums to 100% and youth designated as Hispanic is additional. * Differences were tested within service (Inpatient/Residential versus Outpatient) and custody status (In versus Not) by chi-square tests for categorical variables and analysis of variance with t-tests for continuous variables. An asterisk (*) indicates differences a re significant at p <.05 for this, and all future tables. 9 Thirty-two (32) youth or 12% of the overall sample were in inpatient settings and 182 youth (70%) were in residential treatment. Since some of the inpatient providers were RTC-IV contractors for DCS, these levels of care were combined for this report. 10 This information was supplied by the provider agency at the time of recruitment. Further analyses of actual service files from BADAS and TennCare will be analyzed for more information. 4

12 The distance to inpatient/residential from the youth s homes ranged from 0 to 201 miles, with an average of 33.1 miles. Long distances between treatment and the youth s home community can interfere with family involvement, transition planning, and aftercare. Some states have adopted standards for their managed care Medicaid programs that patients in urban areas be served by providers within 30 miles and those in rural areas, within 60 miles. When payment source (see discussion below) and miles traveled to treatment is examined, rural youth in block grant services meet the standard best: Block grant: rural youth 100% within 60 miles, urban youth 100% within 30 miles, and youth from mixed counties (surrounding urban areas) 44% within 30 miles or 94% within 60 miles; DCS contractors (all residential treatment): rural youth 71% within 60 miles, urban youth 86% within 30 miles, and youth from mixed counties 46% within 30 miles or 70% within 60 miles; and TennCare-paid services: rural youth 77% within 60 miles, urban youth 100% within 30 miles, and youth from mixed counties 53% within 30 miles or 70% within 60 miles. According to the above information, block grant-provided services most often met the criteria for rural youth or those from rural counties surrounding major metropolitan areas (using the 60 mile criteria) and urban youth (using the 30 mile criteria). For all three funding sources, the youth in mixed counties (rural counties surrounding major metropolitan areas) appeared to have the most problems meeting the 30 mile or 60 mile criteria for service delivery. Expected primary payment source is also listed in Table 1. Although all youth had TennCare, only one third of them (32%) were expected to be paid for by TennCare. The primary payment source was expected to be contracts with the Tennessee Department of Children s Services (DCS), which was due to the large proportion of youth in custody and in residential treatment (see Appendix C-1). The block grant funds from the Tennessee Department of Health, Bureau of Alcohol and Drug Abuse Services were considered primary payment source for only 9% of the youth, but all block grant providers confirmed that block grant support of their programs was necessary even when TennCare or DCS contract funding was available. 11 Three-quarters (72%) of the youth in the sample were being treated in programs that received block grants (see Appendix A for a listing of the programs). Data Collection Methods A two-step process was used to recruit potential participants and inform them about the study. Participating providers (see Appendix A) were trained on the study and given packets of recruitment material. They were asked to identify youth who were entering treatment at their agency who met the study criteria (see above) within two weeks of admission. At that time, they told the youth about the study and if the youth was interested in finding out more about the study, he/she gave written consent to the referring provider agency to provide background information to the study (for example: demographics, contact information, type of treatment, anticipated payment source) and to be contacted about the study. Providers were also asked to contact the youth s parent or legal guardian about the study and, in a few cases, written consent was also obtained from the parent/guardian. 11 This issue will be discussed in detail in Northrup and Heflinger (in preparation). 5

