Advances in Adolescent Substance Abuse Treatment and Research Michael Dennis, Ph.D. Chestnut Health...

Advances in Adolescent Substance AbuseTreatment and Research

Michael Dennis, Ph.D.

Chestnut Health Systems,

Bloomington, IL

Presentation for the Adolescent Treatment Initiative, Concord, NH, April 20, 2005. Sponsored by New Futures. 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: [email protected]

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 NH

Summarize major trends in the adolescent treatment system

Review the current knowledge base on treatment effectiveness

Examine the results of recent major studies

Examine how characteristics vary by intensity of juvenile justice system involvement

Goals of this Presentation

Relationship between Past Month Substance Use and Age

Source: Dennis (2002) and 1998 NHSDA

0

10

20

30

40

50

60

70

80

90

10012

13

14

15

16

17

18

19

20

21

22-2

3

24-2

5

26-2

9

30-3

4

35-3

9

50-6

4

65 +

Age

Alcohol Use

Tobacco Use

Binge Alcohol use

Any Illicit Drug Use

Marijuana Use

Age of First Use Predicts Dependence an Average of 22 years Later

Source: Dennis, Babor, Roebuck & Donaldson (2002) and 1998 NHSDA

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.pdf

The Growing Incidence of Adolescent Marijuana Use: 1965-2002

Adult Initiation Relatively Stable

Adolescent Initiation Rising

Importance of Perceived Risk

Source: Office of Applied Studies. (2000). 1998 NHSDA

Mar

ijua

na

Use

Ris

k &

Ava

ilab

ilit

y

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.

Source: Dennis and McGeary (1999) and 1997 NHSDA

Substance Use in the Community

Consequences of Substance Use

Source: Dennis, Godley and Titus (1999) and 1997 NHSDA

Sour

ce:

D. W

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Adolescents with Past Year Alcohol or Other Drug (AOD) Abuse or Dependence

National=8.92%NH=12.21%

Adolescents Needing But Not Receiving Treatment for Alcohol Use

Sour

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Sour

ce:

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t (20

04).

Sta

te E

stim

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of S

ubst

ance

Use

fr

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e 20

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Adolescents Needing But Not Receiving Treatment for Illicit Drug Use


Rates of Use in NH by Age

18

72

63

12

50

21

15

31

7

11

30

7

7

11

2

0 10 20 30 40 50 60 70 80 90 100

Age 12-17

Age 18-25

Age 26+

Any Alcohol Use

Binge Alcohol Use

Any Past MonthIllicit Drug Use

Any Past MonthMarijuana Use

Any Past MonthIllicit BesideMarijuana

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

Rates of SUD and Unmet Tx Need in NH by Age

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

12

31

8

8

26

7

7

10

1

0 5 10 15 20 25 30 35

12

30

7

8

26

6

7

10

1

0 5 10 15 20 25 30 35

Age 12-17

Age26+

Age18-25

Abuse or Dependence Unmet Treatment Need

DrugAlcoholEither

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.samhsa.gov/oas/dasis.htm

50% higher than in 1992

Change in Primary Substance

Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA. http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf

+317% increase in marijuana

-50% decrease in alcohol

+375% increase in stimulants

-21% decrease in cocaine

+144% increase in opiates

Change in Referral Sources

Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf

JJ referrals have doubled and are driving growth

Primary Substance by Referral Source

Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf

More recent marijuana

referrals driven more by JJ

Severity Varies by Level of Care

0%10%20%30%40%50%60%70%80%90%

100%

Weekly use atintake

Dependence First usedunder age 15

Prior Treatment

Outpatient (n=24704)Intensive Outpatient (n=4024)Detoxification or Hospital (n=2062)

Short Term Residential (n=2046)Long Term Residential (n=3124)

Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2002 and 1998 Treatment Episode Data Set (TEDS)

Severity goes up with level of care

STR clients get there younger and sooner

* Weekly use is the Norm

* 1 in 5 report with no past month use

Key Problems in the 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

The size of the NH system is actually coming out of a 7 year decline in admissions

Source: Dennis, Dawud-Noursi, Muck, & McDermeit (Ives), 2002; Godley et al., 2002; Hser et al., 2001; OAS, 2000

NH is also a Heterogeneous Mix of Urban, Small Urban & Rural Systems

1,235,786 people in 9,345 square miles (137.8 people per square mile or ppsm)

