Catherine Martin, MD

Ginny Sprang, PhD

Lisa Clark

Miriam Silman, MSW

Jennifer Cole, PhD

Kristin Dawson, MD

Greg Guenthner, MLIS

Cindy Taylor

Goals and Objectives

• Assess and treat adolescent substance abusers and their families

• Model evidence-based state of the art treatment and educate providers

• Disseminate model treatment interventions to communities with the highest need

• Evaluate and determine the most effective routes of treatment and education

AHARTT

• KY Kids Recovery program

• Senate Bill 200

• Mental health and Substance Abuse Parity & Affordable Care Act that require SA coverage

• Promising Science in Adolescent Substance Abuse

• Wonderful scientific and clinical colleagues

About AHARTT funding:

Kentucky Attorney General Jack Conway's actions:

• Against Merck, which failed to disclose to doctors and patients that taking Vioxx significantly raised the risk of heart attack. Settled for $25M.

• Against GlaxoSmithKline for allegedly failing to disclose that patients taking its diabetes drug, Avandia, were at a higher risk for cardiovascular problems. Settled for $15M.

• The court orders filed in both settlements require that the funds be spent on drug treatment programs.

• 19 substance abuse treatment grant proposals from across the Commonwealth

• KY Kids Recovery program of the Cabinet for Health and Family Services and the Office of Attorney General Jack Conway

• Governor’s Substance Abuse Treatment Advisory Committee (SATAC) chaired by Attorney General Jack Conway

SB 200 SummaryAttempts to ensure improved effectiveness and outcomes in adjudicate youth-

• Focuses the most expensive resources on more serious offenders.

• Provides for earlier access to treatment/supervision and increases funding for services in local communities.

• Establishes oversight and performance measurement for the

FAIR Team

Each judicial district will have a family accountability, intervention, and response team that “shall develop enhanced case management plans and opportunities for services for children.”

AHARTT is the 1st one funded:

1) Talking

2) Training

3) Tracking

4) Treating

AHARTT:

1) Talking

2) Training

3) Tracking

4) Treating

Stakeholder Community Conversation

So far we have had 4 stakeholder meetings

• Lexington

• Morehead

• Hopkinsville

• Covington

What are we learning??

Audience Questions

What barriers have you encountered delivering or obtaining treatment for adolescent substance use?

What resources or supports are available to adolescents in recovery in your community?

Who are the key players we should be talking to (other than the ones in this room today)?

Community Conversation:Access to treatment

• Satellite sites out in communities

• Transportation

• Take the service to the child –home-based

• Utilize Telehealth more

• Quick response

Community Conversation: Teamwork—Who should be talking

• Legislators

• Parks & Recreation; other community non-profits

• Businesses (need skilled workers; clients need jobs and employment)

•MCO support (care delays and denials)

AHARTT:

1) Talking

2) Training

3) Treating

4) Tracking

AHARTT Scholars are working directly in 92 counties from Paducah to Pikeville. Plus 3 programs that draw clients statewide.

Training to be the Best:

• Building Capacity through Learning Community Approach

• Two EBPs Disseminated1) Functional Family Therapy2) CBT (ENCOMPASS)

• Continuing Education Modules

• Embedded in learning communities

ENCOMPASS

Integrated

Treatment

for

Adolescents

and Young

Adults

Evidence-Based Psychiatric and Substance

Treatments for Adolescents

Substance Use Disorders

• Family-based

• Behavioral (CM, incentives)

• Cognitive Behavioral Therapy (CBT)+ MET

Psychiatric Disorders

Conduct Disorder (60-80%)• Family-Based•CBT

Depression, Anxiety(30-40%)•CBT

•Pharmacotherapy

ADHD (30-50%)

•CBT•Pharmacotherapy

Individual CBT is consistently associated with greater sustained or increasing decrease in substance abuse than other evidence-based substance treatment interventions for adolescents (Tripodi et al 2010; Waldron et al., 2008).

Strengths of ENCOMPASS CBT

22

These procedures include:

• 3-day face-to-face training followed by weekly clinical supervision and fidelity/adherence monitoring.

• Randomly selected audio-recorded sessions from each therapist are reviewed, rated for fidelity/adherence and provided written and oral feedback by the Encompass MET/CBT supervisor

Strengths of ENCOMPASS CBT

• Encompass MET/CBT can be individually tailored for patients by selecting the modules (from a menu of modules) that are most clinically relevant for individual patients.

