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Transcript of Assessment and Treatment of Adolescents Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL...
Assessment and Treatment of Adolescents
Michael L. Dennis, Ph.D. Chestnut Health Systems
Normal, IL
Presentation at the Pacific Asia Judges Science and Technology Seminar, November 10-12, 2010, Hyatt Regency Hotel, Tumon, Guam. This
presentation was supported by funds from and data from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174, and CSAT contract no. 270-07-0191. It is available electronically at www.chestnut.org/li/posters . The
opinions are those of the author do not reflect official positions of the government. Please address comments or questions to the author at
Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761 [email protected] or 309-451-7801.
2
1. Examine the prevalence, course, and consequences of adolescent substance use
2. Highlight what it takes to move the field towards evidenced-based practice
3. Present the findings from several recent treatment needs assessment and outcome studies on adolescent substance abuse treatment
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, Dennis & Scott 2007
4
Problems Vary by Age
Source: 2002 NSDUH and Dennis & Scott 2007
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 Category
Over 90% of use and
problems start between the ages of
12-20
It takes decades before most recover or die
People with drug dependence die an
average of 22.5 years sooner than those
without a diagnosis
5
Higher Severity is Associated with Higher Annual Cost to Society Per Person
Source: 2002 NSDUH
$0$231 $231
$725$406
$0$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
No Alcohol orDrug Use
Light Alcohol
Use Only
AnyInfrequentDrug Use
Regular AODUse
Abuse Dependence
Median (50th percentile)
$948
$1,613
$1,078$1,309
$1,528
$3,058Mean (95% CI)
This includes people who are in recovery, elderly, or do not use
because of health problems Higher Costs
6
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
Adolescents 12-17Substance use severity is related to crime and violence
7
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%)
Adolescents 12-17..as well as family, school
and mental health problems
8
7.8%
20.9%
7.2%
0.5%1.0%0.4%0%
5%
10%
15%
20%
25%
12 to 17 18 to 25 26 or older
Abuse or Dependence in past yearTreatment in past year
Substance Use Disorders are Common,But Treatment Participation Rates Are Low
Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH
Over 88% of adolescent and young adult treatment and
over 50% of adult treatment is publicly funded
Few Get Treatment: 1 in 19 adolescents,
1 in 21 young adults, 1 in 12 adults
Much of the private funding is limited to 30
days or less and authorized day by day
or week by week
9
The Movement to Increase Screening
Screening, Brief Intervention and Referral to Treatment (SBIRT) has been shown to be effective in identifying people not currently in treatment, initiating treatment/change and improving outcomes (see http://sbirt.samhsa.gov/ )
The US Preventive Services Task Force (USPSTF, 2004; 2007), National Quality Forum (NQF, 2007), and Healthy People 2010 have each recommended SBIRT for tobacco, alcohol and increasingly drugs
CSAT and NIDA are both funding several demonstration and research projects to develop and evaluate models for doing this
Washington State mandated screening in all adolescent and adult substance abuse treatment, mental health, justice, and child welfare programs with the 5 minute Global Appraisal of Individual Needs (GAIN) short screener
10
Overview of the GAIN-Short Screener (GSS)
A 3- to 5-minute screener Used in general populations to identify or rule-out clients who
will be identified as having a behavioral health disorders on the 60-120 min versions of the GAIN
Easy for use by staff with minimal training or direct supervision
Provides a measure of change Designed for self- or staff-administration, with paper and pen,
computer, or on the web Translated by collaborators into several languages including
French, Japanese, Portuguese, and Spanish so far
11
Factor Structure of GAIN Measures of Psychopathology and Behavior
Source: Dennis, Chan, and Funk (2006)
12
77% 86
%
73%
75%
61%67
%
83%
62%
75%
60%
57%
40% 46
%
12%
12%
47%
37%
35%
12%
11%
0%10%20%30%40%50%60%70%80%90%
100%
Substance AbuseTreatment(n=8,213)
Student AssistancePrograms(n=8,777)
Juvenile Justice(n=2,024)
Mental HealthTreatment (10,937)
Children'sAdministration
(n=239)
Either High on Mental Health High on Substance High on Both
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/
Washington State Results with GAIN Short Screener: Adolescent
Problems could be easily identified & Comorbidity common
13
35%
12%
11%
56%
34%
15%
9%
47%
0%10%20%30%40%50%60%70%80%90%
100%
Substance AbuseTreatment (n=8,213)
Juvenile Justice(n=2,024)
Mental HealthTreatment (10,937)
Children'sAdministration
(n=239)
GAIN Short Screener Clinical Indicators
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/
Adolescent Client Validation of Hi Co-occurring from GAIN Short Screener vs Clinical Records
by Setting in Washington State
Two page measure closely approximated all found in the clinical record after the next two years
14
0 5,000 10,000 15,000 20,000 25,000
Any BehavioralHealth (n=22,879)
Mental Health(21,568)
Substance AbuseNeed (10,464)
Co-occurring(9,155)
Substance Abuse Treatment Student Assistance ProgramJuvenile Justice Mental Health TreatmentChildren's Administration
Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring?
Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/
School Assistance Programs (SAP) largest part of BH/MH system; 2nd largest of SA & Co-
occurring systemsSAP+ SA Treatment
Over half of system
15
Construct Validity of GSS Internalizing Disorder Screener
0%10%20%30%40%50%60%70%80%90%
100%
% Days with MHproblem
Mod/High onEmotional Problem
Scale (EPS)
Mod/High onInternal MentalDistress Scale
(IMDS)
Internalizing Disorder Screener (IDScr)
Fu
ll G
AIN
mea
sure
0 1 2 3 4 5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
16
Construct Validity of GSS Externalizing Disorder Screener
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Days withbehavioralproblems
Mod/High onEmotional Problem
Scale (EPS)
High on BehaviorComplexity Scale
(BCS)
Externalizing Disorder Screener (EDScr)
Fu
ll G
AIN
mea
sure
0 1 2 3 4 5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
17
Construct Validity of GSS Substance Disorder Screener
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Days of AOD use
Past Year Abuse orDependence
Past YearDependence
Substance Disorder Screener (SDScr)
Fu
ll G
AIN
mea
sure
0 1 2 3 4 5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
18
Construct Validity of GSS Crime/Violence Screener
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Days of illegalactivities
Mod/High onIllegal Activity
Scale (IAS)
High onCrime/Violence
Scale (CVS)
Crime and Violence Screener (CVScr)
Fu
ll G
AIN
mea
sure
0 1 2 3 4 5
Source: Dennis 2009, Education Service District 113 (n=979) and King County (n=1002)
19
0%1%2%3%4%5%6%7%8%9%
10%11%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Total Disorder Sceener (TDScr) Score
% w
ithi
n L
evel
of
Car
e
Residential (n=1,965)
OP/IOP (n=2,499)
Low
Mod. High ->
19
Total Disorder Screener Severity by Level of Care: Adolescents
Source: SAPISP 2009 Data and Dennis et al 2006
Residential Median= 10.5(59% at 10+)
Outpatient Median=6.0(30% at 10+)
Few missed
(1/2-3%)
20
GAIN SS Can Also be Used for Monitoring
109
11
910
8
32 2
0
4
8
12
16
20
Intake 3Mon
6Mon
9Mon
12Mon
15Mon
18Mon
21Mon
24Mon
Total Disorder Screener (TDScr)
12+ Mon.s ago (#1s)
2-12 Mon.s ago (#2s)
Past Month (#3s)
Lifetime (#1,2,or 3)
Track Gap Between Prior and current
Lifetime Problems to identify “under
reporting”
Track progress in reducing current
(past month) symptoms)
Monitor for Relapse
21
Use of a short common screener can
Provide immediate clinical feedback that is a good approximation of diagnosis and be used to guide placement and treatment planning
Can be used repeatedly to track change
Support evaluation and planning at program or state level (e.g., needs, case mix, services needed)
Provide practice based evidence to guide future clinical decision
Be incorporated into health risk/ wellness assessments and/or school surveys
22
In practice we need a Continuum of Measurement (Common Measures)
Screening to Identify Who Needs to be “Assessed” (5-10 min)– Focus on brevity, simplicity for administration & scoring– Needs to be adequate for triage and referral– GAIN Short Screener for SUD, MH & Crime– ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD– SCL, HSCL, BSI, CANS for Mental Health– LSI, MAYSI, YLS for Crime
Quick Assessment for Targeted Referral (20-30 min)– Assessment of who needs a feedback, brief intervention or referral for
more specialized assessment or treatment– Needs to be adequate for brief intervention– GAIN Quick – ADI, ASI, SASSI, T-ASI, MINI
Comprehensive Biopsychosocial (1-2 hours) – Used to identify common problems and how they are interrelated– Needs to be adequate for diagnosis, treatment planning and placement
of common problems– GAIN Initial (Clinical Core and Full)– CASI, A-CASI, MATE
Specialized Assessment (additional time per area)– Additional assessment by a specialist (e.g., psychiatrist, MD, nurse,
spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan
– CIDI, DISC, KSADS, PDI, SCAN
Screener Quick C
omprehensive S
pecial
More E
xtensive / Longer/ E
xpensive
23
Longer assessments identify more areas to address in treatment planning
40%
69%
94%98%
22%
13%
3% 0%
22%
8%
1% 0%
9%8%
1% 1%3% 1% 1%7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
GAIN SS GAIN Q(v2)
GAIN Q(v3 -Beta)
