July 2008

Grant Results

SUMMARY

Between 1999 and 2003, researchers at the University of California, San Francisco, and at the Kaiser Foundation Research Institute (Oakland, Calif.) examined access to and utilization of substance abuse services by adolescents in a large, nonprofit health maintenance organization.

Key Findings

  • Higher levels of family conflict and lower levels of parental limit setting were associated with increased alcohol and substance abuse, while a more positive family experience was associated with decreased dependence.
  • Adolescents seeking treatment for substance abuse exhibited higher rates of many psychiatric disorders, compared with those in a control group of teens not in treatment.
  • Adolescents were most likely to have been referred to treatment by parents, often in combination with mental health providers or the legal system.

Funding
The Robert Wood Johnson Foundation (RWJF) provided partial support for the baseline data collection and six-month follow-up with grant ID# 037863 of $348,615 awarded under the Substance Abuse Policy Research Program, to the University of California, San Francisco (for more information see Grant Results).

RWJF also supported a 12-month follow-up data collection with grant ID# 042739 of $125,006 to the Kaiser Foundation Hospitals, Kaiser Foundation Research Institute.

 See Grant Detail & Contact Information
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THE PROBLEM

As a group, adolescents tend to engage in high-risk behaviors, such as substance abuse. Those adolescents who will later have long-term substance abuse problems often begin abusing substances at an early age, and many have mental health or medical problems as well, according to researchers at the University of California, San Francisco.

Many studies show that it is important to treat substance abuse problems early, when they are less severe and when individuals are young. Yet, those in the substance abuse field know little about how adolescents arrive at treatment or about who enters treatment in managed care health plans. How the medical, mental health and substance abuse services interact within the same health care plan creates either access or barriers to substance abuse treatment.

Investigators believe that understanding these interactions will result in the development of more effective service policies.

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RWJF STRATEGY

The Robert Wood Johnson Foundation (RWJF) awarded grant ID# 037863 under its national Substance Abuse Policy Research Program (SAPRP). SAPRP provides support for investigators to conduct policy research on a variety of projects directed at helping the United States reduce the harm caused by substance abuse. Reports on all SAPRP grants are available at the program Web site. See also the Grant Results on SAPRP.

Other RWJF grants outside of SAPRP have addressed the key ingredients in effective adolescent treatment programs (see Grant Results on ID# 039051, Developing a Guide to Treatment Programs for Adolescent Substance Abusers) and other adolescent substance abuse issues (see Grant Results on ID# 033627, Meeting on Youth Substance Abuse and the Juvenile Justice System.) RWJF continues to fund projects directed at adolescent substance abuse treatment through its national programs Reclaiming Futures®: Communities Helping Teens Overcome Drugs, Alcohol and Crime and Bridging the Gap: Research Informing Practice for Healthy Youth Behavior.

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THE PROJECT

Researchers at the University of California, San Francisco, and at the Kaiser Foundation Research Institute (Oakland, Calif.) examined access to and utilization of substance abuse services by adolescents in a large, nonprofit health maintenance organization.

The study sample included 419 youth (12 to 18 years of age), and one parent for each youth, seeking treatment at one of four northern California Kaiser Permanente Chemical Dependency Rehabilitation Programs between May 2000 and June 2002. The researchers addressed the following:

  • System pathways and barriers to substance abuse treatment (such as referral sources and initial identification of substance abuse problems).
  • Characteristics of those entering treatment (demographics; type and severity of substance abuse; age of onset; mental and physical health comorbidity; and educational, legal and family problems).
  • Length of time in treatment and characteristics of those completing versus those dropping out of treatment.
  • Variation of system pathways and barriers to treatment, retention patterns and problem characteristics by gender, ethnicity and age.
  • Differences in primary care providers with high substance abuse referral rates in comparison with those with low referral rates.

Grant ID# 037863, awarded under the Substance Abuse Policy Research Program, provided funding for initial baseline data collection at intake and for six-month follow-up data collection. Support from grant ID# 042739, not under SAPRP, enabled investigators to conduct a 12-month follow-up data collection. The federal Center for Substance Abuse Treatment provided additional support of $278,133.

