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Advances in Adolescent Substance Abuse Treatment and Research

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Title: Advances in Adolescent Substance Abuse Treatment and Research


1
Advances in Adolescent Substance Abuse Treatment
and Research
  • Michael Dennis, Ph.D.
  • Chestnut Health Systems,
  • Bloomington, IL
  • Part of the continuing education workshop,
    Advancing the Field of Adolescent Substance
    Abuse Treatment, Hamden, CT, April 22, 2005.
    Sponsored by the Department of Children and
    Families Substance Abuse Division. The content of
    this presentations are based on treatment
    research funded by the Center for Substance Abuse
    Treatment (CSAT), Substance Abuse and Mental
    Health Services Administration (SAMHSA) under
    contract 270-2003-00006 and several individual
    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 720 West Chestnut, Bloomington, IL
    61701, phone (309) 827-6026, fax (309)
    829-4661, e-Mail junsicker_at_Chestnut.Org

2
Goals of this Presentation
  • Examine the prevalence, course, and consequences
    of adolescent substance use and co-occurring
    disorders
  • Examine the rates of use, substance use disorders
    (SUD) and unmet treatment needs in the US and CT
  • Summarize major trends in the adolescent
    treatment system
  • Review the current knowledge base on treatment
    effectiveness
  • Examine how characteristics vary by intensity of
    juvenile justice system involvement
  • Examine the results of recent major studies

3
Relationship between Past Month Substance Use
and Age
Source Dennis (2002) and 1998 NHSDA
4
Age of First Use Predicts Dependence an Average
of 22 years Later
100
Under Age 15
90
Aged 15-17
80
Aged 18 or older
71
70
63
62
60
51
48
with 1 Past Year Symptoms
50
45
41
39
37
40
34
30
30
23
20
10
0
Alcohol
Marijuana
Other Drugs
Tobacco
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
Tobacco, OR1.3,
Alcohol, OR1.9,
Marijuana, OR1.5,
Other, OR1.5,
Pop.151,442,082
Pop.176,188,916
Pop.71,704,012
Pop.38,997,916
OR1.49
OR2.74
OR2.45
OR2.65
Source Dennis, Babor, Roebuck Donaldson
(2002) and 1998 NHSDA
plt.05
5
The Growing Incidence of Adolescent Marijuana
Use 1965-2002
Source OAS (2004). Results from the 2003
National Survey on Drug Use and Health National
Findings. Rockville, MD SAMHSA.
http//oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.p
df
6
Importance of Perceived Risk
Risk Availability
Marijuana Use
Source Office of Applied Studies. (2000). 1998
NHSDA
7
Actual Marijuana Risk
  • From 1980 to 1997 the potency of marijuana in
    federal drug seizures increased three fold.
  • The combination of alcohol and marijuana has
    become very common and appears to be synergistic
    and leads to much higher rates of problems than
    would be expected from either alone.
  • Combined marijuana and alcohol users are 4 to 47
    times more likely than non-users to have a wide
    range of dependence, behavioral, school, health
    and legal problems.
  • Marijuana and alcohol are the leading substances
    mentioned in arrests, emergency room admissions,
    autopsies, and treatment admissions.