GAIN I
0 Reported
1 Prob.
2 Probs.
3 Probs.
4 Probs.
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
Most substance users have multiple problems
23
5 min. 20 min 30 min 1-2 hr
24
Major Predictors of Bigger Effects Found in Multiple Meta Analyses
1. A strong intervention protocol based on prior evidence
2. Quality assurance to ensure protocol adherence and project implementation
3. Proactive case supervision of individual
4. Triage to focus on the highest severity subgroup
25
Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis
Source: Adapted from Lipsey, 1997, 2005
Average Practice
The more features, the lower
the recidivism
26
Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in Reducing Juvenile 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
27
On-site proactive urine testing can be used to reduce false negatives by more than half
28
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
2929
Percentage Change in Abstinence (6 mo-Intake) by level of Adolescent Community Reinforcement Approach (A-CRA) Quality Assurance
4%
24%36%
0%10%20%30%40%50%60%70%80%90%
100%
Training Only Training,Coaching,
Monitoring
Clinical TrialOnsite Protocol
Monitors
% P
oint
Cha
nge
in A
bsti
nenc
e
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
Effects associated with intensity of quality
assurance and monitoring (OR=13.5)
30
So what does it mean to move 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
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
Having the ability to evaluate client and program outcomes – For the same person or program over time, – Relative to other people or interventions
31
Key Challenges to Delivery of Quality Care in Behavioral Health Systems1. High turnover workforce with variable education
background related to diagnosis, placement, treatment planning and referral to other services
2. Heterogeneous needs and severity characterized by multiple problems, chronic relapse, and multiple episodes of care over several years
3. Lack of access to or use of data at the program level to guide immediate clinical decisions, billing and program planning
4. Missing, bad or misrepresented data that needs to be minimized and incorporated into interpretations
5. Lack of Infrastructure that is needed to support implementation and fidelity
32
1. High Turnover Workforce with Variable Education
Questions spelled out and simple question format
Lay wording mapped onto expert standards for given area
Built in definitions, transition statements, prompts, and checks for inconsistent and missing information.
Standardized approach to asking questions across domains
Range checks and skip logic built into electronic applications
Formal training and certification protocols on administration, clinical interpretation, data management, coordination, local, regional, and national “trainers”
Above focuses on consistency across populations, level of care, staff and time
On-going quality assurance and data monitoring for the reoccurrence or problems at the staff (site or item) level
Availability of training resources, responses to frequently asked questions, and technical assistance
Outcome: Improved Reliability and Efficiency
33
2. Heterogeneous Needs and Severity
Multiple domains Focus on most common
problems Participant self description of
characteristics, problems, needs, personal strengths and resources
Behavior problem recency, breadth , and frequency
Utilization lifetime, recency and frequency
Dimensional measures to measure change with interpretative cut points to facilitate decisions
Items and cut points mapped onto DSM for diagnosis, ASAM for placement, and to multiple standards and evidence- based practices for treatment planning
Computer generated scoring and reports to guide decisions
Treatment planning recommendations and links to evidence-based practice
Basic and advanced clinical interpretation training and certification
Outcome: Comprehensive Assessment
34
3. Lack of Access to or use of Data at the Program Level
Data immediately available to support clinical decision making for a case
Data can be transferred to other clinical information system to support billing, progress reports, treatment planning and on-going monitoring
Data can be exported and cleaned to support further analyses
Data can be pooled with other sites to facilitate comparison and evaluation
PC and web based software applications and support
Formal training and certification on using data at the individual level and data management at the program level
Data routinely pooled to support comparisons across programs and secondary analysis
Over three dozen scientists already working with data to link to evidence-based practice
Outcome: Improved Program Planning and Outcomes
35
4. Missing, Bad or Misrepresented Data
Assurances, time anchoring, definitions, transition, and question order to reduce confusion and increase valid responses
Cognitive impairment check Validity checks on missing,
bad, inconsistency and unlikely responses
Validity checks for atypical and overly random symptom presentations
Validity ratings by staff
Training on optimizing clinical rapport
Training on time anchoring Training answering questions,
resolving vague or inconsistent responses, following assessment protocol and accurate documentation.
