Post on 14-Dec-2015
When the Rite of Passage Goes Wrong: What Parents Should Know Abuse Adolescent Drug and Alcohol Use
Michael Dennis, Ph.D.Chestnut Health Systems, Normal, IL
Presentation on October 29, 2008 at a pre-conference session sponsored by the Council on Chemical Abuse in cooperation with Alvernia College and the Caron Treatment Centers in Reading, PA.. 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: (309) 451-7801, Fax: (309) 451-7763, e-mail: junsicker@Chestnut.Org
2
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 Pennsylvania
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
Goals of this Presentation are to
3
Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246)
Dependence 5%
Abuse 4%
Regular AOD Use 8%
Any Infrequent Drug Use 4%
Light Alcohol Use Only 47%
No Alcohol or Drug Use
32%
Source: 2002 NSDUH
4
Problems Vary by Age
Source: 2002 NSDUH and Dennis et al forthcoming
0
10
20
30
40
50
60
70
80
90
100
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
65+
No Alcohol or Drug Use
Light Alcohol Use Only
Any Infrequent Drug Use
Regular AOD Use
Abuse
Dependence
NSDUH Age Groups
Severity CategoryAdolescent
OnsetRemission
Increasing rate of non-
users
5
Crime & Violence by Substance Severity
0%
10%
20%
30%
40%
50%
60%
Serious FightAt School
Fighting withGroup
Sold Drugs Attacked withintent to harm
Stole (>$50) CarriedHandgun
Dependence (3.9%) Abuse (4.2%)
Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)
Light Alc Use (12.4%) No PY AOD Use (64.3%)
Source: NSDUH 2006
Age 12-17
6
Family, Vocational & MH by Substance Severity
Source: NSDUH 2006
0%
10%
20%
30%
40%
50%
60%
10 or MoreArguments with
Parents
Disliked School GPA = D orlower
MajorDepression
Any MHTreatment
Dependence (3.9%) Abuse (4.2%)
Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)
Light Alc Use (12.4%) No PY AOD Use (64.3%)
Age 12-17
7
1-2 M in 3-4 5-6
6-7 7-8 8-9
9-10 10-20 20-30
1-2 M in 3-4 5-6
6-7 7-8 8-9
9-10 10-20 20-30
Brain Activity on PET Scan Brain Activity on PET Scan After Using CocaineAfter Using Cocaine
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 1989;4(4):371-377.
Rapid rise in brain activity after taking
cocaine
Actually ends up lower than they
started
8
Normal
Cocaine Abuser (10 days)
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 11:184-190, 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 14:169-177, 1993.
Brain Activity on PET Scan Brain Activity on PET Scan After Using CocaineAfter Using Cocaine
With repeated use, there is a cumulative
effect of reduced brain activity which
requires increasingly more stimulation (i.e.,
tolerance)
Even after 100 days of abstinence
activity is still low
10
Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.
pain
Adolescent Brain Development Occurs from the
Inside to Out and from Back to Front
11
Substance Use Careers Last for Decades C
um
ula
tive
Su
rviv
al
Years from first use to 1+ years abstinence302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 27 years from
first use to 1+ years
abstinence
Source: Dennis et al., 2005
12
Substance Use Careers are Longer the Younger the Age of First Use
Cu
mu
lati
ve S
urv
ival
Years from first use to 1+ years abstinence
under 15*
21+
15-20*
Age of 1st UseGroups
* p<.05 (different from 21+)
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Source: Dennis et al., 2005
13
Substance Use Careers are Shorter the Sooner People Get to Treatment
Cu
mu
lati
ve S
urv
ival
20+
0-9*
10-19*
Year to 1st TxGroups
302520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
* p<.05 (different from 20+)Source: Dennis et al., 2005
Years from first use to 1+ years abstinence
14
Treatment Careers Last for Years C
um
ula
tive
Su
rviv
al
Years from first Tx to 1+ years abstinence2520151050
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.10.0
Median of 3 to 4 episodes of treatment over 9 years
Source: Dennis et al., 2005
15
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
16
Trends in Adolescent (Age 12-17) Treatment Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S.Admissions in the U.S.
Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
95,0
17
95,2
71 109,
123
122,
910
129,
859
131,
194
139,
129
137,
596
140,
542
148,
772
160,
750
158,
752
157,
036
142,
646
136,
660
10,000
30,000
50,000
70,000
90,000
110,000
130,000
150,000
170,000
190,000
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year of Admission
Num
ber
of A
dmis
sion
s A
ge 1
2-17
.