13 Once the IMPACT Study staff had the recruitment materials, they contacted the youth and made arrangements to schedule an in-person informed consent process. If the youth continued to agree to participate, the interview was administered. If parent/guardian participation had not yet been obtained, the interviewer obtained their contact information from the youth and got written consent from the youth to contact that person. On several occasions, the youth refused to give such consent, and Vanderbilt did not contact the parent/guardian. When parent/guardian contact information was given, the IMPACT Study staff similarly called and made arrangements for an in-person informed consent process. If the parent/guardian agreed to participate at that point, the interview was administered. Several (15%) parents/guardians were unable to be contacted after multiple attempts, some (10%) refused to participate after being contacted, and 118 participated in interviews. The information from this report is from the baseline youth interview, which was obtained from all youth, unless specifically otherwise noted. These interviews took place, on average, after the youth had been in treatment at the referring substance abuse program for four weeks. The youth were asked to describe their level of substance use prior to starting treatment to function as a baseline for future examination of treatment outcomes. Interviews were scheduled again approximately 6 months after the date of admission, and 1 year after the date of admission. The information from the follow-up interviews will be the subject of future reports. The Interview Protocols contained a series of standardized questionnaires (see Appendix B for a listing and description), other items included as part of the national study, and a series of sitespecific questions. Interviews were conducted by trained interviewers who were required to attend and complete training, then conduct and be screened on pilot administrations of the interview. Youth Behavioral Health Status: Substance Use, Symptoms, Psychosocial Functioning, and SED Status Youth behavioral health status was measured in several ways. First, patterns of substance use are described. Next, emotional and behavioral symptoms and the youth s psychosocial functioning levels are reported. This information is used to determine whether the youth met the criteria to be classified as having a serious emotional disorder and the prevalence of cooccurring substance and mental disorders among this population. Alcohol or Drug Use Types and amount of substance use was determined through subscales of the Addiction Severity Index (ASI) 12 and the Comprehensive Addiction Severity Index for Adolescents (CASI) 13 (see Appendix B). This information is presented in Table Fureman, Parikh, Bragg, & McLellan (1990). 13 Meyers (1996). 6

14 Alcohol or Drug Use* Table 2. Alcohol or Drug Use Service Status Outpatient Inpatient/ Residential All Youth Yes, -Ever used 100% 100% 100% 100% 100% Yes, Past 6 mos. 90% 90% 95% 87% 90% Yes, Past month 36% 58%* 56%* 32% 40% AoD Use Consequences 14 96% 92% 96% 95% 95% Age at First Use (mean years) Number of Children All of the youth reported using alcohol or other drugs at some point during their lifetime. The average age of first use for this group of youth was 11.4 years with a range from 4 to 16 years. Although all youth in treatment had a history of substance use, only 40% reported active use during the month immediately prior to admission. Most (90%) of the youth reported using alcohol or other drugs during the past six months. Fewer (40%) reported use in the month prior to admission to treatment. Those from inpatient/residential services settings who were in state custody (see Appendix C-2) reported less use during the month prior to admission (29%), while those in outpatient programs who were not in state custody report greater use (62%) during the month prior to treatment. The drops in the percentages who used any alcohol or drugs (from past 6 months to past month use) are likely related to the placements in which these youth were living in the month prior to the current treatment admission (see section on Service Use, Table 17, below) and the lesser likelihood of use in controlled settings such as hospitals, residential treatment facilities, and jail, where the youth were monitored 24 hours per day. Type, Amount and Method of Substance Use Table 3 shows the types of substances reported by the youth, and whether they reported their use ever, in the past six months, or the past month prior to admission to treatment. Primary substance use reported by Tennessee youth in publicly-funded treatment was alcohol and cannabis. Most youth reported poly-substance use, with one third using 4 different types of substances over the past 6 months. Although a wide variety and combinations of substance use was reported by these youth, the primary substances reported (ever, past 6 months, past month) were some form of cannabis and alcohol. Three quarters of the youth reported drinking (75%) in the past 6 months with more (84%) smoking cannabis. One quarter of the youth reported cocaine (29%) or opiate (22%) use in the past 6 months by either nasal or smoking. Other drugs reported by over 10% of the youth for the past 6 months included amphetamines, barbiturates, inhalants, hallucinogens, methamphetamines, and prescription/over the counter drugs. 14 Consequences were formed from items designed to measure the interference in daily living that have come about as a result of alcohol or drug use: for example, being fired from a job or expelled from school. 7