8
Substance Use in the Community
Source Dennis and McGeary (1999) and 1997 NHSDA
9
Consequences of Substance Use
Source Dennis, Godley and Titus (1999) and 1997
NHSDA
10
Adolescents with Past Year Alcohol or Other Drug
(AOD) Abuse or Dependence
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
National8.92 CT9.36
11
Adolescents Needing But Not Receiving Treatment
for Alcohol Use
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
National5.55 CT5.22
12
Adolescents Needing But Not Receiving Treatment
for Illicit Drug Use
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
National5.14 CT5.50
13
Rates of Use in CT by Age
100
10
20
30
40
50
60
70
80
90
0
Any Alcohol Use
17
10
Binge Alcohol Use
14
Age 12-17
10
6
Any Past Month
Illicit Drug Use
69
45
Any Past Month
23
Age 18-25
Marijuana Use
20
9
Any Past Month
Illicit Beside Marijuana
63
21
6
Age 26
4
3
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA.
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
14
Rates of SUD and Unmet Tx Need in CT by Age
Abuse or Dependence
Unmet Treatment Need
10
15
20
25
30
35
10
15
20
25
30
35
0
5
0
5
9
9
Either
Age 12-17
5
5
Alcohol
6
6
Drug
23
22
Age 18-25
18
18
9
8
6
6
Age 26
5
5
2
1
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA.
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
15
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
16
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
17
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
18
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
19
Adolescent Treatment Admissions have increased
by 50 over the past decade
Source Office of Applied Studies 1992- 2002
Treatment Episode Data Set (TEDS) http//www.samhs
a.gov/oas/dasis.htm
20
Change in Primary Substance
317 increase in marijuana
-50 decrease in alcohol
375 increase in stimulants
-21 decrease in cocaine
144 increase in opiates
Source OAS 2004, Treatment Episode Data Set
(TEDS) 1992-2002. Rockville, MD SAMHSA.
http//www.dasis.samhsa.gov/teds02/2002_teds_rpt.p
df
21
Change in Referral Sources
JJ referrals have doubled and are driving growth
Source OAS 2004, Treatment Episode Data Set
(TEDS) 1992-2002. Rockville, MD SAMHSA
http//www.dasis.samhsa.gov/teds02/2002_teds_rpt.p
df
22
Primary Substance by Referral Source
More recent marijuana referrals driven more by JJ
Source OAS 2004, Treatment Episode Data Set
(TEDS) 1992-2002. Rockville, MD SAMHSA
http//www.dasis.samhsa.gov/teds02/2002_teds_rpt.p
df
23
Level of Care at Admission
Most Adolescents are treated in Outpatient
Settings
Source Dennis, Dawud-Noursi, Muck McDermeit,
2002 and 1998 Treatment Episode Data Set (TEDS)
24
Severity Varies by Level of Care
100
90
80
70
60
50
40
30
20
10
0
Weekly use at
Dependence
First used
Prior Treatment
intake
under age 15
Outpatient (n24704)
Intensive Outpatient (n4024)
Detoxification or Hospital (n2062)
Long Term Residential (n3124)
Short Term Residential (n2046)
Source Dennis, Dawud-Noursi, Muck McDermeit,
2002 and 1998 Treatment Episode Data Set
(TEDS)
25
Key Problems in the U.S. System
  • Less than 1/10th of adolescents with substance
    dependence problems receive treatment
  • Less than 50 stay 6 weeks
  • Less than 75 stay the 3 months recommended by
    NIDA
  • Under 25 in Residential Treatment successfully
    step down to outpatient care
  • Little is known about the rate of initiation
    after detention
  • Source Dennis, Dawud-Noursi, Muck, McDermeit
    (Ives), 2002 Godley et al., 2002 Hser et al.,
    2001 OAS, 2000

26
Outpatient Level of Care Placement (n655)
III Waiting for Residential/Inpatient Services
(1)
No Treatment Needed (2)
0.5 Early Intervention 24
II. Intensive Outpatient/ Partial
Hospitalization (10)
I. Outpatient Service (63 )
Source The Connecticut Department of Children
and Families Substance Abuse Division, FY2004.
27
Presenting Problems Reported to the
State (primary, secondary, or tertiary)
0
10
20
30
40
50
60
70
80
90
76
Cannabis
24
Alcohol
8
Other SUD
34
External
1
(Crime/Violence)
9
Internal
(Homicide/suicide/ Trauma Related)
3
13
Psychosocial Stress
0
Health
Source The Connecticut Department of Children
and Families Substance Abuse Division, FY2004.
28
Length of Stay (in days) for Adolescent
Outpatient Treatment in CT
100
90
80
70
60
Percent Discharged
50
Still, 50 are gone in less than 90 days
40
30
20
10
0
0
90
180
270
360
Length of Stay (Days)
Source The Connecticut Department of Children
and Families Substance Abuse Division, FY2004.
29
Studies by Date of First Publication
The results of more Clinical Trials were
presented last month at JMATE than had been
published through 2002!
From 1998 to 2002 the number of adolescent
treatment studies doubled and has doubled again
in the past 2 years with twice this many
published in the past 2 years and over 100
adolescent treatment studies currently in the
field Source Dennis , White (2003) at
www.drugstrategies.org
30
Impact on Substance Use and Problems
  • Reductions associated with a wide range of
    12-step treatment (e.g., CD, Hazelden),
    individual and group behavior therapies (e.g.,
    ACRA, AGT, BTOS, CBT, MET, RP), family therapy
    (BSFT, CFT, FDE, FFT, FSN, FST, MDFT, MST, PBFT,
    TIPS), adolescent treatment as usual (outpatient,
    short term, long term/therapeutic communities)
    and continuing care (Step down, ACC)
  • No or minimal change associated with passive
    referrals, Educational units alone, probation
    services as usual, and early unstandardized
    outpatient services as usual
  • Deterioration associated with treatment of
    adolescents in adult units, with adult
    models/materials
  • Source Bukstein Kithas, 2002 Dennis White
    (2003), Lewinsohn et al. 1993 PNLDP, 2003