69% increase from95,017 in 1992
to 160,750 in 2002
15% drop off from 160,750 in 2002 to
136,660 in 2006
17
Median Length of Stay is only 50 days
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/teds02/2002_teds_rpt_d.pdf .
0 30 60 90
Outpatient(37,048 discharges)
IOP(10,292 discharges)
Detox(3,185 discharges)
STR(5,152 discharges)
LTR(5,476 discharges)
Total(61,153 discharges)
Lev
el o
f C
are
Median Length of Stay
50 days
49 days
46 days
59 days
21 days
3 days
Less than 25% stay the
90 days or longer time
recommended by NIDA
Researchers
18
53% Have Unfavorable Discharges
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/teds02/2002_teds_rpt_d.pdf .
0% 20% 40% 60% 80% 100%
Outpatient(37,048 discharges)
IOP(10,292 discharges)
Detox(3,185 discharges)
STR(5,152 discharges)
LTR(5,476 discharges)
Total(61,153 discharges)
Completed Transferred ASA/ Drop out AD/Terminated
Despite being widely recommended, only 10% step down after intensive treatment
19
Past Year Alcohol or Drug Abuse or Dependence
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
8.8% PA vs.8.9% National
20
Adolescent SUD & Treatment
5.4
5.0
0.3
0.3
5.9
5.5
0.3
0.2
8.9
8.4
0.5
0.4
0
1
2
3
4
5
6
7
8
9
10
U.S. Pennsylvania U.S. Pennsylvania
Abuse or Dependence Treatment
Per
cent
Drug Alcohol Either
Still less than 1 in 15 get treatment
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
21
2,75
5
4,15
7
5,14
8
6,18
0
6,59
5
6,37
6
5,45
5
5,47
3 6,05
4
5,85
1
5,57
9
5,15
9
6,45
1
5,24
2
5,11
5
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
OP (77%)
IOP (188%)
Residential(110%)
Detox (-41%)
Change in PA Public Treatment Admissions: Level of Care from 1992 to 2006
Source: OAS, 2006 – 1992-2006 TEDS Data
Dramatic Growth in 1992-1997
22% decrease in the past
decade
Decreased use of Detox
22
Change in PA Public Treatment Admissions: Referral Source from 1995 to 2006
Source: OAS, 2006 – 1992-2006 TEDS Data
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Other (0%)
Other HealthProvider (49%)
School (-10%)
OtherCommunityReferral (60%)
Other AODProvider (494%)
Self/Family(44%)
Juvenile Justice(129%)
Close link to Juv. Just.
23
Change in PA Public Treatment Admissions: Referral Source from 1995 to 2006
Source: OAS, 2006 – 1992-2006 TEDS Data
-
1,000
2,000
3,000
4,000
5,000
6,000
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Marijuana (149%)
Alcohol (14%)
Cocaine (89%)
Hallucinogens (-76%)
Opioids (1429%)
Other Stimulants (-24%)
Psychotropics (329%)
Methamphetamine(173%)Other (79%)
Opioid and Psychotropics are less common but growing fast
Marijuana and Alcohol are the most common problems
24
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
25
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
26
Major Predictors of Bigger Effects
1. Chose a strong intervention protocol based on prior evidence
2. Used quality assurance to ensure protocol adherence and project implementation
3. Used proactive case supervision of individual
4. Used triage to focus on the highest severity subgroup
27
Impact of the numbers of Favorable features on Recidivism (509 JJ studies)
Source: Adapted from Lipsey, 1997, 2005
Average Practice
28
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
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
NOTE: There is generally little or no differences in mean effect size between these brand names
29
Need for Short 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
30
Recovery* by Level of Care
* 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)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Per
cent
in P
ast
Mon
th R
ecov
ery* Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
OP & Resid
Similar
CC better
31
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
32
Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)
The effect of a well implemented weak program is
as big as a strong program implemented poorly
The best is to have a strong
program implemented
well
Thus one should optimally pick the strongest intervention that one can
implement wellSource: Adapted from Lipsey, 1997, 2005
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
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
35
GAIN Clinical CollaboratorsAdolescent and Adult Treatment Program
10/07
GAIN State System
Virgin Islands
01 to 1011 to 25
26 to 130
Indiana
Kansas
MaineMontana
NebraskaNevada
North Dakota
Puerto Rico
Hawaii
New Mexico
South Dakota
Alabama
Arkansas
Iowa
Oklahoma
Rhode Island
South CarolinaDistrict Of ColumbiaTennessee
Utah
Louisiana
W. Virginia
Minnesota
Wisconsin
New Jersey
North Carolina
Alaska
Delaware
Maryland
Pennsylvania
Georgia
KentuckyVirginia
MichiganNew York
Oregon
Colorado
Texas
New Hampshire
Connecticut
Illinois
Missouri
Arizona
Florida
Ohio
Vermont
Idaho
Massachusetts
California
Washington
Wyoming
GAIN-SS State or County System
Number of GAIN SitesMississippi
36
CSAT GAIN Data (n=15,254)
*Any Hispanic ethnicity separate from race group.
