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1.  Integrating Substance Use Treatment Into Adolescent Health Care 
Current psychiatry reports  2012;14(5):453-461.
Substance use (SU) problems are common among adolescents, a serious health risk for them and a major public health problem, but are inadequately addressed in most pediatric health care settings. Primary care offers an excellent context for SU assessment and treatment for adolescents and their families, offering better access and a less stigmatized environment for receiving treatment than specialty programs. This paper examines the literature on the integration of substance use treatment with adolescent health care, focusing on 2 areas: Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Emergency Departments and Primary Care, and School- and College-Based Health Centers.
doi:10.1007/s11920-012-0304-9
PMCID: PMC3638945  PMID: 22872492
Substance use; Adolescent; Pediatric; Psychiatric disorders; Behavioral health; Comorbidity; Screening, brief intervention, and referral to treatment; SBIRT; Alcohol; Drug; Emergency departments; Primary care; School-based health centers; SBHC; Health care; Integration; Assessment; Treatment
2.  Integrating Care for People With Co-Occurring Alcohol and Other Drug, Medical, and Mental Health Conditions 
Most people with alcohol and other drug (AOD) use disorders suffer from co-occurring disorders (CODs), including mental health and medical problems, which complicate treatment and may contribute to poorer outcomes. However, care for the patients’ AOD, mental health, and medical problems primarily is provided in separate treatment systems, and integrated care addressing all of a patient’s CODs in a coordinated fashion is the exception in most settings. A variety of barriers impede further integration of care for patients with CODs. These include differences in education and training of providers in the different fields, organizational factors, existing financing mechanisms, and the stigma still often associated with AOD use disorders and CODs. However, many programs are recognizing the disadvantages of separate treatment systems and are attempting to increase integrative approaches. Although few studies have been done in this field, findings suggest that patients receiving integrated treatment may have improved outcomes. However, the optimal degree of integration to ensure that patients with all types and degrees of severity of CODs receive appropriate care still remains to be determined, and barriers to the implementation of integrative models, such as one proposed by the Institute of Medicine, remain.
PMCID: PMC3625993  PMID: 23580018
Alcohol and other drug use (AODU) disorders; comorbidity; co-occurring disorders; mental health; health care; treatment; treatment outcomes; integrated treatment; combined treatment
3.  Peer Influences on Adolescent Alcohol and Other Drug Use Outcomes 
Journal of Nursing Scholarship  2012;44(1):36-44.
Purpose
To examine the role of family environment and peer networks in abstinence outcomes for adolescents 1 year after intake to alcohol and other drug (AOD) treatment.
Design
Survey of 419 adolescents 13 to 18 years of age at consecutive intakes to AOD treatment programs at four sites of a large health system, with telephone follow-up survey 1 year after intake.
Methods
Examined association of 1-year abstinence with baseline characteristics. Using logistic regression, we examined characteristics predicting 1-year abstinence and predicting having fewer than four substance-using friends at 1 year.
Results
We found that family environment scores related to family conflict, limit setting, and positive family experiences, were not related to abstinence outcomes, but peer networks were related. Adolescents with fewer (less than four) AOD-using friends were more likely to be abstinent than those with four or more AOD-using friends (65% vs. 41%, p = .0002). Having fewer than four AOD-using friends at intake predicted abstinence at 1 year (odds ratio [OR] = 2.904, p = .0002) and also predicted having fewer than four AOD-using friends at 1 year (OR = 2.557, p = 0.0007).
Conclusions
Although family environment is an important factor in the development of AOD problems in adolescents, it did not play a significant role in treatment success. The quality of adolescent peer networks did independently predict positive outcomes.
Clinical Relevance
For physicians, advanced practice registered nurses, and other primary and behavioral care providers who screen and care for adolescents with AOD and other behavioral problems, our finding suggest the importance of focusing on improving the quality of their peer networks.
doi:10.1111/j.1547-5069.2011.01437.x
PMCID: PMC3287367  PMID: 22339982
Adolescent substance use; treatment outcomes; peer networks; family environment
4.  Addiction treatment ultimatums and U.S. health reform: A case study 
AIMS
Increased access to health care, including addiction treatment, has long been a goal of health reform in the U.S. An unanswered question is whether reform will change the way people get to addiction treatment; when treatment is easily accessible, do individuals self-refer, or do they still enter treatment via ultimatums, and if so, from which sources? To begin examining this, we used a single case study of a U.S. health plan that provides access similar to that called for in health reform.
