Understanding Adolescent Co-occurring Disorders and the Movement towards a more Effective Continuum of Community Care

1
Understanding Adolescent Co-occurring Disorders
and the Movement towards a more Effective
Continuum of Community Care

• Michael Dennis, Ph.D.
• Chestnut Health Systems,
• Normal, IL
• Presentation on November 4, 2008 at a conference
  on Continuum of Community Care (Models of
  Systems of Care) for Adolescents with
  Co-Occurring Disorders Best Practices and Model
  Programs from around the Country sponsored by
  OdysseyNH and the Cassey Foundation. This
  presentation reports on treatment research
  funded by the Center for Substance Abuse
  Treatment (CSAT), Substance Abuse and Mental
  Health Services Administration (SAMHSA) under
  contracts 270-2003-00006 and 270-07-0191, as well
  as several individual CSAT, NIAAA, NIDA and
  private foundation grants. The opinions are those
  of the author and do not reflect official
  positions of the consortium or government.
  Available on line at www.chestnut.org/LI/Posters
  or by contacting Joan Unsicker at 448 Wylie
  Drive, Normal, IL 61761, phone [phone],
  Fax [phone], e-mail junsicker_at_Chestnut.
  Org

2
Goals of this Presentation are to

1. Examine the prevalence, course, and consequences
   of adolescent substance use, co-occurring
   disorders and the unmet need for treatment
   overall
2. Summarize major trends in the adolescent
   treatment system and New Hampshire
3. Highlight what it takes to move the field towards
   evidenced-based practice related to assessment,
   treatment, program evaluation and planning
4. Present the findings from several recent
   treatment studies on substance abuse treatment
   research, trauma and violence/crime

3
Severity of Past Year Substance Use/Disorders
(2002 U.S. Household Population age 12
235,143,246)
Dependence 5
Abuse 4
No Alcohol or
Regular AOD
Drug Use 32
Use 8
Any Infrequent
Drug Use 4
Light Alcohol
Use Only 47
Source 2002 NSDUH
4
Problems Vary by Age
NSDUH Age Groups
Increasing rate of non-users
100
Severity Category
90
No Alcohol or Drug Use
80
70
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
Dependence
0
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Source 2002 NSDUH and Dennis et al forthcoming
5
Crime Violence by Substance Severity
Age 12-17
Source NSDUH 2006
6
Family, Vocational MH by Substance Severity
Age 12-17
Source NSDUH 2006
7
Higher Severity is Associated with Higher Annual
Cost to Society Per Person
4,000
Median (50th percentile)
3,500
3,000
2,500
2,000
1,500
1,000
725
406
500
231
231
0
0
0
No Alcohol or
Light Alcohol
Regular AOD
Any
Dependence
Abuse
Infrequent
Drug Use
Use Only
Drug Use
Use
Source 2002 NSDUH
8
Brain Activity on PET Scan After Using Cocaine
Rapid rise in brain activity after taking cocaine
Actually ends up lower than they started
Photo courtesy of Nora Volkow, Ph.D. Mapping
cocaine binding sites in human and baboon brain
in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL,
Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J,
Bendreim B, Gatley ST. et al. Synapse
19894(4)371-377.
9
Brain Activity on PET Scan After Using Cocaine
With repeated use, there is a cumulative effect
of reduced brain activity which requires
increasingly more stimulation (i.e., tolerance)
Normal
Cocaine Abuser (10 days)
Even after 100 days of abstinence activity is
still low
Cocaine Abuser (100 days)
Photo courtesy of Nora Volkow, Ph.D. Volkow ND,
Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey
SL. Long-term frontal brain metabolic changes in
cocaine abusers. Synapse 11184-190, 1992 Volkow
ND, Fowler JS, Wang G-J, Hitzemann R, Logan J,
Schlyer D, Dewey 5, Wolf AP. Decreased dopamine
D2 receptor availability is associated with
reduced frontal metabolism in cocaine abusers.
Synapse 14169-177, 1993.
10
Image courtesy of Dr. GA Ricaurte, Johns Hopkins
University School of Medicine
11
Adolescent Brain Development Occurs from the
Inside to Out and from Back to Front
Photo courtesy of the NIDA Web site. From A Slide
Teaching Packet The Brain and the Actions of
Cocaine, Opiates, and Marijuana.
12
Substance Use Careers Last for Decades
1.0
Median of 27 years from first use to 1 years
abstinence
.9
Cumulative Survival
.8
.7
Years from first use to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
30
25
20
15
10
5
0
Source Dennis et al., 2005
13
Substance Use Careers are Longer the Younger the
Age of First Use
Age of 1st Use Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
.6
.5
under 15
.4
15-20
.3
.2
21
.1
0.0
plt.05 (different from 21)
30
25
20
15
10
5
0
Source Dennis et al., 2005
14
Substance Use Careers are Shorter the Sooner
People Get to Treatment
Year to 1st Tx Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
20
.6
.5
.4
.3
10-19
.2
.1
0.0
0-9
plt.05 (different from 20)
30
25
20
15
10
5
0
Source Dennis et al., 2005
15
Treatment Careers Last for Years
1.0
.9
Cumulative Survival
.8
Median of 3 to 4 episodes of treatment over 9
years
.7
Years from first Tx to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
25
20
15
10
5
0
Source Dennis et al., 2005
16
Key Implications