Sources: CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).
3%
17%
9%
71%
79%
28%
32%
42%
16%
27%
19%
0% 20% 40% 60% 80% 100%
Short Term Residential
Long Term Residential
Intensive Outpatient
Outpatient
15 to 17 years old
12 to 14 years old
Hispanic*
Mixed/Other
Caucasian
African American
Female
CSAT data dominated by
Male, Caucasians, age 15 to 17
CSAT data dominated by
Outpatient
CSAT residential more likely to be over 30 days
37
Substance Use Problems
83%
50%
29%
7%
34%
29%
26%
94%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Past Year Substance Diagnosis
Any Past Year Dependence
Any withdrawal symptoms in the past week
Severe withdrawal (11+ symptoms) in past week
Can Give 1+ Reasons to Quit
Any prior substance abuse treatment
Acknowledges having an AOD problem
Client believes Need ANY Treatment
Source: CSAT 2007 AT Outcome Data Set (n=12,601)
38
Past 90 day HIV Risk Behaviors
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
64%
33%
29%
25%
20%
2%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sexually active
Sex Under the Influence of AOD
Multiple Sex partners
Any Unprotected Sex
Victimized Physically, Sexually, orEmotionally
Any Needle use
39
Co-Occurring Psychiatric Problems
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
66%
50%
42%
35%
24%
14%
63%
45%
31%
22%
9%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Co-occurring Psychiatric
Conduct Disorder
Attention Deficit/Hyperactivity Disorder
Major Depressive Disorder
Traumatic Stress Disorder
General Anxiety Disorder
Ever Physical, Sexual or Emotional Victimization
High severity victimization (GVS>3)
Ever Homeless or Runaway
Any homicidal/suicidal thoughts past year
Any Self Mutilation
40
Past Year Violence & Crime
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
80%
68%
63%
48%
45%
43%
85%
71%
39%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any violence or illegal activity
Physical Violence
Any Illegal Activity
Any Property Crimes
Other Drug Related Crimes*
Any Interpersonal/ Violent Crime
Lifetime Juvenile Justice Involvement
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
41
Three
None
Five to Twelve
Four
Two
One
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Multiple Problems* are the Norm
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Most acknowledge 1+ problems
Few present with just one problem (the
focus of traditional research)
In fact, 45%present acknowledging 5+
major problems
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
42
Number of Problems by Level of Care
39%50% 55%
67%78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
OP IOP LTR MTR STR
0 to 1
2 to 4
5 or more
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
43
15%
45%
70%
0%10%20%30%40%50%60%70%80%90%
100%
Low (OR 1.0)
Mod.(OR=4.8)
High(OR=13.8)
NoneOneTwoThreeFourFive+
No. of Problems* by Severity of Victimization
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Those with high lifetime
levels of victimization
have 117 times higher odds of
having 5+ major
problems** (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Severity of Victimization
44
The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents
In the Community
Using (75% stable)
In Treatment (48% stable)
In Recovery (62% stable)
Incarcerated(46% stable)
5%
12%
7%
20%
24%
10%
26%
7 %
19%7%
27%
3%
Source: 2006 CSAT AT data set
Avg of 39% change status each quarter
P not the same in both directions
Treatment is the most likely path
to recoveryMore likely than adults to stay 90 days in treatment (OR=1.7)
More likely than adults to be diverted
to treatment (OR=4.0)
45
In the Community
Using (75% stable)
12%
27%
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)
* 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 Recovery(62% 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)
The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents
46
In the Community
Using (75% stable)
In Treatment
(48 v 35% stable)
7%
Source: 2006 CSAT AT data set
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)
The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents
47
In the Community
Using (75% stable)
In Treatment
(48 v 35% stable)
In Recovery (62% stable)
Source: 2006 CSAT AT data set
26% 19%
The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents
Probability of Going to Using vs. Early “Recovery” (+ good)-- Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46)-- Past Month Substance Problems (0.48) + Times Urine Screened (1.56)-- Substance Frequency (0.48) + Recovery Environment (r)* (1.47)
+ Positive Social Peers (r)** (1.69)
* 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.
48
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