Methodology

Project investigators gathered data from multiple sources that included the following:

  • Survey interviews, using a computerized questionnaire, with the 419 adolescent subjects and, separately, with one parent each, at intake, six months and 12 months. Survey questions were drawn from standard, tested survey instruments. A matched group of adolescents without a substance abuse diagnosis acted as controls for survey analysis.
  • One focus group with eight adolescent girls, one with eight adolescent boys and one with 20 parents.
  • 25 qualitative interviews, half with chemical dependency treatment providers and half with staff in primary care and mental health clinics who refer adolescents to chemical dependency treatment.
  • Review of medical and administrative records of 100 adolescent patients (13 to 18 years of age) at each of the four Kaiser Permanente catchment areas included in the study who were diagnosed with substance abuse problems in Kaiser Permanente outpatient settings in 1999. With this sample, researchers examined the characteristics of the health plan's adolescent substance abuse population and details about their referral, or non-referral, to chemical dependency treatment.
  • Administrative and clinical databases of the health plan.

See the Appendix for a description of the study sample.

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FINDINGS

Project investigators report key findings in three papers.

Findings related to family environment and its effect on adolescent substance abuse, reported in "Family Environment Factors and Substance Abuse Severity in an HMO Adolescent Treatment Population" and published in Clinical Pediatrics, include:

  • All three family environment factors — family conflict, parental limit setting and perception of family experience — correlated with substance dependence. With higher levels of family conflict and lower levels of limit setting, researchers found increased alcohol and substance abuse, while more positive family experience correlated with decreased dependence. Alcohol and substance abuse increased the most with decreases in parental limit setting.
  • Depression and increased numbers of alcohol or drug-using friends were associated with increased numbers of substance abuse/dependence symptoms. Depression was more often present with family conflict, absence of parental limit setting and negative family experience.
  • In comparison to boys, girls reported higher levels of family conflict, less limit setting and more negative perceptions of family experience. They also reported more substance abuse/dependence symptoms (5.54 versus 4.07 for boys) and more substance-using family members (53 percent versus 39 percent for boys). Depression was significantly more likely to occur in girls (35 percent) than in boys (19 percent), as were anxiety (13 percent versus 3 percent in boys) and conduct disorder (15 percent versus 9 percent in boys).
  • Level of family conflict was more likely to predict severity of substance abuse in boys than in girls. Boys were also significantly more likely to have a diagnosis of attention deficit hyperactivity disorder — 13 percent in comparison to 5 percent in girls.

Findings on the pathways that lead to adolescent treatment for substance abuse in an HMO, reported in "Pathways to Chemical Dependency Treatment for Adolescents in an HMO," published in the Journal of Psychoactive Drugs, include:

  • The average age, for both boys and girls, of an adolescent's first substance use was 12 years. Other than tobacco (which 43 percent reported using), alcohol (28 percent) and marijuana (27 percent) were the most common first substances used. Substance use in the six months prior to the survey included alcohol, cocaine, stimulants, tranquilizers, party drugs and heroin. Higher percentages of girls than boys reported use of each of these.
  • Adolescents reported being referred to treatment by parents (83 percent), mental health providers (35 percent), the legal system (33 percent), self-referral (30 percent), friends (19 percent), health care providers (18 percent) and schools (13 percent). Forty-six percent had received an ultimatum to enter treatment. Mental health and friend referrals were more likely for girls, while boys more often had a legal referral.
  • African-American adolescents were more likely to have a legal referral than white adolescents. Asian Americans more often had a school referral than whites.
  • Almost one-quarter (23 percent) of the study sample reported that they had had mental health treatment prior to their intake in the chemical dependency program. African-American and Hispanic youth, in comparison to whites, were less likely to have had previous mental health treatment. Older youth (17 and 18) in comparison to younger adolescents (13 to 15) and those with a substance-abusing family member were twice as likely to have had prior mental health treatment.
  • The most common barriers to adolescents entering treatment were internal. For example, 69 percent noted that they had resisted treatment since they "didn't think I really needed to be here." External barriers included "inconvenient hours" (44 percent), "didn't know where to go for help" (25 percent) and "lack of transportation" (13 percent). Parents most often (40 percent) reported "timing/scheduling difficulties" as the greatest program barrier.