15 Table 3. Substances Used Service Outpatient Inpatient/ Residential Status All Youth Alcohol Ever used 96% 90% 94% 95% 95% Used past 6 mos 77%* 65% 77% 74% 75% Used past month 24% 31% 33% 22% 26% Cannabis Ever used 99% 98% 100% 98% 98% Used past 6 mos 85% 81% 91% 81% 84% Used past month 27% 52%* 48%* 24% 32% Cocaine Ever used 54% 44% 54% 51% 52% Used past 6 mos 31% 21% 34% 27% 29% Used past month 5% 17%* 13% 5% 7% Crack Ever used 23% 25% 23% 24% 24% Used past 6 mos 10% 8% 11% 9% 9% Used past month 1% 2% 2% 1% 1% Methamphetamine Ever used 21% 19% 24% 19% 21% Used past 6 mos 14% 11% 18% 10% 13% Used past month 3% 6% 3% 3% 3% Other Amphetamines Ever used 27% 37% 28% 29% 29% Used past 6 mos 15% 17% 19% 13% 15% Used past month 3% 6% 5% 3% 4% Barbiturates Ever used 24% 21% 29% 20% 23% Used past 6 mos 14% 13% 18% 11% 13% Used past month 6% - 7% 3% 5% Inhalants Ever used 32% 40% 33% 34% 34% Used past 6 mos 11% 13% 10% 12% 11% Used past month 2% 8% 1% 5% 3% Hallucinogens Ever used 42% 46% 47% 40% 42% Used past 6 mos 20% 19% 23% 18% 19% Used past month 2% 8% 5% 3% 3% Opiates Ever used 39% 48% 40% 41% 40% Used past 6 mos 22% 23% 27% 19% 22% Used past month 3% 13%* 6% 5% 5% Methadone Ever used 5% 4% 7% 4% 5% Used past 6 mos 1% - 3% - 1% Used past month 1% - 1% - <1% Prescription drugs /OTC drugs Ever used to get high 16% 19% 18% 15% 16% Used past 6 months 11% 13% 10% 12% 12% Used past month 3% 10% 3% 5% 5% 8

16 Service Status Inpatient/ Outpatient All Youth Residential Poly-Substance Use (past 6 months) No, only 1 substance used 22% 23% 19% 24% 23% Two substances used 27% 25% 27% 29% 28% Three substances used 15% 21% 16% 16% 16% Four or more substances used 36% 31% 38% 31% 33% Total Youth More than three-quarters (77%) of the youth reported using more than one type of substance in the past 6 months, and one-third used four or more substances during this period. The most prevalent combinations were alcohol and cannabis (70%); cannabis and cocaine (30%); alcohol and cocaine (29%). More than one-quarter (28%) reported using alcohol, cannabis and cocaine during 6 months prior to admission. Table 4 provides information on the level and method of substance use for those youth who had any substance use within the past 6 months. Table 4. Level and Method of Use (for those with any use of the drug during the past 6 months) Inpatient/ Residential Service Status All Youth Outpatient Alcohol Once a month or less 19% 43% 25% 21% 22% 2-3 times a month 24% 18% 27% 21% 23% Once a week 19% 18% 18% 20% 19% 2-6 times a week 27% 7% 14% 29% 24% Daily or more than once daily 12% 14% 16% 11% 12% Mean days used in past month More than 5 drinks per day Once a month or less 53% 66% 57% 53% 55% 2-3 times times a month 16% 10% 11% 17% 15% Once a week 10% 10% 9% 11% 10% 2-6 times a week 15% 7% 16% 12% 14% Daily 6% 7% 7% 6% 7% Cannabis Once a month or less 7% 6% 8% 7% 7% 2-3 times a month 4% 9% 8% 3% 5% Once a week 6% 9% 3% 8% 6% 2-6 times a week 26% 27% 23% 28% 26% Daily or more th an once daily 57% 50% 58% 54% 56% Mean days used in past month Cocaine and Crack Once a month or less 42% 36% 41% 41% 41% 2-3 times a month 12% 9% 7% 14% 11% Once a week 13% 9% 14% 12% 13% 2-6 times a week 13% 27% 24% 10% 15% Daily or more than once daily 20% 18% 14% 24% 20% Mean days used in past month Method Nasal 77% 64% 86% 69% 75% Smoking 20% 36% 14% 28% 23% Injection 2% - - 2% 2% 9