• Adolescence is the peak period of risk for and
  actual on-set of substance use disorders
• Adolescent substance use can have short and long
  terms costs to society
• There are real and often lasting consequence of
  adolescent substance use on brain functioning and
  brain development
• Earlier Intervention during adolescence and young
  adult hood can reduce the duration of addiction
  careers

17
Trends in Adolescent (Age 12-17) Treatment
Admissions in the U.S.
15 drop off from 160,750 in 2002 to 136,660 in
2006
69 increase from 95,017 in 1992 to 160,750 in
2002
Source Office of Applied Studies 1992- 2005
Treatment Episode Data Set (TEDS)
http//www.samhsa.gov/oas/dasis.htm
18
Median Length of Stay is only 50 days
Median Length of Stay

Total
50 days
(61,153 discharges)
Less than 25 stay the 90 days or longer time
recommended by NIDA Researchers
LTR
49 days
(5,476 discharges)
STR
21 days
(5,152 discharges)
Level of Care
Detox
3 days
(3,185 discharges)
IOP
46 days
(10,292 discharges)
Outpatient
59 days
(37,048 discharges)
0
30
60
90
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
19
53 Have Unfavorable Discharges
Despite being widely recommended, only 10 step
down after intensive treatment
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
20
Past Year Alcohol or Drug Abuse or Dependence
7.7 NH vs. 10.8 National
Source OAS, 2006 2003, 2004, and 2005 NSDUH
21
New Hampshire Population and Regions

• 1,235,786 people in 9,3450 square miles (137.8
  people per square mile or ppsm)
• Ranges for 18.8 ppsm in Coos County to 434.6 ppsm
  in Hillsborough County
• Approximately 9 age 12-17, 4 age 18-20, 71 age
  21
• Mix of Urban, Small Urban Rural Systems