31
Effectiveness was also associated with therapies
that technologically were
  • manual-guided
  • had developmentally appropriate materials
  • involved more quality assurance and clinical
    supervision to improve adherence/ implementation
  • achieved early therapeutic alliance and positive
    outcomes
  • successful in engaging adolescents in aftercare,
    support groups, positive peer reference groups,
    more supportive recovery environments

32
Key Points that Have Been Contentious
  • As other therapies have improved, there is no
    longer the clear advantage of family therapy
    found in early literature reviews
  • While there have been concerns about the
    potential iatrogenic effects of group therapy,
    the rates do not appear to be appreciably
    different from individual or family therapy if it
    is done well (important since group tx typically
    costs less)
  • Effectiveness was not consistently associated
    with the amount of therapy over a short period of
    time (6-12 weeks) but was related to longer term
    continuing care
  • Over time, adolescents regularly cycle between
    use, treatment, incarceration and recovery
  • Treatment primarily impacts the short term
    movement from use to non use in the community
  • The long term effectiveness of therapy was
    dependent on changes in the long term recovery
    environment and social risk

33
Other Important Lessons
  • Assessment needs to be very concrete
  • Multiple co-occurring problems are the norm in
    clinical samples of SUD adolescents (60-80
    external disorders, 25-60 mood disorders, 16-45
    anxiety disorders, 70-90 3 or more diagnoses)
  • Adolescents are involved in multiple systems
    competing to control their behavior (e.g, family,
    peers, school, work, criminal justice, and
    controlled environments)
  • Relapse is common in the first 3-12 months
  • Improvements generally come during active
    treatment and are sustained for 12 or more months
  • Family therapies are associated with more change
    post active treatment and less relapse

34
Limitations of the Early Literature
  • Small sample sizes (most under 50)
  • High rates (30-50) of refusals by eligible
    people
  • Unstandardized measures, no measures of abuse or
    dependence, no measures of co-morbidity, crime or
    violence (just arrest)
  • Unstandardized and minimally-supervised therapies
    (making replication very difficult)
  • Minimal information on services received
  • High rates (20-50) of treatment dropout
  • High rates of attrition from follow-up (25-54)
    leading to potentially large (unknown) bias
  • No controlled trials of medication for treating
    withdrawal, substitution therapy, blocking
    therapy, aversive therapy or management of
    cravings (though Buprenorphine studies are now
    under way)

35
Studies are Improving!
  • New studies are likely to have higher rates of
    participation (70-90), treatment completion
    (70-85), and successful follow-up (85-95)
  • They are more likely to involve standardized
    assessments, manual-guided therapy, and better
    quality assurance/clinical supervision
  • They have experimental design, multiple time
    points of assessment and follow-up lasting 1 or
    more years
  • They include economic analysis of their costs,
    cost-effectiveness and benefit cost
  • Many have agreed to pool their data to facilitate
    further comparisons and secondary analysis

36
Studies with Publications Currently Coming Out
  • 1994-2000 NIDAs Drug Abuse Treatment Outcome
    Study of
  • Adolescents (DATOS-A)
  • 1995-1997 Drug Abuse Treatment Outcome Study
    (DOMS)
  • 1997-2000 CSATs Cannabis Youth Treatment (CYT)
    experiments
  • 1998-2003 NIAAA/CSATs 15 individual research
    grants
  • 1998-2003 CSATs 10 Adolescent Treatment Models
    (ATM)
  • 2000-2003 CSATs Persistent Effects of Treatment
    Study (PETS-A)
  • 2002-2007 CSATs 12 Strengthening Communities for
    Youth (SCY)
  • 2002-2007 RWJFs 10 Reclaiming Futures (RF)
    diversion projects
  • 2002-2007 CSATs 12 Targeted Capacity Expansion
    TCE/HIV
  • 2003-2009 NIDAs 14 individual research grants
    and CTN studies
  • 2003-2006 CSATs 17 Adolescent Residential
    Treatment (ART)
  • 2003-2008 NIDAs Criminal Justice Drug Abuse
    Treatment Study
  • (CJ-DATS)
  • 2003-2007 CSATs 36 Effective Adolescent
    Treatment (EAT)
  • 2004-2007 NIAAA/CSATs study of diffusion of
    innovation