Utilization and documentation of other sources of information
Post hoc checks for on-going site, staff or item problems
Outcome: Improved Validity
36
5. Lack of Infrastructure
Direct Services
Training and quality assurance on administration, clinical interpretation, data management, follow-up and project coordination
Data management
Evaluation and data available for secondary analysis
Software support
Technical assistance and back up to local trainer/expert
Development
Clinical Product Development
Software Development
Collaboration with IT vendors (e.g., WITS)
Over 36 internal & external scientists and students
Workgroups focused on specific subgroup, problem, or treatment approach
Labor supply (e.g., consultant pool, college courses)
Outcome: Implementation with Fidelity
37
Some Common Record Based Performance Measures
* NQF: National Quality Forum; WCG: Washington Circle Group; CSAT: Center for Substance Abuse Treatment evaluations; NOMS: National Outcome Monitoring System; NIATX: Network for the Improvement of Addiction Treatment; PFP: Pay for Performance evaluations
NQ
F
WC
G
CS
AT
NO
MS
NIA
TX P
FP
Initiation: Treatment within 2 weeks of diagnosis X X X X X
Engagement: 2 additional sessions within 30 days X X X X X
Continuing Care: Any treatment 90-180 days out X X X
Detox Transfer: Starting treatment within 2 weeks X X
Residential Step Down: Starting OP Tx w/in 2wks X
Evidenced Based Practice: From NREP/Other lists X X X X
Within Cost Bands: see French et al 2009 X X
38
Newer NQF Standards of Care
Annual screening for tobacco, alcohol and other drugs using systematic methods
Referral for further multidimensional assessment to guide patient-centered treatment planning
Brief intervention, referral to treatment and supportive services where needed
Pharmacotherapy to help manage withdrawal, tobacco, alcohol and opioid dependence
Provision of empirically validated psychosocial interventions
Monitoring and the provision of continuing careSource: www.tresearch.org/centers/nqf_docs/NQF_Crosswalk.pdf
39Source: 2008 CSAT AAFT Summary Analytic Dataset
553/771=72%unmet need
218/224=97% to targeted
771/982=79% in need
Assessment combined with treatment records can make better performance measures
Size of the Problem
Extent to which services are currently being targeted
Extent to which services are not reaching those in most need
Treatment Received in the first 3 months
Mental Health Need at Intake
No/Low Mod/High Total
Any Treatment 6 218 224
No Treatment 205 553 758
Total 211 771 982
40
Mental Health Problem (at intake) vs. Any MH Treatment by 3 months
79%
97%
72%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of Clients WithMod/High Need
(n=771/982)*
% w Need but No ServiceAfter 3 months
(n=553/771)
% of Services Going toThose in Need
(n=218/224)
Source: 2008 CSAT AAFT Summary Analytic Dataset
41
Why Do We Care About Unmet Need?
If we subset to those in need, getting mental health services predicts reduced mental health problems
Both psychosocial and medication interventions are associated with reduced problems
If we subset to those NOT in need, getting mental health services does NOT predict change in mental health problems
Conversely, we also care about services being poorly targeted to those in need.
42
Residential Treatment need (at intake) vs. 7+ Residential days at 3 months
36%
52%
90%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of Clients WithMod/High Need
(n=349/980)*
% w Need but NoService After 3 months
(n=315/349)
% of Services Going toThose in Need (n=34/66)
Opportunity to redirect
existing funds through better
targeting
Source: 2008 CSAT AAFT Summary Analytic Dataset
43
More in BZ, CA, CN, JP, MX
ID
ILMO
ND
VI
ME
OK
PR
SD
AR
KS
MS
MT
NM
WVIN
AL
AK
IA
MN
NJNV
RI
SC
UT
HI
LA
DENE
TN
PA
VT
VADC
MI
COKY
GA
OH
OR
MD
AZ
TX
NY
NH
WI
CA
NC
CT
FL
MA
WA
WY
No of GAIN Sites
None (Yet)
1 to 14
15 to 30
31 to 165
Will be using data from the Global Appraisal of Individual Needs (GAIN) Collaborators
State or Regional System
GAIN-Short Screener
GAIN-Quick
GAIN-Full
3/10 43
44
…as well as 6 provinces of Canada and 6 other countries
Canada
MB
NB
NT
PESK
YT
AB
NF
NS
QCBC
ON
NU
Number of GAIN Sites
None (Yet) 1 to 14
15 to 30 31 to 165
State or Regional System
GAIN-Short Screener
GAIN-Quick
GAIN-Full
45
Some numbers as of June 2010
1,501 Licensed GAIN administrative units from 49 states (all by ND) and 7 countries
3,270 users in 396 Agencies using GAIN ABS
60,380 intake assessments (largest in field)
22,045 (88% w 1+ follow-up) from 278 CSAT grantees
22 states, 12 Federal, 6 Canadian provinces, 6 other countries, and 3 foundations mandate or strongly encourage its use
4 dozen researchers have published 179 GAIN-related research publications to date
45
46
The GAIN is ..
A family of instruments ranging from screening, to quick assessment to a full Biopsychosocial and monitoring tools
Designed to integrate clinical and research assessment
Designed to support clinical decision making at the individual client level
Designed to support evaluation and planning at program level
Designed to support secondary analyses and comparisons across individuals and programs
The GAIN is NOT an electronic health record (EHR), but a component that can interface with and support EHRs.