Source U.S. Census 2000 and OAS, 2006 2003,
2004, and 2005 NSDUH
22
Adolescent Substance Use Disorder Treatment
Participation Rates
0
5
10
15
5.4
5.9
US
Drug Disorder
8.9
6.6
New Hampshire
Alcohol Disorder
7.1
10.8
Any Disorder
6.2
8.2
Northern
12.2
6.8
7.7
Central
11.4
6.5
6.6
Southern
10.1
0
5
10
15
Source OAS, 2006 2003, 2004, and 2005 NSDUH
23
Change in NH Public Treatment Admissions Level
of Care from 1992 to 2006
1,000
909
900
758
800
709
654
649
700
560
600
513
488
489
481
OP (136)
416
500
364
363
IOP
328
400
(2167)
246
300
Residential
(-50)
200
Detox
100
(- 91)
-
Growth of IOP
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Source OAS, 2006 1992-2006 TEDS Data
24
Change in NH Public Treatment Admissions
Referral Source from 1995 to 2006
Big Variation Caused by Changes in School,
Community, Family Referrals
No. from Juv. Justice Relatively Stable
Source OAS, 2006 1992-2006 TEDS Data
25
Change in NH Public Treatment Admissions No. of
Prior Admissions from 1995 to 2006
1,000
5 or more Tx
(-97)
900
800
4 Prior Tx
(-100)
700
600
3 Prior Tx
(150)
500
400
2 Prior Tx
(175)
300
1 Prior Tx
200
(197)
100
No Prior Tx
-
(114)
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Source OAS, 2006 1992-2006 TEDS Data
26
Change in NH Public Treatment Admissions Focal
Problems from 1995 to 2006
Marijuana and Alcohol are the most common problems
700
Marijuana
(189)
600
Alcohol (148)
Hallucinogens
500
(-78)
Cocaine (50)
400
Opioids (1750)
300
Stimulants
Opioid, Psychotropics, Stimulants/Meth, and other
drugs are less common but growing fast
(525)
200
Methamphetamine
(300)
100
Psychotropics
(700)
-
Other (700)
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Source OAS, 2006 1992-2006 TEDS Data
27
Summary of Problems in the Treatment System

• The public systems is changing size, referral
  source, and focus
• Less than 50 stay 50 days (7 weeks)
• Less the 25 stay the 3 months recommended by
  NIDA researchers
• Less than half have positive discharges
• After intensive treatment, less than 10 step
  down to outpatient care
• Major problems are not reliably assessed (if at
  all)
• Difficult to link assessment data to placement or
  treatment planning decisions

28
So what does it mean to move the field towards
Evidence Based Practice (EBP)?

• Introducing explicit intervention protocols that
  are
• Targeted at specific problems/subgroups and
  outcomes
• Having explicit quality assurance procedures to
  cause adherence at the individual level and
  implementation at the program level
• Having the ability to evaluate performance and
  outcomes
• For the same program over time,
• Relative to other interventions
• Introducing reliable and valid assessment that
  can be used
• At the individual level to immediately guide
  clinical judgments about diagnosis/severity,
  placement, treatment planning, and the response
  to treatment
• At the program level to drive program evaluation,
  needs assessment, performance monitoring and long
  term program planning

29
Major Predictors of Bigger Effects

• Chose a strong intervention protocol based on
  prior evidence
• Used quality assurance to ensure protocol
  adherence and project implementation
• Used proactive case supervision of individual
• Used triage to focus on the highest severity
  subgroup

30
Impact of the numbers of Favorable features on
Recidivism (509 JJ studies)
Average Practice
Source Adapted from Lipsey, 1997, 2005
31
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Usual Practice in
Reducing Recidivism (29 vs. 40)

• Aggression Replacement Training
• Reasoning Rehabilitation
• Moral Reconation Therapy
• Thinking for a Change
• Interpersonal Social Problem Solving
• MET/CBT combinations and Other manualized CBT
• Multisystemic Therapy (MST)
• Functional Family Therapy (FFT)
• Multidimensional Family Therapy (MDFT)
• Adolescent Community Reinforcement Approach
  (ACRA)
• Assertive Continuing Care

NOTE There is generally little or no
differences in mean effect size between these
brand names
Source Adapted from Lipsey et al 2001, Waldron
et al, 2001, Dennis et al, 2004
32
Other Protocols Targeted at Specific Issues

• Detoxification services and medication,
  particularly related to opioid and
  methamphetamine use
• Tobacco cessation
• Adolescent psychiatric services related to
  depression, anxiety, ADHD, and conduct disorder
• Trauma, suicide ideation, parasuicidal behavior
• Need for child maltreatment interventions (not
  just reporting protocols)
• HIV Intervention to reduce high risk pattern of
  sexual behavior
• Anger Management
• Problems with family, school, work, and probation
• Recovery coaches, recovery schools, recovery
  housing and other adolescent oriented self help
  groups / services

33
On-site proactive urine testing can be used to
reduce false negatives by more than half
Reduction in false negative reports at no
additional cost
Effects grow when protocol is repeated
34
Implementation is Essential (Reduction in
Recidivism from .50 Control Group Rate)
Thus one should optimally pick the strongest
intervention that one can implement well
Source Adapted from Lipsey, 1997, 2005
35
Implications of Implementation Science