37
Adolescent and Adult Treatment Program GAIN
Clinical Collaborators
CSAT
Other Collaborators
Co-occurring Disorder (CD) Studies
Cannabis Youth Treatment (CYT)
RWJF Reclaiming Futures Program
Other RWJF Grantees
Adolescent Treatment Model (ATM)
NIAAA/NIDA Other Grantees
Strengthening Communities for Youth (SCY)
Other Grants/Contracts
Adolescent Residential Treatment (ART)
State, county, or agency systems Other states,
counties, or agencies proposing or considering it
Effective Adolescent Treatment (EAT)
Young Offender Re-Entry Program (YORP)
Targeted Capacity Expansion (TCE) grants
38
(No Transcript)
39
Normal Adolescent Development
  • Biological changes in the body, brain, and
    hormonal systems that continue into mid-to-late
    20s.
  • Shift from concrete to abstract thinking.
  • Improvements in the ability to link causes and
    consequences (particularly strings of events over
    time).
  • Separation from a family-based identity and the
    development of peer- and individual-based
    identities.
  • Increased focus on how one is perceived by peers.
  • Increasing rates of sensation seeking/trying new
    things.
  • Development of impulse control and coping skills.
  • Concerns about avoiding emotional or physical
    violence.

40
Key Adaptation for Adolescents
  • Examples need to be altered to relevant
    substances, situations, and triggers
  • Consequences have to be altered to things of
    concern to adolescents
  • Most adolescents do not recognize their substance
    use as a problem and are being mandated to
    treatment
  • All materials need to be converted from abstract
    to concrete concepts
  • Co-morbid problems (mental, trauma, legal) are
    the norm and often predate substance use
  • Treatment has to take into account the multiple
    systems (family, school, welfare, criminal
    justice)
  • Less control of life and recovery environment
  • Less aftercare and social support
  • Complicated staffing needs

