Developing Effective Drug TreatmentFor Adolescents: Results from the Cannabis Youth Treatment (CYT) Trials

Michael Dennis, Ph.D. Chestnut Health SystemsBloomington, IL

“Scientific Approaches to Improving Practice” Panel Presentation at the American Society of Addiction Medicine (ASAM) 2004 Annual Conference, Washington, DC, April 25, 2004. The opinions are those of the author do not reflect official positions of the government . Available on-line at www.chestnut.org/li/posters.

Acknowledgement

This presentation is based on the work, input and contributions from several other people including: Nancy Angelovich, Tom Babor, Laura (Bunch) Brantley, Joseph A. Burleson, George Dent, Guy Diamond, James Fraser, Michael French, Rod Funk, Mark Godley, Susan H. Godley, Nancy Hamilton, James Herrell, David Hodgkins, Ronald Kadden, Yifrah Kaminer, Tracy L. Karvinen, Pamela Kelberg, Jodi (Johnson) Leckrone, Howard Liddle, Barbara McDougal, Kerry Anne McGeary, Robert Meyers, Suzie Panichelli-Mindel, Lora Passetti, Nancy Petry, M. Christopher Roebuck, Susan Sampl, Meleny Scudder, Christy Scott, Melissa Siekmann, Jane Smith, Zeena Tawfik, Frank Tims, Janet Titus, Jane Ungemack, Joan Unsicker, Chuck Webb, James West, Bill White, Michelle White, Caroline Hunter Williams, the other CYT staff, and the families who participated in this study. This presentation was supported by funds and data from the Center for Substance Abuse Treatment (CSAT’s) Persistent Effects of Treatment Study (PETS, Contract No. 270-97-7011) and the Cannabis Youth Treatment (CYT) Cooperative Agreement (Grant Nos. TI11317, TI11320, TI11321, TI11323, and TI11324). The opinions are those of the author and steering committee and do not reflect official positions of the government .

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

Objectives

Describe the development of manual-guided, cost-effective, outpatient treatment interventions for adolescent drug abusers.

Summarize methodological advances in assessment, retention, supervision, and follow-up

Summarize evidence on their cost, effectiveness, and cost-effectiveness

Examine the diffusion of these methodological and substantive advances to the field.

The Adolescent Marijuana Problem (circa 1997-1998)

Use was starting at younger ages Was at an historically high level among adolescents Potency increased 3-fold from 1980 to 1997 Was three times more likely to lead to dependence

among adolescents than adults Was associated with many health, mental and

behavioral problems Was the leading substance mentioned in adolescent

emergency room admissions and autopsies

The State of Adolescent Treatment(circa 1997-1998)

Marijuana related admissions to adolescent substance abuse treatment increased by 115% from 1992 to 1998

Over 80% of adolescents entering treatment in 1998 had a marijuana problem

Over 80% were entering outpatient treatment Over 75% received less than 90 days of treatment (median of 6

weeks) Evaluations of existing adolescent outpatient treatment suggest

that adult models or less than 90 days of outpatient treatment is rarely effective for reducing marijuana use.

No empirically evaluated treatment manuals were publicly available to help expand or enhance the system

Purpose of CYT

To learn more about the characteristics and needs of adolescent marijuana users presenting for outpatient treatment.

To adapt evidence-based, manual-guided therapies for use in 1.5 to 3 month adolescent outpatient treatment programs in medical centers or community based settings.

To field test the relative effectiveness, cost, cost-effectiveness, and benefit cost of five interventions targeted at marijuana use and associated problems in adolescents.

To provide validated models of these interventions to the treatment field in order to address the pressing demands for expanded and more effective services.

Design

Target Population: Adolescents with marijuana disorders who are appropriate for 1 to 3 months of outpatient treatment.

Inclusion Criteria: 12 to 18 year olds with symptoms of cannabis abuse or dependence, past 90 day use, and meeting ASAM criteria for outpatient treatment

Data Sources: self report, collateral reports, on-site and laboratory urine testing, therapist alliance and discharge reports, staff service logs, and cost analysis.

