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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.

Volunteer Recovery Support for Adolescents (VRSA) is a novel recovery monitoring and support service for youth after discharge from residential treatment for substance use disorders. Study methods and results of a randomized controlled study are presented in a companion paper and provide evidence that VRSA improves pro recovery peer and activity involvement, decreases substance use and related problems, and increases early full remission (Godley et al., under review). This paper describes the VRSA model, how fidelity was monitored, methods used to recruit, retain, train, and supervise volunteers, how well volunteers were able to implement the model, and how adolescents responded to VRSA. As evidenced by successful recruitment of volunteers to cover caseload needs, positive rates of volunteer retention, and favorable recovery support session completion rates, VRSA is a flexible, potentially low-cost model for providing extended recovery support services that is both feasible and acceptable to adolescents. Future research is needed to identify variables that predict volunteer commitment and to investigate if matching gender, race/ethnicity, or other variables affect results.

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

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.

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.

Research on continuing care treatment for adolescents following discharge from primary treatment has demonstrated benefit, yet treatment providers encounter multiple barriers in its implementation. Less formal recovery support following treatment is promising, but controlled trials of effectiveness are lacking. This study reports results of a randomized trial of recovery support provided by student volunteers via telephone to youth discharged from residential treatment. Both direct and indirect effects were predicted for proximal (pro-recovery peers, recovery management activities) and distal (AOD use and problems, AOD remission) outcomes. Method Prior to treatment discharge, participants were randomized to either 9 months of post-treatment Volunteer Recovery Support for Adolescents (VRSA; n = 201) or continuing care services as usual (SAU; n = 201) and assessed over 12 months post- discharge. Results There were significant direct effects for VRSA to have more involvement with pro-recovery peers and recovery management activities than SAU. VRSA also had significant indirect effects on reducing AOD use and problems and increasing remission via increases in pro-recovery peers and recovery management activities at 9- and 12-month assessments. Dose-response analyses demonstrated significant increments of improvement in proximal and distal outcomes as VRSA session completion rate increased, but effectiveness attenuated at the post-VRSA (12- month) follow-up assessment. Conclusion Findings suggest that VRSA is a promising option for post-treatment recovery support, especially in the higher dose range. Additional research is needed to test the feasibility of providing VRSA in the higher dose range to a larger proportion of intent to treat samples and extending VRSA duration.

Emerging adulthood is the period of greatest risk for problematic substance use. The primary aim of the current study was to examine the relationship between a broad measure of child maltreatment and several key outcomes for a large clinical sample of emerging adults ( n = 858) and adolescents ( n = 2,697). The secondary aim was to examine the extent to which the relationship between child maltreatment and treatment outcomes differed between emerging adults and adolescents. Multilevel latent growth curve analyses revealed emerging adults and adolescents who experienced child maltreatment reported significantly greater reductions over time on several treatment outcomes (e.g., substance use, substance-related problems, and emotional problems). Overall, analyses did not support differential relationships between child maltreatment and changes over time in these substance use disorder treatment outcomes for emerging adults and adolescents. The one exception was that although emerging adults with child maltreatment did reduce their HIV risk over time, their improvements were not as great as were the improvements in HIV risk reported by adolescents who had experienced child maltreatment.

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.

Research shows that many adolescents who enter treatment for substance use do not complete the recommended program, and after discharge, do not connect with continuing care services. Furthermore, the majority of adolescents will return to some level of substance use either during or after participation in treatment. Our review found 10 outcome studies of continuing care treatment for adolescents. Five of six studies with randomized designs resulted in significant clinical improvement for youth receiving the experimental continuing care approaches. Key findings of these trials are that more assertive approaches can increase continuing care initiation rates and that rapid initiation of continuing care made a difference in reducing substance use. Findings suggest that continuing care is not only appropriate for those who successfully complete treatment but also for many individuals who do not. Although there are no randomized controlled studies of adolescent participation in mutual aid groups, evidence is accumulating suggesting that matching adolescents to age-appropriate 12-step and other mutual aid groups can support recovery. Research employing adaptive treatment designs holds promise for establishing decision rules as to which adolescents need low-intensity continuing care services and which need more intensive care.