• Depression: negative mood states often trigger substance use. Focus on mood regulation skills.

• ADHD: focus on organizational skills, impulse control, anticipation and planning ahead for high risk situations.

Strengths of ENCOMPASS CBT

Thomas L. Sexton, Ph.D., ABPP and Astrid van Dam

Functional Family Therapy

• Comprehensive, family-focused, evidence-based model addressing co-occurring disorders

• Flexible & adaptive to fit clients across range of cultural contexts, clinic or in-home delivery, voluntary & court-ordered families

• Uses data to drive decisions & improve fidelity

FFT Core Principles

• Problems are embedded in multisystemic, relational risk and protective factors.

• Families are the primary focus of treatment and assessment.

• Obtainable Change Goals are family based.

• Alliance Based Motivation creates positive engagement and lasting change.

• Evidence based clinical decision making results in better community based outcomes.

Stages

Delivered weekly sessions in each treatment phase occur in a successful treatment episode

Engagement Motivation

Behavior Change

Generalization

• Fidelity is tracked with both of these models with individual and group review of cases and tapes of sessions and self monitoring and patient monitoring of progress.

• Also training the trainer for CBT.

Continuing Education Modules

AHARTT:

1) Teamwork

2) Training

3) Tracking

4) Treating

Adolescent Kentucky Treatment Outcome Study (AKTOS)

• Severity of use, withdrawal

• Physical health problems

• Mental health problems

• Clinicians complete intake survey using a secure, online system

• Narrative report is generated

• Research team at UK CDAR completes follow-up at 12 months

Model Clinic

• Assessment and Treatment

• Goal is to manualize and to have onsite clinical experiences

Timeline Followback

• How do we track e-cigs, smokeless tobacco?

• What if TLFB shows use but UDS and CO are negative?

How can we track alcohol use…beyond

Timeline Followback?

Assessment (cont)

• Child Behavior Checklist

• Achenbach Youth

• School Records

AHARTT:

1) Teamwork

2) Training

3) Tracking

4) Treating

Treatment

Functional Family

Therapy

Encompass

Cognitive

Behavioral

Therapy

Contingency

ManagementPharmacotherapy

Dispel

Myths

You do NOT have to be CLEAN to start medication for a co-morbid disorder

Comorbidity, Medication, Psychiatric Disorders & Substance Use

Co-Morbidity

Medication

Psychiatric SxSubstance

Use

Bipolar Lithium Stabilized Mania SU

ADHD Stimulants Impulsivity Attention

Smoking in the lab

No change SU

ADHD + Depression

Bupropion Depression Attention

Smoking

Depression sertraline DepressionNo change inSA

Naloxone NS: You Can Be Saved By A Nose!!! Daniel Wermeling, Pharm.D.Professor, College of Pharmacy

42

Potential Indications/Populations

1. Patient release after emergency medical care involving opioid poisoning/intoxication

2. Suspected history of illicit or nonmedical opioid use

3. Any opioid prescription and … concurrent alcohol, benzodiazepine or SSRI prescription

Would discussing this with the family heighten safety measures with opiates?

January 6, 2014 – FRANKFORT, KY — Gov.

Steve Beshear, First Lady Jane Beshear, and

Attorney General Jack Conway today

announced that heroin overdose reversal kits

will be purchased for Kentucky hospitals with

the highest rates of heroin overdose

deaths. Overdose patients will receive a kit

free of charge when they leave the hospital, so

they or a loved one can prevent another

overdose event and possibly save a life. The

funding is provided through the Substance

Abuse Treatment Advisory Committee (SATAC).

Contingency

Management

45

Contingency

Management

Fish Bowl

# of chips Value

49 $0

45 $5

5 $10

1 $25

CC: Community Recovery

• Faith-based youth groups provide buses & transportation

• Churches host 12-step programs, including some for adolescents

• Peer support

• Advisory Board

Comments and questions….and ANSWERS!!!!!

Community Roll out and next steps

• Outreach to Primary Care, Pharmacists, Dentists,

Community Mental Health Centers

• Establish referrals with agencies, such as:

– Department for Juvenile Justice

– Family Resource and Youth Service Centers

(in schools)

– Administrative Office of the Courts

– Department for Community Based Services

– Department for Public Health

• Create Advisory Board

• Operationalize Model Clinic for duplication in other

areas of the state

NCAA Championship