Ranges from 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+

Source: U.S. Census 2000

<-US avg. 79.6

Pre-2002 Knowledge Base from 36 Studies

9 large multi-site longitudinal studies (ATM, DARP, TOPS, SROS, TCA, NTIES, DATOS-A, DOMS), including 1 large multi-site experiment (Cannabis Youth Treatment - CYT)

24 behavioral treatment studies (12-step, behavioral, family, other outpatient, inpatient, therapeutic communities, engagement, aftercare), including CYT and 1 pharmacology-behavioral (CBT) trial

8 pharmacology treatment studies (bupropion, disulfiram, fluoxetine, lithium, pemoline, sertaline) and 1 pharmacology-behavioral (CBT) trial

Source: Bukstein & Kithas, 2002; Dennis & White (2003), & Lewinsohn et al. 1993; PNLDP, 2003

Key Lessons from Early Literature

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 Recovery often takes multiple attempts and episodes of care that

may take years Improvements generally come during active treatment and are

sustained for 12 or more months Family therapies are associated with less initial change but more

change post active treatment and less relapse

Interventions associated with reduced substance use and problems:

1 experimental and 3 non-experimental studies of 12-step treatment (e.g., CD, Hazelden)

7 experimental studies of behavior therapies (e.g., ACRA, AGT, BTOS, CBT, MET, RP)

8 experimental studies of family therapy (CFT, FDE, FFT, FSN, FST, MDFT, MST, PBFT, TIPS)

6 longitudinal studies of existing outpatient 6 longitudinal studies of existing short term

residential/inpatient 7 longitudinal studies of therapeutic communities (TC) and

other forms of long term residential treatment (LTR)

Another 3 experimental studies have shown that engagement and retention are associated with several interventions (case management, stepping down

residential to OP, assertive aftercare)

Lessons from 9 Pharmacology Studies No controlled trials of medication for treating withdrawal,

substitution therapy, blocking therapy, aversive therapy or management of cravings

– Though NIDA’s Clinical Trials Network (CTN) and Australian researchers are currently studying the effects of Buprenorphine/Naloxone

Most studies of other disorders exclude adolescents with substance use disorders

Small (n of 8-25), short-term (4-12 weeks) studies suggest medication can be used to effectively treat several co-occurring problems:

– Fluoxetine (Prozac®) & Sertaline (Zoloft®) helped reduce depressive symptoms– Lithium carbonate (Eskalith®) reduced bipolar symptoms and positive urine rates– Pemoline (Cylert®) and Bupropion (Wellbutrin®) reduced symptoms of ADHD

Effectiveness was also associated with therapies that technologically were:

manual-guided

had developmentally appropriate materials

involved more quality assurance and clinical supervision

achieved therapeutic alliance and early positive outcomes

successfully engaged adolescents in aftercare, support groups, positive peer reference groups, more supportive recovery environments

Lessons about what did NOT work

Interventions associated with No or Minimal Change: Passive referrals Educational units alone Probation services as usual Early unstandardized outpatient services as usual

Interventions associated with Deterioration: treatment of adolescents in badly managed groups or “groups

including one or more highly deviant individuals” (but NOT! all groups or any CD)

treatment of adolescents in adult units and/or with adult models/materials (particularly outpatient)

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

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

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

They have agreed to pool their data to facilitate further comparisons and secondary analysis

Studies by Date of First Publication

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

Studies with Publications Currently Coming Out 1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of

Adolescents (DATOS-A) 1995-1997 Drug Abuse Treatment Outcome Study (DOMS) 1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments 1998-2003 NIAAA/CSAT’s 14 individual research grants 1998-2003 CSAT’s 10 Adolescent Treatment Models (ATM) 2000-2003 CSAT’s Persistent Effects of Treatment Study (PETS-A) 2002-2007 CSAT’s 12 Strengthening Communities for Youth (SCY) 2002-2007 RWJF’s 10 Reclaiming Futures (RF) diversion projects 2002-2007 CSAT’s 12+ Targeted Capacity Expansion TCE/HIV 2003-2009 NIDA’s 12 individual research grants 2003-2006 CSAT’s 17 Adolescent Residential Treatment (ART) 2003-2008 NIDA’s Criminal Justice Drug Abuse Treatment Study

(CJ-DATS) 2003-2007 CSAT’s 36 Effective Adolescent Treatment (EAT) 2004-2007 NIAAA/CSAT’s study of diffusion of innovation

Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)

Source: www.chestnut.org/li/apss

NIAAA/NIDA Other Grantees

CSAT

Cannabis Youth Treatment (CYT)Adolescent Treatment Model (ATM)Strengthening Communities for Youth (SCY)Adolescent Residential Treatment (ART)Effective Adolescent Treatment (EAT)