41
Length of Stay Varies by Level of Care
Source Adolescent Treatment Model (ATM) Data
42
Adolescents often go through multiple levels of
care
Source Adolescent Treatment Model (ATM) Data
43
Program Evaluation Data
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
44
Years of Use
Source Adolescent Treatment Model (ATM) data
45
Patterns of Weekly (13/90) Use
100
83
80
72
71
61
57
56
60
43
40
29
20
14
20
9
7
4
4
1
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Weekly use of anything
Weekly Marijuana Use
Weekly Alcohol Use
Weekly Crack/Cocaine Use
Weekly Heroin/Opioid Use
Source Adolescent Treatment Model (ATM) data
46
Substance Use Severity
Source Adolescent Treatment Model (ATM) data
47
Change in Substance Frequency Index 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.
48
Change in Substance Problem Index 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.
49
Percent in Recovery (no past month use or
problems while living in the community)
\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.
50
Multiple Co-occurring Problems Were the Norm and
Increased with Level of Care
100
88
80
78
80
70
68
65
56
60
52
52
47
44
44
43
35
36
40
25
21
21
20
0
Conduct
ADHD
Major
Generalized
Traumatic
Any Co-
Disorder
Depressive
Anxiety
Stress
Occurring
Disorder
Disorder
Disorder
Disorder
Outpatient
Long Term Residential
Short Term Residential
Source CSATs Cannabis Youth Treatment (CYT) and
Adolescent Treatment Model (ATM),
51
Change in Emotional Problem Index 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.
52
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
53
High Rates of Victimization are the Norm
Source Adolescent Treatment Model (ATM) data
54
Victimization Is Related to Severity
0.4
0.3
0.2
0.1
Effect Size (f)
0
-0.1
-0.2
-0.3
-0.4
Substance
Substance
General Mental
Traumatic
General
Frequency
Problem Index
Distress Index
Stress Index
Conflict Tactic
Index
(SPI16 f.21)
(GMDI f.32)
(TSI f.25)
Index
(SFI6P f.13)
(GCTI f.20)
Low (n80)
Moderate (31)
High (n102)
Source Titus, Dennis, et al., 2003
55
Victimization Also Interacts with Level of Care
to Predict SA Outcomes
Outpatient
Residential
40
35
30
25
Marijuana Use (Days of 90)
20
15
10
5
0
Intake
6 Months
Intake
6 Months
OP -Acute
OP - Low/Cl.
Resid-Acute
Resid - Low/Cl.
Source Funk, et al., 2003
56
Broad Range of Past Year Illegal Activity
100
95
93
93
86
85
90
82
81
81
80
78
74
80
71
69
68
65
70
60
50
40
30
20
10
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Any illegal activity
Property crimes
Interpersonal crimes
Drug related crimes
Acts of physical violence
Source Adolescent Treatment Model (ATM) data
57
Secondary Analysis by Intensity of Juvenile
Justice System Involvement
Low
Hi
Severity
0
10
20
30
40
50
60
70
80
90
100
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
58
But the Same Issues Exist Across the Continuum
100
90
80
70
60
50
40
30
20
10
0
Dependence
Any Co-occurring
High levels of Victimization
High Crime/ Violence
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
59
Intensity by Other Common Problems
100
90
Focus of JJ Detention
80
70
60
50
40
30
20
10
0
    Any
High levels of
 Any Crime
High Crime/
    Homeless or
    High Health
Victimization
Victimization
Violence
Runaway
Problems
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
60
GAINs Crime and Violence Scale at Intake can
predict 30 Months Recidivism
100
90
80
70
No crime
Incarcerated
60
Substance Use only
50
Non-violent crime
Violent crime
40
X2(8)18.36, plt.05
30
20
10
0
Low (n150)
Moderate (n158)
High (n216)
Source White et al (2003), PETSA
61
Crime/Violence and Substance Problems Interact
to Predict Recidivism
Probability of 12 month recidivism
100
80
60
40
20
0
High
High
Mod.
Mod.
Low
Crime and
Low
Violence
Substance Problem Scale (Abuse/Dependence
symptoms)
Scale
Source Dennis et al 2004
62
Change in Illegal Activity Index 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.
63
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
64
Two Effectiveness Experiments
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Source Dennis et al, 2002
65
Contrast of the Treatment Structures
Individual Adolescent Sessions
CBT Group Sessions
Individual Parent Sessions
Family Sessions/Home Visits
Parent Education Sessions
Total Formal Sessions
Case management/ Other Contacts
Total Expected Contacts
Total Expected Hours
Total Expected Weeks
Source Diamond et al, 2002
66
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
67
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
68
Implementation of Evaluation
  • Over 85 of eligible families agreed to
    participate
  • Quarterly follow-up of 94 to 98 of the
    adolescents from 3- to 12-months (88 all five
    interviews)
  • Collateral interviews were obtained at intake, 3-
    and 6-months on over 92-100 of the adolescents
    interviewed
  • Urine test data were obtained at intake, 3, 6, 30
    and 42 months 90-100 of the adolescents who were
    not incarcerated or interviewed by phone (85 or
    more of all adolescents).
  • Long term follow-up completed on 90 at 30-months
  • Self reported marijuana use largely in agreement
    with urine test at 30 months (13.8 false
    negative, kappa.63)
  • 5 treatment manuals drafted, field tested,
    revised, send out for field review, and finalized
    (10-30,000 copies of each already printed and
    distributed)
  • Descriptive, outcome and economic analyses
    completed

Source Dennis et al, 2002, 2004
69
Adolescent Cannabis Users in CYT were as or More
Severe Than Those in TEDS
Source Tims et al, 2002
70
Demographic Characteristics
Source Tims et al, 2002
71
Institutional Involvement
100
87
80
62
60
47
40
25
20
0
In school
Employed
Current JJ
Coming from
Involvement
Controlled
Environment
Source Tims et al, 2002
72
Patterns of Substance Use

100
73
80
71
60
40
17
20
9
0
Weekly Alcohol
Weekly
Weekly
Significant Time
Tobacco Use
Cannabis Use
Use
in Controlled
Environment
Source Tims et al, 2002
73
Multiple Problems were the NORM
Self-Reported in Past Year
Source Dennis et al, 2004
74
Substance Use Severity was Related to Other
Problems
plt.05
Source Tims et al 2002
75
CYT Increased Days Abstinent and Percent in
Recovery (no use or problems while in community)
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
Source Dennis et al., 2004
76
Similarity of Clinical Outcomes by Conditions
Trial 1
Trial 2
300
50
.
280
40
.
260
30
at Month 12
over 12 months
Percent in Recovery
Total days abstinent
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
plt.05, effect size f0.12
n.s.d., effect size f0.16
Source Dennis et al., 2004
77
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
78
Cost Per Person in Recovery at 12 and 30 Months
After Intake by CYT Condition