4747
EHR can provide practice based evidence: Lessons from a Decade of GAIN data from CSAT Grants
AK
ALAR
AZ
CACO
CT
DCDE
FL
GA
HI
IA
ID
ILIN
KSKY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PARI
SC
SD
TN
TX
UTVA
VTWA
WI
WV
WY
PR VI
AAFTARTATDCBIRTJTDCEARMARKEATFDCJDCOJJDPORPRCFSACSCANSCYTCEYORP
4848
2009 CSAT Data Set by Age
Source: CSAT 2009 Summary Analytic Data Set (n=22,045)
18 Years or Older (18+)
12.7%, (n=2,793)
Under 15 Years Old (<15) 16.1%,
(n=3,547)
15-17 Years Old
71.2%, (n=15,705)
4949
Diagnosis Time Period Matters
57%48%
18%
30%32%
18%
13%19%
63%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Lifetime Past Year Past Month
No Use
Use
Abuse
Dependence
Source: CSAT 2009 Summary Analytic Data Set (n=21,659)
5050
Definition of Substance Use Severity Matters
80%
54%
24%
93%
34%
5%
26%
48%
57%
72%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Past Year Substance Diagnosis
3 or More Years of Use
Weekly Use
Any Past Year Dependence
Any Withdrawal Symptoms in the Past Week
Severe Withdrawal (11+ Symptoms)
Can Give 1+ Reasons to Quit*
Client Believes Need ANY Treatment
Acknowledges Having an AOD Problem
Any Prior Substance Abuse Treatment
Source: CSAT 2009 Summary Analytic Data Set (n=21,816) *(n=11,066)
5151
Multiple Clinical Problems are the NORM!
20%
41%
80%
48%
33%
63%
11%
24%
14%
34%
27%0% 10
%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Alcohol
Cannabis
Other drug disorder
Depression
Anxiety
Trauma
ADHD
CD
Suicide
Victimization
Violence/ illegal activity
Source: CSAT 2009 Summary Analytic Data Set (n=20,826)
5252
The Number of Clinical Problems is related to Level of Care (over lapping but different mix)
41% 45%53%
65%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
OP IOP CC-OP LTR STR
None
One
Two
Three
Four
Five to Twelve
Source: CSAT 2009 Summary Analytic Data Set (n=21,332)
Significantly more likely to
have 5+ problems (OR=5.8)
5353
46%
71%
15%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low (0) Moderate (1-3) High (4-15)
None
One
Two
Three
Four
Five to Twelve
The Number of Major Clinical Problemsis highly related to Victimization
Source: CSAT 2009 Summary Analytic Data Set (n=21,784)
Significantly more likely to have 5+
problems (OR=13.9)
But this is the issue staff least
like to ask about!
54
Overcoming Staff Reluctance with General Victimization Scale
40%
31%
6%10%
1%8%9%
26%
29%7%
57%32%
19%11%
35%
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
Ever attacked w/ gun, knife, other weapon
Ever hurt by striking/beating
Abused emotionally
Ever forced sex acts against your will/anyone
Age of 1st abuse < 18
Any with more than one person involved
Any several times or for long time
Was person family member/trusted one
Were you afraid for your life/injury
People you told not believe you/help you
Result in oral, vaginal, anal sex
Currently worried someone attack
Currently worried someone beat/hurt
Currently worried someone abuse emotionally
Currently worried someone force sex acts
Source: CSAT 2009 Summary Analytic Data Set (n=19,318) 54
5555
B1. Intoxication/Withdrawal Treatment Plan Needs
39%
22%
17%
1%
1%
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
Any Detox or withdrawal services
Ambulatory Detox (Risk/Mild)
Non-opioid Meds
Opiate Meds
Monitoring withdrawal and AOD medscompliance
Source: CSAT 2009 Summary Analytic Data Set (n=17,392)
5656
B2. Biomedical Treatment Plan Needs
60%
33%
29%
17%
6%
1%
1%
78%
3%
4%
11%
16%
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
Tobacco cessation
Accom. for medical conditions
Discuss compliance w/ prescribed meds
Compliance with meds for PH probs
Discuss ER/hospitalization history
Currently treated for med problem
Tetanus shot
Eating disorder
Treatment of infectious diseases
Accommodations current pregnancy
Reduce sexual behavior risk
Reduce needle use/risk
Source: CSAT 2009 Summary Analytic Data Set (n=17,392)
5757
B3. Psychological Treatment Plan Needs
59%
23%
22%
31%
18%
13%
12%
41%
74%
1%
4%
4%
8%
16%
17%
68%
72%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Co-occuring
Consq of behavior control problems
Refer to anger management
Suicidal risk intervention