This study examined client and program factors predicting initiation and engagement for 2,191 adolescents at 28 outpatient substance abuse treatment sites implementing evidence-based treatments. Using Washington Circle criteria for treatment initiation and engagement, 76% of the sample initiated, with 59% engaging in treatment. Analyses used a 2-stage Heckman probit regression, accounting for within-site clustering, to identify factors predictive of initiation and engagement. Adolescents treated in a pay-for-performance (P4P) group were more likely to initiate, whereas adolescents in the race/ethnicity category labeled other (Native American, Asian, Pacific Islander, Native Alaskan, Native Hawaiian, mixed race/ethnicity), or who reported high truancy, were less likely to initiate. Race/ethnicity groups other than Latinos were equally likely to engage. Among White adolescents, each additional day from first treatment to next treatment reduced likelihood of engagement. Although relatively high initiation and engagement rates were achieved, the results suggest that attention to program and client factors may further improve compliance with these performance indicators.

Substance abuse treatment programs represent complex human activity systems in which multiple actors, including clients, counselors, and managers, are nested. Furthermore, treatment programs are nested within the broader environmental context of resource allocation and regulatory enforcement. This special issue of the Journal of Substance Abuse Treatment presents 12 empirical papers that address organizational dynamics within specialty treatment programs. In this introduction to the special issue, the guest editors describe a conceptual framework of organizational dynamics, offer an overview of the articles within this issue, and discuss future prospects for research.

This article addresses less developed areas of clinical research that are of great importance for better understanding the therapeutic process along the continuum of care in youth with alcohol and other substance use disorders (AOSUD). These include the rationale, design, mechanisms of behavior change (MBCs), implementation, monitoring, and outcome-based modification of treatment continuum for youth with AOSUD. The specific objectives are: (1) present current knowledge pertaining to the pretreatment phase including the effect of baseline assessment on treatment outcome; (2) address potential MBCs in treatment; (3) discuss the importance of aftercare, also known as continued care, to prevent postintervention relapse; (4) consider how reconceptualization of therapeutic paradigms might advance the field, in particular treatment algorithm or adaptive treatment strategies addressing poor response to treatment.

Telephone continuing care (TCC) was compared to usual continuing care (UCC) on substance use and related problems among adults discharged from residential treatment. Participants were randomly assigned to receive either UCC or TCC. A tapered TCC protocol, initiated by paraprofessional staff and volunteers, was provided during the first three months following discharge. The TCC condition participants reported high satisfaction ratings with the procedure and were more than twice as likely to enter continuing care than UCC participants. At the three-month point, TCC patients reported significantly fewer past month substance problems than UCC patients. Among the subgroup of lower severity (LS) participants, the TCC-LS sample had both significantly more days abstinent and fewer past month substance problems at three months than the UCC-LS sample. The significant between-group differences in substance use outcomes were not maintained at the six-month follow-up. The high satisfaction ratings and early, favorable response among TCC patients suggest the procedure is promising. Further research with larger samples and over a longer period of time is necessary.

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 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.

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.

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.

Continuity of pharmacotherapy was examined between a state psychiatric hospital and an urban community mental health center. Anecdotal reports from administrators as well as limited empirical research suggested that there would be breaks in the continuity of pharmacotherapy across the two agencies and that the high cost of newer medications would contribute to poor continuity. Clinical chart reviews of 242 discharges over a 5–year period revealed that less than 11% of atypical prescriptions and less than 20% of all psychotropic prescriptions were altered beyond dosage level changes after discharge from a state hospital. Analysis of reasons given (reported) for altering the medication regimen revealed a consistent pattern of changes based on clinical evidence or consumer choice.