Findings on co-occurring mental health and substance abuse problems, reported in a preliminary report entitled Chemical Dependency and Psychiatric Services for Adolescents in Private Managed Care: Implications for Outcomes, include:

  • In comparison with controls, adolescents seeking treatment for substance abuse at chemical dependency clinics in the study exhibited higher rates of depression, anxiety, eating disorders, attention deficit hyperactivity disorder, conduct disorder and conduct disorder including oppositional defiant disorder. In the two years before and the six months after intake, 55 percent of adolescents seeking treatment had received one or more psychiatric diagnoses, compared with 3.4 percent of controls.
  • Girls were more likely than boys to have a psychiatric visit in the six months after intake. Adolescents who reported being more withdrawn, having more physical ailments or being more anxious or depressed also were more likely to have a psychiatric visit during that period than those who reported fewer of these problems.
  • Adolescents receiving psychiatric services were more likely than those who were not receiving them to be abstinent from alcohol (77 percent versus 68 percent) or from alcohol and drugs (63 percent versus 51 percent). Abstinence rates were also significantly higher at clinics that had both chemical dependency and psychiatric services on-site than at those that did not (for alcohol alone: 77 percent versus 68 percent, respectively; for alcohol and drugs: 63 percent versus 52 percent, respectively).

Additional findings — related to referral to treatment by medical providers — include the following from "Adolescents with Substance Diagnoses in an HMO: Factors Associated with Medical Provider Referrals to Substance Abuse and Mental Health Treatment," published in Mental Health Services Research:

  • Adolescents with a documented problem with both alcohol and another substance, as well as those with a history of involvement in the juvenile justice system, were more likely to have a referral to substance abuse treatment. Some 63 percent of adolescents with a documented problem with both alcohol and another substance and 21 percent of those with a history of involvement in the juvenile justice system had a referral to substance abuse treatment. Youth were less likely to receive a referral with a diagnosis of an alcohol use disorder (16 percent) or a diagnosis of a marijuana use disorder (19 percent).
  • Adolescents referred to substance abuse treatment did not differ from those not referred in types of psychiatric diagnoses. However, more of those referred to treatment (24 percent) had documented suicidal behavior than those who were not referred (9 percent).

Limitations

The investigators note several limitations:

  • The findings relate to adolescents referred to substance abuse treatment in a private, commercially insured HMO, with few Medicaid and no uninsured patients and may not be generalizable to the larger adolescent population.
  • Participants self-reported substance abuse retrospectively and family environment factors without corroboration from parents. Such reporting may produce inaccurate or unreliable results.
  • The study scope only allowed access to adolescents who had and kept a chemical dependency treatment intake appointment. Information is not available about all adolescents or about adolescents who had a referral but did not make and keep an intake appointment.

Communications

The researchers reported findings in articles published in Clinical Pediatrics, Mental Health Services Research and Journal of Psychoactive Drugs (in press). They also reported findings in a report on the baseline data collection and summaries of focus groups and provider interviews and in three unpublished articles. The National Institute on Alcohol Abuse and Alcoholism journal Alcohol Health & Research World (now called Alcohol Research & Health) invited the investigators to write a paper on adolescent services and taking research to practice.

The researchers made 17 presentations at meetings of organizations, including the American Public Health Association, the Academy for Health Services Research and Health Policy, the College of Problems of Drug Dependence and the American Society of Addiction Medicine. See the Bibliography for details.