Trial 1 (n299)
Trial 2 (n297)
Cost Per Person in Recovery (CPPR)
30,000
ACRA Effect Largely Sustained
25,000
20,000
15,000
10,000
5,000
0
MET/ CBT5
MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
6,437
10,405
24,725
27,109
8,257
14,222
CPPR at 30 months
3,958
7,377
15,116
6,611
4,460
11,775
CPPR at 12 months
Plt.0001, Cohens f 1.42 and 1.77 at 12
months Plt.0001, Cohens f 0.76 and 0.94 at 30
months
Source Dennis et al., 2003 forthcoming
79
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
Source Dennis et al forthcoming
80
Environmental Factors are also the Major
Predictors of Relapse
AOD use in the home, family problems,
homelessness, fighting, victimization, self help
group participation, structure activities
Baseline
Family
.32
.77
.18
Conflict
Recovery
Environment
-.54
-.13
Risk
.17
.58
.74
Family
.22
.32
-.09
Substance-
Cohesion
Substance
.43
Related
Use
.32
Problems
.82
.19
.11
Social
.19
-.08
.22
Social
Support
Baseline
Baseline
Risk
Model Fit CFI.97 to .99 RMSEA.04 to .06
.21
Peer AOD use, fighting, illegal activity,
treatment, recovery, vocational activity
Baseline
Source Godley et al (2005)
81
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
82
Assertive Continuing Care (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)

83
Assertive Continuing Care (ACC) Hypotheses
Assertive Continuing Care
84
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, forthcoming
85
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, forthcoming
86
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, forthcoming
87
Concluding Comments
  • We are entering a renaissance of new knowledge in
    this area, but are only reaching 1 of 10 in need
  • Several interventions work, but 2/3 of the
    adolescents are still having problems 12 months
    later
  • Effectiveness is related to severity,
    intervention strength, and adherence/implementatio
    n.
  • We need to move beyond focusing on acute episodes
    of care to focus on continuing care and a
    recovery management paradigm
  • It is very difficult to predict exactly who will
    relapse so it is essential to conduct aftercare
    monitoring with all adolescents
  • Juvenile justice referrals are a central factor
    in recent growth of the adolescent treatment
    system and the intensity of JJ involvement is
    correlated with clinical severity

88
Resources
  • Copy of these slides and handouts
  • http//www.chestnut.org/LI/Posters/
  • Assessment Instruments
  • CSAT TIP 3 at http//www.athealth.com/practitioner
    /ceduc/health_tip31k.html
  • NIAAA Assessment Handbook,http//www.niaaa.nih.gov
    /publications/instable.htm
  • GAIN Coordinating Center www.chestnut.org/li/gain
  • Adolescent Treatment Manuals
  • CSAT CYT, ATM, ACC and other manuals at
    www.chestnut.org/li/apss/csat/protocols or
    www.chestnut.org/li/bookstore
  • SAMHSA at http//kap.samhsa.gov/products/manuals/c
    yt/index.htm or NCADI at www.health.org
  • Adolescent Treatment Programs and Studies
  • List of programs by state and summary of pre-2002
    studies at www.drugstrategies.com
  • Cannabis Youth Treatment (CYT)
    www.chestnut.org/li/cyt
  • Persistent Effects of Treatment Study of
    Adolescents (PETSA) www.samhsa.gov/centers/csat/
    csat.html (then select PETS from program
    resources)
  • Adolescent Program Support Site (APSS)
    www.chestnut.org/li/apss
  • Society for Adolescent Substance Abuse Treatment
    Effectiveness (SASATE)
  • Website at www.chestnut.org/li/apss/sasate with
    bibliography
  • E-mail Darren Fulmore ltdfulmore_at_mayatech.comgt to
    be added to list server
  • Next conference is March 21-23, 2005, See website
    or E-mail Darren for information about meeting