• Can identify complex and simple protocols that
  improve outcomes
• Interventions have to be reliably delivered in
  order to achieve reliable outcomes
• Simple targeted protocols can make a big
  difference
• Need for reliable assessment of need,
  implementation, and outcomes

36
GAIN Clinical Collaborators Adolescent and Adult
Treatment Program
New Hampshire
Washington
Vermont
Maine
North
Montana
Dakota
Minnesota
Oregon
Massachusetts
South
Wisconsin
Idaho
Dakota
New York
Michigan
Wyoming
Rhode Island
Pennsylvania
Iowa
Connecticut
Nebraska
Ohio
Nevada
New Jersey
Indiana
Illinois
Utah
W. Virginia
Delaware
Colorado
California
Kansas
Virginia
Missouri
Kentucky
Maryland
North Carolina
Tennessee
District Of Columbia
Oklahoma
New Mexico
Arkansas
South Carolina
Arizona
Number of GAIN Sites
Georgia
Mississippi
0
Alabama
1 to 10
Texas
11 to 25
Louisiana
26 to 130
Alaska
GAIN State System
Florida
GAIN-SS State or
County System
Hawaii
Virgin Islands
Puerto Rico
10/07
37
CSAT GAIN Data (n15,254)
CSAT data dominated by Male, Caucasians, age 15
to 17
CSAT data dominated by Outpatient
CSAT residential more likely to be over 30 days
Any Hispanic ethnicity separate from race group.
Sources CSAT AT 2007 dataset subset to
adolescent studies (includes 2 18 or older).
38
Substance Use Problems
Source CSAT 2007 AT Outcome Data Set (n12,601)
39
Past Year Substance Severity by Level of Care
Note OPOutpatient, IOPIntensive Outpatient
LTR Long Term Residential (90 days) MTR
Moderate Term Residential (30-90 days) STRShort
Term Residential (0-30 days) Source CSAT 2007
AT Outcome Data Set (n12,824)
40
Past 90 day HIV Risk Behaviors
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
41
Sexual Partners by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
42
Co-Occurring Psychiatric Problems
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
43
Co-Occurring Psychiatric Diagnoses by Level of
Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
44
Severity of Victimization by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
45
Severity of Victimization by Gender
Source CSAT 2007 AT Outcome Data Set (n15,254)
46
Past Year Violence Crime
Dealing, manufacturing, prostitution, gambling
(does not include simple possession or use)
Source CSAT AT 2007 dataset subset to adolescent
studies (N15,254)
47
Type of Crime by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
48
Multiple Problems are the Norm
Few present with just one problem (the focus of
traditional research)
Most acknowledge 1 problems
In fact, 45present acknowledging 5 major
problems
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
49
Number of Problems by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
50
Number of Problems by Level of Care
Source CSAT 2007 AT Outcome Data Set (n15,254)
51
No. of Problems by Severity of Victimization
Those with high lifetime levels of victimization
have 117 times higher odds of having 5 major
problems
Severity of Victimization
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
52
CYT
Cannabis Youth Treatment Randomized Field Trial
Coordinating Center Chestnut Health Systems,
Bloomington, IL, and Chicago, IL University
of Miami, Miami, FL University of Conn. Health
Center, Farmington, CT
Sites Univ. of Conn. Health Center, Farmington,
CT Operation PAR, St. Petersburg, FL Chestnut
Health Systems, Madison County, IL Childrens
Hosp. of Philadelphia, Phil. ,PA
Sponsored by Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services
53
Context Circa 1997

• Cannabis had become more potent, was associated
  with a wide of problems (particularly when
  combined with alcohol), and had become the
  leading substances mentioned in arrests,
  emergency room admissions, autopsies, and
  treatment admissions (doubling in in 5 years)
• Over 80 of adolescents with Cannabis problems
  were being seen in outpatient setting
• The median length of stay was 6 weeks, with only
  25 making it 3 months
• There were no published manuals targeting
  adolescent marijuana users in outpatient
  treatment
• The purpose of CYT was to manualize five
  promising protocols, field test their relative
  effectiveness, cost, and benefit-cost and provide
  them to the field