Random Assignment: to one of three treatments within site in two research arms and quarterly follow-up interview for 12 months

Long Term Follow-up: under a supplement from PETSA follow-up was extended to 30 months (42 for a subsample)

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)

ACRAAdolescent Community

Reinforcement Approach(12 weeks)

MDFTMultidimensional Family Therapy

Trial 2Trial 1Incremental Arm Alternative Arm

Two Trials or Study Arms

Randomly Assigns to:

MET/CBT5Motivational Enhancement Therapy/

Cognitive Behavioral Therapy (5 weeks)

(12 weeks)

Source: Dennis et al, 2002

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, Godley et al, in press

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

$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, 2003

Less than average

for 6 weeks

Less than average

for 12 weeks

Implementation of Evaluation

Over 85% of eligible families agreed to participate Quarterly follow-up of 94 to 98% of the adolescents from 3- to

12-months (88% all five interviews) Long term follow-up completed on 90% at 30-months Collateral interviews were obtained at intake, 3- and 6-months

on over 92-100% of the adolescents interviewed Urine test data were obtained at intake, 3, 6, 30 and 42 months

90-100% of the adolescents who were not incarcerated or interviewed by phone (85% or more of all adolescents).

Self report marijuana use largely in agreement with urine test at 30 months (13.8% false negative, kappa=.63)

5 Treatment manuals drafted, field tested, revised, send out for field review, and finalized (10-30,000 copies of each already printed and distributed)

Descriptive, outcome and economic analyses completed

Source: Dennis et al, 2002, in press

Adolescent Cannabis Users in CYT were as or More Severe Than Those in TEDS*

85%

46%

26%

78%

26%

47%

26%

71%

0%

20%

40%

60%

80%

100%

First usedunder age

15

Dependence Weekly ormore use at

intake

PriorTreatment

% o

f A

dm

issi

on

s

.

CYT Outpatient(n=600) TEDS Outpatient (n=16,480)* Adolescents with marijuana problems admitted to outpatient treatment

Source: Tims et al, 2002

Demographic Characteristics

62%

15%

55%50%

30%

83%

17%

0%

20%

40%

60%

80%

100%

Female Male AfricanAmerican

Caucasian Under 15 15 to 16 Singleparentfamily

Source: Tims et al, 2002

Institutional Involvement

25%

87%

47%

62%

0%

20%

40%

60%

80%

100%

In school Employed Current CJInvolvement

Coming fromControlled

Environment

Source: Tims et al, 2002

Patterns of Substance Use

9%17%

71%73%

0%

20%

40%

60%

80%

100%

Weekly Tobacco Use

WeeklyCannabis Use

Weekly AlcoholUse

Significant Timein ControlledEnvironment

Source: Tims et al, 2002

Multiple Problems are the NORM

86%

37%

12%

25%

61%

60%

66%

83%

83%

0% 20% 40% 60% 80% 100%

Any Marijuana Use Disorder

Any Alcohol Use Disorder

Other Substance Use Disorders

Any Internal Disorder

Any External Disorder

Lifetime History of Victimization

Acts of Physical Violence

Any (other) Illegal Activity

Three to Twelve Problems

Self-Reported in Past Year

Source: Dennis et al, under review

Co-occurring Problems are Higher for those Self-Reporting Past Year Dependence

71%

57%

25%

42%

30%37%

22%

5%

13%

22%

0%

20%

40%

60%

80%

100%

Health ProblemDistress*

Acute MentalDistress*

AcuteTraumaticDistress*

AttentionDeficit

HyperactivityDisorder*

ConductDisorder*

Past Year Dependence (n=278) Other (n=322)

Source: Tims et al., 2002 * p<.05

CYT Increased Days Abstinent and Percent in Recovery (no use or problems while in community)

Source: Dennis et al., in press

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%

% i

n R

ecov

ery

at t

he E

nd o

f th

e Q

uart

er .