89
References
  • Babor, T. F., Webb, C. P. M., Burleson, J. A.,
    Kaminer, Y. (2002). Subtypes for classifying
    adolescents with marijuana use disorders
    Construct validity and clinical implications.
    Addiction, 97(Suppl. 1), S58-S69.
  • Buchan, B. J., Dennis, M. L., Tims, F. M.,
    Diamond, G. S. (2002). Cannabis use Consistency
    and validity of self report, on-site urine
    testing, and laboratory testing. Addiction,
    97(Suppl. 1), S98-S108.
  • Bukstein, O.G., Kithas, J. (2002) Pharmacologic
    treatment of substance abuse disorders. In
    Rosenberg, D., Davanzo, P., Gershon, S. (Eds.),
    Pharmacotherapy for Child and Adolescent
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    and Expanded. NY, NY Marcel Dekker, Inc.
  • Dennis, M.L., (2002). Treatment Research on
    Adolescents Drug and Alcohol Abuse Despite
    Progress, Many Challenges Remain. Connections,
    May, 1-2,7, and Data from the OAS 1999 National
    Household Survey on Drug Abuse
  • Dennis, M.L. (2004). Traumatic victimization
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    Time to stop ignoring the elephant in our
    counseling rooms. Counselor, April, 36-40.
  • Dennis, M.L., Adams, L. (2001). Bloomington
    Junior High School (BJHS) 2000 Youth Survey Main
    Findings. Bloomington, IL Chestnut Health
    Systems
  • Dennis, M. L., Babor, T., Roebuck, M. C.,
    Donaldson, J. (2002). Changing the focus The case
    for recognizing and treating marijuana use
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    McDermeit, M. (2003). The need for developing
    and evaluating adolescent treatment models. In
    S.J. Stevens A.R. Morral (Eds.), Adolescent
    substance abuse treatment in the United States
    Exemplary Models from a National Evaluation Study
    (pp. 3-34). Binghamton, NY Haworth Press and
    1998 NHSDA.
  • Dennis, M. L., Godley, S. H., Diamond, G., Tims,
    F. M., Babor, T., Donaldson, J., Liddle, H.,
    Titus, J. C., Kaminer, Y., Webb, C., Hamilton,
    N., Funk, R. (2004). The Cannabis Youth
    Treatment (CYT) Study Main Findings from Two
    Randomized Trials. Journal of Substance Abuse
    Treatment, 27, 197-213.
  • Dennis, M. L., Godley, S. and Titus, J. (1999).
    Co-occurring psychiatric problems among
    adolescents Variations by treatment, level of
    care and gender. TIE Communiqué (pp. 5-8 and 16).
    Rockville, MD Substance Abuse and Mental Health
    Services Administration, Center for Substance
    Abuse Treatment.
  • Dennis, M. L., Perl, H. I., Huebner, R. B.,
    McLellan, A. T. (2000). Twenty-five strategies
    for improving the design, implementation and
    analysis of health services research related to
    alcohol and other drug abuse treatment.
    Addiction, 95, S281-S308.
  • Dennis, M. L. and McGeary, K. A. (1999).
    Adolescent alcohol and marijuana treatment Kids
    need it now. TIE Communiqué
  • (pp. 10-12). Rockville, MD Substance Abuse and
    Mental Health Services Administration, Center for
    Substance Abuse Treatment.

