The Role of Pre-Treatment Traumatic Stress Symptoms in Adolescent Substance Use Treatment Outcomes.

Background: Prominent theories suggest that individuals with co-occurring traumatic stress symptoms (TSS) and substance use (SU) may be less responsive to SU treatment compared to those with SU only. However, empirical findings in adult samples are mixed, and there has been limited work among adolescents. This study assesses the association between TSS and SU treatment outcomes among trauma-exposed adolescents, using statistical methods to reduce potential confounding from important factors such as baseline SU severity. Method: 2,963 adolescents with lifetime history of victimization received evidence-based SU treatment in outpatient community settings. At baseline, 3- and 6-months, youth were assessed using the Global Appraisal of Individual Needs Traumatic Stress Scale and the Substance Frequency Scale. Propensity score weighting was used to mitigate potential confounding due to baseline differences in sociodemographic characteristics and SU across youth with varying levels of TSS. Results: Propensity score weighting successfully balanced baseline differences in sociodemographic factors and baseline SU across youth. Among all youth, mean SU was lower at both 3- and 6- month follow-up relative to baseline, indicating declining use. After adjusting for potential confounders, we observed no statistically significant relationship between TSS and SU at either 3- or 6-month follow-up. Conclusions: Based on this investigation, conducted among a large sample of trauma-exposed youth receiving evidence-based outpatient SU treatment, baseline TSS do not appear to be negatively associated with SU treatment outcomes. However, future research should examine whether youth with TSS achieve better outcomes through integrative treatment for both SU and TSS.

The results of this study provide keenly needed evidence that, among youth with prior victimization, presence and level of traumatic stress symptoms at substance use treatment initiation does not lead to significantly worse treatment outcomes for youth in outpatient treatment. This suggests that evidence-based outpatient substance use treatment modalities may be effective at improving substance use outcomes even when co-existing traumatic stress symptoms are present.

Attitudes and beliefs among Georgia addiction treatment staff about medication for opioid use disorder in adolescents, young adults, and adults: a multi-mixed methods study.

Background: Adverse consequences, including non-fatal overdose and death, are prevalent in adolescents and young adults with opioid use disorder (OUD). Barriers toward medication for opioid use disorder (MOUD) have been identified in adult populations but are poorly understood in youth.Objective: This exploratory multi-mixed methods study examines beliefs and attitudes of addiction treatment program staff about the use of MOUD in youth.Methods: A 40-item survey was distributed electronically to 299 addiction treatment programs in Georgia from May 2020 to January 2021. Participant (N = 215; 74% female) attitudes regarding the use of MOUD in three age groups (adolescents (aged 16-17), young adults (aged 18-25), and adults (aged 26+) on a 6-point Likert scale were compared using paired samples t-tests. A series of one-way ANOVA analyses examined differences in attitudes and beliefs across participant characteristics. Verbatim responses to qualitative survey questions were analyzed using a coding reliability approach to thematic analysis.Results: Participants were less likely to support MOUD in adolescents (M = 3.68, SD 1.5) compared with young (M = 4.38, SD 1.36, t = 8.19, p < .001, d = .51) and older adults (M = 4.64, SD 1.3, t = 9.83, p < .001 d = .74). Participants endorsed higher response rates for the use of both naltrexone and buprenorphine over methadone in young adults. A total of 1,412 text responses were reviewed. Participants highlighted barriers to acceptance and use of MOUD in adolescents including safety concerns and impact on brain development.Conclusions: The results support a comprehensive approach to reducing the barriers to using medications to treat OUDs in adolescent populations. Formal and focused continuing education to correct attitudes and beliefs about MOUD treatment for adolescents is necessary.

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.

Narrative review: Revised Principles and Practice Recommendations for Adolescent Substance Use Treatment and Policy.