Targeted Capacity Expansion (TCE) grants

Other CollaboratorsRWJF Reclaiming Futures ProgramOther RWJF Grantees

Other Grants/Contracts

Co-occurring Disorder Studies

Young Offender Re-Entry Program (YORP)

Adolescent Treatment Program GAIN Clinical Collaborators

State, County, or Agency-wide systems(also negotiating with 12 states/counties)

Since 1997, the data has been pooled to create one of the largest benchmark data sets in the field

17,464

32,054

57,360

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

Cu

mul

ativ

e G

AIN

In

terv

iew

s(o

bse

rvat

ion

s)

Prior to FY2003

FY2004 FY2005 FY2006

Largest Combined Adolescent Data Set

~ Half of all Adolescent

Treatment Data

One of the Largest Data Sets in the Field with

1+ year follow-up (2nd only to ASI)

74,670..and we are still growing

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.

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

Length of Stay Varies by Level of Care

Source: Adolescent Treatment Model (ATM) Data

0%

50%

100%0 30 60 90 120

150

180

210

240

270

300

330

360

390

Length of Stay

Perc

ent S

till

in T

reat

men

t

Long Term Residential (median=155 days; n=222)

Short Term Residential (median=40 days; n=589)

Outpatient (median= 213 days; n=47)

Adolescents often go through multiple levels of care

Source: Adolescent Treatment Model (ATM) Data

0%

50%

100%0 30 60 90 120

150

180

210

240

270

300

330

360

390

Length of Stay

Perc

ent S

till i

n T

reat

men

t

Index Episode of Care (median=52 days; n=1380)

System Episode of Care (median=73 days; n=1380)

Length of Stay Across Episodes of care is about 50% longer

Program Evaluation Data

Level of Care Clinics Adolescents 1+ FU*

Outpatient/ Intensive Outpatient (OP/IOP)

8 560 96%

Long Term Residential (LTR)**

4 390 98%

Short Term Residential (STR)**

4 594 97%

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

Years of Use

Source: Adolescent Treatment Model (ATM) data

3 0 1

3127

19

3339 37

33 33

43

0

10

20

30

40

50

60

70

80

90

100

OP/IOP (n=560) LTR (n=390) STR (n=594)

Less than 1 1-2 years 3-4 years 5 or more years

Patterns of Weekly (13+/90) Use


61

71

83

56 57

72

20

29

43

4 714

1 49

0

20

40

60

80

100

OP/IOP (n=560) LTR (n=390) STR (n=594)

Weekly use of anything Weekly Marijuana Use

Weekly Alcohol Use Weekly Crack/Cocaine Use

Weekly Heroin/Opioid Use

7

21 17

Weekly Other Drug Use

29

4441

13+ Days in Controlled Environment

Substance Use Severity


71

93

62

70

89

2925

7

35

27

10

75

0

10

20

30

40

50

60

70

80

90

100

OP/IOP (n=560) LTR (n=390) STR (n=594)

Lifetime Substance Dependence Past year Dependence

Lifetime Substance Abuse Past year Abuse

Change in Substance Frequency Indexby Level of Care\a

\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\t,s,ts

Change in Substance Problem Indexby Level of Care\a


Change in Substance Problem Index Past Month T-Score (TSPIM) by Level of Care\a

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,s,ts

OP\t,s,ts

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, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

0%

20%

40%

60%

80%

100%

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\t,s

Multiple Co-occurring Problems Were the Norm and Increased with Level of Care

Source: CSAT’s Cannabis Youth Treatment (CYT) and Adolescent Treatment Model (ATM),

44

2125

21

70

47 43

7880

65

88

56

3635

68

445252

0

20

40

60

80

100

ConductDisorder

ADHD MajorDepressiveDisorder

GeneralizedAnxietyDisorder

TraumaticStress

Disorder

Any Co-OccurringDisorder

Outpatient Long Term Residential Short Term Residential

Change in Emotional Problem Indexby Level of Care\a


40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,s,ts

OP\t,s

Pattern of SA Outcomes is Related to the Pattern of Psychiatric Multi-morbidity

Source: Shane et al 2003, PETSA data

Months Post Intake (Residential only)0 3 6 12

Nu

mb

er o

f P

ast

Mon

th S

ub

stan

ce P

rob

lem

s

2+ Co-occurring 1 Co-occurring No Co-occurring

Multi-morbid Adolescents start the highest, change the most, and relapse the most