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CONCLUSIONS

The investigators offer the following conclusions:

  • Despite contact with medical or mental health providers, few adolescents received referrals to chemical dependency treatment from these providers. Schools and other institutions with which adolescents have regular contact and where their alcohol and drug problems may be more visible could "play a larger role in the identification of problems and referral to treatment" (in "Pathways to Chemical Dependency Treatment for Adolescents in an HMO").
  • The severity of substance use and high levels of psychiatric and medical comorbidity in teens entering chemical dependency treatment programs indicates a "need for a more integrative, structured, and accessible system of coordinated care for adolescents and their families," both "within health plans as well as between medical care and other social systems" (in " Pathways to Chemical Dependency Treatment for Adolescents in an HMO").
  • Since most of the adolescents treated in the chemical dependency program had a need for psychiatric services, receiving even minimal psychiatric services is important (in "Chemical Dependency and Psychiatric Services for Adolescents in Private Managed Care: Implications for Outcomes").

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SIGNIFICANCE TO THE FIELD

The investigators note that:

  • "There have been few managed care studies [of adolescent access to substance abuse treatment] and none in private settings." As a result, this study has generated a great deal of interest among clinicians at Kaiser Permanente health plan and among experts in the substance abuse field. Health plan clinicians have requested the involvement of the research team in efforts to improve services and regional policies relating to the treatment of patients with dual substance abuse and mental health disorders. A variety of academic organizations and government agencies have invited the investigators to present study findings at national conferences and meetings.

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LESSONS LEARNED

  1. Having multiple funding sources helps bring research to practice through increased project visibility and widespread dissemination of findings. Since different funders have different reporting requirements, even small pieces of funding can have this effect. (Project Director)
  2. While qualitative work (interviews, focus groups, etc.) requires a lot of effort, it is very important in policy studies. It is useful in understanding results, getting a buy-in from clinicians who feel that their voices are heard and in developing follow-up questionnaires. (Project Director)
  3. Maintaining a sample over a long study period requires multiple strategies. "We sent reminders to parents and to the adolescents and rewarded them with gift certificates if they updated their contract information." The interviewers developed good relationships with the parents, which led to parents' commitment to the study and a willingness to keep the interviewers informed of the whereabouts of their children. (Project Director)

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AFTER THE GRANT

A grant jointly funded by three federal agencies — the National Institute on Drug Abuse, the National Institute on Alcohol and Alcoholism and the Center for Substance Abuse Treatment — supported three- and five-year follow up interviews and continued study of the sample of adolescents enrolled in chemical dependency treatment programs.

Results of further data analysis were published in a 2006 article, "Health Care Services Use by Adolescents with Intakes in an Outpatient Alcohol and Drug Treatment Program," (by Parthasarathy S and Weisner C) in the American Journal on Addictions (15[1]: 113–121). The abstract is available online.

In the article, which examined the effect of rehabilitation services on participants' post-treatment medical expenditures, the project team noted that:

  • Prior to treatment, the adolescents entering chemical dependency programs had significantly higher rates of emergency room and inpatient services use compared to non-substance abusing adolescents.
  • One year after treatment, the rates of emergency room and inpatient services use for adolescents in chemical dependency programs did not significantly decrease.

In the article, the researchers used the findings to suggest that the participants' medical and mental health problems were severe enough to make short-term reductions in post-treatment cost negligible or nonexistent.

As of July 2008, the project director had received funding for seven-year follow up interviews from the National Institute on Drug Abuse, and was in the process of applying for funding from the National Institute on Alcohol and Alcoholism to support nine-year data collection and final analysis.

According to the project director, the seven- and nine-year data collection will allow the project team to study the maturation period from adolescence to emerging adulthood, during which developmental issues and health services can play a significant role in decreased substance use. Additionally, the project team will examine the role of insurance loss, peer influences and significant life transitions such as marriage and parenthood on the participants' service use and substance abuse.