Problems reading and writing
Compliance with psych meds
Currently treated for psych problem
Self-mutilation
Monitor self-mutilation
Cognitive impairment
Discuss lifetime mh hosp. history
Coordination with justice system
Consq of interpersonal illegal acts
Consq of drug-related illegal acts
Discuss lifetime arrest history
Consq of other illegal acts
Civil court proceedings
Source: CSAT 2009 Summary Analytic Data Set (n=18,733)
5858
B4.Readiness Treatment Plan Needs
81%
16%
9%
3%
79%
73%
63%
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
Any Treatment Readiness Issues
Wrap-around or casemanagement services
Any pressure to be in treatment
Required to go to treatment
Reviw expectations for length oftreatment
Review dissatisfaction w/treatment
Partner to understandtreatment process
Source: CSAT 2009 Summary Analytic Data Set (n=9,169)
5959
B5. Relapse Potential Treatment Plan Needs
67%
2%
84%
30%
28%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
High Relapse Potential
Recovery coach or mentor
Continuing Care aftercontrolled environment
Significant time in controlledenvironment
Discuss substance abusetreatment history
Source: CSAT 2009 Summary Analytic Data Set (n=21,239)
6060
B6. Environment Treatment Plan Needs
63%
32%
29%
26%
32%
47%
54%
56%
70%
85%
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
Attended school in past 90 days
Coping with psycho-socialstressors
Child maltreatment
Recent school problems
Dissatisfaction withenvironment
Family fighting in the home
Vocational or governmentassistance
Substance use in the home
Employed in past 90 days
Housing situation
Source: CSAT 2009 Summary Analytic Data Set (n=14,952)
6161
NOMS: Early Treatment Outcomes
56%
66%
76%
84%
72%
58%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Initiation within 14 days
Evidenced Based Practice
Engagement for at least 6weeks
Any Continuing Care (91-180 days)
Substance Use-Abstinent/Reduced 50% at 3 Months
12 month cost within bandsfor initial type of treatment
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups (n=11,668)
6262
NOMS: Post Treatment Outcome (6-12 mo)
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups
41%
90%
71%
12%
89%
80%
66%
17%
44%
99%
76%
68%
47%
44%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Use
Abuse/Dependence Sx*
Physical Health
Mental Health
Nights of Psychiatric Inpatient
Illegal Activity
Arrests
Housed in Community**
Family/Home Problems
Vocational Problems
Social Support/Engagement
Recovery Environment Risk
Quarterly Cost to Society
In Work/School**
Reduced 50%or NoProblemNo Problem
*This variable measures the last 30 days. All others measure the past 90 days
**The blue bar represents an increase of 50% or no problem
6363
But Need to Control for the lack of Problems at Intake
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups
98%
79%
13%
33%37%
52%
78%
61%
11%37%
42%19%
5%
2%
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
Use
Abuse/Dependence Sx*
Physical Health
Mental Health
Nights of Psychiatric Inpatient
Illegal Activity
Arrests
Housed in Community
Family/Home Problems
Vocational Problems
Social Support/Engagement
Recovery Environment Risk
Quarterly Cost to Society
In Work/School
* Variable measures the last 30 days. All others measure the past 90 days.
6464
Change in Number of Positive NOMS Outcomes (Last Follow up – Intake)
Source: CSAT 2009 SA Data Set subset to 1+ Follow ups (n=18,770)
8%6%8%
14%
12%
29%
11%
13%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Total
Five or More
Four
Three
Two
One
None
Negative one
Less than negative one
78% Improved in 1 or more areas (29% in 5 or more)
65
Any Illegal Activity can be better predicted by using Intake Severity on Crime/Violence and Substance Problem Scales
58%46%
36%53%
33%26%44%
27%20%
0%
20%
40%
60%
An
y I
leg
al
Ac
tiv
ity
(mo
nth
s1
-6)
High Mod Low LowMod
High
Crime/Violence Scale (Intake)
Substance Problem Scale
(Intake)
Source: CSAT 2008 V5 dataset Adolescents aged 12-17 with 3 and/or 6 month follow-up (N=9006)
Intake Crime/ Violence Severity
Predicts Recidivism
Intake Substance Problem Severity
Predicts Recidivism