17 Service Status All Youth Inpatient/ Residential Outpatient Meth- & Other Amphetamines Once a month or less 48% 25% 47% 43% 44% 2-3 times a month 11% 38% 21% 11% 15% Once a week 4% 12% - 9% 6% 2-6 times a week 22% - 26% 14% 18% Daily or more than once daily 15% 25% 5% 23% 17% Mean days used in past month * 11.6 Method Oral 35% 63% 32% 75% 39% Nasal 37% - 37% 17% 32% Smoking 24% 37% 27% 8% 26% Inhalants Once a month or less 36% 67% 56% 36% 42% 2-3 times a month 32% - 22% 27% 26% Once a week 12% 33% - 23% 16% 2-6 times a week 12% - 11% 9% 10% Daily or more than once daily 8% - 11% 5% 7% Mean days used in past month Hallucinogens Once a month or less 49% 44% 55% 43% 48% 2-3 times a month 17% 44% 20% 23% 22% Once a week 19% - 15% 17% 16% 2-6 times a week 15% - 5% 17% 12% Daily or more than once daily - 12% 5% - 2% Mean days used in past month Method Oral 98% 100% 100% 97% 98% Smoking 2% - - 3% 2% Opiates Once a month or less 42% 40% 36% 46% 42% 2-3 times a month 18% 30% 23% 18% 20% Once a week 13% - 9% 12% 11% 2-6 times a week 16% 30% 18% 18% 18% Daily or more than once daily 11% - 14% 6% 9% Mean days used in past month Method Oral 83% 70% 73% 85% 80% Nasal 7% 10% 9% 6% 7% Smoking 4% 10% 9% 3% 5% Injection 6% 10% 9% 6% 7% Tobacco Use Smoking Cigarettes (% yes) 85% 92% 90% 85% 87% Other tobacco use (snuff, dipping, chewing)(% yes) 17% 15% 21% 14% 16% 10

18 Consequences of Alcohol or Drug Use The youth were also asked about a series of consequences of their substance use, using items from the Substance Use Disorders Diagnostic Schedule (SUDDS) 15 (see Appendix B). Often, the severity of alcohol or drug use is examined by including information on the consequences of use. The consequences of alcohol or drug use for these youth are reported in Table 5. Information on consequences for the past 6 months is reported. Table 5. Consequences of Alcohol or Drug Use During Past 6 Months Service Status Inpatient/ Outpatient Residential All Youth Took more for same effect 55% 60% 58% 55% 56% Withdrawal symptoms 25% 29% 33% 22% 26% Used to avoid or reduce 24% 17% 25% 22% 23% hangover Used when not intended to 42% 50% 54% 38% 44% Used longer than intended 56% 58% 64% 53% 57% Wanted to stop but couldn t 41% 48% 44% 41% 42% Set rules but failed to follow 42% 48% 45% 41% 43% Two days without sobering 49% 52% 52% 48% 50% up Unable to do something 36% 40% 37% 37% 37% planned Couldn t remember what 49% 44% 49% 48% 48% said/done Missed work or school 56% 42% 58% 51% 53% because of Trouble at work or school 43% 33% 41% 41% 41% Kicked out of school 29% 12% 25% 27% 26% So reckless someone could 36% 25% 41% 30% 34% be hurt Driven/ridden while using 77% 67% 83% 71% 75% Auto accident as a result 21% 12% 15% 22% 19% Arrested or stopped 37% 31% 42% 33% 36% Possession / sale 40% 29% 35% 39% 38% Family/friend objected to use 77% 71% 83% 72% 76% Became violent while using 47% 42% 57% 40% 46% Mean number of consequences endorsed Total Youth Harrison & Hoffman (1987). 11