90
References - continued
  • Dennis, M. L., Titus, J. C., Diamond, G.,
    Donaldson, J., Godley, S. H., Tims, F., Webb, C.,
    Kaminer, Y., Babor, T., Roebeck, M. C., Godley,
    M. D., Hamilton, N., Liddle, H., Scott, C., CYT
    Steering Committee. (2002). The Cannabis Youth
    Treatment (CYT) experiment Rationale, study
    design, and analysis plans. Addiction, 97,
    16-34..
  • Dennis, M. L., Titus, J. C., White, M., Unsicker,
    J., Hodgkins, D. (2003). Global Appraisal of
    Individual Needs (GAIN) Administration guide for
    the GAIN and related measures. (Version 5 ed.).
    Bloomington, IL Chestnut Health Systems. Retrieve
    from http//www.chestnut.org/li/gain
  • Dennis, M.L., White, M.K. (2003). The
    effectiveness of adolescent substance abuse
    treatment a brief summary of studies through
    2001, (prepared for Drug Strategies adolescent
    treatment handbook). Bloomington, IL Chestnut
    Health Systems. On line Available at
    http//www.drugstrategies.org
  • Dennis, M. L. and White, M. K. (2004).
    Predicting residential placement, relapse, and
    recidivism among adolescents with the GAIN.
    Poster presentation for SAMHSA's Center for
    Substance Abuse Treatment (CSAT) Adolescent
    Treatment Grantee Meeting Feb 24 Baltimore,
    MD. 2004 Feb.
  • Diamond, G., Leckrone, J., Dennis, M. L. (In
    press). The Cannabis Youth Treatment study
    Clinical and empirical developments. In R.
    Roffman, R. Stephens, (Eds.) Cannabis
    dependence Its nature, consequences, and
    treatment . Cambridge, UK Cambridge University
    Press.
  • Diamond, G., Panichelli-Mindel, S. M., Shera, D.,
    Dennis, M. L., Tims, F., Ungemack, J. (in
    press). Psychiatric syndromes in adolescents
    seeking outpatient treatment for marijuana with
    abuse and dependency in outpatient treatment.
    Journal of Child and Adolescent Substance Abuse.
  • French, M.T., Roebuck, M.C., Dennis, M.L.,
    Diamond, G., Godley, S.H., Tims, F., Webb, C.,
    Herrell, J.M. (2002). The economic cost of
    outpatient marijuana treatment for adolescents
    Findings from a multisite experiment. Addiction,
    97, S84-S97.
  • French, M. T., Roebuck, M. C., Dennis, M. L.,
    Diamond, G., Godley, S. H., Liddle, H. A., and
    Tims, F. M. (2003). Outpatient marijuana
    treatment for adolescents Economic evaluation of
    a multisite field experiment. Evaluation
    Review,27(4)421-459.
  • Funk, R. R., McDermeit, M., Godley, S. H.,
    Adams, L. (2003). Maltreatment issues by level of
    adolescent substance abuse treatment The extent
    of the problem at intake and relationship to
    early outcomes. Journal of Child Maltreatment, 8,
    36-45.
  • Godley, S. H., Dennis, M. L., Godley, M. D.,
    Funk, R. R. (2004). Thirty-month relapse
    trajectory cluster groups among adolescents
    discharged from outpatient treatment. Addiction,
    99 (s2), 129-139,
  • Godley, M. D., Godley, S. H., Dennis, M. L.,
    Funk, R., Passetti, L. (2002). Preliminary
    outcomes from the assertive continuing care
    experiment for adolescents discharged from
    residential treatment. Journal of Substance Abuse
    Treatment, 23, 21-32.
  • Godley, S. H., Jones, N., Funk, R., Ives, M., and
    Passetti, L. L. (2004). Comparing Outcomes of
    Best-Practice and Research-Based Outpatient
    Treatment Protocols for Adolescents. Journal of
    Psychoactive Drugs, 36, 35-48.
  • Godley, M. D., Kahn, J. H., Dennis, M. L.,
    Godley, S. H., Funk, R. R. (2005). The
    stability and impact of environmental factors on
    substance use and problems after adolescent
    outpatient treatment. Psychology of Addictive
    Behaviors.

91
References - continued
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    S. C., Fletcher, B. W., Brown, B. S., Anglin,
    M. D. (2001). An evaluation of drug treatments
    for adolescents in four U.S. cities. Archives of
    General Psychiatry, 58, 689-695.
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    J.R., Andrews, J.A. (1993). Adolescent
    psychopathology, I prevalence and incidence of
    depression and other DSM-III-R disorders in high
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    Health Services Administration. Retrieved, from
    http//www.samhsa.gov/statistics
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    (2003). Treatment outcomes among adolescents with
    substance abuse problems The relationship
    between comorbidities and post-treatment
    substance involvement. Evaluation and Program
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  • Tims, F. M., Dennis, M. L., Hamilton, N., Buchan,
    B. J., Diamond, G. S., Funk, R., Brantley, L.
    B. (2002). Characteristics and problems of 600
    adolescent cannabis abusers in outpatient
    treatment . Addiction, 97, 46-57.
  • Titus, J. C., Dennis, M. L., White, W. L., Scott,
    C. K., Funk, R. R. (2003). Gender differences
    in victimization severity and outcomes among
    adolescents treated for substance abuse. Journal
    of Child Maltreatment, 8, 19-35.
  • White, M. K., Funk, R., White, W., Dennis, M.
    (2003). Predicting violent behavior in adolescent
    cannabis users The GAIN-CVI. Offender Substance
    Abuse Report, 3(5), 67-69.
  • White, M. K., White, W. L., Dennis, M. L.
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    substance abuse treatment. Counselor, 5(2),
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    Use from the 2002 National Survey on Drug Use and
    Health. Rockville, MD OAS, SAMHSA.
    http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
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