Source Dennis et al, 2002
54
Two Effectiveness Experiments
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Source Dennis et al, 2002
55
Actual Treatment Received by Condition
ACRA and MDFT both rely on individual, family and
case management instead of group
FSN adds multi family group, family home visits
and more case management
And MDFT using more family therapy
MET/CBT12 adds 7 more sessions of group
With ACRA using more individual therapy
Source Dennis et al, 2004
56
Average Episode Cost (US) of Treatment
--------------------------------------------Econo
mic Cost------------------------------------------
--------- Director Estimate-----
4,000
3,322
3,500
3,000
2,500
Average Cost Per Client-Episode of Care
1,984
2,000
1,559
1,413
1,500
1,197
1,126
1,000
500
-
ACRA (12.8 weeks)
MET/CBT5 (6.8 weeks)
MET/CBT5 (6.5 weeks)
MET/CBT12 (13.4 weeks)
FSN (14.2 weeks w/family)
MDFT(13.2 weeks w/family)
Source French et al., 2002
57
CYT Increased Days Abstinent and Percent in
Recovery
90
90
Days Abstinent
80
80
Percent in Recovery
70
70
60
60
50
50
Days Abstinent Per Quarter
in Recovery at the End of the Quarter
40
40
30
30
20
20
10
10
0
0
Intake
3
6
9
12
no use, abuse or dependence problems in the past
month while in living in the community
Source Dennis et al., 2004
58
Similarity of Clinical Outcomes by Conditions
Not significantly different by condition.
Trial 1
Trial 2
300
50
.
280
40
.
260
30
over 12 months
at Month 12
Total days abstinent
Percent in Recovery
240
20
220
10
200
0
MET/ CBT5
MET/
FSN
MET/ CBT5
ACRA
MDFT
(n102)
CBT12
(n102)
(n99)
(n100)
(n99)
269
256
260
251
265
257
Total Days Abstinent
0.28
0.17
0.22
0.23
0.34
0.19
Percent in Recovery
n.s.d., effect size f0.06
n.s.d., effect size f0.06
n.s.d., effect size f0.12
n.s.d., effect size f0.16
Source Dennis et al., 2004
59
Moderate to large differences in
Cost-Effectiveness by Condition
Trial 2
Trial 1
20
20,000
16
16,000
12
12,000
Cost per person in recovery
at month 12
over 12 months
Cost per day of abstinence
8
8,000
4
4,000
0
0
MET/
MET/ CBT5
FSN
MET/ CBT5
ACRA
MDFT
CBT12
4.91
6.15
15.13
9.00
6.62
10.38
CPDA
CPPR
3,958
7,377
15,116
6,611
4,460
11,775
plt.05 effect size f0.48
plt.05 effect size f0.22
plt.05, effect size f0.72
plt.05, effect size f0.78
Source Dennis et al., 2004
60
36 Site Replication on MET/CBT5
WA
NH
ME
VT
MT
ND
OR
MN
MA
NY
WI
ID
SD
MI
WY
RI
CT
PA
IA
NE
NJ
IL
OH
IN
NV
UT
DE
WV
CO
VA
CA
KS
MD
KY
MO
DC
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
CYT 4 Sites
TX
LA
FL
AK
HI
Source Dennis, Ives, Muck, 2008
61
Range of Effect Sizes (d) for Change in Days of
Abstinence (intake to 12 months) by Site
1.40
1.40
6 programs completely above CYT
1.20
1.20
1.00
1.00
0.80
0.80
Cohens d
0.60
0.60
0.40
0.40
0.20
0.20
75 above CYT median
0.00
0.00
4 CYT Sites (f0.39) (median within site d0.29)
36 EAT Sites (f0.21) (median within site d0.49)
Source Dennis, Ives, Muck, 2008
62
Source Morral and Stevens 2003al 2006
63
Program Evaluation Data
Level of Care Clinics Clinics Adolescents 1 FU
Outpatient/ Intensive Outpatient (OP/IOP) Outpatient/ Intensive Outpatient (OP/IOP) 8 560 96
Long Term Residential (LTR) Long Term Residential (LTR) 4 390 98
Short Term Residential (STR) Short Term Residential (STR) 4 594 97
Total Total 16 1544 97
Completed follow-up calculated as 1
interviews over those due-done, with site varying
between 2-4 planned follow-up interviews. Of
those due and alive, 89 completed with 2
follow-ups, 88 completed 3 and 78 completed
4. Both LTR and STR include programs using CD
and therapeutic community models
64
Adolescents more likely to transfer
Source Adolescent Treatment Model (ATM) Data
65
Change in Substance Frequency Scale by Level of
Care\a
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
66
Change in Substance Problem Scaleby Level of
Care\a
LTR more like OP on symptoms count
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
67
Percent in Recovery (no past month use or
problems while living in the community)
Longer term outcomes are similar on substance use
\a Source Adolescent Treatment Model (ATM)
data Levels of cares coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
68
Change in Emotional Problem Scaleby Level of
Care\a
Note the lack of a hinge Effect is generally
indirect (via reduced use) not specific
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
69
Pattern of SA Outcomes is Related to the Pattern
of Psychiatric Multi-morbidity
2 Co-occurring 1 Co-occurring
No Co-occurring
Multi-morbid Adolescents start the highest,
change the most, and relapse the most
Number of Past Month Substance Problems
0
6
12
3
Months Post Intake (Residential only)
Source Shane et al 2003, PETSA data
70
Change in Illegal Activity Scaleby Level of
Care\a
Residential Treatments have a specific effect
Outpatient Treatments has an indirect effect
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
71
CSAT Adolescent Treatment GAIN Data from 203
level of care x site combinations
Source Dennis, Funk Hanes-Stevens, 2008
72
Ratings of Problem Severity (x-axis) by
Treatment Utilization (y-axis) by Population Size
(circle size)
1.00
F. Hi- Hi (CC)
H. Hi-Hi (Intx Sx PH/MH Tx) 12
0.80
12