OBJECTIVE: In 2014, the U.S. National Institute on Drug Abuse released the "Principles of Adolescent Substance Use Disorder Treatment," summarizing previously established evidence and outlining principles of effective assessment, treatment, and aftercare for substance use disorders (SUD). Winters et al. (2018) updated these principles to be developmentally appropriate for adolescents. This review builds on that formative work and recommends updated adolescent assessment, treatment, and aftercare principles and practices. METHOD: The Cochrane, MEDLINE-PubMed, and PsychInfo databases were searched for relevant studies with new data about adolescent substance use services. This article updates the 13 original principles; condenses the 8 original modalities into 5 practices; and highlights implications for public policy approaches, future funding, and research. RESULTS: Key recommendations from the principles include integrating care for co-occurring mental health disorders and SUDs, improving service accessibility including through the educational system, maintaining engagement, and addressing tension between agencies when collaborating with other youth service systems. Updates to the treatment practices include adoption of Screening, Brief Intervention and Referral to Treatment (SBIRT), investment in social programs and family involvement in treatment, expanding access to behavioral therapies and medications, increasing funding to harm reduction services, supporting reimbursement for continuing care services, and increasing investment in research. CONCLUSION: These revised principles of adolescent assessment, treatment, and aftercare approaches and practices aim to establish guidance and evidence-based practices for treatment providers, while encouraging necessary support from policymakers and funding agencies to improve the standard of care for adolescent SUD services.

Multi-level alignment processes in the sustainment of a youth substance use treatment model following a federal implementation initiative: A mixed method study.

INTRODUCTION: Government agencies have identified evidence-based practice (EBP) dissemination as a pathway to high-quality behavioral health care for youth. However, gaps remain about how to best sustain EBPs in treatment organizations in the U.S., especially in resource-constrained settings like publicly-funded youth substance use services. One important, but understudied, determinant of EBP sustainment is alignment: the extent to which multi-level factors that influence sustainment processes and outcomes are congruent, consistent, and/or coordinated. This study examined the role of alignment in U.S. states' efforts to sustain the Adolescent Community Reinforcement Approach (A-CRA), an EBP for youth substance use disorders, during the COVID-19 pandemic. METHODS: In this mixed methods study, the qualitative investigation preceded and informed the quantitative investigation. We interviewed state administrators and providers (i.e., supervisors and clinicians) from 15 states that had completed a federal A-CRA implementation grant; providers also completed surveys. The sample included 50 providers from 35 treatment organizations that reported sustaining A-CRA when the COVID-19 pandemic began, and 20 state administrators. In qualitative thematic analyses, we applied the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to characterize alignment processes that interviewees described as influential on sustainment. We then used survey items to quantitatively explore the associations described in qualitative themes, using bivariate linear regressions. RESULTS: At the time of interview, staff from 80 % of the treatment organizations (n = 28), reported sustaining A-CRA. Providers from both sustainer and non-sustainer organizations, as well as state administrators, described major sources of misalignment when state agencies ceased technical assistance post-grant, and because limited staff capacity conflicted with A-CRA's training model, which was perceived as time-intensive. Participants described the pandemic as exacerbating preexisting challenges, including capacity issues. Sustainer organizations reported seeking new funding to help sustain A-CRA. Quantitative associations between self-rated extent of sustainment and other survey items largely followed the pattern predicted from the qualitative findings. CONCLUSIONS: The COVID-19 pandemic amplified longstanding A-CRA sustainment challenges, but treatment organizations already successfully sustaining A-CRA pre-pandemic largely continued. There are missed opportunities for state-level actors to coordinate with providers on the shared goal of EBP sustainment. A greater focus on alignment processes in research and practice could help states and providers strengthen sustainability planning.

A tutorial comparing different covariate balancing methods with an application evaluating the causal effects of substance use treatment programs for adolescents.