METHOD
Using a case study method of data from studies conducted in a large, private non-profit, integrated managed care health plan which includes addiction services, we examined the prevalence and source of ultimatums to enter treatment, and the characteristics of those receiving them. The plan is highly representative of changes to U.S. health care and other countries due to health reform.
RESULTS
Many individuals entering addiction treatment had received an ultimatum stemming from employment, legal, medical, and family sources. Having more employment problems, an occupation with public safety concerns, being older, male, and ethnicity predicted an employment ultimatum. Higher legal problem severity predicted a legal ultimatum. More men (and younger people) had family ultimatums, and more women (and older people) had medical ultimatums. Being younger, male, married, having higher employment and family problem severity, and being drug or combined drug/alcohol dependent rather than dependent on alcohol-only predicted an ultimatum from one’s family. On the whole, an ultimatum from one source was not related to having one from another source. Those most likely to receive ultimatums from multiple sources were women, those separated/divorced, and those having higher psychiatric and legal problem severity.
CONCLUSIONS
Even in an insured population with good access to addiction treatment, individuals often receive ultimatums to enter treatment rather than being self-referred. Understanding the treatment entry process, and how it is affected by health care systems, could benefit from international and other comparative research.
PMCID: PMC3225963  PMID: 22135620
alcohol and drug treatment systems; treatment entry; coercion
5.  Access to Treatment for Adolescents With Substance Use and Co-Occurring Disorders: Challenges and Opportunities 
Objective
To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions.
Method
We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits.
Results
Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include “high deductible” plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy.
Conclusion
In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.
doi:10.1016/j.jaac.2010.03.019
PMCID: PMC3045032  PMID: 20610133
adolescent; substance; psychiatric; co-occurring; barriers
6.  Integrating Care for People With Co-Occurring Alcohol and Other Drug, Medical, and Mental Health Conditions 
Alcohol Research & Health  2011;33(4):338-349.
Most people with alcohol and other drug (AOD) use disorders suffer from co-occurring disorders (CODs), including mental health and medical problems, which complicate treatment and may contribute to poorer outcomes. However, care for the patients’ AOD, mental health, and medical problems primarily is provided in separate treatment systems, and integrated care addressing all of a patient’s CODs in a coordinated fashion is the exception in most settings. A variety of barriers impede further integration of care for patients with CODs. These include differences in education and training of providers in the different fields, organizational factors, existing financing mechanisms, and the stigma still often associated with AOD use disorders and CODs. However, many programs are recognizing the disadvantages of separate treatment systems and are attempting to increase integrative approaches. Although few studies have been done in this field, findings suggest that patients receiving integrated treatment may have improved outcomes. However, the optimal degree of integration to ensure that patients with all types and degrees of severity of CODs receive appropriate care still remains to be determined, and barriers to the implementation of integrative models, such as one proposed by the Institute of Medicine, remain.
PMCID: PMC3625993  PMID: 23580018
Alcohol and other drug use (AODU) disorders; comorbidity; co-occurring disorders; mental health; health care; treatment; treatment outcomes; integrated treatment; combined treatment
7.  Substance Use, Symptom, and Employment Outcomes of Persons With a Workplace Mandate for Chemical Dependency Treatment 
Objective
This study examined the role of workplace mandates to chemical dependency treatment in treatment adherence, alcohol and drug abstinence, severity of employment problems, and severity of psychiatric problems.
Methods
The sample included 448 employed members of a private, nonprofit U.S. managed care health plan who entered chemical dependency treatment with a workplace mandate (N=75) or without one (N=373); 405 of these individuals were followed up at one year (N=70 and N=335, respectively), and 362 participated in a five-year follow up (N=60 and N=302, respectively). Propensity scores predicting receipt of a workplace mandate were calculated. Logistic regression and ordinary least-squares regression were used to predict length of stay in chemical dependency treatment, alcohol and drug abstinence, and psychiatric and employment problem severity at one and five years.
Results
Overall, participants with a workplace mandate had one- and five-year outcomes similar to those without such a mandate. Having a workplace mandate also predicted longer treatment stays and improvement in employment problems. When other factors related to outcomes were controlled for, having a workplace mandate predicted abstinence at one year, with length of stay as a mediating variable.
Conclusions
Workplace mandates can be an effective mechanism for improving work performance and other outcomes. Study participants who had a workplace mandate were more likely than those who did not have a workplace mandate to be abstinent at follow-up, and they did as well in treatment, both short and long term. Pressure from the workplace likely gets people to treatment earlier and provides incentives for treatment adherence.
doi:10.1176/appi.ps.60.5.646
PMCID: PMC2878200  PMID: 19411353

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