0.60
G. Hi-Mod (Env Sx/ PH Tx) 9
C
E
Average Current Treatment Utilization
.
Hi- Mod
0.40
Mod-Mod
B
14
14
Low- Mod
0.20
20
A
D
0.00
Low-Low
Hi-Low
8
12
-0.20
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
Average Current Problem Severity
73
Variance Explained in NOMS Outcomes
\1 Past month \2 Past 90 days All
statistically Significant
74
Predicted Count of Positive Outcomes by Level of
Care Cluster A Low - Low (n1,025)
75
Best Level of Care Cluster A Low - Low
(n1,025)
76
Predicted Count of Positive Outcomes by Level of
Care Cluster C Mod-Mod (n1209)
10
10
9
9
8
8
7
7
6
6
5
5
4
4
3
3
2
2
Outpatient
Intensive Outpatient
Outpatient - Continuing Care
Residential
77
Best Level of Care Cluster C Mod-Mod (n1209)
78
Predicted Count of Positive Outcomes by Level of
Care Cluster F Hi-Hi (CC) (n968)
10
10
9
9
8
8
7
7
6
6
5
5
4
4
3
3
2
2
Outpatient
Intensive Outpatient
Outpatient - Continuing Care
Residential
79
Best Level of Care Cluster F Hi-Hi (CC) (n968)
80
Predicted Count of Positive Outcomes by Level of
Care Cluster G. Hi-Mod (Env/PH) (n749)
81
Best Level of Care Cluster G Hi-Mod (Env/PH)
(n749)
82
Change in Days Abstinent (while in community) by
Level of Care and Gender
Source CSAT 2007 AT Outcome Data Set (n11,013)
83
MALES Change in Days Abstinent in Community by
type of Outpatient Approach
90
80
70
60
50
Days of abstinence in Community
40
30
20
10
0
Intake
Last Follow-up
Source CSAT 2007 AT Outcome Data Set (n11,013)
84
FEMALES Change in Days Abstinent in Community by
type of Outpatient Approach
90
80
70
60
50
Days of abstinence in Community
40
30
20
10
0
Intake
Last Follow-up
Source CSAT 2007 AT Outcome Data Set (n11,013)
85
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents


Incarcerated

(46 stable)
In the

In Recovery
Community

(62 stable)
Using


(75 stable)






Avg of 39 change status each quarter
In Treatment

(48 stable)

Source 2006 CSAT AT data set
86
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents

• Probability of Going from Use to Early Recovery
  ( good)
• Age (0.8) Female (1.7),
• Frequency Of Use (0.23) Non-White (1.6)
• Self efficacy to resist relapse (1.4)
• Substance Abuse Treatment Index (1.96)

In the
12

In Recovery
Community

(62 stable)
Using


27
(75 stable)



Probability of from Recovery to Using ( bad)
Freq. Of Use (5998.00) - Initial Weeks in
Treatment (0.97) Illegal Activity (1.42) -
Treatment Received During Quarter (0.50) Age
(1.24) - Recovery Environment (r) (0.69)
- Positive Social Peers (r) (0.70)

• Average days during transition period of
  participation in self help, AOD free structured
  activities and inverse of AOD involved
  activities, violence, victimization,
  homelessness, fighting at home, alcohol or drug
  use by others in home
• Proportion of social peers during transition
  period in school/work, treatment, recovery, and
  inverse of those using alcohol, drugs, fighting,
  or involved in illegal activity.

87
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents

• Probability of Going from Use to Treatment (
  good)
• Age (0.7) Times urine Tested (1.7),
• Treatment Motivation (1.6)
• Weeks in a Controlled Environment (1.4)

In the

Community

Using


(75 stable)



7



In Treatment

(48 v 35 stable)

Source 2006 CSAT AT data set
88
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents



In the

In Recovery
Community

(62 stable)
Using


(75 stable)



26
19

• Average days during transition period of
  participation in self help, AOD free structured
  activities and inverse of AOD involved
  activities, violence, victimization,
  homelessness, fighting at home, alcohol or drug
  use by others in home
• Proportion of social peers during transition
  period in school/work, treatment, recovery, and
  inverse of those using alcohol, drugs, fighting,
  or involved in illegal activity.

In Treatment

(48 v 35 stable)

Source 2006 CSAT AT data set
89
Recovery by Level of Care
100
Outpatient (79, -1)
90
Residential(143, 17)
80
Post Corr/Res (220, 18)
70
CC better
60
Percent in Past Month Recovery
50
OP Resid Similar
40
30
20
10
0
Pre-Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Recovery defined as no past month use, abuse,
or dependence symptoms while living in the
community. Percentages in parentheses are the
treatment outcome (intake to 12 month change) and
the stability of the outcomes (3months to 12
month change) Source CSAT Adolescent Treatment
Outcome Data Set (n-9,276)
90
Cumulative Recovery Pattern at 30 months
5 Sustained
Recovery
37 Sustained
19 Intermittent,
Problems
currently in
recovery
39 Intermittent,
currently not in
recovery
The Majority of Adolescents Cycle in and out of
Recovery
Source Dennis et al, forthcoming
91
Findings from the Assertive Continuing Care
(ACC) Experiment

• 183 adolescents admitted to residential substance
  abuse treatment
• Treated for 30-90 days inpatient, then discharged
  to outpatient treatment
• Random assignment to usual continuing care (UCC)
  or assertive continuing care (ACC)
• Over 90 follow-up 3, 6, 9 months post
  discharge

Source Godley et al 2002, 2007
92
Time to Enter Continuing Care and Relapse after
Residential Treatment (Age 12-17)
100
90
80
70
Relapse
60
Percent of Clients
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source Godley et al., 2004 for relapse and 2000
Statewide Illinois DARTS data for CC admissions
93
ACC Enhancements

• Continue to participate in UCC
• Home Visits
• Sessions for adolescent, parents, and together
• Sessions based on ACRA manual (Godley, Meyers et
  al., 2001)
• Case Management based on ACC manual (Godley et
  al, 2001) to assist with other issues (e.g., job
  finding, medication evaluation)