Randomized controlled trials are the gold standard for measuring causal effects. However, they are often not always feasible, and causal treatment effects must be estimated from observational data. Observational studies do not allow robust conclusions about causal relationships unless statistical techniques account for the imbalance of pretreatment confounders across groups and key assumptions hold. Propensity score and balance weighting (PSBW) are useful techniques that aim to reduce the observed imbalances between treatment groups by weighting the groups to look alike on the observed confounders. Notably, there are many methods available to estimate PSBW. However, it is unclear a priori which will achieve the best trade-off between covariate balance and effective sample size for a given application. Moreover, it is critical to assess the validity of key assumptions required for robust estimation of the needed treatment effects, including the overlap and no unmeasured confounding assumptions. We present a step-by-step guide to the use of PSBW for estimation of causal treatment effects that includes steps on how to evaluate overlap before the analysis, obtain estimates of PSBW using multiple methods and select the optimal one, check for covariate balance on multiple metrics, and assess sensitivity of findings (both the estimated treatment effect and statistical significance) to unobserved confounding. We illustrate the key steps using a case study examining the relative effectiveness of substance use treatment programs and provide a user-friendly Shiny application that can implement the proposed steps for any application with binary treatments.

Substance use severity as a predictor for receiving medication for opioid use disorder among adolescents: An analysis of the 2019 TEDS.

BACKGROUND: Medication for opioid use disorder (MOUD) is vastly underutilized in adolescents. Existing treatment guidelines for OUD largely focus on adults, providing limited guidance for pediatric populations. Limited information is known about use of MOUD in adolescents based on substance use severity. METHODS: This secondary data analysis examined how patient-level variables influenced the receipt of MOUD in adolescents aged 12-17 (n = 1866) using the Treatment Episode Data Set (TEDS) 2019 Discharge data set. A crosstabulation and chi-square statistic evaluated the relationship between a proxy for clinical need based on high-risk opioid use (either reporting daily opioid use within the past 30 days and/or history of injection opioid use) for MOUD in states with and without adolescents receiving MOUD (n = 1071). A two-step logistic regression analysis in states with any adolescents receiving MOUD examined the explanatory power of demographic, treatment intake, and substance use characteristics. RESULTS: Completion of 12th grade, a GED, or beyond, decreased the likelihood of receiving MOUD (odds ratio [OR]= 0.38, p = 0.017), as did being female (OR = 0.47, p = .006). None of the remaining clinical criteria were significantly associated with MOUD, although a history of one or more arrests increased the likelihood of MOUD (OR = 6.98, p = 0.06). Only 13% of individuals who met criteria for clinical need received MOUD. CONCLUSIONS: Lower education could serve as a proxy for substance use severity. Guidelines and best practices are needed to ensure the proper distribution of MOUD to adolescents based on clinical need.

Comparing organization-focused and state-focused financing strategies on provider-level reach of a youth substance use treatment model: a mixed-method study.

BACKGROUND: Financial barriers in substance use disorder service systems have limited the widespread adoption-i.e., provider-level reach-of evidence-based practices (EBPs) for youth substance use disorders. Reach is essential to maximizing the population-level impact of EBPs. One promising, but rarely studied, type of implementation strategy for overcoming barriers to EBP reach is financing strategies, which direct financial resources in various ways to support implementation. We evaluated financing strategies for the Adolescent Community Reinforcement Approach (A-CRA) EBP by comparing two US federal grant mechanisms, organization-focused and state-focused grants, on organization-level A-CRA reach outcomes. METHOD: A-CRA implementation took place through organization-focused and state-focused grantee cohorts from 2006 to 2021. We used a quasi-experimental, mixed-method design to compare reach between treatment organizations funded by organization-focused versus state-focused grants (164 organizations, 35 states). Using administrative training records, we calculated reach as the per-organization proportion of trained individuals who received certification in A-CRA clinical delivery and/or supervision by the end of grant funding. We tested differences in certification rate by grant type using multivariable linear regression models that controlled for key covariates (e.g., time), and tested threats to internal validity from our quasi-experimental design through a series of sensitivity analyses. We also drew on interviews and surveys collected from the treatment organizations and (when relevant) interviews with state administrators to identify factors that influenced reach. RESULTS: The overall certification rates were 27 percentage points lower in state-focused versus organization-focused grants (p = .01). Sensitivity analyses suggested these findings were not explained by confounding temporal trends nor by organizational or state characteristics. We did not identify significant quantitative moderators of reach outcomes, but qualitative findings suggested certain facilitating factors were more influential for organization-focused grants (e.g., strategic planning) and certain barrier factors were more impactful for state-focused grants (e.g., states finding it difficult to execute grant activities). DISCUSSION: As the first published comparison of EBP reach outcomes between financing strategies, our findings can help guide state and federal policy related to financing strategies for implementing EBPs that reduce youth substance use. Future work should explore contextual conditions under which different financing strategies can support the widespread implementation of EBPs for substance use disorder treatment.