High Rates of Victimization are the Norm


71

82 84

52

6973

45

5662

2519

37

0

10

20

30

40

50

60

70

80

90

100

OP/IOP (n=560) LTR (n=390) STR (n=594)

Lifetime History of Victimization Acute Victimization

Past Year Victimization Past 90 Day Victimization

Victimization Is Related to Severity

Source: Titus, Dennis, et al., 2003

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

0.3

0.4

SubstanceFrequency

Index(SFI6P; f=.13)

SubstanceProblem Index(SPI16; f=.21)

General MentalDistress Index(GMDI; f=.32)

Traumatic Stress Index

(TSI; f=.25)

GeneralConflict Tactic

Index(GCTI; f=.20)

Eff

ect S

ize

(f)

High (n=102)Moderate (31)Low (n=80)

Use goes up with

Moderate Victim.

Pathology goes up

with High Victim.

Victimization Also Interacts with Level of Care to Predict SA Outcomes

Source: Funk, et al., 2003

0

5

10

15

20

25

30

35

40

Intake 6 Months Intake 6 Months

Mar

ijua

na U

se (

Day

s of

90)

OP -Acute OP - Low/Cl. Resid-Acute Resid - Low/Cl.

Outpatient Residential Traumatized groups have higher severity

Acute trauma group does not respond to OP

Both groups respond to residential treatment

Broad Range of Past Year Illegal Activity


7478

82

69 7168

86

65

8580 81 81

939395

0

10

20

30

40

50

60

70

80

90

100

OP/IOP (n=560) LTR (n=390) STR (n=594)

Any illegal activity Property crimes Interpersonal crimes

Drug related crimes Acts of physical violence

Change in Illegal Activity Indexby Level of Care\a


40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\s

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low (n=150) Moderate (n=158) High (n=216)

No crime

Incarcerated

Substance Use only

Non-violent crime

Violent crimeX2(8)=18.36, p<.05

GAIN’s Crime and Violence Scale at Intake can predict 30 Months Recidivism

Odds of committing

violent crime 4.5

times higherSource: White et al (2003), PETSA

Crime/Violence and Substance Problems Interact to Predict Recidivism

Low

Mod.

High

LowMod

.High0%

20%

40%

60%

80%

100%

Substance Problem Scale(Abuse/Dependence symptoms)

Crime and Violence

Scale

Source: Dennis et al 2004

Pro

babi

lity

of

12 m

onth

rec

idiv

ism

The probability of committing

another crime goes up with

the CVS score

The probability of committing another crime

goes up with the SPS score

Knowing both is the best predictor

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)

Source: Godley et al 2002

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)

Assertive Continuing Care (ACC)Hypotheses

Assertive Continuin

g Care

General Continuin

g Care Adherence

Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA)

Early Abstinence

GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence

Sustained Abstinence

Early abstinence will be associated with higher rates of long term abstinence.

Usual Continuing Care (UCC): Expectation vs. Performance

Source: Godley et al 2002

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Expected

Weekly Tx Weekly 12 step meetings

Regular urine tests

Contact w/probation/school

Follow up on referrals

Relapse prevention

Communication skills training

Problem solving component

Meet with parents 1-2x month

Weekly telephone contact

Referrals to other services

Discuss probation/school compliance

Adherence: Meets 7/12 criteria

UCC

ACC Improved Adherence

Source: Godley et al 2002, forthcoming

0% 10%

20%

30%

40%

50%

60%

70%

80%

Weekly Tx Weekly 12 step meetings

Regular urine tests

Contact w/probation/school

Follow up on referrals*

ACC * p<.05

90%

100%

Relapse prevention*

Communication skills training*

Problem solving component*

Meet with parents 1-2x month*

Weekly telephone contact*

Referrals to other services*

Discuss probation/school compliance*

Adherence: Meets 7/12 criteria*

UCC

GCCA Improved Early (0-3 mon.) Abstinence


24%

36% 38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)

Low (0-6/12) GCCA

43%

55% 55%

High (7-12/12) GCCA * p<.05

Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence


19% 22% 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)

Early(0-3 mon.) Relapse

69%

59%

73%

Early (0-3 mon.) Abstainer * p<.05

Next Steps for ACC

Preliminary findings and manual published, main findings under review

Currently in use in eight clinical sites

ACC 2 experiment is currently testing– the ACC intervention model in a multi-site trial – whether or not participants get contingency

management (CM) alone or with ACC– CM is targeted at reducing use and increasing

prosocial activities

Secondary Analysis by Intensity of Juvenile Justice System Involvement

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Severity

Detention 14+ days (n=433)