Aims This paper provides a description of the rationale, study design, treatments and assessment procedures used in the Cannabis Youth Treatment (CYT) experiment. Design CYT was designed to (a) test the relative effectiveness, cost and benefit–cost of five promising treatment interventions under field conditions and (b) provide evidence based manual-guided models of these interventions to the treatment field. Setting The study involved two community-based treatment programs and two major medical centers. Participants Participants were 600 adolescents recruited from the regular intake who were between the ages of 12 and 18, had used marijuana in the past 90 days, and met one or more criteria of dependence or abuse. Interventions Participants were randomly assigned to one of five interventions: Motivational Enhancement Therapy (MET), Cognitive Behavioral Therapy (CBT), Family Support Network (FSN), Adolescent Community Reinforcement Approach (ACRA), or Multidimensional Family Therapy (MDFT). Measurements Self-report data were collected at intake, 3, 6, 9 and 12 months post discharge using the Global Appraisal of Individual Needs (GAIN), as well as several supplemental self-reports, collateral reports, urine testing, and service logs. Findings This paper reports on the study's implementation including the psychometric properties of the measures (alphas over 0.8), validity of self-report (kappa over 0.6), high rates of treatment completion (81% completed two or more months), and high rates of follow-up (over 94% per wave). Conclusions The feasibility of implementing the CYT manual-guided treatment and quality assurance model in community-based adolescent treatment programs is discussed.

Recent reports describe alarming trends of adolescent drug use and a lack of treatment for substance use disorder symptoms. Early efforts in adolescent treatment relied on adult models that may not have considered the unique needs of adolescents. Recently, there has been an increased emphasis in developing intervention models designed specifically for adolescents. This article provides descriptions of current approaches to adolescent substance abuse treatment and summaries of research assessing the effectiveness of these models.

Several market forces including the federal government (Government Performance and Results Act of 1993), managed behavioral health care, and accreditation organizations such as JCAHO, NCQA, and CARF are placing increasing emphasis on substance abuse treatment programs to use performance indicators to monitor quality of outcomes. Discharge status is a frequently cited performance indicator with high intuitive appeal to serve as a low-cost proxy indicator of therapeutic outcome. Researchers are just beginning to address the relationship of discharge status to therapeutic outcomes for adolescents treated for substance abuse. The purpose of the present study was to assess the relationship between discharge status and therapeutic outcomes after discharge from a residential treatment program for adolescents. Eighty-six clients were categorized based on the discharge status assigned to them by the treatment program and interviewed using the Global Appraisal of Individual Needs (GAIN) questionnaire at in...