Days Abstinent

Percent in Recovery

Similarity of Clinical Outcomes by Conditions

Source: Dennis et al., in press.

200

220

240

260

280

300

Tota

l day

abs

tine

nt .

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

FSNM (n=102)

MET/ CBT5 (n=99)

ACRA (n=100)

MDFT (n=99)

Trial 1 Trial 2

Moderate to large differences in Cost-Effectiveness by Condition

Source: Dennis et al., in press

$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

Evaluating the Long Term Effects of Treatment

Short Term Outcome Stability Difference between average of

early (3-6) and latter (9-12) follow-up interviews

Treatment OutcomeDifference between intake and average

of all short term follow-ups (3-12)

Long Term Stability Difference between average of short term

follow-ups (3-12) and long term follow-up (30)

Source: Dennis et al, under review, forthcoming

Month

Z-S

core

-0.60

-0.50

-0.40

-0.30

-0.20

-0.10

0.00

0 3 6 9 12

15

18

21

24

27

30

Freq. of Use

Sub. Prob.

Cumulative Recovery Pattern at 30 months:(The Majority Vacillate in and out of Recovery)

Source: Dennis et al, forthcoming

37% Sustained Problems

5% Sustained Recovery

19% Intermittent, currently in

recovery

39% Intermittent, currently not in

recovery

Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition

Source: Dennis et al., in press; 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

Integrated family therapy (MDFT) was more cost effective than

adding it on top of treatment (FSN) at 30 months

MET/CBT-5, -12 and ACRA more cost effective at

12 months

Average Cost to Society Varied More by Site than Condition

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

0 3 6 9 12 15 18 21 24 27 30

Months from Intake

UCHC, Farmington, CT (-24%, -44%)

PAR, St. Petersburg, FL (-22%, -49%)

CHS, Madison Co., IL (-8%, -51%)

CHOP, Philadelphia, PA (+18%, -34%)

Source: French et al, 2003; forthcoming

How does CYT compare with Regular OP/IOP: Frequency of Substance Use

40

42

44

46

48

50

52

54

56

58

60

0 3 6 9 12

Months from Intake

Subs

tanc

e F

requ

ency

Sca

le T

-Sco

re CYT Average Outpatient

ATM Average Outpatient

`

How does CYT compare with Regular OP/IOP: Substance Abuse/Dependence Problems

40

42

44

46

48

50

52

54

56

58

60

0 3 6 9 12

Months from Intake

Subs

tanc

e P

robl

em S

cale

T-S

core CYT Average Outpatient

ATM Average Outpatient

`

Dissemination and Impact

Papers published on design, validation, characteristics, matching, clinical contrast, treatment manuals, therapist reactions, 6 month outcomes, cost, benefit cost

Papers with main clinical and cost-effectiveness findings at 12 months in press and 30 month findings being submitted this year.

Interventions being replicated as part of over four dozen studies currently or about to go into the field

20 to 30,000 copies of each of the 5 manuals distributed to policy makers, providers, individual clinicians and training programs (via NCADI or www.chestnut.org/li/apss )

The Global Appraisal of Individual Needs (GAIN) assessment has been used in over 70 subsequent adolescent treatment studies and combined into one large data base that will be used to support case mix adjustments, benchmarking and meta analysis

Supervision, Retention, and Follow-up models also being replicated in these adolescent treatment studies

CYT was part of a Renascence of Adolescent Treatment Research/Practice

From 1998 to 2002 the number of adolescent treatment studies doubled and has doubled again in the past 2 years – with over 100 currently in the field

Source: Dennis &, White (2003) at www.drugstrategies.org.