Volunteer Recovery Support for Adolescents: Using propensity score based methods to understand dosage effects within a randomized controlled trial.

BACKGROUND: In a recently published randomized controlled trial (RCT) of Volunteer Recovery Support for Adolescents (VRSA), a secondary finding indicated that better adherence to planned VRSA telephone session frequency resulted in significantly higher remission rates relative to lower session adherence. However, interpretation of this dose-response relationship may have been confounded by participant characteristics such as baseline levels of substance use and mental health problems. METHODS: The present study used statistical methods designed to approximate RCTs when comparing more than two nonequivalent groups that include an assessment of the potential impact of omitted variables. Classification and Regression Tree (CRT) analysis was used to establish the cut-point between high (H) and low (L) VRSA dosage groups. Because we were interested in generalizing to youth with poor attendance, the L-VRSA group served as the reference group. Balancing weights for H-VRSA and a services as usual (SAU) control group were calculated to ensure similarity of baseline pretreatment characteristics to the reference group, and sensitivity of findings to unobserved confounding variables was assessed. RESULTS: Findings suggested that superior remission rates at the end of the intervention phase were the result of high adherence to planned VRSA session frequency. Recommendations to achieve high VRSA participation among a larger segment of youth and to test whether longer VRSA duration improves the stability of recovery outcomes are provided. CONCLUSION: Few published dose-response studies have adequately controlled for selection confounds from both observed and unobserved confounding. As such, the present study aims to both assess the impact of different dosage levels of VRSA and provide a template for how to apply state-of-the-art statistical methods designed to approximate randomized controlled trials to such studies.

Trends and age-related disparities in opioid use disorder treatment admissions for adolescents and young adults.

BACKGROUND: Treatment of opioid use disorder (OUD) in adolescents and young adults is imperative to reduce the risk of overdose and other opioid-related harms. Limited information has been published about national trends in health disparities including utilization, access to medication for opioid use disorder (MOUD), and treatment retention of adolescents and young adults with OUD. METHODS: This secondary data analysis tested for trends and age-related disparities in national OUD treatment admissions, as well as length of stay (defined as continuous enrollment in some form of treatment at a program) and planned use of MOUD for adolescents (age 12-17) and young adults (age 18-24) using the Treatment Episode Data Set from 2008 to 2017. The study also used data from the National Survey on Drug Use and Health to identify population prevalence of OUD and presentation to OUD treatment in adolescents and young adults compared to older adults (age 25+). RESULTS: OUD treatment admissions significantly decreased over the decade by 63% (z = 2.61, p < .01) for adolescents and 13% (z = 2.25, p < .01) for young adults. The rate of planned MOUD at intake increased from 1.1% to 3.0% for adolescents but did not achieve significance. MOUD was more commonly recommended in young adults across the time period (13.5 to 21.8%, z = 2.24, p < .01). Treatment length of stay did not change significantly for adolescents, but did increase for young adults from 2008 to 2017 in the 91+ (19.9-23.9%, z = 2.22, p < .01) and 181+ days (9.7-12.5%, z = 2.26, p < .01) categories. Relative to older adults, the percent of people with OUD presenting for OUD treatment is significantly lower for adolescents (44.6% vs. 3.6%, OR = 0.05, p < .05) and young adults (44.6% vs. 22.2%, OR = 0.36, p < .05). Among those who initiated treatment, lower rates occurred of planned MOUD for adolescents (93% vs. 2%, OR = 0.002, p < .05) and young adults (93% vs. 56%, OR = 0.10, p < .05). CONCLUSIONS: A significant unmet need exists for OUD treatment and recommendation of MOUD in adolescents and young adults with OUD. These trends are concerning given increasing rates of opioid-related emergency room admissions and deaths during the same time period. Federal and state funders should examine adolescent and young adult's services separately from older adults (25+) to reduce age-related access disparities and ensure adequate MOUD treatment capacity.