Adolescents with the most severe alcohol and other drug (AOD) use disorders are typically admitted to residential treatment. Of the more than 21,000 U.S. adolescents admitted to residential treatment supported by public funds in 2009, 53% received an unfavorable discharge and 76% failed to complete 90 days of treatment (United States Department of Health and Human Services, 2009), the length of stay threshold associated with better outcomes (Hser et al., 2001). Additional research has shown that 60–70% of adolescents relapse within 90 days after residential treatment (Brown, Vik, & Creamer, 1989; Godley, Godley, Dennis, Funk, & Passetti, 2002). Providing continuing care following addiction treatment can improve clinical outcomes (Dennis & Scott, 2007; Godley, Godley, Dennis, Funk, & Passetti, 2007; Kaminer, Burleson, & Burke, 2008; Kim et al., 2011; McKay, 2009; Saitz, Larson, LaBelle, Richardson, & Samet, 2008; Winters, Stinchfield, Latimer, & Lee, 2007), but relatively few adult and adolescent patients attend even one continuing care session following discharge from residential treatment (Donovan, 1998; Godley & Godley, 2011). Although some adolescent patients lack motivation to follow through with continuing care referrals, structural barriers exist as well. Residential treatment programs receiving state and/or Medicaid reimbursement typically serve large geographical areas, requiring referral to treatment organizations closer to the patient’s home after residential treatment. A recent study showed that continuing care was initiated about half the time for those with planned residential discharges and less than 10% of the time for those with unplanned discharges (Godley & Godley, 2012). Only one randomized trial of continuing care for youth discharged from residential treatment has been published, and that study examined the effects of Assertive Continuing Care (ACC; Godley et al., 2007). This intervention was developed to overcome barriers to continuing care participation by sending clinicians trained in the Adolescent Community Reinforcement Approach (A-CRA) and case management (Godley, Godley, & Dennis, 2001) to meet with youth in their school, home, or other community location within two weeks of discharge. In this experiment, adolescents assigned to ACC after residential treatment were significantly more likely than those receiving Usual Continuing Care (UCC) to receive continuing care (94% vs. 54%) and attend more sessions. Main effects of ACC were found for abstinence from their primary drug, marijuana, over a 9-month follow-up (d=.32). Decreases for alcohol and other drugs were all in the predicted direction but not significant (Godley et al., 2007). The effects of ACC may be due to the combination of (a) case management services designed to increase adherence to the requirements of school and/or juvenile justice – two common social systems in which youth are involved; (b) A-CRA for the adolescent, which uses both operant learning and cognitive behavior therapy procedures to identify and increase reinforcing pro-social activities and facilitates the development of improved communication, relapse prevention, and other skills; (c) A-CRA sessions for both the adolescent and caregiver; and (d) homework assigned after each session to practice a new skill and engage in a new or recurring pro-social activity. Despite the durable success of ACC in the initial trial relative to UCC, effect sizes for both marijuana and alcohol were small, suggesting that additional improvements to the model should be considered. Contingency Management (CM) interventions have been successfully added to the Community Reinforcement Approach and Cognitive Behavior Therapy in trials with adults to further improve substance use outcomes (Higgins, Silverman, & Heil, 2007). The effectiveness of CM in addiction treatment is rapid and reliable through the active phase by providing contingent reinforcement for drug abstinence and, in some studies, treatment attendance or verifiable activities. Only a few controlled studies combining CM with other treatments have been conducted for adolescents with AOD use disorders, and none were continuing care studies. Compared to a family court condition, a juvenile drug court intervention enhanced with Multi-Systemic Therapy plus CM evidenced large effects in decreasing substance use (ESs = 0.0.38 to 2.48) and criminal behavior (ESs = −0.04 to 1.88; Henggeler et al., 2006), and CM combined with parent training and Motivational Enhancement/Cognitive Behavior Therapy (MET/CBT) was more effective for adolescents than MET/CBT alone in increasing continuous abstinence from marijuana during the 3-month treatment phase (d=0.48) but less so over extended follow-up (Stanger, Budney, Kamon, & Thostensen, 2009). In studies by Azrin and colleagues (Azrin et al., 1994, 2001), a multi-component Family Behavior Therapy intervention including parent-mediated CM for abstinence and pro-social activities significantly reduced drug use compared to supportive counseling (Azrin et al., 1994) but in a second study, did not reduce drug use more than a cognitive behavioral problem-solving condition (Azrin et al., 2001). The available evidence suggests that adding CM to cognitive behavioral therapies is a promising strategy to improve adolescents’ drug use outcomes. Although several studies with adults found CM combined with CBT interventions to be more effective than either CM or CBT alone (Higgins et al., 2007; Kadden, Litt, Kabela-Cormier, & Petry, 2007), other studies found that CM alone was as effective (Rawson et al., 2002) or more effective than CM and CBT combined (Carroll et al., 2012). Because CM alone has demonstrated effectiveness with adults and is relatively straightforward to implement, it merits testing with adolescents as a post-treatment continuing care intervention. In summary, CM has demonstrated efficacy in producing abstinence for adults and, in combination with other interventions, for adolescents. In addition, ACC has shown promise in a single trial sustaining abstinence for significantly more youth than UCC, but the effects were relatively small. For the present study, it was expected that the immediate contingent reinforcement offered through CM would improve engagement in pro-social activities and lead to greater improvement in abstinence outcomes, but because the ACC intervention is designed to increase abstinence (through increasing pro-social activities, social skills, relationship with parents, and better adherence to education and juvenile justice requirements), it was unclear whether this would exceed ACC alone. The combination of CM and ACC might provide additional sustained benefit by rapid contingent reinforcement of abstinence and pro-social activities via CM with skills training and case management provided through ACC; however, this has never been tested. The present study reports the results of a randomized trial to assess the degree to which three experimental approaches were more successful at engaging youth in post-residential continuing care and maintaining AOD abstinence during the 12 months following residential discharge relative to a UCC alone condition: (a) CM, a well-established, replicable evidence-based intervention; (b) ACC, a multi-component intervention with behavioral, CBT, and case management elements; and (c) CM +ACC, a combination of both approaches.