NIAAA/NIDA Other Grantees

CSAT’s Adolescent Treatment Programs Currently Using the GAIN or CYT Txs

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

Other CSAT Grantees

Other Collaborators

RWJF Reclaiming Futures Program

RWJF Other RWJF Grantees

Conclusions

The CYT interventions provide replicable models of effective brief (1.5 to 3 month) treatments that can be used to help the field maintain quality while expanding capacity.

While a good start, the CYT interventions were still not an adequate dose of treatment for the majority of adolescents.

The majority of adolescents continued to vacillate in and out of recovery after discharge from CYT.

More work needs to be done on providing a continuum of care, longer term engagement and on going recovery management.

Adolescent treatment can be cost effective and cost beneficial to society

CYT also helped to spur a new wave of methodological improvements related to assessment, supervision, retention, and follow-up that benefit researchers, evaluators, and program planners

Contact Information

Michael L. Dennis, Ph.D., CYT Coordinating Center PILighthouse Institute, Chestnut Health Systems720 West Chestnut, Bloomington, IL 61701Phone: (309) 827-6026, Fax: (309) 829-4661E-Mail: Mdennis@Chestnut.Org

Manuals and Additional Information are Available at: CYT: www.health.org/govpubs or www.chestnut.org/li/bookstore

PETSA: www.samhsa.gov/centers/csat/csat.html (then select PETS from program resources)

APSS: www.chestnut.org/li/APSS (copies of CYT and over a dozen other adolescent treatment manuals and information on the Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)

CYT Related References

Babor, T. F., Webb, C. P. M., Burleson, J. A., & Kaminer, Y. (2002). Subtypes for classifying adolescents with marijuana use disorders Construct validity and clinical implications. Addiction, 97(Suppl. 1), 58-69.

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), 98-108.

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. (in press). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment.

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. 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.

Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebuck, M. C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C. K., & CYT Steering Committee. (2002). The Cannabis Youth Treatment (CYT) experiment Rationale, study design, and analysis plans. Addiction, 97 (Suppl. 1), S16-S34.

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., White,M.A., Titus, J.C. & Godley, M.D. (in press). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2002. (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems.

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.

CYT Related References - continued

Godley, M.D., Kahn, J.H., Dennis, M.L., Godley, S.H., & Funk, R.R. (in press). The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment. Psychology of Addictive Behavior.

Godley, S. H., White, W. L., Diamond, G., Passetti, L., & Titus, J. (2001). Therapists' reactions to manual-guided therapies for the treatment of adolescent marijuana users. Clinical Psychology Science and Practice, 8(4), 405-417.

Godley, S. H., Meyers, R. J., Smith, J. E., Godley, M. D., Titus, J. M., Karvinen, T., Dent, G., Passetti, L., & Kelberg, P. (2001). The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 4). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

Hamilton, N., Brantley, L., Tims, F., Angelovich, N., & McDougall, B. (2001). Family Support Network (FSN) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 3). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

Jensen, K. A. (2001). The effects of adolescent peer-based intervention Contextual influence of peers during cannabis treatment. University of South Florida.

Liddle, H. A. (2002). Multidimensional Family Therapy (MDFT) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 5). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

Petry, N. M., & Tawfik, Z. (2001). A comparison of problem gambling and non-problem gambling youth seeking treatment for marijuana abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 40(11), 1324-1331.

Roebuck, M. C., French, M. T., & Dennis, M. L. (2004). Adolescent marijuana use and school attendance. Economics of Education Review, 23(2), 145-153.

Sampl, S., & Kadden, R. (2001). Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users 5 Sessions (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 1). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

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. (in press). Cannabis Youth Treatment (CYT) Overview and summary of preliminary findings. H. A. Liddle, & C. L. Rowe (Eds.), Treating adolescent substance abuse State of the science . Cambridge, UK Cambridge University Press.

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.

Webb, C., Scudder, M., Kaminer, Y., Kadden, R., & Tawfik, Z. (2002). The MET/CBT 5 Supplement 7 Sessions of Cognitive Behavioral Therapy (CBT 7) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 2). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.