Knowing both is a better predictor(high –high group is 5.5 times more
likely than low low)
While there is risk, most (42-80%) actually do not commit
additional crime
66
Outcomes May be Hidden by Subgroups: Example of HIV Risk Outcomes
-0.0
3
-0.1
0 -0.0
2
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
A. Low Risk
B. Mod. RiskW/O Trauma
C. Mod. RiskWith Trauma
D. High Risk
Total
Coh
en's
Eff
ect S
ize
d
Unprotected Sex Acts (f=.14)
Days of Victimization (f=.22)
Days of Needle Use (f=1.19)
-0.3
9
0.20
-0.0
4
-0.0
8
0.00
0.15
-0.2
9
0.01
0.10
0.27
0.00
-0.6
9
Source: Lloyd et al 2007
CYT Cannabis Youth Treatment Randomized Field Trial
Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services
Coordinating Center:Chestnut Health Systems, Bloomington, IL, and Chicago, ILUniversity of Miami, Miami, FLUniversity of Conn. Health Center, Farmington, CT
Sites:Univ. of Conn. Health Center, Farmington, CTOperation PAR, St. Petersburg, FLChestnut Health Systems, Madison County, ILChildren’s Hosp. of Philadelphia, Phil. ,PA
68
Randomly Assigns to:
MET/CBT5Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Trial 2Trial 1Incremental Arm Alternative Arm
Cannabis Youth Treatment (CYT) Experiments
ACRAAdolescent Community
Reinforcement Approach(12 weeks)
MDFTMultidimensional Family Therapy
Randomly Assigns to:
MET/CBT5Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
(12 weeks)
Source: Dennis et al, 2002
69
5
10
5
11
14
23
0
5
10
15
20
25
MET/CBT5
MET/CBT12
MET/CBT12 +
FSN
MET/CBT5
ACRA MDFT
Hou
rs
Day
s
CaseManagement
FamilyCounseling
Collateral only
Multi-Familygroup
Multi-ParticipantGroup
Participant only
Incremental Arm Alternative Arm
Actual Treatment Received by Condition
Source: Dennis et al, 2004
MET/CBT12 adds 7 more sessions of
group
FSN adds multi family group,
family home visits and more case management
ACRA and MDFT both rely on
individual, family and case management instead of group
With ACRA using more individual therapy
And MDFT using more
family therapy
70
$1,559$1,413
$1,984
$3,322
$1,197$1,126
$-
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
MET/C
BT5 (6.8
wee
ks)
MET/C
BT12 (1
3.4 w
eeks
)
FSN (14.2
wee
ks w
/family
)
MET/C
BT5 (6.5
wee
ks)
ACRA (12.8
wee
ks)
MDFT(1
3.2 w
eeks
w/fa
mily)
$1,776
$3,495
NTIES E
st (6
.7 wee
ks)
NTIES E
st.(1
3.1 w
eeks
)
Ave
rage
Cos
t P
er C
lien
t-E
pis
ode
of C
are
|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|
Average Episode Cost ($US) of Treatment
Source: French et al., 2002
Less than average
for 6 weeks
Less than average
for 12 weeks
Integrating family therapy
was less expensive
than adding it
71
CYT Increased Days Abstinent and Percent in Recovery*
Source: Dennis et al., 2004
0
10
20
30
40
50
60
70
80
90
Intake 3 6 9 12
Day
s A
bsti
nent
Per
Qua
rter
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
% in
Rec
over
y at
the
End
of
the
Qua
rter
Days Abstinent
Percent in Recovery
*no use, abuse or dependence problems in the past month while in living in the community
72
Similarity of Clinical Outcomes by Conditions
Source: Dennis et al., 2004
200
220
240
260
280
300
Tot
al d
ays
abst
inen
t.
over
12
mon
ths
0%
10%
20%
30%
40%
50%
Per
cent
in R
ecov
ery
. at
Mon
th 1
2
Total Days Abstinent* 269 256 260 251 265 257
Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19
MET/ CBT5 (n=102)
MET/ CBT12
FSN (n=102)
MET/ CBT5 (n=99)
ACRA (n=100)
MDFT (n=99)
Trial 1 Trial 2
* n.s.d., effect size f=0.06** n.s.d., effect size f=0.12
* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16
Not significantly different by condition.
But better than the average for OP in ATM (200 days of
abstinence)
73
Moderate to large differences in Cost-Effectiveness by Condition
Source: Dennis et al., 2004
$0
$4
$8
$12
$16
$20
Cos
t per
day
of
abst
inen
ce o
ver
12 m
onth
s
$0
$4,000
$8,000
$12,000
$16,000
$20,000
Cos
t per
per
son
in r
ecov
ery
at m
onth
12
CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38
CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5MET/
CBT12FSN MET/ CBT5 ACRA MDFT
* p<.05 effect size f=0.48** p<.05, effect size f=0.72
Trial 1 Trial 2
* p<.05 effect size f=0.22 ** p<.05, effect size f=0.78
MET/CBT5 and 12 did better