Within the context of an initiative to implement evidence-based practices (EBPs) for adolescents with substance use disorders, this study examined the extent to which staff factors measured at an initial EBP training workshop were predictive of EBP competence and turnover status of staff (N = 121) measured 6, 9, and 12 months posttraining. By the final assessment point, 52.3% of staff transitioned to the employed/EBP-competent category, 26.6% transitioned to the not employed/not EBP-competent category, 4.6% transitioned to the not employed/EBP-competent category, and 16.5% had not transitioned out of the initial category. Multilevel multinomial regression analysis identified several measures that were significant predictors of staff transitions to the not employed/not EBP-competent category (e.g., program needs, job satisfaction, burnout) and transitions to the employed/EBP-competent category (e.g., months in position, pressures for change, influence). Findings have implications for the development and testing of strategies to train and retain staff to deliver EBPs in practice settings.

Multiple evidence-based treatments for adolescents with substance use disorders are available; however, the diffusion of these treatments in practice remains minimal. A dissemination and implementation model incorporating research-based training components for simultaneous implementation across 33 dispersed sites and over 200 clinical staff is described. Key elements for the diffusion of the Adolescent Community Reinforcement Approach and Assertive Continuing Care were: (a) three years of funding to support local implementation; (b) comprehensive training, including a 3.5 day workshop, bi-weekly coaching calls, and ongoing performance feedback facilitated by a web tool; (c) a clinician certification process; (d) a supervisor certification process to promote long-term sustainability; and (e) random fidelity reviews after certification. Process data are summarized for 167 clinicians and 64 supervisors.

Background Rewarding provider performance has been recommended by the Institute of Medicine as an approach to improve the quality of treatment, yet little empirical research currently exists that has examined the effectiveness and cost-effectiveness of such approaches. The aim of this study is to test the effectiveness and cost-effectiveness of providing monetary incentives directly to therapists as a method to improve substance abuse treatment service delivery and subsequent client treatment outcomes. Design Using a cluster randomized design, substance abuse treatment therapists from across 29 sites were assigned by site to either an implementation as usual (IAU) or pay-for-performance (P4P) condition. Participants Substance abuse treatment therapists participating in a large dissemination and implementation initiative funded by the Center for Substance Abuse Treatment. Intervention Therapists in both conditions received comprehensive training and ongoing monitoring, coaching, and feedback. However, those in the P4P condition also were given the opportunity to earn monetary incentives for achieving two sets of measurable behaviors related to quality implementation of the treatment. Outcomes Effectiveness outcomes will focus on the impact of the monetary incentives to increase the proportion of adolescents who receive a targeted threshold level of treatment, months that therapists demonstrate monthly competency, and adolescents who are in recovery following treatment. Similarly, cost-effectiveness outcomes will focus on cost per adolescent receiving targeted threshold level of treatment, cost per month of demonstrated competence, and cost per adolescent in recovery. Trial Registration Trial Registration Number: NCT01016704

The current study examined the predictive validity of the Washington Circle (WC) continuity of care after long-term residential treatment performance measure, as well as the impact of assertive continuing care interventions on achieving continuity of care. This measure is a process measure that focuses on timely delivery of a minimal floor of services that are necessary to provide sufficient quality of treatment but should not be construed to be the optimal continuity of care after residential treatment for any specific adolescent. Participants included 342 adolescents who were admitted to long-term residential treatment and randomly assigned to either standard continuing care or an assertive continuing care condition. Overall, results provide initial support for the WC continuity of care after residential treatment performance measure as a useful predictor of 3-month recovery status. Additionally, assignment to an assertive continuing care condition was found to significantly increase the likelihood of achieving continuity of 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.