Comparative effectiveness of individual versus family-based substance use treatment on adolescent self-injurious thoughts and behaviors.

INTRODUCTION: Self-injurious thoughts and behaviors (SITB) are of increasing concern among adolescents, especially those who use substances. Some evidence suggests that existing evidence-based substance use treatments (EBTs) could impact not only their intended substance use targets but also SITB. However, which types of substance use treatments may have the greatest impact on youth SITB is not yet clear. Based on prior literature showing that family support and connection may buffer youth from SITB, we initially hypothesized that family-based EBTs would show greater improvement in SITB compared to those receiving individually focused EBTs and that the size of the effects would be small given the comparison between two active, evidence-based interventions, and base rates of SITB. METHODS: In a sample of 2893 youth in substance use treatment, we compared the effectiveness of individually and family-based EBTs in reducing SITBs. The study used entropy balancing and regression modeling to balance the groups on pre-treatment characteristics and examine change in outcomes over a one-year follow-up period. RESULTS: Both groups improved in self-injury and suicide attempts over the one-year study period, but only youth in individual treatment improved in suicidal ideation. However, the study found no significant difference between the changes over time in the two groups for any outcome. As expected, effect sizes were small and power was constrained in this study given the rarity of the outcomes, but effect sizes are similar to those observed with substance use outcomes. CONCLUSIONS: The results provide important exploratory evidence on the potential relative effectiveness of these two treatments for SITBs. This study supports prior findings that EBTs for youth substance use may help to improve SITB and suggests that different treatment formats (individual or family-based) could result in different benefits for SITB outcomes.

Comparing two federal financing strategies on penetration and sustainment of the adolescent community reinforcement approach for substance use disorders: protocol for a mixed-method study.

BACKGROUND: Sustained, widespread availability of evidence-based practices (EBPs) is essential to address the public health and societal impacts of adolescent substance use disorders (SUD). There remains a particularly significant need to identify effective financing strategies, which secure and direct financial resources to support the costs associated with EBP implementation and sustainment. This protocol describes a new project comparing two types of U.S. federal grant mechanisms (i.e., a type of financing strategy), which supported the implementation of the Adolescent Community Reinforcement Approach (A-CRA) EBP for SUD, through either organization-focused or state-focused granting of funds. The Exploration-Preparation-Implementation-Sustainment (EPIS) framework will guide our study aims, hypotheses, and selection of measures. METHOD: We will employ a longitudinal, mixed-method (i.e., web surveys, semi-structured interviews, document review, focus groups, administrative data), quasi-experimental design to compare the grant types' outcomes and examine theoretically informed mediators and moderators. Aim 1 will examine the proportion of eligible clinicians certified in A-CRA with adequate fidelity levels (i.e., penetration outcomes) at the end of grant funding. Aim 2 will examine the sustainment of A-CRA up to 5 years post-funding, using a 10-element composite measure of treatment delivery and supervision activities. We will integrate the new data collected from state-focused grant recipients (~85 organizations in 19 states) with previously collected data from organization-focused grant recipients (Hunter et al., Implement Sci 9:104, 2014) (82 organizations in 26 states) for analysis. We will also use sensitivity analyses to characterize the effects of observed and unobserved secular trends in our quasi-experimental design. Finally, aim 3 will use comparative case study methods (integrating diverse quantitative and qualitative measures) to identify and disseminate policy implications about the roles of state- and organization-focused federal grants in efforts to promote adolescent SUD EBP implementation and sustainment. DISCUSSION: The proposed research will have direct, practical implications for behavioral health administrators, policymakers, implementation experts, and the public. It will offer new knowledge that can directly inform financing strategies to support large-scale, sustained EBP delivery in behavioral health-while advancing implementation science through the use of novel methods to study financing strategies and sustainment.