94
Assertive Continuing Care (ACC)Hypotheses
Assertive Continuing Care
95
ACC Improved Adherence
100
20
30
10
40
50
60
70
80
90
0
Weekly
Tx
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence Meets 7/12 criteria
Source Godley et al 2002, 2007
96
GCCA Improved Early (0-3 mon.) Abstinence
100
90
80
70
60
50
38
36
40
30
24
20
10
0
Any AOD (OR2.16)
Alcohol (OR1.94)
Marijuana (OR1.98)
Low (0-6/12) GCCA
Source Godley et al 2002, 2007
97
Early (0-3 mon.) Abstinence Improved Sustained
(4-9 mon.) Abstinence
100
90
80
70
60
50
40
30
22
22
19
20
10
0
Any AOD (OR11.16)
Alcohol (OR5.47)
Marijuana (OR11.15)
Early(0-3 mon.) Relapse
Source Godley et al 2002, 2007
98
Post script on ACC

• The ACC intervention improved adolescent
  adherence to the continuing care expectations of
  both residential and outpatient staff doing so
  improved the rates of short term abstinence and,
  consequently, long term abstinence.
• Despite these GAINs, many adolescents in ACC (and
  more in UCC) did not adhere to continuing care
  plans.
• The ACC1 main findings are published and findings
  from two subsequent experiments are currently
  under review
• CSAT is currently replicating ACRA/ACC in 32
  sites
• The ACC manual is being distributed via the
  website and the CD you have been provided.

99
Need for Tracks, Phases and Continuing Care

• Almost a third of the adolescents are returning
  to treatment, 23 for the second or more time
• We need to understand what did and did not work
  the last time and have alternative approaches
• We need tracks or phases that recognize that they
  may need something different or be frustrated by
  repeating the same material again and again
• We need to have better step down and continuing
  care protocols

100
Recommendations for Further Developments

• Evidenced based interventions can come from both
  research and practice
• Evidence based interventions can improve
  implementation of treatment and treatment
  outcomes
• Practice based evidence can be used to improve
  outcomes and is of equal importance
• Evidenced based interventions and their outcomes
  can be replicated in practice
• Continuing care and is a key determinant of long
  term outcomes

101
Recommendations for Further Developments

• We need to target the latter phases of treatment
  to impact the post-treatment recovery environment
  and/or social risk groups that are the main
  predictors of long term relapse
• We need to move beyond focusing on acute episodes
  of care to focus on continuing care and a
  recovery management paradigm
• We need to better understand the impact of
  involvement in juvenile justice system and how it
  can be harnessed to help
• More work is need on the use of schools as a
  location for providing primary treatment (they
  have entrée to the population and appear to be
  the venue of choice) and recovery-schools to
  provide support for those coming out of
  residential treatment

102
Resources for Finding Promising Programs

• Screeners and Other Measures related to
  adolescents
• CSAT TIP 42- http//store.health.org/catalog/produ
  ctDetails.aspx?ProductID16979
• NIAAA Handbook- pubs.niaaa.nih.gov/publications/As
  sesing20Alcohol
• Drug Strategies Handbook- www.drugstrategies.com/t
  eens
• GAIN Coordinating Center- www.chestnut.org/li/gai
  n
• Co-Occurring Center for Excellence-
  www.coce.samhsa.gov/cod_resources/cb_assessment.ht
  m
• Prevention Programs related to adolescents
• Substance use- modelprograms.samhsa.gov/
• Suicide- www.sprc.org/
• Violence- www.sshs.samhsa.gov/
• Co-Occurring Cen. for Excel.- http//www.coce.samh
  sa.gov/cod_resources/cb_prevention.htm
• Other materials- http//www.health.org/
• Treatment Programs related to adolescents
• Substance use disorder (SUD)- www.chestnut.org/li/
  apss/CSAT/protocols
• Mental disorder (MD) systems of care-
  http//www.mentalhealth.samhsa.gov/cmhs/ChildrensC
  ampaign/practices.asp
• Traumatic disorders and child maltreatment-
  www.nctsnet.org
• Co-Occurring Cen. for Excel.- www.coce.samhsa.gov/
  cod_resources/cb_treatmentservice.htm