This study examined the rates and correlates of self-reported receipt for mental health services among 1,190 adolescents, aged 12–19, who were admitted to community-based substance abuse outpatient clinics and had a co-occurring mental health problem. Utilization of mental health service was ascertained 3 months post-intake. About one third (35%) of adolescents with a co-occurring mental health problem identified at intake received mental health service in the 3 months after treatment entry. After holding other correlates constant, history of mental health treatment, suicidal behavior, family history of mental disorder and insurance coverage at intake were associated with mental health service utilization at the 3-month follow up. Predictors of service utilization varied by gender and racial/ethnic status. Implications for integrated substance use and mental health services are discussed.

Aims To identify adolescent relapse trajectory groups following discharge from out-patient substance abuse treatment. Design, setting and participants Adolescents aged 12–18, who were assigned randomly to one of five out-patient interventions (n = 563) in four United States communities and followed-up 3, 6, 9, 12 and 30 months post-intake. Outcome measures Self-report measures of days using any alcohol or other drugs (AOD), days of alcohol use, days of cannabis use, days of heavy use, days of crack/cocaine use, days of heroin/opiate use, days AOD use interfered with responsibilities and days in a controlled environment. Findings Adolescents can be grouped empirically into five relapse trajectories over 30 months following out-patient treatment: (a) low AOD use with limited days in a controlled environment; (b) low AOD use with high days in a controlled environment; (c) moderate/decreasing AOD use; (d) increasing AOD use; and (e) consistently high AOD use. Conclusions There was considerable heterogeneity in the relapse trajectories, varying by the initial response to treatment, the stability (versus increase/decrease) of the response and an interaction with time in a controlled environment. Cannabis and alcohol were the two main substances involved, although the two groups with the poorest trajectories had increasing levels of cocaine, opiate and other substance use at the 30-month follow-up. This study demonstrates the chronicity of substance use even among a subgroup of adolescents and the importance of studying more complex longitudinal patterns of recovery.

In many treatment systems, adolescents referred to residential treatment have the most serious alcohol or other substance use disorders and are at high risk of relapse. Upon discharge, these adolescents are typically referred to continuing care services, however, linkage to these services is often problematic. In this study, 114 adolescents (76% male) who stayed at least 7 days in residential treatment were randomly assigned to receive either usual continuing care (UCC) or UCC plus an assertive continuing care protocol (ACC) involving case management and the adolescent community reinforcement approach. ACC participants were significantly more likely to initiate and receive more continuing care services, to be abstinent from marijuana at 3 months postdischarge, and to reduce their 3-month postdischarge days of alcohol use. Preliminary findings demonstrate an ACC approach designed for adolescents can increase linkage and retention in continuing care and improve short-term substance use outcomes.

The Chicago Target Cities demonstration project was designed to improve the effectiveness and accessibility of substance abuse treatment in large metropolitan areas. The primary interventions included centralized intake (CIU), comprehensive standardized assessment procedures, and management of a centralized wait list. A part of this project, the effectiveness of a case management model implemented through the CIU, was tested. Participants were randomly assigned to one of two conditions, case management (CM) or no case management (No-CM). The primary objectives of the CIU case management model were to improve the show rate to treatment, provide referrals to ancillary services, and to support treatment completion. Participants in both groups could also receive other support services provided by staff for the treatment agencies. CM participants were significantly more likely to show to treatment (78.9%) than No-CM participants (71.8%). Case management was found to primarily improve the show rates for younger participants, who without CM were significantly less likely to show for treatment than older participants. CM participants were significantly more likely to receive referrals to non substance abuse treatment services than No-CM participants, although the number of referrals was low in both conditions. No differences were found in the amount or length of substance abuse treatment services received by participants in the two conditions.