Probation/parole and urine monitoring 14+ days (n=472)

Other current arrest or JJ status (n=303)

Other detention, parole, or probation (n=374)

Past arrest or JJ status (n=170)

Past year illegal activity (n=298)

Source: CYT & ATM Data

LowHi

Intensity by Level of Care

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Short Term Residential

Long Term Residential

Outpatient/IOP

Step Down OP

Total

Detention 14+ days (n=433) Probation/parole and urine monitoring 14+ days (n=472)Other detention, parole, or probation (n=374) Other current arrest or JJ status (n=303)Past arrest or JJ status (n=170) Past year illegal activity (n=298)


Intensity by Demographics



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Female Caucasian AfricanAmerican

Hispanic NativeAmerican

Other

Females and Caucasians more likely in lower

intensityMinorities More

Likely to be in higher intensity

Intensity by Demographics (continued)



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Age 11-15 Years Age 15-17 Years Age 18+ Years Single Parent

High Severity More likely to be 15-17 years olds and

from Single Parent FamiliesLow Intensity More Likely to

be Still Committing

Crime

Intensity by Substance Use Disorder Diagnosis


Source: CYT & ATM Data; a\ Self report for past year

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Substance Disorder Dependence Abuse

Current Intensity Inversely related to Substance Use Severity

Past Involvement a Mix of Severity

Intensity by External Diagnoses



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any External Conduct Disorder ADHD

Intensity by Internal Diagnoses/Problems


Source: CYT & ATM Data \b n=1838 because some sites did not ask trauma questions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Internal

Major Depression

SuicideIdeation

GeneralizedAnxiety

TraumaRelated

Curvilinear Relationship between Intensity and Internal Distress

Intensity by Pattern of Co-occurring Disorders



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

None Internal Only External Only Both

Most Internal Distress is Multi-morbid with External (and Substance Use) Disorders

Intensity by Other Common Problems



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AnyVictimization

High levels ofVictimization

Any Crime

High Crime/Violence

Homeless orRunaway

High HealthProblems

Focus of JJ Detention

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

We need to move beyond focusing on minor variations in therapy (behavioral brand names) and 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

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/cyt/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 <[email protected]> to be added to list server– Next conference is March 21-23, 2005, See website or E-mail Darren for information about

meeting

ReferencesBabor, 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 Psychiatric Disorders, Second Edition, Revised 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 among adolescents in substance abuse treatment: 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 disorders. Addiction, 97 (Suppl. 1), S4-S15.

Dennis, M.L., Dawud-Noursi, S., Muck, R., & 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.

References - continuedDennis, 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.

References - continuedHser, Y., Grella, C. E., Hubbard, R. L., Hsieh, 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.Lewinsohn, P.M., Hops, H., Roberts, R.E., Seeley, J.R., Andrews, J.A. (1993). Adolescent psychopathology, I: prevalence and incidence of depression and other

DSM-III-R disorders in high school students. J Abn Psychol, 102, 133-144. National Academy of Sciences (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy

Press.Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance Abuse and Mental Health Services

Administration. Retrieved, from http://www.samhsa.gov/statistics.Office of Applied Studies (OAS) (1999). Treatment Episode Data Set (TEDS) 1992-1997: National admissions to substance abuse treatment services. Rockville,

MD: Author. [Available online at <http://www.icpsr.umich.edu/SAMHDA>.]Office of Applied Studies (OAS) (2000). Treatment Episode Data Set (TEDS) 1993-1998: National admissions to substance abuse treatment services. Rockville,

MD: Author. [Available on line at <http://www.icpsr.umich.edu/SAMHDA.html>.]Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance Abuse and Mental Health Services

Administration. Retrieved, from http://www.samhsa.gov/statisticsOffice of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS) retrived fromhttp://www.samhsa.gov/oas/dasis.htmPhysician Leadership on National Drug Policy (PNLDP, 2002) Adolescent Substance Abuse: A Public Health Priority. Providence, RI: Brown University.

Retrieved from http://www.plndp.org/Physician_Leadership/Resources/resources.htmlShane, P., Jasiukaitis, P., & Green, R. S. (2003). Treatment outcomes among adolescents with substance abuse problems: The relationship between comorbidities

and post-treatment substance involvement. Evaluation and Program Planning, 26, 393-402.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. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), 24-28.

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

Advances in Adolescent Substance Abuse Treatment and Research Michael Dennis, Ph.D. Chestnut Health...

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