Expanding outcomes when considering the relative effectiveness of two evidence-based outpatient treatment programs for adolescents.

The current study seeks to advance understanding about how to address substance use and co-occurring mental health problems in adolescents. Specifically, we compared the effectiveness of two evidence-based treatment programs (Motivational Enhancement Treatment/Cognitive Behavior Therapy, 5 Sessions [MET/CBT5] and Adolescent Community Reinforcement Approach [A-CRA]) for both substance use and mental health outcomes (i.e., crossover effects). We used statistical methods designed to approximate randomized controlled trials when comparing nonequivalent groups using observational study data. Our methods also included an assessment of the potential impact of omitted variables. We found that after applying balancing weighting to ensure similarity of the baseline samples (given the nonrandomized study design), both groups significantly improved on the two substance use outcomes (days abstinent and percent of youth in recovery) and on the two mental health outcomes (post-traumatic stress disorder (PTSD) symptoms and general emotional problems). Youth in A-CRA were significantly more likely to be in recovery at the 3-month follow-up compared to youth in MET/CBT5, but the size of this effect was very small. Youth receiving MET/CBT5 appeared to show significantly more improvement in the two mental health measures compared to youth in A-CRA, though these effect sizes were also very small. The findings indicate that adolescents with co-occurring substance use and mental health problems improve on both substance use and mental health outcomes with both treatments even though they are not specifically targeting mental health problems.

Treatment Retention and Outcomes with the Adolescent Community Reinforcement Approach in Emerging Adults with Opioid Use.

Treatment retention and engagement of emerging adults with opioid use disorders can be particularly challenging. This study compares treatment outcomes of young adults with primary opioid use (OU) to those with primary marijuana or alcohol use (MAU), who received the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based therapy for the treatment of substance use. The MAU and OU groups were comprised of an outcome sample of 419 young adults ages 18-25. Groups were compared on intake demographics, clinical characteristics, and measures of treatment retention and other associated factors, including treatment initiation and engagement. Outcome measures were administered at A-CRA intake and at 3, 6, and 12 months post-intake. Both groups were similar in treatment retention, initiation, and engagement. Both groups showed a similar decrease in alcohol (p < .001) and marijuana use (p < .001). The OU group had significantly less opioid use at 3 months (p < .001) and maintained this decrease, but did not improve to the level observed in the MAU group at the 12-month follow-up. The Adolescent Community Reinforcement Approach merits further study as a behavioral treatment for young adults with opioid use.

Contingent reinforcement of personal goal activities for adolescents with substance use disorders during post-residential continuing care.

Contingency management (CM) is efficacious in improving outcomes of substance-abusing patients, but CM studies are relatively rare in adolescents. CM approaches can reinforce both abstinence and adherence to treatment-related goal areas. This paper describes 1,739 different activities in 10 goal areas (e.g., education, family/friends, and social/recreational) chosen by 86 adolescents who were participating in a multiple week CM study that reinforced both abstinence and adherence with goal-related activities. The mean activities selected was 20, and the mean completed was 13. Overall, 1,114 or 64% of chosen activities were completed. The clinical feasibility of activity incentive programs for adolescents is discussed.

One-year treatment patterns and change trajectories for adolescents participating in outpatient treatment for the first time.

The American Society on Addiction Medicine's Patient Placement criteria are commonly used in adolescent treatment. However, the use of these criteria and how they affect the course of treatment and interact with adolescent change has not been examined. Twelve-month treatment patterns were examined for 176 adolescents who entered their first ever episode in a treatment system using these criteria. Forty-one percent of the adolescents received additional treatment after their initial outpatient episode with over 30 unique treatment sequences (i.e., various combinations of outpatient, intensive outpatient, and residential treatment). Significant differences in treatment patterns were found between the change trajectory groups. For example, adolescents who participated in only one outpatient treatment episode were more likely to be in the low alcohol and drug use (AOD) group and less likely to have high rates of time in a controlled environment or to report moderate AOD use. Over one-third of the adolescents participated in additional treatment and almost one-quarter of those who only participated in outpatient treatment had problematic use. These findings suggest the need for clinical monitoring protocols that can be used to identify adolescents needing additional treatment or recovery services.