Objective To test whether pay for performance (P4P) is an effective method to improve adolescent substance use disorder treatment implementation and efficacy. Design Cluster randomized trial. Setting Community-based treatment organizations. Participants Twenty-nine community-based treatment organizations, 105 therapists, and 986 adolescent patients (953 with complete data). Intervention Community-based treatment organizations were assigned to 1 of the following conditions: the implementation-as-usual (IAU) control condition or the P4P experimental condition. In addition to delivering the same evidence-based treatment (ie, using the Adolescent Community Reinforcement Approach [A-CRA]), each organization received standardized levels of funding, training, and coaching from the treatment developers. Therapists in the P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (ie, A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions (ie, target A-CRA) that has been found to be associated with significantly improved patient outcomes. Main Outcome Measures Outcomes included A-CRA competence (ie, a therapist-level implementation measure), target A-CRA (ie, a patient-level implementation measure), and remission status (ie, a patient-level treatment effectiveness measure). Results Relative to therapists in the IAU control condition, therapists in the P4P condition were significantly more likely to demonstrate A-CRA competence (24.0% vs 8.9%; event rate ratio, 2.24; 95% CI, 1.12-4.48; P = .02). Relative to patients in the IAU control condition, patients in the P4P condition were significantly more likely to receive target A-CRA (17.3% vs 2.5%; odds ratio, 5.19; 95% CI, 1.53-17.62; P = .01). However, no significant differences were found between conditions with regard to patients' end-of-treatment remission status. Conclusion Pay for performance can be an effective method of improving treatment implementation. Trial Registration clinicaltrials.gov Identifier: NCT01016704

Traditional disulfiram treatment has often been ineffective because of a failure to maintain usage. The present study with 43 alcoholics compared: (1) a traditional disulfiram treatment, (2) a socially motivated Disulfiram Assurance program and (3) a Disulfiram Assurance program combined with reinforcement therapy. About five sessions were given for each program. At the 6-month follow-up, the traditional treatment clients were drinking on most days and no longer taking the medication. The Disulfiram Assurance treatment resulted in almost total sobriety for married or (cohabitating) clients but had little benefit for the single ones. The combined program produced near-total sobriety for the single and married clients. These results indicate a promising integration of chemical, psychological and social treatment of alcoholism.

Behavior change professionals have developed treatment programs for a wide variety of health care problems affecting adolescents. Although a substantial data base of experimentally tested techniques exists for obesity, smoking prevention, and dysmenorrhea, much work remains in other areas. For example, the case studies reported on neurodermatitis and the survey work in teenage alcohol abuse must give way to systematic interventions employing group experimental designs. In addition, behavioral procedures should be compared to other treatments. Also, component analysis should be performed when multiple treatment strategies are used. Finally, strategies aimed at increasing the generalization of treatment, such as from classrooms to different community settings in substance abuse prevention programs and maintenance of treatment effects over long follow-up periods, are necessary. Only in this way will the efficacy of behavioral interventions for specific health problems be established. The leading causes of mortality among adolescents are due to accidents. Of the total number of deaths due to accidents, approximately 50% are attributed to motor vehicle accidents (National Safety Council, 1977). Many of these accidents are due to negligence, substance abuse, and, in general, immature behavior (Bakwin & Bakwin, 1972). In spite of a slow but consistent trend toward lower accidental deaths over time (National Safety Council, 1977), there still is a need for interventions designed to decrease risk-taking behavior, substance abuse, and carelessness in adolescents. Again, behavior change professionals might follow the example set by researchers who have begun to develop successful strategies for decreasing onset of cigarette smoking. These interventions and research methods, designed for use in schools, may provide a promising approach for addressing other kinds of prevention problems. It also seems appropriate to categorize cigarette smoking not only as a risk factor in the development of cardiovascular disease (Kuller, 1976), but also as a member of the risk-taking behaviors. Thus, procedures used to prevent cigarette smoking might also be adapted to prevent other kinds of risk-taking behaviors among adolescents. The work of McAlister et al. (1980), in preventing alcohol abuse as well as cigarette smoking by use of the same or similar procedures, is a case in point. Use of a procedure designed to train competency in refusing peer pressure has clear implications for reducing other risk-taking behaviors, such as reckless driving, drug abuse, and swimming and boating accidents.(ABSTRACT TRUNCATED AT 400 WORDS)