The National Association of State Alcohol and Drug Abuse Directors (NASADAD) is issuing practice guidance to adolescent substance use disorder (SUD) treatment services. Based on an advance copy received by ADAW, guidance provides comprehensive information on the essential elements of treatment and recovery systems for adolescents.

Over the course of the next several months, NASADAD will hold webinars for state youth coordinators that will provide more information to the SSAs (single state authorities) — the state directors with authority over the Substance Abuse Prevention and Treatment (SAPT) block grant. The guidance, however, is not restricted to the use of block grant funds and has no mandates. It could be used for Medicaid or other payers as well, according to NASADAD. The purpose is to better inform SUD services for adolescents across the states.

Language in the document can be incorporated into contracts with treatment providers to ensure that evidence-based, high-quality treatment is delivered to adolescents ages 12 to 18, according to NASADAD.

The project, which was funded under a subcontract to JBS International, under a Substance Abuse and Mental Health Services Administration (SAMHSA) contract, originated in the states themselves, said Henrick Harwood, NASADAD’s director of research and program applications, in an interview with ADAW last week. “Many of the states had been putting together their own documents,” he said. “Other states had been struggling with [adolescent SUD services], and when they heard about this, they wanted to know more.” SAMHSA’s Center for Substance Abuse Treatment funded the development of the project, because they wanted to collect the best state methods being used to manage adolescent treatment systems, added Harwood, who is also NASADAD’s deputy executive director.

“Each state was inventing their own guidelines, their own practices, on how to manage and purchase youth services,” he said. “SAMHSA said, ‘We can help to resource this,’ and gave us a grant to work with the states.”

At least 24 states (Arizona, California, Colorado, Delaware, Georgia, Illinois, Indiana, Kansas, Louisiana, Massachusetts, Minnesota, Mississippi, Missouri, Montana, New York, North Carolina, Oklahoma, Oregon, South Carolina, Texas, Utah, Washington, Wisconsin and Wyoming) have existing documentation on adolescent treatment standards and/or guidelines for the treatment of adolescents with SUDs.

The 56-page document, called the State Adolescent Substance Use Disorder Treatment and Recovery Practice Guide, encompasses best practices derived from the State Youth Substance Abuse Coordinators Committee, a component of NASADAD’s National Treatment Network’s Adolescent Treatment Committee. SAMHSA gave “input and suggestions,” but the document is a result of a “consensus-building process that involved the expertise of the state youth coordinators,” said Harwood.

Three broad sections

The document is divided into three broad sections: principles of care, service elements and administrative considerations. While the language could be used in regulations and contracts, the document is not meant to dictate specific services or practices, but to give states options to consider.

The principles of care section includes guidance on integrated care, trauma-informed care, family-centered care, and evidence-based practices, including medication-assisted treatment.

Buprenorphine

The guidance is for patients ages 12 to 18; while the majority of adolescent patients in treatment are 16 to 18, some, especially those in the “experimenting” phase, are younger. But the problem is that the SUD treatment system, in particular for opioids, has been geared toward older males, said NASADAD Executive Director Rob Morrison. “Now we’re seeing incremental steps to change on the adolescent side,” he said.

While medication-assisted treatment is considered the first-line therapy for adults with serious opioid addiction, with either methadone or buprenorphine, there has been less consensus on the appropriateness of medication-assisted treatment for adolescents. This guidance notes that buprenorphine is appropriate for adolescents age 16 and older. “The effectiveness of buprenorphine products for adolescents under the age of 16 has not been established,” notes the guidance, citing SAMHSA’s Center for Substance Abuse Treatment. “However, medication-assisted treatment with buprenorphine should be considered part of the menu of treatment options for adolescents over 16.”

Providers who are treating adolescents who have been using opioids “need to be aware of the options,” said Harwood. “They need to consider whether or not using medications might be useful, and buprenorphine has been tested with teens.”

In addition to medication-assisted treatment, the service elements section includes screening, assessment, planning, physical health, case management/care coordination, medication-assisted withdrawal, treatment levels of care, individual and group counseling, co-occurring mental health disorders, and recovery services (transportation, continuing care, education, youth vocational and employment services, housing assistance, pregnant and parenting youth, mutual aid groups, peer-to-peer coaching, and recovery coaching and mentoring).

The administration section includes a focus on designated authority — who (the SSA, state or county) has the authority to procure and oversee adolescent SUD services. There is also information on documentation of treatment records, including compliance with regulations such as 42 CFR Part 2 (confidentiality), monitoring and quality improvement, workforce, and patient rights.

Best practice

The guidance “is meant to be a best practices document,” said Harwood. “We recognize that states are in different positions, but this is a set of guidelines, things to work towards, ideals.”

Asked whether this document is something that an SSA could take to a governor to advocate for treatment services, Morrison responded, “To the extent that governors are going to get into this detailed level, it could be used to show what state experts regarded as the categories that should be considered.” However, he added that “this is mainly for the state agency, to look at what options other states are taking."

However, most of the recommendations in the guidance document would not require legislative or executive changes, said Harwood. “This is more for the purchasing authorities,” he said. “Most of these options are doable within statutory authority.”

By providing language that can be put into contracts with service providers, the document can help the SSAs make sure that treatment for adolescents is evidence-based, said Morrison. “So often we talk about issues and platitudes, but not about the nuts and bolts of how to get there,” he said. “This is about the actual issues that states have to consider.”

The guidance document is not directed at drug courts or juvenile courts, but at treatment, said Harwood. “We are fully aware that many of the kids who go into treatment are involved with drug courts or juvenile courts,” he said, adding that about 40 percent of the people including adults who receive treatment through public dollars are involved with some kind of court. He conceded that the adequacy of treatment services for people in the court system is a “running concern” that goes back decades.

Webinars

Starting next month, NASADAD will have one webinar a month for youth coordinators, devoted to each of the three main sections, said Shalini Wickramatilake-Templeman, research analyst with NASADAD. “The goal will be to train the youth coordinators,” she said.

There are 48 youth coordinators — almost one in every state — said Wickramatilake-Templeman. “They have the general oversight of SUD programs for youth in their respective states,” she said.

The states will in turn reach out to providers. NASADAD on its own doesn’t have the ability to train the hundreds of providers in the system, said Harwood.

States are “interested in getting the training.” Like any new policy or innovation, it will take several years to move ahead, he said, noting that purchasing cycles take time to change. “This is a process,” he said. “But states are moving ahead with this.”

For the guidance, go to http://nasadad.org/wp-content/uploads/2014/10/State-Adolescent-Substance-Use-Disorder-Treatment-and-Recovery-Practice-Guide.pdf.

Bottom Line…

NASADAD has issued a guidance document that purchasers of adolescent substance use disorder treatment can incorporate into contracts to improve the quality of services.