19 Three quarters of the youth (76%) admitted that their families or friends had objected to their substance use during the past 6 months. They also reported many other consequences and risky behavior associated with their substance use: Three quarters (75%) admitted to either driving or riding in a car while using, with 19% being involved in an automobile accident as a result of substance use. They reported having to use more to get the same effect (56%), going at least two days without sobering up (50%), using longer than intended (57%), and using even when they had not intended to do so (44%). Two-thirds reported school or work problems related to substance use: 53% had missed school or work, 41% had gotten in trouble because of their use, and one quarter (26%) said they had been kicked out of school in the past 6 months due to substance use. Another way to look at consequences is to summarize the different types of consequences of substance use reported by the youth. Table 6 summarizes the information presented above. The most frequently reported consequences of substance use among all youth were interpersonal problems related to use, dangerous behavior, interference with role obligations (family, work, school), and excessive use. Table 6. Consequences of Substance Use : Summary Scores Service Status Inpatient/ Outpatient Residential All Youth Tolerance Problems 55% 60% 58% 55% 56% Withdrawal 36% 31% 39% 34% 36% Excessive Use 65% 69% 73% 62% 66% Cannot Stop Use 56% 60% 57% 57% 57% Time Spent in Use 49% 52% 52% 48% 50% Sacrifice Activities for Use 49% 46% 46% 49% 49% Counter Indicators to Use 49% 44% 49% 48% 48% Role Obligations 69% 52% 66% 66% 66% Interfered With Dangerous Behavior 80% 73% 88% 74% 79% While Using Substance-Related Legal 56% 48% 55% 54% 54% Problems Interpersonal Problems 83% 77% 89% 78% 82% Total Youth

20 Diagnostic Indicators of Substance Abuse or Dependence Levels of substance use were determined using a combination of information on amount of use and consequences of use. This approach was based on that of the DSM-IV 16 that requires the following criteria to be met: Substance Abuse: documentation of substance use and impairment, based on at least one of the following consequences: failure to fulfill major role obligations at work, school, or home; recurrent used in situations where it is physically hazardous; substance-related legal problems; or continued use despite interpersonal problems related to use. Approximately 21% of the inpatient/residential youth, and 25% of those admitted to outpatient programs met criteria for substance abuse (see Table 7). Substance Dependence: documentation of substance use and impairment indicated on at least three of the following: tolerance; withdrawal; excessive use; unsuccessful attempts to stop use; great deal of time spent in obtaining the substance or using; social, occupational, or recreational activities are given up or reduced due to use; or the substance is continued to be used despite knowledge of harmful effects. Based on reported substance use and related consequences, seven of ten (70%) of the youth admitted to inpatient/residential, and 67% of the youth admitted to outpatient programs could be classified as having substance dependence (see Table 7). 17 Table 7. Diagnostic Indicators Service Status Outpatient Inpatient/ Residential All Youth Diagnostic Indicator No diagnosis 6% 8% 5% 8% 6% Possible abuse 3% - - 3% 2% Abuse 21% 25% 27% 19% 22% Dependence 70% 67% 68% 70% 70% Total Overall, 9% of the youth admitted to inpatient/residential, and 8% of those admitted to outpatient programs were rated as no diagnosis or only possible abuse since their level of substance use over the past 6 months was reported as none and they reported no or limited consequences of substance use over that time period American Psychiatric Association (1994). 17 We want to thank consultant Norman Hoffman, Ph.D., who developed the analyses plans for determining diagnostic indicators of substance use. 18 Reports of no substance use correspond with the youth being placed in restrictive settings (inpatient hospital, residential treatment facility, jail, diagnostic shelter) over the past 6 months. This is discussed in more detail under Services Use below. 13

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