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GRANT DETAILS & CONTACT INFORMATION

Project

Substance Abuse Treatment for Adolescents in Managed Care

Grantee

University of California, San Francisco (San Francisco,  CA)

  • Pathways to Substance Abuse Treatment for Adolescents in an HMO
    Amount: $ 348,615
    Dates: November 1999 to April 2003
    ID#:  037863

Contact

Constance Weisner, Dr.P.H., M.S.W.
(415) 476-7473
conniew@lppi.ucsf.edu

Grantee

Kaiser Foundation Hospitals, Kaiser Foundation Research Institute (Oakland,  CA)

  • Follow-Up Study of Adolescent Substance Abuse Treatment in Managed Care
    Amount: $ 125,006
    Dates: August 2001 to October 2003
    ID#:  042739

Contact

Stacy Sterling, M.S.W., M.P.H.
(510) 891-3614
Stacy.A.Sterling@kp.org

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Study Sample Description

The study sample included 419 adolescents (12 to 18 years of age), and a parent for each, who had sought treatment at one of four Kaiser Permanente Chemical Dependency Rehabilitation Programs between May 2000 and June 2002. The sample had the following characteristics:

  • It was 34 percent female.
  • The mean age was 16.1 years. The largest percentages were 16 (28 percent) and 17 (29 percent) years of age.
  • Forty-four percent had a parent with a substance abuse problem.
  • It was ethnically heterogeneous: 65 percent indicated one ethnicity (with 47 percent indicating white only) and 35 percent indicated more than one. For purposes of analysis, ethnic status of those noting more than one ethnicity was organized as: 49 percent white, 20 percent Hispanic, 16 percent African American, 9 percent Native American/Alaska Native and 6 percent Asian/Pacific Islander.
  • Sixty-two percent of parents reported a family income of over $75,000, 25 percent between $30,000 and $75,000 and 14 percent under $30,000.
  • Only 7 percent of parents did not graduate from high school; 24 percent had a college or a postgraduate degree.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Ammon L, Sterling S, Mertens J and Weisner C. "Adolescents in Private Chemical Dependency Programs: Who is at Risk for HIV?" Journal of Substance Abuse Treatment, 29(1): 39–45, 2005. Abstract available online.

Scott M, Hinman A, Mertens J and Weisner C. "Gender Differences Among Adolescents with Substance Abuse Diagnoses in an HMO Membership Sample." Unpublished.

Scott M, Parthasarathy S, Kohn C, Hinman A, Sterling S and Weisner C. "Adolescents with Substance Diagnoses in an HMO: Factors Associated with Medical Provider Referrals to Substance Abuse and Mental Health Treatment." Mental Health Services Research, 6(1): 47–60, 2004. Abstract available online.

Sterling S, Kohn C, Lu Y and Weisner C. "Pathways to Chemical Dependency Treatment for Adolescents in an HMO." Journal of Psychoactive Drugs, 36(4): 439–453, 2004. Abstract available online.

Sterling S and Weisner C. "Chemical Dependency and Psychiatric Services for Adolescents in Private Managed Care: Implications for Outcomes." Alcoholism: Clinical and Experimental Research, 29(5): 801–809, 2005. Abstract available online.

Wu NS, Lu Y, Sterling S and Weisner C. "Family Environment Factors and Substance Abuse Severity in an HMO Adolescent Treatment Population." Clinical Pediatrics, 43(4): 323–333, 2004. Abstract available online.

Reports

Sterling S and Kohn C. Pathways to Substance Abuse Treatment for Adolescents: Implications for Policy. Summary of Provider Interviews. Oakland, Calif.: Kaiser Permanente Northern California Division of Research, 2002.

Sterling S, Hinman A, Kohn C and Weisner C. Pathways to Substance Abuse Treatment for Adolescents: Implications for Policy. Summary of Focus Groups. Oakland, Calif.: Kaiser Permanente Northern California Division of Research, 2002.

Sterling S, Mertens J, Lu Y, Hinman A, Kohn C and Weisner C. Pathways to Substance Abuse Treatment for Adolescents: Implications for Policy. Final Report — Baseline. Oakland, Calif.: Kaiser Permanente Northern California Division of Research, 2002.

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Report prepared by: Mary B. Geisz
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Victor Capoccia
Program Officer: Constance M. Pechura

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