than FSN
ACRA did better than MET/CBT5, and both did better than MDFT
74
Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition
Source: Dennis et al., 2003; forthcoming
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
CPPR at 30 months** $6,437 $10,405 $24,725 $27,109 $8,257 $14,222
CPPR at 12 months* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5 MET/ CBT12 FSNM MET/ CBT5 ACRA MDFT
Trial 1 (n=299) Trial 2 (n=297)
Cos
t P
er P
erso
n in
Rec
over
y (C
PP
R)
* P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months
Stability of MET/CBT-5
findings mixed at 30 months
MET/CBT-5, -12 and ACRA more cost effective at
12 months
Integrated family therapy (MDFT) was more cost effective than
adding it on top of treatment (FSN) at 30 months
ACRA Effect Largely Sustained
75
Some Numbers as of 2010
Over 100,000 copies of manuals distributed
Large scale replications of MET/CBT5 (36 sites) done and A-CRA (76 sites) under way
All interventions involved in multiple additional trials and demonstration
Led to wide spread use of the GAIN in adolescent treatment and pooling of data across grantees – current n=22,000 (88% with 1+ follow-up)
Sanctuary Inc of Guam just won an Offender Re-entry Grant from CSAT to use A-CRA, ACC & GAIN last month
75
76
Comparison of 9 Adol Tx Approaches
Seven Challenges (Schwebel, 2004) (n=114) Chestnut Health Systems (CHS; Godley et al. 2002)
Treatment (n=192) Adolescent Community Reinforcement Approach (A-CRA;
Godley et al., 2001) -CYT/AAFT (n=2144) A-CRA-Other (n=276) Multi-Systemic Therapy (MST; Henggeler et al., 1998)
(n=85) Multi-Dimensional Family Therapy (MDFT; Liddle, 2002)
(n=258) Motivational Enhancement Therapy-Cognitive Behavior
Therapy (METCBT; Sampl & Kadden, 2001)-CYT/EAT (n=5262)
MET/CBT-Other (n=878) Family Support Network (FSN; Hamilton et al., 2001)
(n=369)76
77
Two sets of outcomes
Mental Health Emotional Problems Scale Days of Victimization Days of Traumatic Memories
Other Outcomes Substance Problems Scale Substance Frequency Scale Illegal Activities Scale HIV Risk Change Index
77
78
Change (post-pre) Effect Size for Emotional Problems by Type of Evidenced Based Treatment
-0.5
4
-0.4
3
-0.4
5 -0.3
9
-0.3
7
-0.3
7
-0.3
4 -0.2
9
-0.2
9
-0.1
8
-0.2
8
-0.1
9
-0.3
2
-0.1
9
-0.1
5
-0.2
1 -0.1
3 -0.0
8
-0.0
8
-0.0
9
-0.1
4
-0.2
2
-0.0
4
-0.1
3
-0.1
2 -0.0
8
-0.1
6
-0.80
-0.60
-0.40
-0.20
0.00
0.20
SevenChallenges
(n=114)
CHSTreatment(n=192)
A-CRA-CYT/AAFT
(n=2144) MST(n=85)
MDFT(n=258)
METCBT-CYT/EAT(n=5262)
METCBT-Other
(n=878) FSN
(n=369)
A-CRA-Other
(n=276)
Cha
nge
Eff
ect S
ize
d ((
mea
n fo
llow
-up
- m
ean
inta
ke)/
std
dev
. int
ake)
Emotional Problem Scale Days of traumatic memories Days of victimization
Four best on mental health outcomes include 7 challenges,
CHS, A-CRA, & MST
79
Change (post-pre) Effect Size for Core Treatment Outcomes by Type of Evidenced Based Treatment
-0.5
4
-0.4
3
-0.4
5 -0.3
9
-0.3
7
-0.3
7
-0.3
4 -0.2
9
-0.2
9
-0.6
2
-0.6
5
-0.4
3
-0.4
5
-0.5
0
-0.3
8 -0.3
3
-0.4
7
-0.3
6-0.3
0
-0.3
7
-0.4
2
-0.4
3 -0.3
8 -0.3
3 -0.2
6
-0.5
1
-0.4
8
-0.1
5 -0.1
1
-0.2
8
-0.3
9
-0.3
8
-0.1
7
-0.1
9
-0.2
9 -0.2
3
0.00 0.
04
-0.2
3
-0.3
8
-0.1
8 -0.1
1
-0.1
7
-0.3
0
-0.1
8
-0.3
2
-0.3
0
-0.3
6
-0.4
1 -0.3
6
-0.2
7
-0.2
6
-0.3
7 -0.3
1
-0.80
-0.60
-0.40
-0.20
0.00
0.20
SevenChallenges
(n=114)
CHSTreatment(n=192)
A-CRA-CYT/AAFT
(n=2144) MST(n=85)
MDFT(n=258)
METCBT-CYT/EAT(n=5262)
METCBT-Other
(n=878) FSN
(n=369)
A-CRA-Other
(n=276)
Cha
nge
Eff
ect S
ize
d ((
mea
n fo
llow
-up
- m
ean
inta
ke)/
std
dev
. int
ake)
Emotional Problem Scale Substance Problem Scale Substance Frequency Scale
HIV Risk Scale Illegal Activity Scale Average
Four best on treatment outcomes include A-CRA, MST, MDFT, & FSN
80
Recommendations
The two programs that appear best at optimizing impact on emotional problems and other outcomes are A-CRA and MST
While A-CRA targets a mix of BA and MA therapists, MST targets MA level therapists and family therapists that are often in short supply
Both have coordinating centers that provide training and technical assistance, thought A-CRA’s is subsidized by CSAT through its large replication in over 76 sites
80