Contingency management for attendance to group substance abuse treatment administered by clinicians in community clinics.

Contingency management (CM) is effective in enhancing retention in therapy. After an 8-week baseline, four community-based substance abuse treatment clinics were exposed in random order to 16 weeks of standard care with CM followed by 16 weeks of standard care without CM or vice versa. In total, 75 outpatients participated. Patients who were enrolled in the clinics when the CM treatment phase was in effect attended a significantly greater percentage of therapy sessions than patients who were enrolled in treatment when CM was not in effect. This study is one of the first to investigate CM in community settings implemented entirely by community clinicians, and results suggest that CM is effective in improving therapy attendance.

The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders.

AIMS: This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence. DESIGN: Two-group randomized design. SETTING: Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States. PARTICIPANTS: A total of 183 adolescents, ages 12-17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment. INTERVENTION: Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits. MEASUREMENTS: Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. FINDINGS: ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. CONCLUSIONS: ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study

The impact of continuing care adherence on environmental risks, substance use, and substance-related problems following adolescent residential treatment.

The effectiveness of adolescent treatment to reduce substance use has been demonstrated by a number of different literature reviews, yet longer term outcome studies have suggested that continued alcohol and other drug use is common. Participation in continuing care services and reductions in environmental risk factors (e.g., peer substance use or alcohol or drug use in the home) have both been found to be associated with improved posttreatment substance use. The authors conducted Path analysis to examine the experimental direct effect of the Assertive Continuing Care Protocol (S. H. Godley, M. D. Godley, & M. L. Dennis, 2001) on general continuing care adherence following residential treatment and the protocol's indirect effect (via general continuing care adherence) on social and environmental risk factors, as well as subsequent substance use and substance-related problems. Supporting previous findings, the final model indicates that greater adherence to continuing care is associated with reductions in environmental risk, which in turn is associated with reduced adolescent substance use and substance-related problems 9 months after discharge from residential treatment.

The effect of therapists' adherence and competence in delivering the adolescent community reinforcement approach on client outcomes.

[Correction Notice: An Erratum for this article was reported in Vol 31(1) of Psychology of Addictive Behaviors (see record 2016-59284-001). In the article, the disclosed interest for Mark D. Godley in the author note is misrepresented. The accurate representation is that the organization employing Mark D. Godley, Chestnut Health Systems, receives fees for A-CRA training. In addition, the disclosed interest statement for Jane Ellen Smith and Robert J. Meyers should read Jane Ellen Smith and Robert J. Meyers each have private consulting businesses that conduct workshops on CRA or A-CRA; they also receive royalties on the CRA book. All versions of this article have been corrected.] Central to the debate over the implementation of empirically supported treatments is whether therapist skill has a measurable, positive relationship with client outcome. The fidelity and skill with which therapists deliver treatments have been studied under the constructs of adherence and competence. Evidence for a relationship between adherence and competence and client outcomes has been mixed, possibly due to small sample sizes, potentially inadequate measures for rating therapists' skill, and limited statistical methods. The current study used a data set in which 91 therapists provided services to 384 clients from the Assertive Adolescent and Family Treatment project. Therapists trained to deliver the Adolescent Community Reinforcement Approach (A-CRA) submitted audiorecorded sessions to independent raters during their training process. Measures of adherence and competence derived from session ratings were examined in a multilevel model for associations with client substance use outcomes at 3-, 6-, and 12-month follow-ups. Therapist competence was significantly predictive of decreases in clients' days of substance use. Therapist adherence was not predictive of client substance use outcomes in the full sample; however, when only those clients who completed the 12-month follow-up were included, between-therapists adherence was found to be predictive of a decrease in client substance use. This study adds to the evidence that competence in the delivery of treatment is associated with better client treatment outcomes. Adherence may be associated with better treatment outcomes as it was in follow-up completers. Future research should investigate the nature of the relationship between protocol-specific adherence and competence and client outcomes. (PsycINFO Database Record